Bowel Strictures Research Articles

Bowel perforation in a pediatric patient with congenital generalized lipodystrophy type 4

Abstract Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disorder that affects adipocyte development. Presentation varies based on type. A 12-year old female with CGL type 4, developed a sigmoid colon perforation in the setting of colonic wall hypertrophy after colonoscopy. She presented to the emergency room (ER) with several days of worsening abdominal pain and fevers. The initial evaluation was concerning for infectious versus inflammatory colitis. She was admitted for gastroenterology (GI) consultation for the complaint of abdominal pain. The patient had an established history of constipation management with laxatives. Full GI evaluation, including infectious panel as well as esophagogastroduodenoscopy (EGD) and colonoscopy, was negative. During the colonoscopy some difficulty with passage of the colonoscope past 25 cm was reported and therefore a gastroscope was used. She met criteria to start a clear liquid diet following the procedure. Two days after the colonoscopy, she had pneumoperitoneum on abdominal radiographs and was taken to the operating room for exploratory laparotomy. At the time of surgery, copious fibrinopurulent exudate was found throughout the abdominal cavity, as well as a thickened sigmoid colon/rectum and perforation with a contained abscess at the rectosigmoid junction. Sigmoid colectomy and end colostomy were performed. Pathologic examination demonstrated diffuse colonic wall thickening, a serosal defect that did not extended to the mucosa and several early diverticula. The pathology report stated that the presence of microscopic perforations could not be ruled out. The patient had an uneventful post-operative recovery. Congenital generalized lipodystrophy type 4 is a rare disease. We suspect an association between the muscular hypertrophy and the clinical presentation of bowel wall thickening and stricture. Given the rare nature of this disorder, clinicians that evaluate patients with CGL type 4 for constipation should have a suspicion for the possibility of colonic strictures. Rarely the condition can advance to perforation.

CLINICAL PROFILE, DRUG RESISTANCE PATTERN AND TREATMENT OUTCOMES OF ABDOMINAL TUBERCULOSIS PATIENTS IN WESTERN INDIA.

Abdominal tuberculosis is an increasing problem in developing world. The objective of the study was to describe the clinical presentations, drug resistance pattern and treatment outcomes of abdominal tuberculosis in Western India. All the cases of abdominal tuberculosis from May 2014 to April 2017, diagnosed on the basis of clinical profile and gross morphological findings at endoscopy, imaging, followed by histology and/or GeneXpert and MGIT culture were included. All patients received antitubercular drug (AKT) therapy according to national protocol. Patients were followed from diagnoses till completion of treatment and various parameters were studied. Out of the 176 patients, 48% were males. Abdominal pain was most common complaint in 83.5%. On colonoscopy terminal ileum and ileocaecal valve were most commonly involved segments. Upper gastrointestinal tract was involved in four patients. Overall ulceronodular lesions were most common followed by ulcerative/nodular lesion. Strictures in bowel were seen in 28 (15.9%) patients with ileocaecal valve being most commonly involved, of which 23 had symptomatic relief with AKT and only three required dilatation. Histopathology showed granuloma in 80.8% cases. MGIT was positive in 43 (35.80%) cases and GeneXpert was positive in 35 (26.1%) cases. Eight patients had multi drug resistant tuberculosis. Only two patients required surgical management. Abdominal tuberculosis with wide spectrum of presentation, can still be managed with early diagnosis and treatment even in patients with sub acute intestinal obstruction. Weight gain or resolving symptoms were considered early markers of treatment response. Patients with stricture can become asymptomatic with medical treatment alone.

Small bowel strictures.

Strictures of the small bowel are an underdiagnosed entity with significant morbidity because of obstruction and risk of perforation and penetrating disease. Recent advances in imaging, enteroscopy, and therapeutic advances particularly in Crohn's disease have enabled gastroenterologists to target and individualize management of small bowel strictures, preventing untimely surgery and complications. All patients with obstructive symptoms, suspected small bowel disease, and negative panendoscopy should be evaluated for small intestinal strictures with cross-sectional imaging and considered for capsule endoscopy. Furthermore, the role of device-assisted enteroscopy, initially employed as a diagnostic tool, has evolved into triaging and delivering further medical and interventional treatments.

Role of Ultrasound Elastography in the Detection of Fibrotic Bowel Strictures in Patients with Crohn's Disease: Systematic Review and Meta-Analysis.

To perform a systematic review with meta-analysis to assess whether ultrasound elastography can have a diagnostic role in detecting fibrotic bowel strictures in patients with Crohn's disease. MEDLINE via the PubMed, Ovid Embase, Scopus and Cochrane Library databases, and abstracts of international conference proceedings were searched up to March 31, 2018. Studies were included if they assessed the performance of abdominal ultrasound elastography in detecting fibrotic bowel strictures in patients with Crohn's disease using histology or the need for surgery after medical treatment as a reference standard. The quality of the studies was assessed using Quality Assessment of Diagnostic Accuracy Studies. 6 studies including a total of 217 patients with Crohn's disease and 231 bowel segments, of which 76 were bowel segments with fibrotic stricture, were selected. Three studies used strain ratio and three studies used strain value as parameters of bowel stiffness. Both the pooled standardized mean strain ratio and the pooled standardized mean strain value were higher in bowel segments with fibrotic strictures than in those without fibrotic strictures with a standardized mean difference of 0.85 (95 % confidence level [CI]: 0 to 1.71; p = 0.05) and 1.0 (95 % CI: -0.11 to 2.10; p = 0.08), respectively. There was a high heterogeneity between studies. All studies were at "high risk" or "unclear risk" of bias. Ultrasound elastography could be able to detect fibrotic bowel strictures in patients with Crohn's disease. Well-designed high quality diagnostic studies with a large sample size are needed.

Early Initiation of Anti-TNF is Associated with Favourable Long-term Outcome in Crohn's Disease: 10-Year-Follow-up Data from the Swiss IBD Cohort Study.

The optimal timing of treatment escalation in Crohn's disease [CD] remains a challenging issue, and very little is known about its long-term development following early versus late administration of anti-TNF antibodies. The long-term outcome of Swiss CD patients was comparatively assessed in an up to 10-year follow-up, using patients participating in the Swiss Inflammatory Bowel Disease Cohort Study [SIBDCS]. Prospectively collected SIBDCS patient data, including disease history, baseline characteristics at enrolment, and course of disease, were analysed in patients with early versus late [<24 versus ≥24 months after diagnosis] and no anti-TNF treatment. A reduced risk of developing bowel stenosis was found in patients who received early anti-TNF treatment. This association was seen in patients overall and also in the subgroups of CD patients without pre-existing complications [Log-rank test: p < 0.001].Furthermore, osteoporosis and anaemia were observed significantly less frequently in patients who received early anti-TNF treatment, compared with either patients who received treatment late [p < 0.001 and p = 0.046, respectively] or were never [p < 0.001 for both] treated with anti-TNF antibodies. Patients with early anti-TNF administration sought medical consultations significantly less often, including gastroenterologists in private practice [p = 0.017], ambulatory [outpatient] hospital visits [p = 0.038], and a composite of any medical visits [p = 0.001]. The percentage of patients unable to work was lowest for early-anti-TNF-treated patients, in comparison with patients who were treated late or never [3.6% vs 8.8% vs 3.7%, p = 0.016]. In CD patients within the SIBDCS, early anti-TNF administration was found to be associated with several indicators of a more favourable long-term outcome.

Risk of surgery in patients with stricturing type of Crohn's disease at the initial diagnosis: a single center experience.

Background/AimsIt remains uncertain which patients with stricturing-type Crohn’s disease (CD) require early small bowel surgery after the initial diagnosis. We aimed to clarify clinical characteristics associated with the intervention in such condition of CD.MethodsWe retrospectively evaluated the clinical course of 53 patients with CD and small bowel strictures who were initially treated with medications after the initial diagnosis. We investigated possible associations between small bowel surgery and the following: clinical factors and radiologic findings at initial diagnosis and the types of medications administered during follow-up.ResultsTwenty-eight patients (53%) required small bowel resection during a median follow-up period of 5.0 years (range, 0.5–14.3 years). The cumulative incidence rates of small bowel surgery at 2, 5, and 10 years were 26.4%, 41.0%, and 63.2%, respectively. Univariate analysis indicated that obstructive symptoms (P=0.036), long-segment stricture (P<0.0001), and prestenotic dilation (P<0.0001) on radiography were associated with small bowel surgery, and immunomodulatory (P=0.037) and biological therapy (P=0.008) were significant factors during follow-up. Multivariate analysis revealed that long-segment stricture (hazard ratio [HR], 4.25; 95% confidence interval [CI], 1.78–10.53; P=0.001) and prestenotic dilation (HR, 3.41; 95% CI, 1.24–9.62; P=0.018) on radiography showed a positive correlation with small bowel surgery, and biological therapy (HR, 0.40; 95% CI, 0.15–0.99; P=0.048) showed a negative correlation.ConclusionsCD patients with long-segment stricture and prestenotic dilation on radiography seem to be at a higher risk of needing small bowel surgery. For such patients, early surgical intervention might be appropriate, even at initial diagnosis.

Non-occlusive intestinal ischemia in the ascending colon and rectum: a pediatric case occurring during encephalitis treatment

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare and severe pathological condition that can cause intestinal necrosis without mechanical obstruction of the mesenteric artery. NOMI often develops during the treatment of severe disease in elderly patients and mostly occurs in the intestine supplied by the superior mesenteric artery (SMA). We experienced a 12-year-old patient with NOMI that was segmentally localized in the ascending colon and rectum during encephalitis treatment.Case presentationA 12-year-old boy was hospitalized with limbic encephalitis. On day 41 after admission, he abruptly developed hypotension following diarrhea and fever, and presented abdominal distension. A computed tomography scan revealed pneumatosis intestinalis localized in the ascending colon and rectum coexisting with portal venous gas. The presence of peritoneal signs required an emergency laparotomy. Intraoperatively, skip ischemic lesions were found in the ascending colon and the rectum without bowel perforation. SMA and superior rectal arterial pulsation were present, and the patient was diagnosed with NOMI. The remaining colon, from the transverse to the sigmoid colon, appeared intact. We performed a distal ileostomy without bowel resection. Postoperative colonoscopies were carried out and revealed rectal and ascending colon stenosis with ulceration but demonstrated the patency of the two lesions. We confirmed the improvement of the transient bowel strictures; therefore, the ileal stoma was closed 14 months after the previous laparotomy.ConclusionNOMI can be present in childhood during encephalitis treatment and can be segmentally localized in the ascending colon and the rectum. Although NOMI is most often seen in elderly patients, we should also consider the possibility of NOMI when pediatric patients with severe illness manifest abdominal symptoms.

Efficacy, Tolerability, and Safety of Low-Volume Bowel Preparations for Patients with Inflammatory Bowel Diseases: The French Multicentre CLEAN Study.

Standard high-volume polyethylene glycol [PEG] bowel preparations [PEG-4L] are recommended for patients with inflammatory bowel disease [IBD] undergoing colonoscopy. However, low-volume preparations [≤2 L of active volume] are often used in clinical practice. The aim of this study was to evaluate the efficacy, tolerability, and safety of the various bowel preparations for patients with IBD, including low-volume preparations. We conducted a French prospective multicentre observational study over a period of 1 month. Patients aged 18-75 years with IBD with an indication of colonoscopy independent of the study were enrolled. The choice of the preparation was left to the investigators, as per their usual protocol. The patients' characteristics, disease, and colonoscopy characteristics were recorded, and they were given self-reported questionnaires. Twenty-five public and private hospitals enrolled 278 patients. Among them, 46 had a disease flare and 41 had bowel stenoses. Bowel preparations for colonoscopy were as follows: 42% received PEG-2L, 29% received sodium picosulfate [Pico], 15% received PEG-4L, and 14% had other preparations. The preparation did not reach the Boston's score efficacy outcome in the PEG-4L group in 51.2% of the patients [p = 0.0011]. The preparation intake was complete for 59.5% in the PEG-4L group, compared with 82.9% in the PEG-2L group and 93.8% in the Pico group [p < 0.0001]. Tolerability, as assessed by the patients' VAS, was significantly better for both Pico and PEG-2L compared with PEG-4L, and better for Pico compared with PEG-2L [p = 0.008; p = 0.0003]. In multivariate analyses, low-volume preparations were independent factors of efficacy and tolerability. Adverse events occurred in 4.3% of the patients. Preparations with PEG-2L and Pico were equally safe, with better efficacy and tolerability outcomes compared with PEG-4L preparations. The best efficacy/tolerance/safety profile was achieved with the Pico preparation.

P030 DELAYED DIAGNOSIS OF CROHN’S DISEASE IS COMMON AND ASSOCIATED WITH AN INCREASED RISK OF DISEASE COMPLICATIONS

There is increasing emphasis on early diagnosis and intervention in inflammatory bowel disease (IBD), in particular Crohn’s disease (CD). Early treatment with effective medications can prevent IBD progression towards complications, surgery and disability. We aimed to characterize diagnostic delay in IBD and assess if a prolonged delay in diagnosis is associated with disease complications. We utilized IBD Partners, a validated online cohort of IBD patients. A survey was developed assessing self-reported diagnostic delay (time from symptom onset to diagnosis) and perceived reasons for delay. We extracted data on demographics, disease characteristics, medications and clinical outcomes. The survey was distributed monthly for five months. Delayed diagnosis was defined a priori as more than 1 year or more than 2 years. Our primary outcome of interest was characterizing diagnostic delay comparing ulcerative colitis (UC) and CD. Our secondary outcome of interest was the impact of delayed diagnosis of CD on risk of complications defined as a composite endpoint of history of bowel resection, fistula, stricture, and/or abscess. We performed descriptive statistics and assessed delay in diagnosis using Chi-square tests. Multivariable logistic regression was performed to assess the association of delay and CD complications adjusting for biologic use and covariables that were significant in univariable analysis at the p<0.05 level. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) are reported. 2,341 IBD patients were offered the delay in diagnosis survey and 1121 were completed. 757 (68%) IBD patients reported a delay in diagnosis and completed the module. 364 (32%) patients did not think there was a delay in their diagnosis and did not complete module. 484 (63.9%) reported a delay > 1 year and 364 (48.1%) reported a delay > 2 years (Table 1). CD patients were more likely than UC patients to report a delay of greater than 1 year (70% vs. 48% p<0.0001) or greater than 2 years (52.2% vs. 37% p = 0.0008). There was no significant difference in delay when stratifying by gender and race. Patients reported seeing a mean of 3.5 physicians before establishing an IBD diagnosis. An uncertain or wrong initial diagnosis by a primary care provider (58.2%) or a gastroenterologist (28.3%) were reported as the most common reason for delay (Figure 1). Adjusting for age at diagnosis, ileal disease location and biologic use, diagnostic delay of greater than 2 years was significantly associated with disease complications (aOR 1.71, 95% CI 1.01 – 2.91, p = 0.047). 68% of patients reported a delay in diagnosis of their IBD. Among CD patients, 70% reported a delay greater than one year. Diagnostic delay is significantly longer in patients with CD. Prolonged delay was associated with poor outcomes. Future studies are needed to identify ways to best mitigate diagnostic delay in IBD.

P030 DELAYED DIAGNOSIS OF CROHN’S DISEASE IS COMMON AND ASSOCIATED WITH AN INCREASED RISK OF DISEASE COMPLICATIONS

There is increasing emphasis on early diagnosis and intervention in inflammatory bowel disease (IBD), in particular Crohn’s disease (CD). Early treatment with effective medications can prevent IBD progression towards complications, surgery and disability. We aimed to characterize diagnostic delay in IBD and assess if a prolonged delay in diagnosis is associated with disease complications. We utilized IBD Partners, a validated online cohort of IBD patients. A survey was developed assessing self-reported diagnostic delay (time from symptom onset to diagnosis) and perceived reasons for delay. We extracted data on demographics, disease characteristics, medications and clinical outcomes. The survey was distributed monthly for five months. Delayed diagnosis was defined a priori as more than 1 year or more than 2 years. Our primary outcome of interest was characterizing diagnostic delay comparing ulcerative colitis (UC) and CD. Our secondary outcome of interest was the impact of delayed diagnosis of CD on risk of complications defined as a composite endpoint of history of bowel resection, fistula, stricture, and/or abscess. We performed descriptive statistics and assessed delay in diagnosis using Chi-square tests. Multivariable logistic regression was performed to assess the association of delay and CD complications adjusting for biologic use and covariables that were significant in univariable analysis at the p<0.05 level. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) are reported. 2,341 IBD patients were offered the delay in diagnosis survey and 1121 were completed. 757 (68%) IBD patients reported a delay in diagnosis and completed the module. 364 (32%) patients did not think there was a delay in their diagnosis and did not complete module. 484 (63.9%) reported a delay > 1 year and 364 (48.1%) reported a delay > 2 years (Table 1). CD patients were more likely than UC patients to report a delay of greater than 1 year (70% vs. 48% p<0.0001) or greater than 2 years (52.2% vs. 37% p = 0.0008). There was no significant difference in delay when stratifying by gender and race. Patients reported seeing a mean of 3.5 physicians before establishing an IBD diagnosis. An uncertain or wrong initial diagnosis by a primary care provider (58.2%) or a gastroenterologist (28.3%) were reported as the most common reason for delay (Figure 1). Adjusting for age at diagnosis, ileal disease location and biologic use, diagnostic delay of greater than 2 years was significantly associated with disease complications (aOR 1.71, 95% CI 1.01 – 2.91, p = 0.047). 68% of patients reported a delay in diagnosis of their IBD. Among CD patients, 70% reported a delay greater than one year. Diagnostic delay is significantly longer in patients with CD. Prolonged delay was associated with poor outcomes. Future studies are needed to identify ways to best mitigate diagnostic delay in IBD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Jejunal obstruction due to ischemic stricture: an unusual presentation

Background: The most common causes of mechanical small bowel obstruction are postoperative adhesions and hernias. Other etiologies of small bowel obstruction include, diseases intrinsic to the wall of the small intestine, like tumors, strictures, intramural hematoma and processes that cause intraluminal obstruction like intussusception, gallstones, foreign bodies etc. Ischaemic enteritis is a rare etiology, reported only in about 0.1% of cases. Ischaemic strictures of the small bowel are a result of decreased blood supply to the small intestine. They require surgical intervention for their management.Methods: Author presented a 40 year-old diabetic female who presented with upper GI obstruction of 2month duration. Her history of illnesses included stroke, myocardial infarction and a transient episode of intestinal obstruction occurring simultaneously 3years ago. On investigations, she was found to have an occlusive distal jejunal stricture. Author studied the literature for the various management options and selected the most appropriate one for her.Results: Exploratory laparotomy with resection and end to end anastomosis of the jejunal segment was done. The histopathology of the segment revealed ischaemic enteritis with large vessel blockade causing stricture. The patient had an uneventful post op recovery and is asymptomatic two months since.Conclusions: Ischaemic enteritis results in small intestinal obstruction due to intestinal stenosis in its chronic phase. Diagnostic delay is due to the differential diagnoses and missing out on the transient phase of early ischemia.

Endoscopic Management of Crohn’s Disease Strictures

Crohn’s disease is a chronic inflammatory condition of the gastrointestinal tract which can result in luminal stenosis and up to 90% of patients requiring surgery during their lifetime. Medical management aims to reduce the inflammatory burden to prevent the development of inflammatory strictures, progression to fibro-stenosis and subsequent obstructive symptoms. Endoscopic balloon dilatation (EBD) is a well-established, safe technique in the management of short strictures to prevent patients having multiple surgical resections. In this review the evidence and safety of EBD for colonic and small bowel strictures will be discussed as well as adjuvant techniques (including endoscopic stenting and endoscopic intralesional therapy), current trials and new evidence on the medical management of stricturing disease.

Intravenous Contrast-Enhanced Ultrasound for Assessing and Grading Postoperative Recurrence of Crohn's Disease.

The aim was to investigate the contribution of contrast-enhanced ultrasound (CEUS) to improve the results of US in the evaluation of recurrence in postsurgical Crohn's disease (CD) and establish its role in the assessment of the severity. Anastomotic site was assessed in 108 postsurgical CD patients with B-mode, color Doppler and CEUS. Bowel wall thickness (WT), transmural complications or stenosis, color Doppler grade, and bowel wall contrast enhancement (BWCE)-using time-intensity curves-were correlated with endoscopic Rutgeerts score. A receiver operating characteristic (ROC) curve was built to establish the best cutoff to predict recurrence and the severity. A US scoring system was elaborated in order to determine the grade of recurrence. Ileocolonoscopy detected recurrence in 90 (83.3%) subjects and severe recurrence in 62. WT ≥ 3mm had an accuracy of 90.7% in the detection of endoscopic recurrence. The combination of parameters-WT ≥ 3mm and BWCE (≥ 46%)-demonstrated similar accuracy (90.7%). A WT ≥ 5mm showed the best specificity (100%) for the diagnosis of recurrence and a WT ≥ 6mm the best specificity (95.7%) for the detection of severe recurrence. The combination of sonographic parameters-WT ≥ 6mm or WT between 5 and 6mm with BWCE ≥ 70%, or complications-obtained the best results grading the recurrence (sensitivity, specificity, and accuracy of 90.3%, 87%, and 88.9%, respectively). US shows high sensitivity and specificity for the diagnosis of postsurgical recurrence. When combined with CEUS, it can improve the detection of severe recurrence.

Experience with the Redo Pull-Through for Hirschsprung's Disease.

Aim:This study aims to evaluate the need of Redo pull-through (Re PT) procedures for Hirschsprung's disease (HD) and suggest preventive strategies.Materials and Methods:Patients who underwent redo procedures for HD from 1980 to 2016 by a single surgeon were retrospectively reviewed.Results:Of 167 patients operated for HD, 32 underwent Re PT; 7 were previously operated by the same surgeon, while 25 were referred from outside. Indication for Re PT included residual disease including the rectal pouch following-Duhamel (12), false-negative biopsy (3), retraction of bowel (5), anorectal stricture (2), bowel twist (1), cuff inversion (2), postmyectomy continued symptoms after primary PT (1), fecal fistula (1), Re PT after surgery for adhesive intestinal obstruction (3), bleeding (1), and combination of causes, including scarred perineum (1). Age at follow-up ranged from 2.5 to 26 years. Proximal diversion was performed in 19 and 14 underwent open Scott Boley's/Soave PT and 5 ileoanal anastomosis. Of the remaining, nondiverted 13 patients, 5 underwent transanal endorectal PT and 8 underwent PT of colostomy.Conclusions:Most patients of Re PT came after an initial Duhamel's procedure. Retraction of bowel, inversion of cuff, twist, distal bowel stricture, and perianal fibrosis were found after Scott Boley procedure. Proper planning with an initial diversion, nutritional buildup, barium study evaluation, frozen section facility, experienced pathologist, and an expert surgeon are prerequisites for a successful outcome after an initial as well as Re PT.

A Case of Posttraumatic Delayed Small Bowel Stenosis Treated with Single Incision Laparoscopic Surgery

A Case of Posttraumatic Delayed Small Bowel Stenosis Treated with Single Incision Laparoscopic Surgery

Assessment of Bowel Inflammation and Strictures by Magnetic Resonance Enterography in Long-term Crohn's Disease.

Crohns disease [CD] is a chronic inflammation in the gut that often progresses to fibrosis. Magnetic resonance enterography [MRE] is an important diagnostic tool in evaluating CD. We aimed to assess the prevalence of inflammation and stricturing disease in patients with long-term CD, and to investigate associations with clinical factors. We performed a follow-up analysis of a population-based cohort of 237 CD patients in south-eastern Norway 20 years after diagnosis; 95 patients were examined with MRE, and the magnetic enterographic global score [MEGS] was calculated. We assessed inflammation and strictures during the follow-up. Association of the MEGS and bowel strictures with clinical variables was examined by univariate regression analysis. Of the 237 patients, 62 [65.3%] had active inflammation mostly affecting the terminal ileum; 35 [36.8%] had substantial inflammation according to MEGS, which associated with inflammatory biomarkers during the follow-up; and 25 [26.3%] had stricturing disease that associated with age (odds ratio [OR] = 0.92), initial use of systemic steroids [OR = 3.36], and inflammatory biomarkers. Most patients with strictures were treated with surgery without recurrence [n = 24, 42.1%] and seven [21.2%] strictures in the terminal ileum healed without surgery. Twenty years after the diagnosis, the majority of patients had active inflammation, often complicated by stricturing disease. Most patients with strictures were treated with surgery without recurrence, and some strictures resolved over time. Inflammatory biomarkers, extensive and complicated disease type, and use of systemic medication associated with both inflammation and stricturing disease.

Does MR enterography offer added value after a recent CT in the evaluation of abdominal pain in Crohn's disease patients?

PurposeTo determine if there is added value in performing MR enterography shortly after a contrast-enhanced CT of the abdomen and pelvis in patients with Crohn's disease presenting with acute abdominal pain. Materials and methodsA total of 45 consecutive patients who underwent MRE examination <7 days after a CT met our strict inclusion criteria. Independent and blinded review of both MRE and CT exams was performed by two abdominal radiologists. ResultsThere were no significant differences in detection of various findings associated with Crohn's disease between modalities. These findings included abscess, fistula, bowel wall thickening, free fluid, stricture, and bowel obstruction. There was moderate interobserver agreement with CT (Kappa: 0.52, 95% CI: [0.4–0.6]) and fair with MRE (Kappa: 0.36, 95% CI:[0.3 = 0.5]). ConclusionThe routine use of MRE after a diagnostic CT should be avoided, as it provides no additional valuable information, at the expense of extra patient risks, discomfort, and higher health care costs.

Clinical features and risk factors of surgical complications after intersphincteric resection for low rectal cancer following neoadjuvant chemoradiotherapy

Objective: To explore clinical features and prognosis factors of surgical complications after intersphincteric resection (ISR) for low rectal cancer following neoadjuvant chemoradiotherapy. Methods: The clinical data of 132 patients with low rectal cancer who underwent ISR following neoadjuvant chemoradiotherapy from September 2010 to June 2017 at Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University were retrospectively reviewed. There were 100 males and 32 females, with the age of (52.9±11.4) years and distance to anal verge of 3.9 cm. Records of perioperative complication (POC) within 30 days after surgery, anastomotic leakage (AL), and anastomotic stenosis (AS) were analyzed. POC was recorded according to the Clavien-Dindo classification. AL was graded by ISREC system and classified into the early AL within 30 days after surgery and delayed AL beyond 30 days. AS was defined as narrowing of the bowel lumen at the anastomosis that prevented passage through a colonoscope with a 12 mm diameter. According to the shape of narrowing, AS was recorded as the stenosis in situ or stenosis with long-segment bowel above. Univariate and multivariate analysis were used to identify risk factors of anastomotic complications. Results: Among the 132 patients, full-dose radiotherapy and diverting stoma were performed in 128 (97.0%) patients, respectively. In entire cohort, AL was found in 41 (31.1%) patients, including 32 patients with clinical leakage (24.2%). The median time for diagnosis of AL was 37 days (2 to 214 days) after surgery. There were 25 patients (18.9%) who were diagnosed with delayed AL beyond 30 days. Chronic presacral sinus formation was detected in 22 of 129 (17.1%) patients at 12 months from surgery. Among the 128 eligible patients, 36 (28.1%) were diagnosed as AS, including 24 (18.8%) patients with stenosis in situ and 12 (9.4%) patients with bowel stenosis above. After a median follow-up of 26 months, 7(5.3%) patients received permanent colostomy and the other 20(15.2%) patients retained a persistent ileostomy, owing to anastomotic complications. Results of multivariate analysis showed that radiation colitis was an independent prognosis factor of AL after ISR (OR=5.04, 95% CI: 2.05 to 12.43, P=0.000); male gender (OR=5.19, 95% CI: 1.24 to 21.75, P=0.024) and AL (OR=8.49, 95% CI: 3.32 to 21.70, P=0.000) were independent prognosis factors of AS after ISR. Conclusions: Surgical complications are common after ISR for low rectal cancer patients with neoadjuvant chemoradiotherapy. A high rate of AL is observed after long-term follow-up, which is associated with AS. Increasing awareness of anastomotic complications after ISR should be raised, especially for male patients with radiation colitis.

Pediatric Gastritis, Gastropathy, and Peptic Ulcer Disease.

1. Desiree Sierra, MD* 2. Mary Wood, MD* 3. Sneha Kolli, MD* 4. Lina Maria Felipez, MD† 1. *Department of Medical Education and 2. †Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Nicklaus Children’s Hospital, Miami, FL * Abbreviations: H2RA: : histamine 2 receptor antagonist IBD: : inflammatory bowel disease NSAID: : nonsteroidal anti-inflammatory drug PPI: : proton pump inhibitor PUD: : peptic ulcer disease Providers should be able to identify the signs and symptoms of peptic ulcer disease in children, select the proper diagnostic tests needed to confirm the diagnosis, and describe adequate treatment regimens to start once the diagnosis is confirmed. After completing this article, readers should be able to: 1. Understand the mechanism and pathogenesis of gastritis, gastropathy, and peptic ulcer formation. 2. Recognize the symptoms of and risk factors for gastritis, gastropathy, and peptic ulcer disease. 3. Understand which patients warrant referral to a gastroenterologist for possible endoscopy. 4. Review the role of Helicobacter pylori in peptic ulcer disease. 5. Review the treatment of peptic ulcer disease with and without the presence of H pylori. Gastritis, gastropathy, and peptic ulcer disease (PUD), collectively known as acid peptic disease, are often described as a spectrum of the same disease. Although these conditions are more common in adults, their incidence in the pediatric population is clinically significant. Left untreated, gastritis can progress to PUD, which can result in serious complications such as perforation, bleeding, bowel strictures, and obstruction. Studies describing the role of Helicobacter pylori , nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and other causes have helped to further expand our understanding of gastritis and PUD in children. Direct visualization and the ability to biopsy with endoscopy have revolutionized the diagnosis and treatment of these diseases. The incidence of PUD in children is lower than that in adults. Based on several international studies, the incidence in children varies from 2% to 8%. (1)(2) The incidence of bleeding ulcers is lower and is estimated to be between 0.5 and 4.4 of 100,000 individuals. (3) These rates …

Post-Mesenteric Thrombotic Enteropathy: Small Bowel Stricture Is an Underestimated Chronic Complication after Mesenteric Venous Thrombosis

Journal of the American College of Surgeons 227(4):p S293-S294, October 2018. | DOI: 10.1016/j.jamcollsurg.2018.07.608