Original Articles

Congenital Bands: A Rare Cause Of Adult Intestinal Obstruction

Authors Dr. Dnyanesh Belekar
K J Somaiya Medical College & Research Centre, Ayurvihar, Sion, Mumbai - India 400022

Dr. Amogh R Vaishampayan
K.J.Somaiya Medical College and Research centre, Sion, Thane - India 400022

Dr. Sandesh B Singh
K.J.Somaiya Medical College and Research centre, Sion, Colaba - India 400022
Corresponding Author Dr. Dnyanesh Belekar
K J Somaiya Medical College & Research Centre, Ayurvihar, Sion, Mumbai - India 400022
Submitting Author Dr. Dnyanesh M Belekar
Terna Medical College & Hospital, Terna Sahyadri Specialty Hospital & Research Center, Nerul (West) - India 400706

Plus Speciality:

GASTROENTEROLOGY

Keywords:

Congenital, bands, intestinal, obstruction

How to cite the article:

Belekar D, Vaishampayan AR, Singh SB. Congenital Bands: A Rare Cause Of Adult Intestinal Obstruction. WebmedCentral plus GASTROENTEROLOGY 2014;5(4):WMCPLS00148
doi: 10.9754/journal.wplus.2014.00148

Copyright:

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Submitted on: 24 Mar 2014 09:18 AM
Accepted on: 08 Apr 2014 11:22 AM
Published on: 17 Apr 2014 06:15 AM

Abstract


Acute Intestinal obstruction is one of the commonest surgical emergencies encountered. Various causes are responsible for this of which post operative adhesions are most common. Congenital bands form one of the rarer causes. In a previously operated patient for exploratory laparotomy congenital bands are rare to find as either they should have been divided at that time. Here we would like to report such rarer surgical entity encountered at our institute.

CaseHistory


25 years old male presented with complaints of pain in abdomen, nausea with bilious vomiting and constipation for 3-4 days presented to the casualty. Patient complained of sudden onset severe colicky abdominal pain predominant in peri-umbilical region associated with 3-4 episodes of bilious vomiting. He also complained of obstipation since last 4 days. Patient had a history of previous abdominal surgery for vehicular accident about 15-20 yrs back when he had undergone exploratory laparotomy for hemo-peritoneum however the details of the surgery could not be obtained.

On examination, patient was mildly febrile with a temp 98.8°F, pulse of 92 beats/min and Blood pressure of 128/76 mm Hg. He had an abdominal distension with diffuse tenderness in all abdominal quadrants with epigastrium and umbilical region showing guarding. Rectal examination was normal. Healed midline laparotomy scar was unremarkable. Laboratory investigations revealed neutrophillic leucocytosis and raised ESR.


Figure 1: Narrowing of segment of Jejunum due to Congenital Band

Erect abdominal X-ray revealed multiple air-fluid levels s/o small intestinal obstruction. USG of abdomen suggested the similar findings with dilatation of small bowel loops with minimal inter bowel free fluid. Upon failure of conservative treatment patient was subjected to exploratory laparotomy. In most cases, adhesions are usual occurrence in a previously operated patient presenting with intestinal obstruction. However a congenital vascular band was found causing a closed loop in which a part of small bowel was entrapped.

The band was vascularized by one of the branches of the superior mesenteric artery. The band extended from the jejunum to the root of the mesentery at the level of the second lumbar vertebrae. No signs of ischemia bowel were noted. At the superior end, band had caused narrowing in a jejunal segment resulting in a stricture formation. Stricturoplasty was performed for the same. Appendix was also found to be trapped in the band and hence was removed in view of possible inflammation. The band was ligated at both ends and divided between ligatures. Postoperative outcome was uneventful and the patient was discharged on the seventh postoperative day. At follow up after 3 months patient is healthy. He has been advised to follow up every 3 monthly.

 


Figure 2: Congenital band engulfing appendix


Figure 3: Congenital band running from anti-mesenteric border

Discussion


Intestinal obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency at times. The condition is often treated conservatively over a period of 2–5 days with the patient's progress regularly monitored by an assigned physician. Surgical procedures are performed on failure of conservative methods or in life threatening cases wherein patients present with a complete obstruction with vascular compromise with or without septicemic shock.

Acute small bowel obstruction is one of the commonest emergencies presenting to the surgical department. Adhesions are by far the most frequent causes followed by hernias, tumors, intussusception, volvulus, foreign bodies, strictures, inflammatory bowel disease etc...Obstruction by a congenital band is usually observed in childhood and rarely seen in adults. Congenital bands cause 3% of all intestinal obstruction and almost always lead to small bowel obstruction. In adults, obstruction due to bands is even rarer. An anomalous congenital band could be included in the differential diagnosis of intestinal obstruction. This clinical situation requires early surgical intervention that will be diagnostic and therapeutic1 congenital bands can be located at various locations intraperitoneally such as those running between ascending colon and terminal ileum followed by ligament of Treitz and terminal ileum; between the right lobe of liver and terminal ileum; and between the right lobe of liver and ascending colon;2  from the iliac fossa to the sigmoid mesocolon3 bands starting from jejunum and running to the mesentery are  however rare. These bands are thought to be the anomalies of the mesentery and are considered along with the other causes of congenital obstruction mainly in children such as duodenal atresia, malrotation, superior mesentery artery syndrome, enteric duplications as well as several other entities. Ladd's bands is a typical example of a anomalous congenital band, it is a fibrous peritoneal tissue which extends from ceacum and extend to the posterior peritoneum and/or sub-hepatic region. Ladd's bands result in compression of the 2nd or 3rd duodenal portions, which leads to intestinal obstruction4

Patients usually present in a classical manner of acute intestinal obstruction with symptoms of pain in abdomen, distension, vomiting and constipation in different compositions and hence are difficult to diagnose preoperatively. Ultrasonography and contrast enhanced computed tomography of abdomen and pelvic studies may provide the interim details like location of obstruction and distended bowel loops. These investigations may even help excluding other major diagnosis but none can point out at bands. Plain X rays are not useful except for confirming small bowel obstruction5 Diagnostic laparoscopy can be useful for diagnosis as well as treatment of congenital bands and can very well distinguish between bands and adhesions6 Treatment in most cases is surgical and mainly involves releasing of the bands. Stricture and/or bowel narrowing with or without vascular compromise needs to be dealt with accordingly.

Summary


Hence acute small bowel obstruction diagnosed to be at the level of duodenum or jejunum  especially when barium upper GI studies show normal duodenal rotation and duodeno-jejunal fixation anomalous congenital bands should be considered as a differential diagnosis.7 In the present case in spite of previous history of laparotomy where adhesions were thought to be the cause of obstruction, congenital bands were found to be the one causing it which possibly have been missed during previous laparotomy making it a rare occurrence.

References


1. Sozen S, Emir S, Yazar FM, Altinsoy HK, Topuz O, Vurdem UE, Cetinkunar S, Ozkan Z, Guzel K. Small bowel obstruction due to anomalous congenital peritoneal bands - case series in adults;Bratisl Lek Listy. 2012;113(3):186-9.
2.Akgur FM, Tanyel FC, Buyukpamukcu N, Hicsonmez A. Anomalous congenital bands causing intestinal obstruction in children. J Pediatr Surg. 1992;27:471–3.
3. Lin DS, Wang NL, Huang FY, Shih SL. Sigmoid adhesion caused by a congenital mesocolic band. J Gastroenterol. 1999;34:626–8.
4. Long FR, Kramer SS, Markowitz RI, Taylor GE. Radiographic patterns of intestinal malrotation in children. Radiographics 1996;16:547-56.  
5. Cyrochristos Dimitrios, Alexiou A. George, Ziogas Dimosthenis, and Xiropotamos Nikolaos.Intestinal Obstruction Due to an Anomalous Congenital Band. Saudi J Gastroenterol. 2008 January; 14(1): 36–37.
6. Wu JM, Lin HF, Chen KH, Tseng LM, Huang SH. Laparoscopic diagnosis and treatment of acute small bowel obstruction resulting from a congenital band. Surg Laparosc Endosc Percutan Tech. 2005;15:294–6.
7. Sarkar D, Gongidi P, Presenza T, Scattergood E. Intestinal Obstruction from Congenital Bands at the Proximal Jejunum: A Case Report and Literature Review. J Clin Imaging Sci 2012;2:78

Source(s) of Funding


None

Competing Interests


None

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