Sigmoid volvulus (SV) is an uncommon cause of intestinal obstruction resulting from axial twisting of the sigmoid colon around its mesenteric base. In the absence of complications, endoscopic detorsion is considered the first-line treatment, whereas urgent surgery is required in cases of perforation, peritonitis, or failed detorsion (1). The "coffee bean sign" (massively dilated sigmoid loop directed to the right upper quadrant) and the "whirl sign" (twisting of mesentery and vessels) are well-established radiological findings of SV (2). By contrast, endoscopic features are less well characterized, and evaluating mucosal ischemia or necrosis endoscopically remains challenging. Completely black mucosa is indicative of full-thickness necrosis, while borderline ischemia may present with variably discolored mucosa, including yellowish and reddish spots. In 2021, Uysal et al. described this finding as the "fallen leaves in autumn" sign, reflecting superficial necrosis with preserved viability of deeper layers. We report the case of an 83-year-old male admitted to the emergency department with abdominal pain and rectal bleeding. Imaging revealed classic signs of SV (Figure 1). During endoscopic detorsion, findings consistent with borderline ischemia were noted: loss of submucosal vascularity and scattered reddish-yellowish dots, some confluent. Areas suspected of complete necrosis displayed black mucosa with a sandpaper-like appearance (Figure 2). The patient underwent surgery for irreversible ischemia (Figure 3) but unfortunately died a few days later due to postoperative complications. This case highlights that the "fallen leaves in autumn" sign may serve as a useful endoscopic descriptor of borderline ischemia in SV, complementing established radiological features.

Small intestinal bacterial overgrowth (SIBO) refers to an abnormal increase in the number of bacteria in the small intestine and is observed in various diseases. SIBO can also develop after long-term use of proton pump inhibitors (drug-induced SIBO), bariatric surgery, gastrectomy, and other surgeries (postoperative SIBO). The aim of this narrative review is to summarize all of the published information on the treatment of SIBO in as much detail as possible and present it separately for each specific disease and intervention associated with SIBO. The most extensively studied drug for the treatment of SIBO is rifaximin. It eliminates SIBO in 63% of cases; however, most studies lack a control group. Small RCTs assessing the effects of this antibiotic on SIBO have reported conflicting results, and a meta-analysis showed no effect. A large RCT is required to verify the results of uncontrolled studies. Neomycin and norfloxacin showed efficacy in the treatment of SIBO in single RCTs, with elimination rates of 20 and 100%, respectively. Ciprofloxacin, rifamycin, metronidazole, and other antibiotics, as well as ursodeoxycholic acid, showed positive effects for the treatment of SIBO, but only in uncontrolled studies or in comparison with rifaximin or other drugs. The reported elimination rates were 54%, 67%, 79%, and 75%, respectively. Eradication therapy for Helicobacter pylori infection eliminated SIBO at a rate of approximately 70%. Probiotics have been tested for treatment of SIBO in various diseases. VSL#3 and Saccharomyces boulardii CNCM I-745 were effective in RCTs, with elimination rates of 58% and 80%, respectively. In conclusion, when selecting SIBO treatment regimens, those that have demonstrated the greatest efficacy for a specific concomitant disease should be preferred, despite the generally low level of evidence supporting these approaches in most cases.

Trichobezoars are rare intragastric masses composed of ingested hair, most commonly affecting young females with underlying psychiatric conditions. Rapunzel syndrome is a rare variant characterized by extension beyond the stomach into the small intestine. We report the case of a 27-year-old female with a 6-month history of abdominal pain, vomiting, weight loss, and intolerance to oral intake. Endoscopy revealed a large gastric trichobezoar occupying ~90% of the gastric lumen, causing functional pyloric obstruction. Contrast-enhanced computed tomography demonstrated marked gastric and proximal duodenal dilation with imaging features suggestive of secondary superior mesenteric artery (SMA) syndrome (Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149-56. https://doi.org/10.1159/000102097; Ganss A, Rampado S, Savarino E et al. Superior mesenteric artery syndrome: a prospective study in a single institution. J Gastrointest Surg 2019;23:997-1005. https://doi.org/10.1007/s11605-018-3984-6). Surgical exploration confirmed a giant trichobezoar extending from the pylorus to near the cardia with duodenal extension. Complete removal was achieved via laparotomy and anterior gastrotomy. The postoperative course was uneventful, and psychiatric evaluation confirmed trichotillomania and trichophagia. This case highlights the importance of multimodal diagnosis and suggests a possible pathophysiological relationship between severe gastric obstruction and secondary SMA syndrome.

Anastomotic leakage and anastomotic stenosis are among the most severe complications of rectal resection, among patients receiving neoadjuvant radiotherapy, the incidence of anastomotic stricture ranges from 3% to 6%. Anastomotic stricture can lead to abdominal pain and bowel obstruction, significantly affecting the quality of life and sometimes necessitating the creation of permanent stomas. This article reviews the definition of rectal anastomotic stricture. The development of anastomotic stricture is closely related to multiple factors, such as the healing characteristics of the bowel wall, local ischemia, anastomotic leakage, and the effects of preoperative radiotherapy. Furthermore, the choice of surgical anastomosis techniques significantly impacts the incidence of strictures. To enhance treatment outcomes for anastomotic strictures, this review summarizes different therapeutic strategies for membranous and tubular strictures. Transanal endoscopic resection and reconstruction surgery has significant advantages in the treatment of severe rectal anastomotic stenosis, providing standardized suggestions and guidance for the treatment of this clinical difficulty.

Colorectal serrated polyps are now recognized as an important pathway in colorectal carcinogenesis. An association between serrated polyposis syndrome (SPS) and duodenal serrated lesions sharing a similar immunophenotype in both the colon and duodenum has been reported in the literature. We present a case of a 38-year-old male who presented in June 2023 with abdominal pain and fever. Initial investigations, including multiple computed tomography scans of the abdomen and pelvis, revealed an appendiceal abscess and small bowel intussusception involving two segments of the jejunum without evidence of obstruction, along with multiple polyps throughout the small and large bowel suggestive of an intestinal polyposis syndrome. Further evaluation with colonoscopy, esophagogastroduodenoscopy, and magnetic resonance enterography confirmed the presence of numerous polyps of varying sizes involving the duodenum, jejunum, ileum, and all segments of the colon. The initial differential diagnosis included familial adenomatous polyposis, Peutz-Jeghers syndrome, and PTEN hamartoma tumor syndrome. The patient subsequently developed complicated small bowel obstruction due to intussusception and underwent open small bowel resection. Multiple intestinal polyps were identified, and histopathological examination confirmed the diagnosis of SPS. At a later stage, the patient was planned for subtotal colectomy, preceded by elective endoscopic polypectomy, which achieved clearance of the left colon up to 20 cm from the anal verge. Gross examination of the colectomy specimen revealed more than 20 large polyps measuring up to 4 cm. Histopathological analysis demonstrated colonic serrated polyposis without evidence of invasive malignancy, wall infiltration, or lymph node involvement, with clear surgical margins.

Large bowel obstruction (LBO) accounts for approximately one-quarter of all intestinal obstructions. LBO may arise from mechanical obstruction due to benign or malignant etiologies, or from functional obstruction such as acute colonic pseudo-obstruction. Because clinical presentation varies by acuity, etiology, and ileocecal valve competency, early recognition and prompt evaluation are essential to prevent complications, including ischemia and perforation with potential for sepsis and mortality. Patients with acute obstruction typically present with abdominal pain, distension, and obstipation, whereas malignant obstruction often develops gradually with progressive constipation and abdominal distension, leading to dehydration, electrolyte abnormalities, and malnutrition. Computed tomography has become the preferred diagnostic modality due to its ability to identify the transition point, help define the cause and severity of obstruction, and potentially detect complications such as ischemia or perforation. Endoscopy serves both diagnostic and therapeutic roles in selected patients, including detorsion for sigmoid volvulus, decompression for pseudo-obstruction, and tissue diagnosis or stent placement in malignant obstruction. Initial management focuses on resuscitation, correction of electrolyte abnormalities, mitigation of aspiration risk, and gastrointestinal decompression. Definitive management depends on the underlying etiology. Malignant LBO requires individualized planning based on tumor location, patient physiology, and institutional expertise, with options including oncologic resection with or without colostomy, proximal surgical diversion and staged resection, or endoscopic stenting with staged resection. Self-expanding metallic stents may serve as bridges to surgery and reduce the need for a stoma. Benign causes, including diverticular strictures, volvulus, inflammatory bowel disease-related strictures, anastomotic strictures, and fecal impaction, require tailored endoscopic or operative interventions. Across etiologies, short delays to intervention may be appropriate for stable patients undergoing optimization; however, early definitive management should be the usual approach. In cases where intervention is delayed, careful surveillance for developing ischemia or perforation is mandatory. (J Trauma Acute Care Surg . 2026;101: 1-12. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved).

Nodular lymphoid hyperplasia (NLH) is a rare, benign condition of lymphoid proliferation within the gastrointestinal tract. NLH is a recognized feature of specific immunodeficiency syndromes, including common variable immunodeficiency and selective IgA deficiency. NLH may develop throughout the gastrointestinal tract; however, it usually develops in the small intestine. We report an extremely unusual case of previously undiagnosed selective IgA deficiency presenting with subacute rectosigmoid obstruction.

Rapunzel syndrome is a rare manifestation of trichobezoar in which a gastric hair mass extends beyond the pylorus into the small intestine. It typically presents with abdominal pain, nausea, vomiting, early satiety, weight loss, or bowel obstruction. Presentation of acute pancreatitis is uncommon and may delay diagnosis. We report a previously healthy nine-year-old girl who presented with progressive epigastric pain, nausea, vomiting, decreased oral intake, and constipation. Laboratory evaluation demonstrated markedly elevated lipase levels consistent with acute pancreatitis. Abdominal ultrasound revealed intrahepatic and extrahepatic biliary ductal dilatation without gallstones or choledocholithiasis. Symptoms initially improved with supportive care; however, persistent pain and a palpable epigastric mass prompted further imaging. Computed tomography demonstrated a large gastric trichobezoar extending into the jejunum, consistent with Rapunzel syndrome, with associated intussusception and compression of the pancreatic duct. The patient underwent exploratory laparotomy with complete bezoar removal, followed by resolution of symptoms and normalization of lipase levels. This case highlights Rapunzel syndrome as a rare mechanical cause of pediatric pancreatitis and emphasizes the importance of considering extrinsic compression when pancreatitis occurs with biliary dilatation and normal liver biochemical findings.

Intussusception is a condition in which one segment of the intestine (intussusceptum) telescopes into the lumen of an adjacent segment (intussuscipiens), potentially leading to obstruction. Giant colonic lipomas are rare and often asymptomatic, but when large enough, can serve as a lead point for intussusception. We present the case of a 62-year-old male patient who presented with nausea and vomiting. A computed tomography (CT) abdomen/pelvis without contrast showed intussusception of the ascending colon into the transverse colon without bowel obstruction, along with a lobulated fatty mass at the tip of the intussusceptum. This mass was suspected to be a colonic lipoma serving as the lead point. Due to the patient's benign abdominal exam, emergent surgical intervention was deferred. A colonoscopy then revealed a large, 5 cm pedunculated lipoma in the transverse colon near the hepatic flexure. An Endoloop was applied and tightly cinched around the base of the lesion. He was discharged in stable condition with recommendations for close gastroenterology follow-up. The purpose of presenting this case is to highlight the utilization of endoscopy in management of colonic intussusception caused by a structural lesion, as well as the importance of considering intussusception as the cause of a patient's nausea and vomiting (although it is a rare cause in adults). A CT scan is helpful in establishing this diagnosis and guiding management. Furthermore, if intussusception is suspected in an adult, it is important to consider a structural lesion that may be acting as a lead point, such as an intraluminal tumor or mass.