Cm Of Jejunum Research Articles

PSI-25 Improvements in the jejunal villus morphometry and increases in the number of goblet cells with the addition of humic substances from vermicompost in weaned pigs

Abstract An experiment was carried out with the objective of evaluating the effects of the addition of humic substances (HS) from vermicompost in the feed on the histology measurements and number of goblet cells in the jejunal villus in piglets at weaning. Piglets (n = 200) were housed in groups of five in elevated pens and were assigned to one of four treatments: 1 = Positive control diet (PC) with antibiotic growth promoter (AGP), 2 = Negative control diet (NC) without AGP, 3 and 4 = Diets without AGP added with 2500 and 5000 ppm HS, respectively. HS were extracted from a vermicompost made of sheep and pig manure using an alkaline solution and added in dry form to the feed. A basal sample of 5 cm of jejunum was taken from 10 piglets at weaning; the same was done on d 3 and 7 post-weaning, selecting 5 piglets per treatment. The samples were processed to apply different stains: () eosin and hematoxylin for morphometric analysis: villus height, villus thickness, villus area, crypt depth and the villus eight to crypt depth ratio; 2) Pass Schiff to quantify neutral goblet cells; 3) Alcian Blue pH 1.0 for heavily sulfated goblet cells; and 4) Alcian Blue pH 2.5 for non-sulfated acid goblet cells. Ten villi per animal were evaluated. Images were analyzed with Leica interactive measurement software. The results were subjected to ANOVA in a randomized complete block design. Regarding the histology of villus in the jejunum, on d 3 post-weaning the pigs added with HS had a greater villus height (3 = 317.75, 4 = 310.46 vs 2 = 278.08 and 1 = 307.12 µm; P < 0.05; SEM = 10.86), villus width (3 = 94.64, 4 = 95.04 vs 2 = 85.39, and 1 = 93.51 µm; P < 0.01; SEM = 2.32); and villus area (3 = 95841, 4 = 93678 Vs 2 = 76646 and 1 = 93471 µm2; P < 0.01; SEM = 4343), compared with the NC. The crypt depth was greater in piglets added with HS (3 = 236.78, 4 = 241.85 vs 1 = 194.65 and 2 = 203.01 µm; P < 0.01; SEM = 6.57) compared with the PC and NC. On d 7 postweaning, the piglets added with HS showed greater villus height (3 = 293.24, 4 = 282.45 vs 1 = 258.95 and 2 = 253.03 µm; P < 0.01; SEM = 7.89); villus area (3 = 101354, 4 = 94,575 vs 1 = 85,633 and 2 = 82,125 µm2; P < 0.01; SEM = 3818) and crypt depth (3 = 326.82, 4 = 337.28 vs 2 = 283.88 and 1 = 321.53 µm; P < 0.01; SEM = 8.285) compared with the PC and NC. The number of neutral, heavily sulfated and non-sulfated goblet cells at 3 and 7 d post-weaning were significantly reduced in all treatments compared with weaning; but with the addition of HS a greater number (P < 0.05) of goblet cells per villus were shown. The results suggest that HS from vermicompost improves the intestinal morphometry and increases the number of goblet cells that produce protective intestinal mucus at 3 and 7 d post-weaning in pigs.

S3435 Jejunal Diverticula: A Lesser Known Cause for Massive Lower GI Bleeding

Introduction: Small bowel diverticula are rare. We describe a case of Jejunal diverticula that caused massive lower GI bleeding requiring surgical intervention. Case Description/Methods: A 77 year old male presented to our ER with sudden onset bright red blood per rectum. The patient first noticed 2 days ago that his stool was dark red followed by red streaking on toilet paper. A few hours later he developed rectal urgency followed by another large bloody bowel movement along with associated diaphoresis, LLQ cramping and presyncope. Past medical history included GERD, BPH, Hypertension and Polycythemia Vera. He had never undergone an EGD and his last screening colonoscopy was normal 5 years ago. Labwork revealed acute anemia with Hb of 7.7 g/dL (baseline 13) and one unit of RBCs was therefore transfused. Emergent EGD and colonoscopy were performed and these were unremarkable apart from sigmoid diverticulosis. The following day massive rectal bleeding recurred and this time a radionuclide bleeding scan was obtained which was positive for active bleeding in small bowel lumen at the LUQ. Interventional Radiology did not feel the area was approachable for embolization. 6 additional units of RBCs were given due to persistent bleeding. General Surgery was called and the patient was taken to OR for exploratory laparotomy with small bowel resection. Diffuse proximal Jejunal diverticulosis was found to be actively bleeding with blood traveling all the way to distal colon. 60 cm of Jejunum was transected 30 cm from the ligament of Treitz. The patient had an unremarkable postoperative recovery with no further episodes of bleeding and stable Hemoglobin on serial CBCs. Discussion: Diverticulosis involving the small bowel, especially the Jejunum, is rare. These lesions have a higher incidence in the elderly and are acquired as a result of increased intraluminal pressure. They are thin and friable due to lack of muscularis layer. Concurrent colonic diverticulosis is common. Traditionally considered to be asymptomatic and incidental findings on imaging or surgical exploration, Jejunal diverticula can uncommonly cause lower GI bleeding. Traditional endoscopy is unhelpful given the lack of accessibility of the small bowel. CT Angiography and Nuclear Medicine bleeding scans may be beneficial to localize bleeding. Hemorrhage is usually brisk, requiring massive blood transfusion to maintain hemodynamics. Unstable patients should undergo emergent laparotomy so that resection of the involved segment can be performed.

Life-threatening gastrointestinal bleeding caused by jejunal heterotopic gastric mucosa in an adult dog: a rare case report

BackgroundHeterotopic gastric mucosa has been scarcely reported in the veterinary literature. Its presence can be asymptomatic or associated with various clinical signs ranging from apathy, vomiting, to abdominal pain. This report illustrates the presence of heterotopic gastric mucosa in the jejunum of an adult dog. It is the first to describe severe anemia, requiring acute blood transfusion, following intestinal hemorrhage caused by heterotopic gastric mucosa.Case presentationA twelve-year-old, intact male Maltese dog was presented with a history of apathy, vomiting and anemia. The dog was on a strict diet for recurrent diarrhea, food intolerance and skin allergy. Clinical examination revealed severe anemic mucous membranes and painful abdominal palpation. Blood examination confirmed severe regenerative anemia. Ultrasonography showed an intestinal neoplasm, gall bladder sludge and non-homogeneous liver parenchyma. Three-view thoracic radiographs failed to show any metastatic lesions or enlarged lymph nodes. After initial stabilization and blood transfusion, a midline exploratory laparotomy was performed. Three different masses were found in the jejunum. Resection and anastomosis of approximately 40 cm of jejunum was performed, followed by liver and lymph node biopsy and placement of an esophagostomy tube. Two days after surgery the dog started to clinically improve and was discharged from the hospital on the sixth day after surgery. Histopathology revealed the intestinal masses to be heterotopic gastric mucosa associated with intramural cystic distensions, multifocal ulceration and bleeding into the intestinal lumen. Two years after surgery, the dog did not have a recurrence of anemia or gastrointestinal signs.ConclusionsThis case demonstrates that heterotopic gastric mucosa can be considered one of the differential diagnoses in case of severe anemia due to gastrointestinal hemorrhage and suspected intestinal tumors. Although in most described cases in literature the finding seems to be incidental on necropsy, our report shows that heterotopic gastric mucosa can be the etiology of life-threatening signs. In addition, because no recurrent diarrhea episodes occurred after surgical resection of the ectopic tissue, it is likely that the heterotopic gastric mucosa was the cause of the food intolerance signs in this dog.

Intrauterine Volvulus

Although volvulus is mostly seen in infancy, rare cases of intrauterine volvulus have also been reported. Fetal ultrasonographic (USG) examination of a 32-year-old woman at the 24th gestational week, showed focal dilatation of the intestines with an increased wall echogenity of the dilated segments. At the subsequent visits USG revealed progressive dilatation of the intestines. The patient presented with preterm labor at the 32nd gestational week. Cullen's sign developed on newborn's abdominal skin over time. During the operation, there was a stiff, yellowcolored, fibrinous pouch, jejunal and ileal atretic ends (25 cm of jejunum was remaining). We started total parenteral nutrition (TPN) because of short bowel syndrome. The patient died due to TPN-related sepsis at age 40 days. Timely diagnosis and treatment of intrauterine volvulus cases is very difficult because there are mostly non-specific signs, which have many differential diagnoses. This fact negatively affects mortality and morbidity for intrauterine volvulus cases.

A rare case of jejunal adenocarcinoma with brain metastasis

Small bowel malignancies are rare entity, with adenocarcinoma being one of common type along with neuroendocrine tumours. Associated with Crohns, celiac disease, FAP and HNPCC. Jejunal adenocarcinoma produce vague symptoms, accounting for late presentation leading to difficult and delayed diagnosis in favour of poor prognosis. Diagnosis is established by CECT abdomen and CEA levels. Ro resection with regional lymphadenectomy and jejunojejunal anastomosis is preferred followed by adjuvant FOLFOX chemotherapy. Here we presenting a 68 years old male, anaemic with vague abdominal pain for 3 months, CECT showed malignant wall thickening involving 10 cm of proximal jejunal loop with no enlarged lymph nodes and CEA was elevated. Proceeded with laparotomy, an irregular hard mass of 10×10 cm involving 20 cm of jejunum with transverse colon infiltration with multiple mesenteric nodes found, composite resection with jejunojejunostomy and colocolic anastomosis done. Histopathology showed poorly differentiated jejunal adenocarcinoma with colonic infiltration with reactive nodes and post operatively on day 7, patient developed seizures and weakness of left upper and lower limbs, MRI brain showed solitary metastasis 2×2 cm in right frontal region and PET CT showed brain metastasis and multiple intraabdominal lymph node, lung and prostate metastasis, planned SBRT for brain metastasis and palliative chemotherapy. Lymph node, liver and peritoneum are common site of metastasis for small bowel adenocarcinoma, very rarely brain metastasis can occur in short time and to be considered if neurological symptoms occur pre and postoperatively.

Skeletal muscle mitochondrial network dynamics in metabolic disorders and aging

With global demographics trending towards an aging population, the numbers of individuals with an age-associated loss of independence is increasing. A key contributing factor is loss of skeletal muscle mitochondrial, metabolic, and contractile function. Recent advances in imaging technologies have demonstrated the importance of mitochondrial morphology and dynamics in the pathogenesis of disease. In this review, we examine the evidence for altered mitochondrial dynamics as a mechanism in age and obesity-associated loss of skeletal muscle function, with a particular focus on the available human data. We highlight some of the areas where more data are needed to identify the specific mechanisms connecting mitochondrial morphology and skeletal muscle dysfunction.

Incidental finding of jejunal diverticula during laparotomy for suspected adhesive small bowel obstruction: A case report.

Introduction and importanceJejunal diverticula are usually asymptomatic and are discovered incidentally. While rare, their complications may be life-threatening. They should be considered as differential diagnoses in undiagnosed complaints of chronic abdominal pain, malabsorption, anemia, gastrointestinal bleed and intestinal obstruction.Case presentationA 66-year lady, known hypertensive and hypothyroidism with history of hysterectomy presented with symptoms suggestive of small bowel obstruction. Intraoperatively adhesions between loops of the small intestine, multiple diverticula with two of them impending perforation were found. Resection of 10 cm of jejunum containing diverticula with end-to-end anastomosis was performed. She had uneventful recovery and on 2 months of follow-up she was doing well.Clinical discussionAlthough diverticula can be found anywhere along the gastrointestinal tract, jejunal diverticula are rare. Most patients are asymptomatic, symptoms if present is non-specific that delay diagnosis causing patients to land up with complications. They are diagnosed incidentally on endoscopy or imaging rather than through clinical suspicion. Asymptomatic cases do not mandate treatment while symptomatic cases can be managed conservatively with surgery being reserved for those with complications.ConclusionSmall bowel obstruction due to jejunal diverticula is a rare entity, a diagnosis of which can be confirmed only intra-operatively. So it must be borne as a differential in small bowel obstruction. Timely diagnosis and management will prevent life-threatening complications of it.

P-70: Native Jejunal Conduit for Urinary Diversion in Enbloc Liver-Intestine-Kidney Transplantation for a Patient with Irradiation Enteritis and Cystitis

Background: Recipients requiring kidney-enbloc visceral allograft often face challenges during transplantation. We report a case with a unique technique of urinary diversion in enbloc liver-intestine-kidney transplantation for irradiation enteritis and cystitis. Methods: The patient is a 65 year-old man with Crohn's disease and history of anal adenocarcinoma treated with abdominoperineal resection and adjuvant chemo- and radiotherapy. Case will be presented with pictures and/ or video. Results: The patient developed gut failure due to short gut and multiple bowel obstructions secondary to radiation enteritis. Urinary incontinence developed after irradiation caused frequent urinary tract infection leading to kidney failure. He was listed for combined liver-intestine-kidney transplantation and received en-bloc allograft from a 35 year-old male brain-dead donor. During evisceration of native organs, frozen abdomen was encountered and subtotal enterectomy leaving 30 cm of jejunum was performed. Urinary bladder was rock hard with no augmentation, unacceptable to implant the allograft ureter. Arterial inflow was established with an aortic conduit between the native and allograft infra-renal aorta. The native jejunum was transected at 10 cm and the proximal segment was connected to allograft jejunum to establish the continuity of alimentary tracts. The distal 20 cm of native jejunum was anastomosed to allograft ureter for urinary diversion Postoperative course was unremarkable with adequate urinary output and allograft functions. The patient was well rehabilitated in hospital due to lack of safe rehabilitative facilities during COVID pandemic and discharged home on post-operative day 47. Conclusion: Combined kidney and visceral transplantation in the setting of irradiated bladder requires pre-operative planning of urinary reconstruction with several options. When native intestine is available and not damaged from original disease, urinary diversion using the native jejunum is the safest option amongst others including cystoplasty and urinary diversion using allograft ileum.

Intestinal rehabilitation with ultrashort bowel syndrome due to necrotizing fungal enteritis

Abstract Introduction Ultra-short bowel syndrome (USBS) was once considered incompatible with life. It can be secondary to multiple cases but most rarely infection or autoimmune disease. Case: We discuss a 13-yr old female with Polyarteritis Nodosa complicated by a necrotizing fungal infection due to C. tropicalis who developed USBS after requiring extensive resection of her bowel, omentum and abdominal wall due to an invasive fungal infection, leaving her with less than 5 cm of jejunum and residual left colon. With intestinal rehabilitation she was able to be weaned down to 70% enteral nutrition and 30% TPN. Conclusion Ultra-short bowel syndrome is increasing in the pediatric population as rates of survival continue to improve. After management of the acute disease, in this case severe infection and vascular disease, long term management with a focus on providing high-quality multidisciplinary intestinal rehabilitation is vital as well as minimizing PN complications.

Intrauterine intestinal volvulus prompting emergency delivery and surgery in a 32wk fetus

Abstract Fetal intestinal volvulus is a medical emergency with potentially fatal consequences thus requires a high index of suspicion and prompt intervention. Echogenic dilated bowels, Whirlpool/Coffee bean signs, polyhydramnios, fetal anemia, fetal ascites with aperistalsis, nonreaasuring CTG are few important diagnostic signs. Mostly it has been described without associated malrotation,as segmental volvulus due to malfixation of gut with or without associated anaomalies such as meconium ileus, CDH, abdominal wall defects. We describe for the first time a case of 1.9kg female fetus detected to have intestinal volvulus associated with multiple ileal atresias and mesenteric defect. The fetus had classical Whirlpool sign, polyhydramnios and anemia, was delivered by emergency Ceasarian Section, post natally detected to have tense abdomen, confirmed Whirlpool sign on post natal USG, underwent emergency laparotomy, resection of necrotic ileal loops & I-C junction and Jejuno-Colic anastomosis. Child adapted to elemental feeding with 50cm of Jejunum without Ileo-cecal valve without shortbowel syndrome. Importance of multidisciplinary perinatal care, possible intrauterine vascular accident in pathogenesis of atresia and fetal volvulus has been emphasized in the case report.

Irreversible Electroporation for De-epithelialization of Murine Small Intestine

BackgroundNonthermal irreversible electroporation (NTIRE) has been shown to ablate the small intestinal epithelium while maintaining submucosal and muscularis propriae integrity. NTIRE is used here in a first-in-mouse study to eliminate the native intestinal stem cell population to understand optimal parameters and timeline of mucosal regeneration. MethodsAdult C57 background mice underwent laparotomy and electroporation of 1.5 cm of jejunum using a BTX 830 ECM electroporator and electrode calipers. Parameters were varied by voltage, pulse number, interval, and duration to determine optimal de-epithelialization. Electroporated segments were extracted 1 to 3 d after intervention with same-animal control segment. Cross sections were preserved, and measurements were taken to compare effects of parameters on villi height, crypt depth, crypt obliteration, and serosal thickness. ResultsMorbidity was limited at a standard set of electroporation parameters (14%), and increased with higher voltage, longer interval, and shorter or longer pulses. Serosa/muscularis thickness was unaffected by varying interventions. Crypt depth and obliterated crypts were most affected by modulating pulse number, intervals, and duration. Villi height was most significantly shortened by altering pulse duration, with limited recovery by day 3, otherwise mucosal regeneration was observed in most cases by this point. ConclusionsNTIRE is an effective method of denuding small intestinal epithelium in mice and temporarily ablating crypts while sparing the support scaffold for native regeneration. This first-in-mouse study of electroporation suggests it is a practical tool that can be utilized in a small mammalian system.

Jejunal Diverticulosis Is a Rather Difficult Diagnosis: Report of a Case and Review of the Literature

Jejunal diverticulosis is most commonly an incidental intraoperative finding, while rarely can be a clinical diagnosis as demonstrated in our case and on published articles in the literature. Besides the rarity of the disease, a second factor that incommodes the preoperative diagnosis is the vague symptomatology. The case of a 72-year-old male patient is described, who was complaining for mild intensity abdominal pain, with no other specific symptoms. A leucocytosis of 12.500/mm³ was revealed, with all other laboratory tests being within normal limits. CT scan showed bubbles of free air in abdominal cavity and the decision for surgical exploration was taken. In the operating room multiple large diverticula were found along the jejunum without obvious perforation. A resection of 105 cm of jejunum was performed. Patient’s postoperative recovery was uneventful and two years later he does not complain of any abdominal symptoms. Postoperatively an expert radiologist was asked to read and explain the preoperative CT scan. Radiologist’s diagnosis was that the patient had either multiple jejunal diverticula or trapped free air in peritoneal cavity. Consequently, the preoperative diagnosis is feasible with a prompt cooperation between surgeon and radiologist and a better interpretation of CT scan findings from the radiologist.

Human small intestine is capable of restoring barrier function after short ischemic periods.

AIMTo assess intestinal barrier function during human intestinal ischemia and reperfusion (IR).METHODSIn a human experimental model, 6 cm of jejunum was selectively exposed to 30 min of ischemia (I) followed by 30 and 120 min of reperfusion (R). A sham procedure was also performed. Blood and tissue was sampled at all-time points. Functional barrier function was assessed using dual-sugar absorption tests with lactulose (L) and rhamnose (R). Plasma concentrations of citrulline, an amino acid described as marker for enterocyte function were measured as marker of metabolic enterocytes restoration. Damage to the epithelial lining was assessed by immunohistochemistry for tight junctions (TJs), by plasma marker for enterocytes damage (I-FABP) and analyzed by electron microscopy (EM) using lanthanum nitrate as an electrondense marker.RESULTSPlasma L/R ratio’s were significantly increased after 30 min of ischemia (30I) followed by 30 min of reperfusion (30R) compared to control (0.75 ± 0.10 vs 0.20 ± 0.09, P < 0.05). At 120 min of reperfusion (120R), ratio’s normalized (0.17 ± 0.06) and were not significantly different from control. Plasma levels of I-FABP correlated with plasma L/R ratios measured at the same time points (correlation: 0.467, P < 0.01). TJs staining shows distortion of staining at 30I. An intact lining of TJs was again observed at 30I120R. Electron microscopy analysis revealed disrupted TJs after 30I with paracellular leakage of lanthanum nitrate, which restored after 30I120R. Furthermore, citrulline concentrations closely paralleled the histological perturbations during intestinal IR.CONCLUSIONThis study directly correlates histological data with intestinal permeability tests, revealing that the human gut has the ability of to withstand short episodes of ischemia, with morphological and functional recovery of the intestinal barrier within 120 min of reperfusion.

Severe Bleeding Due to Jejunal Diverticulosis

Introduction: Jejunal diverticulosis is a very rare condition and usually remains asymptomatic. We describe a case of severe bleeding in a 65 years old patient that underwent surgery to remove the hemorrhagic segment. Case report: A 65 years old male patient, physician, entered the ER with a one day history of dizziness, nausea and black stools. An upper endoscopy and a colonoscopy were performed and the site of bleeding was not reached. Ileoconoscopy achieved the terminal ileum and all the segments were full of blood coming from an upper segment of the bowel. Since the bleeding worsened, an arteriography was performed and an embolization was apparently successfully done in order to stop the bleeding. Unfortunately 6 hours later the patient developed another huge bleeding and than a videocapsule was performed that showed the presence of multiple diverticula in the jejunum with active bleeding coming from that site. The patient underwent surgery with removal of 37 cm of jejunum with countless diverticula. The bleeding stopped immediately and the patient recovered completely in a few days, remaining asymptomatic. Discussion: In case of severe GI bleeding with anemia usually an upper endoscopy and colonoscopy must be performed to try detecting the origin of the bleeding. On this case presented, both tests were unsuccessfully performed and couldn't find the site of bleeding. Even an arteriography were not able to stop the bleeding that was later on diagnosed as being from jejunum diverticulosis by a videocapsule exam. Laparoscopic surgery was needed to remove 37 cm of jejunum filled with diverticula. Conclusion: Diverticular disease of the jejunum is a very rare condition, and causing severe bleeding is extremely uncommon. The case presented had his diagnosis done by a videocapsule endoscopy test, since the upper endoscopy and the ileocolonoscopy were not able to reach the site of bleeding. The surgical treatment is indicated mainly for those cases with bleeding and multiple diverticula.Figure 1

Análise morfométrica da parede intestinal e dinâmica de mucinas secretadas no jejuno de frangos suplementados com probiótico Bacillus subtilis cepa C3102

Resumo O objetivo deste estudo foi analisar a morfometria da parede intestinal e a dinâmica de mucinas secretadas no jejuno de frangos de corte suplementadas com probiótico Bacillus subtilis cepa C3102. Foram utilizados 720 pintinhos com um dia de vida, divididos em dois grupos: GA (Grupo controle) - aves alimentadas com ração sem suplementação de Bacillus subtilis cepa C3102 (1º ao 35º dia) e GB (Grupo tratado) - aves alimentadas com ração com suplementação de Bacillus subtilis cepa C3102 (1º ao 35º dia). Aos 7 e 35 dias 2cm do jejuno foram coletados e submetidos à rotina de processamento histológico. Cortes transversais de 1μm foram corados pela técnica do Alcian Blue (AB) para detecção de sialomucinas (pH 0,5) e sulfomucinas (pH 2,5), como também para contagem de células caliciformes presentes. A análise histoquímica revelou uma maior quantidade de sialomucinas presentes no jejuno dos animais que foram suplementados com probiótico Bacillus subtilis cepa C3102 (GB), quando comparados com os animais do grupo controle (GA). O número de células caliciformes presentes no grupo tratado (GB) foi superior ao grupo controle (GA).

Case of Massive Gastrointestinal Hemorrhage Post Renal Transplant: A Diagnostic Conundrum

Introduction: CMV infection is a major cause of morbidity and mortality in immunocompromised patients. Renal transplantation confers an increased risk of UGI bleed however invasive CMV disease causing life threatening hemorrhage is a rarer entity. We describe a case of recurrent massive GI bleed due to invasive CMV disease which responded remarkably to timely antiviral treatment. Case: 34 yo female w/PMH of ESRD due to HTN was admitted for elective deceased donor transplant. Both the patient and donor were CMV +. Post transplant induction therapy with TAG-basilixumab was done followed by MMF-tacrolimus for maintenance. Further hospital course was complicated by renal vein thrombosis (s/p thrombectomy) and intestinal ischemic necrosis (s/p resection of 60 cm of jejunum). While in recovery, she had multiple episodes of melena and drop in hematocrit. PPI drip was initiated and EGD showed severe esophagitis, gastritis with large antral clot limiting further exam. Bleeding continued to recur and PRBC transfusions were needed. Angiogram was non-diagnostic however gastroduodenal artery was embolized without any success. Repeat EGD showed esophagitis with multiple duodenal ulcers, anastomosis site was clean. Esophageal biopsy was consistent with invasive CMV disease, serum CMV DNA PCR was elevated. Treatment was initiated with valganciclovir. The patient improved and her bleeding subsequently resolved. Discussion: CMV infection is common among donors and recipients prior to transplantation. Risk of CMV disease is elevated with transplant between CMV+ donor and recipient which increases with use of lymphocyte-depletion induction therapy, as seen in our case. In such patients primary prophylaxis with antiviral therapy decreases the incidence of significant CMV disease. It usually presents as mononucleosis-like illness and other organs can be involved. GI bleeding is caused by erosions or ulcerations however life threatening bleed is rare. Our case stresses the need to recognize invasive CMV disease as an important cause of UGI bleed in renal transplant patients. Diagnosis is made with lab tests in appropriate clinical setting. In our patient with e/o esophagitis, duodenal ulceration, diagnosis was confirmed with elevated CMV DNA PCR levels and demonstration of CMV inclusions on biopsy. Treatment includes antiviral therapy such as ganciclovir or valganciclovir with reduction of immunotherapy.Figure 1Figure 2Figure 3Conclusion: Our case highlights the importance of recognising invasive CMV disease as a causative agent of significant GI bleed in renal transplant patients. Also to recognize the importance of appropriate patient selection for primary prophylaxis against CMV disease to limit its incidence and associated morbidity post renal transplant.

Internal hernia after laparoscopic-assisted proximal gastrectomy with jejunal interposition for gastric cancer: a case report.

Internal hernia after gastrectomy is a rare complication. It can progress rapidly to vascular disturbance, necrosis, and perforation, therefore early diagnosis and surgical treatment is essential. We present a case of internal hernia following laparoscopic-assisted proximal gastrectomy with jejunal interposition reconstruction in a 68-year-old man, who presented with acute abdominal pain and vomiting. Computed tomography showed a whirl sign, ascites, and a closed-loop formation of the small intestine. We diagnosed an internal hernia and performed emergency surgery. Laparotomy revealed chyle-like ascites and extensive small intestine with poor color. We recognized that about 20 cm of jejunum from the ligament of Treitz was strangulated behind the pedicle of the jejunum lifted during laparoscopic-assisted proximal gastrectomy. We relieved the strangulation, whereupon the color of the strangulated intestine was restored. Therefore, we did not perform intestinal resection and reconstruction. Finally, we fixed the jejunal pedicle and mesentery of the transverse colon. We report this case as there are few reported cases of internal hernia after laparoscopic-assisted proximal gastrectomy.

A huge low-grade fibromyxoid sarcoma of small bowel mesentery simulating hyper immune splenomegaly syndrome: A case report and review of literature

Low-grade fibromyxoid sarcoma (LGFMS) is a rare non epithelial tumour. It usually arises from the smooth muscles of the extremities. It is, however, occasionally reported to arise from other regions of the body. We report the case of a 32 year old man who complained of a progressive abdominal swelling of 4 months duration. There was associated abdominal discomfort and weight loss. Abdominal examination revealed a non-tender intra abdominal mass filling the abdomen completely. Abdominal ultrasound suggested a massive splenomegaly. Abdomina Computerized Tomography (CT) scan was not done due to financial constraints. At laparotomy, a large, pearl-coloured mass was found within the mesentery of the proximal jejunum, with dilated, tortuous vessels. It was resected along with the overlying 60 cm of jejunum. It weighed 7.5 kg. Histology and immunohistochemistry confirmed the diagnosis of lowgrade fibromyxoid sarcoma. Post-operative period was uneventful and there were no features of recurrent after 2 year of follow up. LGFMS may cause a diagnostic dilemma, especially in a third world setting where preoperative diagnosis is hampered by lack of facilities and poverty. A high index of suspicion is needed for preoperative diagnosis, which is necessary for proper planning of the operation.

Clinical problem-solving: Short bowel syndrome in an infant

The present case report describes the clinical problems encountered over a five-month period in an infant born with jejunal atresia, extensive midgut volvulus and a microcolon. After an initial surgical resection, the patient had no remaining ileum and his ileocecal valve was also removed. The patient had 35 cm of jejunum, which was successfully lengthened to 60 cm using enteral nutrition and two bowel-lengthening procedures (serial transverse enteropathy procedures). Bouts of cholestatic liver disease, sepsis and small bowel bacterial overgrowth were vigorously treated. The patient was discharged at 5.5 months of age and is now 40 months of age. He is at the 50th percentile for both height and weight, and is developing normally. The outcome for infants with short bowel syndrome has improved significantly in the past few years due to intestinal rehabilitation programs, which integrate nutritional, surgical and pharmacological approaches tailored to individual needs.

Reconstruction of short bowel syndrome after internal hernia in a pregnant woman with previous bariatric surgery

INTRODUCTIONBariatric surgery is most often performed with the laparoscopic Roux-en-Y gastric bypass. A complication to the laparoscopic Roux-en-Y gastric bypass is internal hernia, which occurs in up to 16% of the patients. Since the laparoscopic Roux-en-Y gastric bypass is performed in women of fertile age, internal hernia may occur during pregnancy. PRESENTATION OF CASEA 22-year old woman with a history of laparoscopic Roux-en-Y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis. Extensive surgery was performed leaving the patient with an intact duodenum, 15cm of jejunum, 35cm of ileum and colon. Parenteral nutrition was initiated and ten months after the internal hernia, intestinal continuity was re-established. Ten weeks later the patient reached parenteral nutrition independence. DISCUSSIONInternal hernia after laparoscopic Roux-en-Y gastric bypass can be difficult to diagnose, especially during pregnancy and might be severe and life threatening for both mother and child. CONCLUSIONObstetricians and abdominal surgeons must be aware of this condition. Surgery should be performed on a wide indication. When bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure.