Background and Clinical Significance: Chronic intestinal pseudo-obstruction (CIPO) clinically presents as a mechanical obstruction. When patients present with signs of impending ischemia, emergency exploratory laparotomy is indicated. Differentiating CIPO from other etiologies preoperatively is highly challenging, making intraoperative findings and definitive histopathology crucial for an accurate diagnosis. This report aims to elucidate a novel macroscopic presentation of myopathic CIPO and explore the potential biomechanical mechanisms underlying the observed structural anomaly. Case Presentation: A 37-year-old male with no prior abdominal surgery presented with a high-grade bowel obstruction and early signs of ischemia. Emergency laparotomy revealed a unique "braided dough twist" anomaly of the distal small bowel, prompting a segmental resection. Subsequent histopathological and immunohistochemical evaluations revealed severe outer longitudinal muscle atrophy with an intact enteric nervous system, confirming myopathic CIPO. Following surgery, the patient recovered uneventfully with significant nutritional improvement. Conclusions: Myopathic CIPO can manifest as a striking "braided" bowel anomaly-a macroscopic presentation previously undocumented in the literature. This case illustrates that determining the optimal extent of resection relies heavily on intraoperative visual and tactile assessment, and that comprehensive histopathological profiling is essential for establishing a definitive diagnosis and elucidating the underlying biomechanical mechanisms of this unique structural anomaly.

A Japanese man in his 60 s with end-stage kidney disease due to diabetic nephropathy, who initially underwent peritoneal dialysis (PD) and was transferred to combined PD and hemodialysis (HD) therapy 4 years prior, was admitted to our hospital for surgical treatment of lumbar spinal canal stenosis. His rehabilitation continued well after successful surgery; however, he suddenly presented with abdominal pain and cloudy peritoneal dialysate, along with an increased white blood cell count in the peritoneal dialysate effluent, suggesting PD-associated peritonitis. Intraperitoneal administration of antibiotics was ineffective, and contrast-enhanced computed tomography showed areas of poor contrast enhancement and pneumatosis intestinalis in the colon. Emergency laparotomy revealed non-occlusive mesenteric ischemia (NOMI), leading to intestinal resection with ileostomy creation. He made good progress after the surgery and was eventually discharged while receiving thrice-weekly HD. NOMI is a well-known life-threatening condition, and its outcomes in patients receiving dialysis therapy are reportedly unfavorable. Furthermore, to our knowledge, there have been no reported cases of NOMI in patients receiving combined PD and HD therapy. Further accumulation of similar cases is needed to clarify appropriate approaches for treating NOMI in these patients.

Blunt bowel and mesenteric injuries (BBMI) are diagnostically challenging and may evolve despite apparent radiological resolution. This case describes biphasic small bowel perforation following non-operative management (NOM) after blunt abdominal trauma, highlighting limitations of conservative strategies and the need for prolonged vigilance. A 57-year-old woman sustained a Grade 4 small bowel perforation after a motor vehicle collision. She presented 7 days post-accident with abdominal pain but was haemodynamically stable and elected NOM. Interval computed tomography at 23 days demonstrated apparent resolution. At 21 weeks, she re-presented with crescendo abdominal pain, nausea, and vomiting. Imaging confirmed recurrent perforation at the original site. Laparotomy revealed a 3 cm full-thickness perforation adjacent to a chronic fibrotic stricture and mesenteric defect. Ileocolic resection was performed. Radiological resolution does not equate to definitive healing in high-grade BBMI. Trauma-induced chronic ischaemia may drive delayed stricture formation and late perforation, warranting structured long-term follow-up, and patient education.

BACKGROUND Small bowel obstruction (SBO) is a common surgical emergency, most frequently caused by postoperative adhesions or hernias. SBO resulting from migration of an intrauterine device (IUD) is exceedingly rare but can be life‑threatening. CASE REPORT We present 2 cases of postmenopausal women with long-term IUD retention (>30 years) who developed acute abdominal pain and clinical signs of intestinal obstruction. Preoperative abdominal CT revealed dilated small bowel loops with surrounding fluid and inflammatory changes, along with an ectopic ring-shaped IUD through which a segment of ileum herniated. Emergency laparotomy confirmed a strangulated obstruction and necrotic bowel in both cases, which required segmental bowel resection and primary anastomosis. Postoperative recovery was uneventful in both patients. A review of the literature indicates that such complications predominantly occur in postmenopausal women. Prolonged device retention, particularly with O-shaped IUDs, is associated with older age at presentation. Progressive uterine atrophy and myometrial thinning after menopause increase the risk of chronic erosion and eventual perforation with intraperitoneal migration. If the IUD is not encapsulated by the omentum, it provides an opportunity for small bowel loops to herniate through its central opening, ultimately resulting in strangulated intestinal obstruction. CONCLUSIONS These cases highlight the importance of recognizing IUD migration as a rare cause of mechanical small bowel obstruction, especially in women with a remote history of IUD placement. Prompt imaging evaluation and timely surgical intervention are critical to prevent bowel ischemia and reduce morbidity.

Mesenteric ischemia is a potentially deadly condition that occurs due to the lack of blood supply to the intestine. There is also emerging evidence that the mesenteric circulation may result in vascular dysfunction and ischemic damage caused by environmental contaminants especially heavy metals such as lead and mercury. Persistent exposure leads to endothelial dysfunction through the generation of oxidative stress, nitric oxide depletion, mitochondrial dysfunction and inflammatory signaling pathways. This hypothesis-generating narrative review integrates toxicological and vascular evidence to propose that chronic low-level exposure to these metals could represent an underrecognized etiological factor in mesenteric ischemia. The main molecular mechanisms, including oxidative stress, endothelial dysfunction, mitochondrial dysfunction, and vascular remodeling, are discussed, and the potential synergistic toxicity of the combined exposure to metals is considered. Additionally, several crucial diagnostic biomarkers are mentioned, such as intestinal fatty acid-binding protein (I-FABP), alpha-glutathione S-transferase (α-GST), C-reactive protein (CRP), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and malondialdehyde (MDA). A knowledge of the connection between mesenteric vascular injury and exposure to heavy metals may aid in the development of improved methods of diagnosis and treatment.

Mesenteric ischemia (MI) represents a spectrum of vascular intestinal injuries for which delayed diagnosis remains the leading determinant of outcomes. Despite advances in multidetector CTA technology and endovascular therapy, substantial variation persists in how mesenteric ischemia is defined, imaged, interpreted, and incorporated into clinical pathways. This AJR Expert Panel Narrative Review provides radiologists with pragmatic guidance for mesenteric ischemia evaluation on imaging. Key issues considered include the pathophysiologic spectrum and diagnosis of acute mesenteric ischemia (AMI); CT protocol optimization (including the role of spectral CT); vascular pathologies that lead to occlusive or nonocclusive AMI; CT features associated with ischemia and necrosis; scoring systems for estimating necrosis likelihood; interventional and surgical management; evaluation of postischemic reperfusion; chronic mesenteric ischemia; and the emerging role of dedicated mesenteric stroke centers in reducing time to revascularization. A simplified four-phase framework is presented to illustrate the temporal progression of CT findings in occlusive arterial AMI from occlusion without visible bowel ischemia, to early ischemia, late ischemia, and irreversible transmural necrosis. The article concludes with consensus statements addressing image acquisition, interpretation, and reporting, with the aim of supporting radiologists who serve as first-line decision makers in the diagnosis and management of mesenteric ischemia.

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas-filled cysts within the submucosal or subserosal layers of the intestinal wall. Although often asymptomatic and detected incidentally, PCI may be associated with significant underlying gastrointestinal or systemic pathology. We report two young adults from Addis Ababa, Ethiopia, who presented with long-standing upper gastrointestinal symptoms, including early satiety, postprandial epigastric pain, reflux, vomiting, and marked weight loss. Clinical, laboratory, and endoscopic evaluations confirmed gastric outlet obstruction (GOO) secondary to chronic duodenal stenosis. Both patients underwent retrocolic gastrojejunostomy with truncal vagotomy and Braun's anastomosis. During surgery, multiple gas-filled cystic lesions consistent with PCI were incidentally identified on the serosal surface of the small intestine. There were no signs of bowel ischemia, perforation, or peritonitis. No bowel resection was performed, and PCI was managed conservatively. Postoperative recovery was uneventful in both cases, with complete symptom resolution and significant weight gain at follow-up. These cases emphasize that PCI may occur secondary to chronic mucosal disruption and increased intraluminal pressure in GOO. Recognition of PCI in this clinical context is essential to guide appropriate management. When incidentally detected in the absence of complications, PCI does not warrant specific surgical intervention. Management should instead focus on addressing the underlying pathology to avoid unnecessary bowel resection.

Fecaloma is a rare but clinically significant cause of large bowel obstruction, often associated with chronic constipation and underlying conditions affecting bowel motility. We report the case of a 50-year-old man with a history of intellectual disability who presented with a 10-day history of progressive abdominal pain, obstipation, abdominal distension, vomiting, and intolerance to oral intake. Physical examination revealed a distended abdomen with decreased bowel sounds and no signs of peritoneal irritation. Laboratory findings were unremarkable except for a mild elevation of lactate dehydrogenase (LDH). Contrast-enhanced computed tomography (CT) demonstrated marked colonic dilation with a heterogeneous intraluminal mass in the sigmoid colon, consistent with a fecaloma, causing complete large bowel obstruction without evidence of perforation or ischemia. Given the severity of the presentation and clinical deterioration, the patient underwent urgent exploratory laparotomy, confirming a large impacted fecaloma with significant proximal colonic dilation. A sigmoidectomy with end colostomy (Hartmann's procedure) was performed without complications. The postoperative course was favorable, with adequate stoma function and no evidence of infection or leakage. Histopathological analysis confirmed chronic mechanical obstruction with adaptive muscular hypertrophy and pressure-related mucosal changes, without malignancy. This case highlights the importance of considering fecaloma as a differential diagnosis in large bowel obstruction, particularly in vulnerable populations. In addition, it underscores the role of timely imaging and surgical intervention in preventing severe complications.

Small bowel neuroendocrine tumors (NETs) are typically indolent neoplasms that often present with vague abdominal symptoms and are frequently diagnosed only after regional or metastatic spread has occurred. Mesenteric nodal metastases may provoke a desmoplastic reaction resulting in bowel tethering, luminal narrowing, mesenteric vascular compromise, obstruction, and intestinal ischemia. We report the case of a 49-year-old man with no prior abdominal surgery who presented with three months of intermittent abdominal pain followed by abrupt worsening to diffuse severe abdominal pain and emesis. Computed tomography demonstrated small bowel obstruction with concern for a closed-loop obstruction at the level of a 2.5 × 1.6 cm mesenteric mass, with associated bowel wall thickening concerning for ischemia. The patient underwent emergency exploratory laparotomy with resection of strangulated small bowel, en bloc resection of a stellate mesenteric mass, primary anastomosis, and appendectomy. Pathology demonstrated mesenteric lymph nodes positive for metastatic well-differentiated NET, grade 1, with extranodal extension and lymphatic space invasion. Tumor cells were positive for synaptophysin, chromogranin, CD56, and CK AE1/AE3, with a Ki-67 index of less than 1%. No definite primary lesion was identified in the resected bowel specimen, but the overall clinicopathologic findings strongly suggested an occult small bowel primary. The postoperative course was uncomplicated, and the patient improved clinically after surgery. This case highlights that even low-grade NETs may first present as a surgical emergency due to mesenteric metastatic disease and fibrosis rather than carcinoid syndrome. In patients with a virgin abdomen, chronic intermittent abdominal pain, weight loss, and an obstructing mesenteric mass, small bowel NET should remain in the differential diagnosis.

Idiopathic Mesenteric Phlebosclerosis is a rare and misdiagnosed gastrointestinal condition marked by mesenteric venous sclerosis and calcification, which can lead to chronic mesenteric ischemia and colonic irregularities. This study reports a 68-year-old male with recurrent abdominal bloating and constipation, initially misdiagnosed as intestinal obstruction. The medical history of the patient included prolonged use of Gardenia Jinhua Wan, a herbal preparation containing Gardenia. Imaging studies, including CT scans, revealed calcified mesenteric veins and colonic wall thickening, while colonoscopy indicated deep blue mucosa with ulcerations and stricture, which are the characteristic features of IMP. Histopathological analysis validated chronic inflammation and submucosal fibrosis, and Masson trichrome-positive staining ruled out amyloidosis (Congo red-negative). The IMP diagnosis was confirmed after the discontinuation of the herbal remedy, while mesalazine and aspirin significantly alleviated symptoms. This case highlights the importance of considering IMP as the differential diagnosis of chronic gastrointestinal problems, particularly when associated with the use of herbal medicine. These findings suggest that early identification and imaging results, including venous calcifications and endoscopic mucosal discolouration, are crucial for preventing misinterpretation and unwarranted interventions.

Histologic evaluation of colonic biopsies in patients with chronic diarrhea or long-standing colitis is frequently performed in the setting of incomplete clinical, endoscopic, or laboratory information. In this context, overlapping morphologic features across different etiologies often lead to nonspecific or misleading diagnoses, such as "chronic colitis," with potential implications for patient management. To improve diagnostic clarity and clinicopathologic communication, the Italian Group of Digestive Disease Pathology (GIPAD) developed a structured, pattern-based histologic approach for the interpretation and reporting of adult colitis with chronic architectural damage, based on multidisciplinary discussion and critical appraisal of the literature. Distinct histologic patterns are described and correlated with relevant differential diagnoses. Major patterns of colitis with chronic architectural damage are identified, and for each pattern, key morphologic features and principal differential diagnoses-including inflammatory bowel disease and other conditions such as drug-related injury, ischemia, infection, diversion colitis, and immune-mediated disorders-are discussed. A pattern-based histologic approach provides a practical framework for reporting colitis with chronic architectural damage. This strategy narrows differential diagnoses, avoids nonspecific terminology, and supports clinical decision-making, while preserving the primacy of integrated clinicopathologic diagnosis when sufficient information is available.

Myocardial ischemia-reperfusion injury (MIRI) remains a critical clinical condition with limited preventive and therapeutic strategies, underscoring the need for novel interventions. The gut-heart axis and exosomal crosstalk hold therapeutic promise for cardioprotection, yet the fundamental question of which specific gut cells release the beneficial exosomes is unanswered. This study aimed to elucidate whether ginseng polysaccharides WGPA exert remote cardiac protection by regulating intestinal immune homeostasis, specifically through promoting the release of exosomes from regulatory T cells (Tregs). Using integrated in vivo and in vitro models, we evaluated the protective effects of WGPA against MIRI. The results demonstrated that WGPA pretreatment significantly attenuated myocardial injury and improved cardiac function. Mechanistically, WGPA selectively activated intestinal Tregs and enhanced the release of HSP70-enriched exosomes. These exosomes entered systemic circulation and were delivered to the heart, where surface HSP70 interacted with TLR4 on cardiomyocytes, activating downstream protective signaling pathways and ultimately suppressing cardiomyocyte death and inflammatory responses. Our study reveals for the first time a complete mechanism by which medicinal plant polysaccharides confer cross-organ cardioprotection via the "intestinal Tregs-exosome-heart" axis, providing a novel theoretical basis and a potential intervention strategy for the prevention and treatment of MIRI.

Senna laxative, one of the major stimulant laxatives, has received less attention regarding its potential risk of intestinal ischemia in the elderly population. An 87-year-old female with a past medical history of chronic constipation developed abdominal pain and fever after oral ingestion of senna laxative for constipation and was subsequently diagnosed with ischemic bowel disease upon hospitalization. Symptomatic and supportive treatment, such as antibiotics, acid inhibition and stomach protection, fluid replenishment, and intravenous nutrition, was given. After treatment, the patient's condition stabilized, her symptoms improved, and she was allowed to leave the hospital. This case highlights that the use of senna laxative in elderly patients may lead to severe ischemic intestinal disease. Clinicians should be vigilant about the adverse reactions of senna laxative in elderly patients.

Endovascular aneurysm repair (EVAR) is a treatment method that has become increasingly popular for abdominal aortic aneurysms (AAA) due to its ease of application, reduced hospital stay, and its suitability as an alternative for patients who cannot tolerate open surgery. Although the early outcomes of EVAR are better than those of open surgery, complications such as endoleak, migration, thrombosis or kinking of the endograft limbs, graft infection, and secondary rupture may occur. In this study, we present a patient who underwent EVAR at another institution approximately 10 years earlier and was admitted to our clinic with complaints of deterioration in general condition, fever, and melena. Laboratory examination of 73-year-old man revealed a white blood cell (WBC) count of 17,100, hemoglobin level of 9.5 g/dL, and C-reactive protein (CRP) level of 261 g/L. Computed tomography (CT) revealed thrombosis within the EVAR graft, free air surrounding the graft, fractures in the graft stents, and displacement of the right limb beyond the aorta at the level of the iliac bifurcation. The endograft was observed to have migrated toward the duodenum and formed a fistula. The pa-tient, who presented with sepsis, underwent emergency surgery. Initially, a left axillofemoral bypass was performed to relieve ischemia in the left leg. Subsequently, a laparotomy was performed with the joint participation of the general surgery and cardiovascular surgery departments. Intra-abdominal fecal contamination and rupture of the sigmoid colon were observed. The abdomen was lavaged, the sigmoid colon and rectum were excised, and a colostomy was created. An aortotomy was then performed, and the main body of the graft and its left limb were removed. The duodenum was opened, and the fistulized right limb of the endograft was also removed. No additional vascular intervention was required due to abdominal contamination, adequate collateral circulation in the right leg, likely due to the chronic nature of the process, and the absence of ischemia. The aorta was ligated at the infrarenal level, and the patient, who required high-dose inotropic support, was transferred to the intensive care unit. The patient died in the eighth postoperative hour. To our knowledge, this case represents a rare and unique complication that has not been previously reported in the literature. By presenting this case, we aim to draw attention to the long-term complications of EVAR and emphasize the importance of open surgery in patients with a high life expectancy.