Acute Duodenitis Research Articles

FRI676 Undiagnosed Celiac Disease: A Silent Offender Of Male Osteoporosis

Abstract Disclosure: I.E. Hernandez Castro: None. A.M. Ludeña De Freitas: None. M.S. Martinez Aguiar: None. G. Irizarry: None. Osteoporosis affects both genders, with higher incidence in women after menopause. In men, it's often overlooked, leading to significant morbidity and mortality, if not diagnosed and treated early. Hip fractures in men have higher mortality than in women.Celiac disease is an immune reaction to gluten, causing nutrient malabsorption and inflammation-mediated injury to the small intestine, in genetically predisposed patients. It can lead to severe osteoporosis, especially if the disease remains undiagnosed for a long time.A 64-year-old male patient who does not follow any regular medical care, was transported to the emergency department due to dizziness, blurry vision, and left arm numbness for one day evolution. Physical examination was unremarkable, no signs of tetany noted. Laboratories showed corrected calcium 4.4mg/dL, sodium 130 mEq/L, potassium 2.5 mmol/L, phosphorus 4.41. PTH intact level 465.3 pg/mL, and ionized calcium level 5.2 mg/dL, measured after supplementation. Further studies revealed 24 hours urine calcium, sodium, and creatinine 52mg/day, 107mmol/day, and 1118mg/day, respectively. DEXA scan reported low bone mineral density (BMD) at AP spine L1-L4 of 0.860 with T-score of -3.0, BMD at femur neck of 0.579 with T-score of -3.8, and BMD at femur total of 0.622 with T-score of -3.6. The latter findings indicated severe osteoporosis, a rare and unexpected finding in a male patient younger than 70 years of age. Tissue transglutaminase IgA was positive with value of 611 u/mL and serum IgA 242mg/dL. Pathology report from tissue of the duodenum reported small bowel mucosa with focal gastric foveolar metaplasia and acute duodenitis, negative for dysplasia or malignancy. Immunohistochemical study for Helicobacter Pylori was positive and biopsy findings taken from the stomach, antrum, and body revealed gastric mucosa with moderate chronic active inflammation without intestinal metaplasia. Patient was diagnosed with secondary hyperparathyroidism due to celiac disease, a well-known studied risk factor for osteoporosis. Celiac disease caused malabsorption of nutrients and electrolytes, including calcium, which is essential for bone health. A gluten-free diet and supplements of oral calcium and vitamin D were started. Antiresorptive medications for osteoporosis were not started at this moment due to hypocalcemia and vitamin D deficiency. This case highlights the importance of considering Celiac disease as an uncommon but important etiology of osteoporosis. This malabsorptive condition should always be included among the differential diagnosis in male patients presenting with unexplained electrolyte imbalance and secondary hyperparathyroidism. Approximately 20% of diagnosed osteoporosis cases are men, and early diagnosis and treatment are crucial in preventing associated morbidity and mortality, especially if complicated by a hip fracture. Presentation: Friday, June 16, 2023

Morphological assessment of changes in internal organs of rats with introduction of targeted drug “Sutent” in experiment

Objective. To establish in the experiment the changes in histological structure of the internal organs and blood indices in laboratory rats with intragastric introduction of the drug Sutent in the doses of 7 mg/kg and 35 mg/kg of the weight.
 Materials and methods. The study was conducted on 48 breedless white rats divided into the following groups: groups 1 and 4 received cytotoxic drug Sutent in the dose of 7 mg/kg (therapeutic dose), groups 2 and 5 Sutent in the dose of 35 mg/kg (fivefold exceeding the therapeutic dose), groups 3 and 6 the control groups. In groups 1, 2, 3 animal were killed 30 days after the onset of the experiment, in groups 4, 5, 6 two weeks after the drug withdrawal. Every day during 30 days, the experimental groups were introduced the intragastric drug Sutent in the form of aqueous suspension in the purified water; in the control group the rats received the purified water in the equivalent volume. The histological preparations of organs stained with hematoxylin and eosin as well as the hematological indices of blood were investigated.
 Results. The development of hypochromic anemia, thrombocytopenia and granulocytopenia in the was identified. While studying the histological structure of organs, in all experimental groups there was detected a disturbed circulation in the form of venous hyperemia and blood stasis in the capillaries, the development hemorrhages in the lung, liver, kidneys, adrenal glands, pancreas, gastric and esophageal mucosa. In the liver, pancreas and adrenal glands, dystrophic changes in the cells and necrosis foci were observed. In group 2, affection of the cerebral cortex nerve cells, heart cardiomyocytes, thyroid cells, acute duodenitis with formation of microabscesses was established.
 Conclusions. Introduction of Sutent in the dose of 35 mg/kg, compared with the dose of 7 mg/kg, caused a more expressed hematological, hepatological, cardiological and neurological toxicity, more obvious lesion of endocrine organs; it also contributed to the development of associated secondary infection and acute duodenitis.

S3525 A Rare Case of Campylobacter and Strongyloides stercoralis Co-infection in an Immunocompetent Host

Introduction: Strongyloides stercoralis is a parasitic nematode mainly seen in immigrants and military personnel from endemic areas. Most cases in immunocompetent hosts are incidental findings or present with mild gastrointestinal (GI), respiratory or dermal symptoms. Co-infection with organisms like Campylobacter coupled with anatomical abnormalities such as a hiatal hernia can produce similar symptoms delaying diagnosis and treatment. Case Description/Methods: A 75 year-old-woman presented with persistent watery diarrhea, nausea, dyspepsia, and non-bloody and non-bilious vomiting over the past five days. She also had an unintentional weight loss of 50 pounds over the past three months. She denied any recent travel, rashes, or fevers/chills. On presentation, she was hemodynamically stable with generalized abdominal tenderness on physical exam. CT of the abdomen revealed a moderately-sized hiatal hernia. Serologies were significant for normocytic anemia, thrombocytosis, and eosinophilia (white blood cell count 5300, eosinophils 6.6%). Stool studies were positive for Campylobacter and she was started on azithromycin. She initially felt better and was subsequently discharged on azithromycin. She then presented three days later with complaints of nausea, and bloody emesis. Upper endoscopy with biopsy was done which showed a Los Angeles grade D reflux esophagitis and duodenitis. Histological evaluation revealed S. stercoralis in the duodenal mucosa (Figure 1). Initial ova and parasite cultures from a week ago further confirmed the diagnosis. She was then started on an extended course of ivermectin with a resolution of her symptoms and was discharged home. Discussion: Campylobacter is an enteric gram-negative bacterium that also affects the GI tract and can mimic S. stercoralis infection clinically. Co-infection with this organism occurs due to its similar mode of transmission, however, there have only been a few cases documented in literature. Diagnosis is made by stool testing and serology, however, stool tests are only positive in 50-60% of cases. Eosinophilia may or may not be present. Clinicians should be aware that despite having underlying structural abnormalities such as a hiatal hernia, an EGD with biopsy is warranted to rule out infectious etiologies especially in the presence of eosinophilia as seen above. Early diagnosis and treatment are essential in preventing disseminated disease, especially in immunocompromised patients.Figure 1.: Hematoxylin and Eosin stain of the duodenum revealing acute duodenitis with associated Strongyloides stercoralis in the intestinal crypts and lumen.

Distribution of duodenal tuft cells is altered in pediatric patients with acute and chronic enteropathy.

Clinical interest into the function of tuft cells in human intestine has increased in recent years. However, no quantitative study has examined intestinal tuft cells in pathological specimens from patients. This study quantified tuft cell density by using a recently identified marker, specific for tyrosine phosphorylation (pY1798) of girdin (also known as CCDC88A or GIV) in the duodenum of pediatric patients. Deidentified sections with pathological diagnosis of acute duodenitis, ulcer, or celiac disease, and age-matched normal control were analyzed under double-blind conditions. Immunostaining for pY1798-girdin demonstrated the distinct shape of tuft cells with and filopodia-like basolateral membrane structure and a small apical area, which densely expressed gamma-actin. As compared to normal tissues, the specimens diagnosed as celiac disease and duodenal ulcer had significantly fewer tuft cell numbers. In contrast, acute duodenitis showed varied population of tuft cells. The mucosa with severe inflammation showed lower tuft cell numbers than the specimens with none to mild inflammation. These results suggest that loss of tuft cells may be involved in prolonged inflammation in the duodenal mucosa and disrupted mucosal integrity. pY1798-girdin and gamma-actin are useful markers for investigating the distribution and morphologies of human intestinal tuft cells under healthy and pathological conditions.

POST-VAGOTOMY GASTROPARESIS – A CASE REPORT

We present Mr M.A. a 27 year old Nigerian of the Yoruba tribe who has been having recurrent dyspeptic symptoms for 5 years but not previously endoscopically evaluated for peptic ulcer disease who now presented with six days history of abdominal pain which was initially epigastric but later became generalized associated with four episodes of vomiting and a day history of abdominal distension and fever. He was acutely ill-looking and dehydrated. The Abdomen was moderately distended, does not move with respiration, generalized tenderness with guarding and rebound tenderness, intra-abdominal organs were difficult to palpate due to the guarding. Bowel sound was absent. Examination of the other systems was not remarkable. A provisional diagnosis of Generalized peritonitis likely secondary to perforated peptic ulcer was made. He had an emergency exploratory laparotomy under general anaesthesia. He was commenced on intravenous fluids and parenteral proton pump inhibitor(PPI) and antibiotics. Intra-op findings include 2 liters of bilious peritoneal fluid, Multiple fibrous adhesions, a 2.5cm x 2cm gastric perforation at the anterior wall of the antrum and a grossly normal bowel. The surgical operation performed was a Graham Omental patch closure of the gastric defect with Bilateral Truncal Vagotomy and Peritoneal lavage. Post-operative state was satisfactory and he was later discharged. He presented at the gastroenterology out-patient clinic eight months later with complaints of early satiety, feeling of indigestion and episodes of vomiting. Vomitus is usually offensive / foul smelling and contains undigested or partially digested stale food substances. Abdominal examination revealed a positive succussion splash. Other clinical examination findings were not remarkable. A Provisional Diagnosis of suspected Gastric outlet obstruction probably secondary to a chronic duodenal ulcer was made. Endoscopy findings revealed copious fluid and food debris in the stomach cavity which had an offensive smell with remnants of partially digested stale food substances seen. There was poor peristaltic activity and the stomach was poorly distensible. There were multiple areas of mucosa erosions seen in the gastric cardia and corpus. No corporal or antral lesion seen. The pyloric ring was normal and the duodenum was normal. Diagnosis- (1) Endoscopic features of Gastroparesis likely secondary to previous Bilateral Truncal Vagotomy. No evidence of mechanical obstruction of the Gastric outlet. (2) Gastric Cardia and Corporal mucosa lesions likely secondary to Stasis Gastritis. Histology of biopsy specimens showed acute on chronic non-specific gastritis and acute duodenitis. He was commenced on empirical first line Helicobacter pylori eradication triple therapy (PPI, Amoxycillin and Clarithromycin) and a prokinetic drug (Domperidone). He had made significant clinical improvement with resolution of the symptoms by the time he was seen in the clinic three weeks later. He was tolerating oral food intake adequately and he had no new complaints. He was counselled on dietary modification and placed on long term prokinetic agent (Domperidone) and long-term PPI therapy with regular clinic follow-up. The initial management of post-vagotomy gastroparesis should be conservative as many symptoms resolve with time, this occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input. Modification of dietary habits, such as regular intake of small meals, and use of prokinetic drugs bring about symptomatic relief in most patients.

Gastrointestinal findings in 26 adults with common variable immunodeficiency: The fickle nature of the disease manifests in gastrointestinal biopsies.

The aim of the present study was to demonstrate the histopathological findings in gastrointestinal (GI) biopsies in adults with common variable immunodeficiency (CVID). A total of 172 GI biopsies of 26 patients with CVID obtained over a 16-year period were reevaluated. Findings were analyzed using descriptive analyzes and χ2 test. Female-to-male ratio was 1.36. The median age at diagnosis was 36±13.94 (16-72) years. Chronic esophagitis was noted in 3 patients. The absence of plasma cells in the stomach, duodenum, and colon was observed in 16, 14, and 9 patients, respectively. Divergent results for the presence of plasma cells in concurrent stomach and duodenum samples were found in 11 (44%) patients. Nodular lymphoid hyperplasia (NLH) was notable in the duodenum (56%). The mean number of eosinophils in one high-power field was significantly higher in duodenal biopsies with NLH (27.21 vs. 14.37, p=0.002). Active inflammation was more prominent in the colon (91%) than in the stomach (65%) and duodenum (60%). Helicobacter pylori infection was found in 57.6%, including a case with persistent infection by the coccoid form. Celiac-like villous blunting and increased intraepithelial lymphocytes were seen in 40% and 24%, respectively. In addition, 23% had giardiasis associated with acute duodenitis and duodenal NLH (p<0.05). CVID gastroenteropathy is a challenging entity, and due to the heterogeneity in the presence and distribution of plasma cells throughout the GI tract and diverse disease course, multiple concurrent biopsies may be needed for tissue diagnosis. Duodenal CVID may present with villous alterations and giardiasis, and NLH appears to be an important clue in the duodenum. The association between duodenal NLH and eosinophil infiltration deserves further investigation.

A Case of Henoch-Schönlein Purpura on Endoscopy

Vasculitis of Gastrointestinal (GI) tract presents with abdominal pain, nausea, vomiting, and bleeding. It is difficult to diagnose vasculitis through endoscopy due to low diagnostic yield of endoscopic biopsies and therefore it is important to consider clinical feature. We present a case of IgA vasculitis involving GI tract, emphasizing role of multidisciplinary approach. A 77 years old man with medical history of Grave's disease, atrial fibrillation, osteoarthritis, gout, and hypertension presented to Emergency Room due to worsening abdominal pain, nausea, vomiting, and blood in stool. Patient reported abdominal pain for 3 weeks, diffuse and dull and becoming periumbilical and reproducible without any relieving or exacerbating factors. He reported early satiety without weight loss. Complete metabolic panel (CMP) and complete blood count (CBC), and Lactic Acid were normal however patient had 2gram urine protein. He had periumbilical tenderness and bilateral lower extremities pitting edema with purpuric patches. Abdomen and Pelvic CT scan showed nonspecific wall thickening of distal esophagus, stomach, cecum, distal ileum, and small segment of jejunum. On Enteroscopy nodular appearing fundic mucosa with ulcerations was seen, biopsy showed ischemic gastropathy. Second portion of Duodenum showed nodular appearing mucosa while Third portion showed an ulcerated duodenal lesion which was biopsied and showed ulcer with acute duodenitis. Proximal Jejunum was normal however ulceration with surrounding erythema was noted distally and biopsy showed ulcerative jejunitis. Colonoscopy showed scattered areas of ulceration and erythema extending from rectum to terminal ileum which was biopsied and showed features of resolving acute ischemia. Rheumatology was consulted and punch biopsy from lower extremity showed granular deposit of IgA surrounding superficial dermal vessel compatible with Henoch-Schönlein Purpura. Renal biopsy showed focal mesangial proliferation with segmental inflammatory glomerulopathy with sclerosis consistent with IgA nephropathy. Patient was started on high dose steroids 80mg/day. Renal function was followed and was stable therefore steroids were tapered off. Patient underwent repeat Colonoscopy and Enteroscopy after 1 year of being off of steroids which showed normal mucosa. Our case highlights difficulty in diagnosing vasculitis through endoscopy and shows clinical course of vasculitis of GI tract through follow-up endoscopy.

Histologic Features of Gastrointestinal Tract Biopsies in IgA Vasculitis (Henoch-Schönlein Purpura).

Immunoglobulin A (IgA) vasculitis or Henoch-Schönlein purpura (HSP) typically occurs in the pediatric population, although rare cases also occur in adults. Gastrointestinal (GI) involvement is common. The "classic" histologic finding in IgA vasculitis (HSP) is leukocytoclastic vasculitis (LCV); other histologic features in biopsies of IgA vasculitis (HSP) have only been rarely described. The pathology archival files at our institution were searched for GI biopsies from patients with IgA vasculitis (HSP). Slides were retrieved and histologic and clinical features were reviewed. We identified 16 patients with IgA vasculitis (HSP) with a GI biopsy series, including both adult and pediatric patients. The most common histologic abnormality was lamina propria hemorrhage (all cases) with many cases also showing lamina propria fibrin deposition with red cell sludging and nuclear debris (7 cases). Twelve of the 16 duodenal biopsies had acute duodenitis; 3 of which were severe and erosive. Several also had an eosinophilic infiltrate. Seven of the 9 jejunal and/or ileal biopsies had acute jejunitis or ileitis. An acute colitis or proctitis was observed in 9/12 colorectal biopsies. Four biopsies contained LCV; in each of these cases, the involved vessels were small capillaries within the lamina propria. Only 1 biopsy contained deeper submucosal vessels, but they were uninvolved. Sites involved by LCV included the colorectum (2 cases), colorectum and terminal ileum, terminal ileum only, duodenum, and jejunum (1 case each). All patients presented with abdominal pain; 13/16 developed a rash, 1 following the index biopsy. Other presenting symptoms included diarrhea and/or hematochezia (8 cases), nausea/vomiting (5 cases), and intussusception (1 case). Four patients had concurrent skin biopsies showing LCV; only 1 of these patients had LCV on GI biopsy. Indications for biopsy included nonspecific presenting symptoms, absence of rash at presentation, and/or failure to respond adequately to steroid therapy. Biopsies are commonly performed in patients with or without suspected IgA vasculitis (HSP) to rule out infection, inflammatory bowel disease, and less commonly, vasculitis. In general, vasculitis is not commonly observed in GI biopsies of patients with IgA vasculitis (HSP), and the spectrum of findings includes neutrophilic infiltrate within the small bowel and colon, with the duodenum most commonly affected. While the clinical and histologic findings may mimic early inflammatory bowel disease, the presence of predominant small bowel involvement, especially erosive duodenitis, should raise suspicion for IgA vasculitis (HSP). Biopsies should be obtained before steroid therapy is initiated, if possible.

The vanishing duodenal polyp: mesenteric invagination presenting as duodenal pseudopolyp

Duodenal polypoid masses are an uncommon finding mainly diagnosed incidentally at endoscopy or surgery. We report a 39-year-old female patient with symptoms of intermittent stabbing pain in the upper right...

This Aimless Cobra Spits Blood: A Dieulafoyʼs Lesion as the Cause of Massive Hematemesis

Introduction: Dieulafoy's lesion is a tortuous, dilated aberrant submucosal artery that can erode through the mucosa and rupture spontaneously to cause severe gastrointestional bleeding. The lesion is most commonly found in the proximal stomach along the lesser curvature within 6 cm of gastroesophageal junction. It has up to 80% mortality rate because of its tendency to cause intermittent but severe bleeding and diagnostic challenges.Table 1: Neuroendocrine Tumor Characteristics on Surgical PathologyFigure 1Figure 2Case: A 39-year-old Hispanic male presented with sudden onset of melena and painless massive hematemesis. He was a nonsmoker and nonalcoholic with no history of NSAID use. His past medical history was significant for GERD and similar complaints of melena and hematemesis 8 years previously. Extensive prior investigations including CT abdomen and pelvis, esophagogastroduodenoscopy (EGD) and nuclear medicine scan failed to reveal the source of bleeding. He was hemodynamically stable at the time of presentation but his hemoglobin dropped from a baseline of 13 to 8. EGD showed mild reflux esophagitis, acute duodenitis, and gastric varices in the fundus of the stomach. CTA showed a small tangle of abnormally enlarged tortuous bleeding vessels along the posterior cardia of stomach with the absence of early venous return, suggestive of multiple Dieulafoy's lesions. IR-guided mesenteric angiogram was subsequently performed with successful embolization of multiple Dieulafoy's lesions arising from the proximal splenic artery and coursing through the region of the gastric cardia and fundus. The patient had an uneventful recovery and he was discharged home. He did not have recurrence of bleeding and his hemoglobin was within the normal limits at a 3 month follow-up visit.Figure 3Discussion: Diagnosis of Dieulafoy's lesion presents a formidable challenge for physicians and radiologists. Endoscopy is the diagnostic modality of choice but it is often unrevealing due to small size of the Dieulafoy's lesion, normal appearance of surrounding mucosa and intermittent bleeding patterns. These lesions have been known to be mistaken for other entities such as arteriovenous malformations, aneurysms, Mallory-Weiss tears and gastric varices, such as in our case. Contrast-enhanced CT and angiography can be helpful in cases where initial endoscopy fails to reveal the diagnosis of Dieulafoy's lesion and can offer minimally invasive therapeutic alternatives to surgical resection through selective arterial embolization.

Prospective small bowel mucosal assessment immediately after chemoradiotherapy of unresectable locally advanced pancreatic cancer using capsule endoscopy: a case series.

In this case series, three consecutive patients with unresectable locally advanced pancreatic cancer (ULAPC) underwent capsule endoscopy (CE) before and after chemoradiotherapy (CRT) to evaluate duodenal and jejunal mucosa, and to examine the relationship between CE findings and dose distribution. CE after CRT showed duodenitis and proximal jejunitis in all three patients. The most inflamed region was the third part of the duodenum, and in dose distribution, this was the closest region to the center of irradiation. This case series shows that CE can safely diagnose acute duodenitis and proximal jejunitis caused by CRT for ULAPC, and that dose distribution is possible to predict the degree of duodenal and jejunal mucosal injuries.

Diagnostic Utility of Duodenal Biopsy in Upper Endoscopy Performed for Abdominal Pain

Introduction: The ability of endoscopy to predict microscopic duodenal abnormality has not been well characterized, and the diagnostic utility of duodenal biopsy (DB) in the setting of abdominal pain (AP) is unclear. Aim: To assess the value of duodenal biopsy during the work-up for abdominal pain. Methods: Retrospective observational study of all esophagogastroduodenoscopies (EGD) performed at the University of Colorado hospital 2007-2012 for the indication of AP that had DB performed. One thousand, four hundred-eight cases were isolated, 469 had DB performed, with 67 removed based on exclusion criteria. Endoscopy and pathology reports were assessed for correlation, and clinic notes were reviewed to assess if DB helped determine the cause of the AP. Results: Endoscopy had a sensitivity of 53.6% and specificity of 73.7% for detecting microscopic abnormality, with a positive predictive value of 58.9% and a negative predictive value of 69.3% (table). Only the finding of “acute duodenitis” appeared reliably predictive of microscopic pathology (Figure 1). Regarding AP, of the 402 cases analyzed (Mean age 45, 67% female), 44 (9.5%) had erosive esophagitis, and 64 (13.7%) had peptic ulcer disease, but 295 did not have a clear cause for AP after full work-up (EGD, serologies, etc). Of these 295 cases, only 5 had diagnostic value from DB (1.7%). A sub-population of 37 patients for whom the etiology of AP was not identified were found to have increased intraepithelial lymphocytes of unclear cause (e.g. negative celiac work-up).Figure 1: All cases with abnormal duodenal biopsy results after pathologic review, split into endoscopically normal (dark) and abnormal (light). 3a represents all abnormal biopsies split up into the broad categories: Increased IELs and/or villous change, active and/or chronic inflammation, and miscellaneous. 3b represents the Increased IELs and/or villous change population split into its component parts. 3c represents the inflammation population split into its component parts. Miscellaneous referred to any of the following: polyps, brunner’s gland hyperplasia, isolated eos, mast cells, focal adenomatous change. All categories are based on the description documented in the available pathology reports.Conclusion: EGD is useful in regards to causes of AP, as peptic ulcers and esophagitis were common in our study. However, only a few cases seemed to demonstrate diagnostic utility of DB, suggesting that routine DB during the work-up for abdominal pain is of limited value. Since macroscopic to microscopic correlation is unreliable, clinicians need to know before visualizing the duodenum whether a biopsy is indicated. Further research is needed regarding the clinical significance of lymphocytic duodenosis.Table 1: Utility of Duodenal Biopsy

Reversible Acute Duodenitis as a Complication of Endoscopic Biliary Stenting

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Is Routine Duodenal Biopsies (DBx) Necessary during Upper Gastrointestinal Endoscopies (EGD)?

Purpose: Controversies exist whether DBx should be an integral part of EGD. Unsuspected celiac disease (CeDi), parasites when diarrhea is absent and stool yield is low can be found by routine Bxs. Polymorphs (PMNs) have been proposed as a reliable marker for acute duodenitis (AD) and chronic active duodenitis (CAD). The importance of chronic duodenitis (CD) who do not show PMNs remains unclear. Methods: DBx were done on 435 pts during EGD. Classification of duodenitis is based on Whitehead et al. criteria. Findings were correlated with age, sex, race, H pylori (HP) on gastric Bxs and histology. We had 136 males (M) and 299 females (F) age from 14–102, mean age of 57; 354 African American (AA), 57 Caucasian (CAU), 17 Hispanic (HI), 5 Asian (AS). 2 pts were less than 20 yrs old. Results: AD was present in 1 pt, CAD in 12 (2.8%). CD in 386 (88.7%); 365 had mild CD (83.9%). 21 moderate CD (4.8%). 26 Bxs were normal (N, 6%). 10 pts (2.3%) had findings of congestion in 2, lymphangiectasia 2, villous atrophy 4, pseudolipomatous 1, adenomatous change 1. When mild CD and N Bxs were excluded significant duodenal inflammation (SDI) were present in 10.1% of pts (11% of M, 9.7% F, 17.3% AA 8.7%, CAU and 20% AS pts, none in 17 HI). SDI is increased with increasing age (7.6% from 20–39, 9.4% 40–49, 11.7% over 60 yr of age). Although overall SDI was not different in H P+ and–pts (9.8% vs. 10.4%), HP– pts showed age related increased SDI and HP+ did not. Lymophoid aggregate and follicules are seen in 13 pts, 10 was HP+, only 1 had N gastric histology (p < 0.05). 0.9% of Bxs were compatible with CeDi: 3 had chronic active gastritis. Out of 199 pts with significant gastric inflammation (SGI), 23 had SDI (12.1%) as opposed to 21/246 with mild or no gastritis. (8.5%, p= 0.33). Out of 48 pts with intestinal metaplasia (IM) 7 (14.6%) had SDI; while 27/387 (9.5%) with no IM (p= 0.08). Conclusions: SDI occurred in 10.1% of pts; equally in M and F who are not suspected to have duodenal disease. CeDi was uncommon in our population (0.9%). SDI increased with increasing age and showed same age relation in HP- pts. SDI occurred with similar incidence with HP + and - pts. Severity of GI did not correlate with DI however more pt with IM had SDI when compared with no IM. Summary: DBx should be considered during EGD in view of SDI in 10% of pts especially in AAs, ASs, in pts older than 60 and who is also known to have IM.

Histopathologic Characterization of Acute Gastritis and Duodenitis Induced by Inoculation ofEscherichia coliO157 in Mice

Objective: To examine the effect of intragastric inoculation of an Escherichia coli O157 strain, which does not have such pathogenic factors as the stx , eae and EHEC- hlyA genes, on the induction of acute gastritis and duodenitis in BALB/c mice. Design: Time-dependent histopathologic changes were characterized in stomach and duodenum mucoepithelium by light and transmission electron microscopy. Results: The acute gastritis was characterized by inflammation and polymorphonuclear leukocyte infiltration that was followed by lymphocyte infiltration of the lamina propria, mucoepithelial erosions, mucoepithelial cell necrosis and haemorrhage from 1.5 to 24 h after inoculation. At 24 h, lymphocytes infiltrated the mucoepithelium. The acute duodenitis was characterized by polymorphonuclear leukocytic and lymphocytic infiltration of the lamina propria and by vacuolar degeneration of columnar epithelial cells from 1.5 to 24 h after inoculation. Inflammatory cells, including eosinophils, infiltrated mainly the lamina propria from 1.5 to 6 h after inoculation in both stomach and duodenum. Conclusions: our results showed that E. coli O157 inoculation icduced acute gastritis and duodenitis, independent of such pathogenic factors as stx , eae and EHEC- hlyA . Keywords: Escherichia coli O157, infection model, acute gastritis, acute duodenitis, BALB/c mouse.

Acute duodenitis and duodenal ulceration after burns. Clinical and pathological characteristics

The clinical and pathological characteristics of Curling ulcer were defined by early and serial endoscopic examination of the duodenum in 37 burned patients. Duodenal disease was present in 27 patients and occurred only in patients with burns involving more than 38 percent of the total body surface. Erosive "duodenitis" could occur within 12 hours after injury and was usually associated with acute gastric disease. Isolated duodenitis occurred only in patients with pancreatitis. Contrast roentgenograms did not reliably show the superficial mucosal disease. Duodenal ulcerations were present in 12 patients and developed on a background of diffuse superficial mucosal injury. Other complications in the patient's postburn course influenced disease progression. Hemorrhage occurred in six patients with duodenal disease, usually originating from a posterior duodenal ulcer. Uncomplicated ulcers invariably healed within five weeks after diagnosis.

Nursing stresses in the intensive care unit.

To the Editor:— The report of the Committee on Nursing, Stresses on the Nurse in an Intensive-Care Unit ( 208 :332, 1969), recognizes a new problem incurred nursing staff concurrent with the development of intensive-care units (ICU). A case of paroxysmal auricular tachycardia and a case of acute duodenitis in the intensive-care unit of Clara Maass Memorial Hospital, prompted a review of our personnel practices which may provide partial solutions to some of the problems expressed Vreeland and Ellis. First, personnel should be selected with care. Although no clearly defined profile of successful ICU nurses exist, we have found them to be young, healthy, well motivated, and energetic to the point of exuberance. They are not always classified as the most academic as defined prior nursing school evaluation but demonstrate nursing ability early in their careers. Ellis and Vreeland recognize the anxiety caused by insecurity in knowledge or

Acute infectious duodenitis (infectious jaundice): Report of 76 cases

Summary 1. An epidemic of acute duodenitis with and without jaundice occurred during the fall and winter months of 1937–38. 2. The outstanding symptoms were abdominal pain, vomiting, headache, vertigo, and jaundice. 3. Forty cases eventually developed jaundice. 4. Thirty-six cases did not show definite jaundice. 5. The disease was self-limited, usually lasting two to four weeks.

Symposium on Right Upper Abdominal Pain

DR. BALFOUR stated that pain in the right upper quadrant might be due to lesions in various locations, viz., in the right upper quadrant, elsewhere in the abdomen, in the chest, and to general disease. The most frequent conditions in the right upper quadrant causing pain are lesions in the gall bladder and the duodenum. The more severe the symptoms attributable to these conditions, the greater relief is obtained from surgery. On the other hand, the less severe the symptoms, the less likely is relief to be obtained from surgery. Among the diseases occurring elsewhere in the abdomen the ones most likely to produce pain in the right upper quadrant are those associated with the appendix. The diseases within the chest with which pain in the right upper quadrant is most frequently associated are coronary thrombosis, pneumonia, and pleurisy, especially of the diaphragmatic type. Among general diseases most frequently associated with pain in the right upper quadrant are tabes and herpes zoster. Discussing the treatment of duodenal ulcer, Dr. Balfour showed a series of lantern slides illustrating the various operations for duodenal ulcer. Dr. Kirklin showed a very fine series of lantern slides, illustrating duodenal and gall-bladder diseases, these being the chief conditions in the right upper quadrant which are demonstrable radiologically. He stated that the radiologist should recognize lesions of the duodenum in 100 per cent of the cases, although he might not be able to identify the lesion in all the cases. Duodenal ulcer is recognizable radiologically in 95 per cent of the cases, the fluoroscope being of prime importance in the diagnosis. In acute perforations of the gastro-intestinal tract a diagnostic sign is the presence of gas above the liver and underneath the diaphragm. Acute duodenitis gives characteristic findings, namely, a recticular network of barium in the duodenum, irritability of the first and second parts of the duodenum, and absence of the characteristic crater of an ulcer. A number of characteristic slides of diverticulum of the duodenum were shown. Hypertrophy of the pyloric muscle was shown in a number of slides. The characteristic appearance was an elongated, slightly irregular area of barium connecting the pyloric end of the stomach and the duodenal cap. It is narrow and definitely distinguishable from ulcer and carcinoma. A very complete analysis was given by Dr. Kirklin of his work in cholecystography, in which he uses the oral method. Lantern slides showed the following findings: normal concentration of the dye, irregularities in size of the gall bladder, deficiency in concentration of the dye, gallstones accentuated by the dye, and papilloma and adenoma. In Dr. Kirklin's hands this method is correct in 97.1 per cent in showing poorly functioning gall bladder, is correct in 96.8 per cent in showing non-functioning gall bladder, and is correct in 89.5 per cent in demonstrating normal gall bladder.

CATARRHAL JAUNDICE IN INFANCY

Catarrhal jaundice, or acute duodenitis with icterus, is a common disease in children between the ages of 3 and 6 years. It is, however, only infrequently met in children under 2 years of age, and is extremely rare during the first year of life. Holt, 1 for example, states that he has never seen a case in a child under 2 years of age. Henoch, 2 the father of pediatrics, saw only two cases in children under 1 year in all his wide experience, one of these being 8 weeks, the other 5 months old. Flesch, 3 writing from Bokay's clinic, classes catarrhal jaundice in infants under 1 year as among the greatest rarities, and in looking over the records of Bokay's Stefanie Children's Hospital for a period of ten years, found only one typical case (a baby 1 month old) among 160,000 admissions. Starck 4 reports 65 cases of