Duodenal Research Articles

Morphological analysis of the digestive tract of Antillean manatee (Trichechus manatus manatus, Linnaeus, 1758) in northeast Brazil

Morphological studies of the digestive tract are relevant to know the biology and understand the eating habits to conserve species. Our objective was to analyze macroscopically and microscopically the digestive tract of Antillean manatee (Trichechus manatus manatus). Samples were collected from 20 animals found dead stranded on the coast of northeastern Brazil or that died during the rehabilitation process in captivity between July 1995 and March 2017. The macroscopic analysis of the gastrointestinal tract was carried out from the in loco monitoring of the two necropsies. For microscopic evaluation, tissue fragments were collected during necropsy, fixed with 10% buffered formaldehyde and subjected to routine histological processing, with 5 μm thick slices, and subsequently submitted to the Hematoxylin-Eosin staining method, the Verhoeff method, and the periodic acid-Schiff method. Macroscopically, neonates and adults have the same digestive tract structures, namely esophagus, stomach, duodenum, jejunum, ileum, cecum, colon, and rectum. The microscopic analysis demonstrated that the digestive tract is formed by four histological layers (mucosa, submucosa, muscularis, and serosa or adventitia). In the esophagus, esophageal glands are absent and there are elastic fibers in the submucosal layer and between the external muscle and adventitial layers. The stomach has a structure called the cardiac gland, which microscopically presents ontogenetic differences regarding the depth of the lining epithelium and the orderly distribution of cells along the gastric gland. In the duodenal ampulla and in the diverticula, duodenal glands were identified in the submucosa. The luminal portion of the mucous layer of the cecal ampulla, colon, and rectum is lined by keratinized stratified squamous epithelium. The digestive tract of the species Antillean manatee is similar to what has been reported for the order Sirenia.

Comparative results of treatment of superior mesenteric artery syndrome in children by forming bypass anastomoses

Introduction. Superior mesenteric artery syndrome (SMAS) is a rare cause of chronic duodenal obstruction in children. It is defined as a compression of the inferior horizontal branch of the duodenum (DU) between aorta and the superior mesenteric artery (SMA). Various methods of surgical correction of the disease have been proposed in the literature, but a comparative analysis of their effectiveness has not been carried out. Objective: the comparative analysis of using various options of bypass anastomoses (side-to-side duodenojejunostomy, Roux-en-Y duodenojejunostomy) for SMAS in children was carried out. Materials and methods: thirty-four patients were treated with SMAS at the clinic of the Federal State Budgetary Institution of Children’s City Clinical Hospital named after. N.F. Filatov for the period from 2012 to 2023. Patients were divided into 2 groups: operated on by forming a side-to-side bypass duodenojejunostomy (group 1 - 21 children (61.8%)) and Roux-en-Y (group 2 - 13 children (38.2%). A retro- and prospective analysis of the results of their treatment was carried out. The average age was 15 years 7 months (from 8 years 5 months to 17 years 8 months). Girls were predominant 85.3%. Standard investigations were performed: ultrasound, fluoroscopy, and computer tomography of the organs of the abdominal cavity with contrast, esophagogastroduodenoscopy, laboratory research methods. The WHO AntroPlus program was used to assess the physical condition of the children. Results: the groups were assessed in terms of anthropometric indicators, gender composition and age. The following causes of SMAS were identified in both groups: weight loss caused by neuropsychiatric diseases - 29.4%; growth spurt - 26.5%; weight loss due to other reasons (repeated surgeries, diseases accompanied by weight loss, etc.) - 23.5%; without an obvious reason - 17.6% (6 people), correction of scoliotic deformity - 2.9%. The analysis showed that statistically significant differences were identified in the duration of surgery. The average duration of the operation in group 1 was 78.10±21.53 minutes, in group 2 - 103.46 ±18.19 minutes (p=0.001*). There was no statistically significant difference between groups in the postoperative period and in the complications (bleeding from the surgical site 8.8% (3 people) and reactive pancreatitis 5.9% (2 people)). Conclusion: no statistically significant difference was found in the results of both types of operations. However, the laparoscopic side-to-side duodenojejunostomy bypass is preferable due to the simplicity and quickness of performing.

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

Spigelman IV: can intensive cold snaring avoid duodenectomy in familial adenomatous polyposis?

Upper gastrointestinal surveillance is recommended for patients with familial adenomatous polyposis (FAP) who develop multiple duodenal adenomas as well as colonic adenomas. It is more than three decades since the St. Mark’s Hospital group, London published a scoring system for duodenal polyposis in FAP, the “Spigelman classification” [1]. The classification groups patients into stages from 0 to IV based on the number, size, and pathology (villosity and grade of dysplasia) of polyps, including biopsies from the duodenal ampulla and peri-ampullary area. The relevance of this system for assessing risk was demonstrated in a subsequent study where the risk over a 10-year period of duodenal cancer was only 2 %–3 % in patients with initial scores II and III, but reached 36 % at stage IV [2].

Heterogenous expression of endocrine and progenitor cells within the neonatal porcine pancreatic lobes-Implications for neonatal porcine islet xenotransplantation.

Neonatal porcine islets (NPIs) are a source of islets for xenotransplantation. In the pig, the pancreatic lobes remain separate, thus, when optimizing NPI isolation, the pancreatic lobes included in the pancreatic digest should be specified. These lobes are the duodenal (DL), splenic (SL) and connecting (CL) lobe that correspond to the head, body-tail, and uncinate process of the human pancreas. In this study we are the first to evaluate all three neonatal porcine pancreatic lobes and NPIs isolated from these lobes. We report, a significant difference in endocrine and progenitor cell composition between lobes, and observed pancreatic duct glands (PDG) within the mesenchyme surrounding exocrine ducts in the DL and CL. Following in vitro differentiation, NPIs isolated from each lobe differed significantly in the percent increase of endocrine cells and final cell composition. Compared to other recipients, diabetic immunodeficient mice transplanted with NPIs isolated from the SL demonstrated euglycemic control as early as 4 weeks (p < 0.05) and achieved normoglycemia by 6 weeks post-transplant (p < 0.01). For the first time we report significant differences between the neonatal porcine pancreatic lobes and demonstrate that NPIs from these lobes differ in xenograft function.

Involvement of endoand exoantigens in the development of the autoimmune reaction

The immune inflammatory reaction is involved in the formation of structural damage in organs with low immune resistance, but the causal stages of the formation of this reaction are poorly understood. Clinicians are faced with the fact that in patients with acute and chronic pancreatitis of alcoholic etiology, a reactive inflammatory reaction is observed in the mucous membrane (MM) of the stomach and / or duodenum. This effect was the reason that experimental studies were carried out on 45 white Wistar rats weighing 180-220 g. and duodenum (DOD). For this, a classical immunization scheme was used. Rats were taken out of the experiment on days 5, 10, and 17; after autopsy, morphological studies of the pancreas, gastric mucosa, and SOD were performed. Undoubtedly, the emerging immune response of the macroorganism to damage contributes to the development of an autoimmune reaction, in response to destruction and an inflammatory reaction, as a result, structural and functional damage to its own tissues occurs. The involvement of several organs in the inflammatory reaction depends on the local immune tolerance of the organ to endoantigens. A decrease in tolerance leads to a combined pathology, the impetus for which is damage to the “primary” organ, which is not always possible to identify. At the same time, antibodies to endoantigens are formed from damaged cellular structures.

Diagnostic value of endoscopic ultrasonography in periampullary duodenal tumours.

The objective of this study was to investigate the diagnostic value of endoscopic ultrasonography (EUS) for tumours around the duodenal ampullary. A retrospective analysis was performed on cases diagnosed and treated in our hospital from October 2016 to August 2021 due to the lesions around the duodenal ampulla. All patients received EUS, abdominal enhanced computed tomography (CT) and magnetic resonance imaging combined with magnetic resonance cholangiopancreatography (MRI-MRCP). Pathological diagnosis was used to verify the accuracy of the imaging findings. The detection rates of periampullary tumours by EUS, abdominal enhanced CT and MRI-MRCP were determined and compared. A total of 86 patients were included in this study. According to the pathological diagnosis, the detection rate of EUS was 87% (36/41) for periampullary tumour lesions with a tumour diameter <1 cm, which was significantly higher than that of MRI-MRCP (59%, 24/41) (P = 0.003) and CT (44%, 18/41) (P < 0.001). For periampullary tumour lesions with a tumour diameter ≥1 cm, the detection rate of MRI-MRCP was 93% (42/45), which was significantly higher than that of EUS (78%, 35/45) (P = 0.036) and CT (76%, 34/45) (P = 0.02). EUS can accurately detect tumour lesions around the ampullary part of the duodenum with minimal gas interference. For periampullary tumour lesions <1 cm, EUS has better diagnostic accuracy than abdominal-enhanced CT and MRI-MRCP. In addition, a biopsy of the lesion can be performed at the same time during the EUS examination. Therefore, EUS has an important clinical significance and value in the diagnosis of duodenal periampullary tumours.

A Subset of Pancreatoblastomas May Arise From an Adenomatous Precursor: An Ampullary Pancreatoblastoma and Adjacent Adenoma With a Shared Molecular Phenotype in an Adult Patient.

Pancreatoblastomas are rare pediatric tumors. In adults, they are exceedingly rare and seem to have a worse prognosis. Most are sporadic, though rare, cases occur in patients with familial adenomatous polyposis. Unlike pancreatic ductal adenocarcinomas, pancreatoblastomas are not believed to arise from dysplastic precursor lesions. Clinical history, along with endoscopic, pathological, and molecular findings, was reviewed for a 57-year-old male patient with an ampullary mass who presented with obstructive jaundice. Microscopic examination showed a pancreatoblastoma subjacent to an adenomatous polyp with intestinal differentiation and low-grade dysplasia. Both tumors had abnormal p53 (complete loss) and nuclear β-catenin immunostaining. Mutational panel analysis showed an identical CTNNB1 (p.S45P) mutation in both. This case adds to our understanding of the pathogenesis of these rare tumors and suggests that a subset may arise from an adenomatous precursor. In addition, this case is just the second pancreatoblastoma to originate in the duodenal ampulla, and the preceding case suggests that an ampullary location leads to earlier diagnosis. Moreover, this case highlights the difficulty in diagnosing pancreatoblastoma on limited tissue specimens and illustrates the need to include pancreatoblastoma in the differential diagnosis in all tumors in and around the pancreas, including those in adult patients.

S2673 If It Bleeds, It Leads: Endoscopic Presentation of Hemosuccus Pancreaticus

Introduction: A 65 year old male presented as a transfer for further evaluation of multifactorial shock. Pertinent medical comorbidities included active alcohol use disorder and mild alcohol associated hepatitis. On OSH presentation, he was treated for multifactorial shock in setting of new atrial fibrillation with rapid ventricular response and MSSA bacteremia, and was subsequently transferred to our facility. Case Description/Methods: On arrival, he had been started on systemic anticoagulation in light of his new diagnosis of atrial fibrillation and had downtrending hemoglobin from previously normal baseline ∼15 to a nadir of 7-8. Several episodes of witnessed melena were documented, and the gastroenterology service was consulted. He had no known prior history of GI bleeding or cirrhosis. Endoscopic evaluation noted a small amount of hematin in the stomach without concerning source lesions. Examination of the duodenum was initially only notable for scant fresh red blood and small, clean based ulcers thought secondary to recent hypotension and ischemia. On prolonged examination of the duodenum intermittent fresh blood was observed originating from the ampulla, consistent with a diagnosis of hemosuccus pancreaticus. Follow up dedicated CT angiography showed a thrombosed aneurysm in the pancreatic head, abutting the distal main pancreatic duct, that was concerning for the likely source lesion. The patient and family were offered interventional radiology intervention, but instead opted for hospice placement. Discussion: Hemosuccus pancreaticus is typically associated with pancreatic pathology that ultimately causes luminal bleeding via erosion of pancreatic blood vessels in communication with the pancreatic duct. The source of bleeding is often an arterial aneurysm or pseudoaneurysm and associated bleeding can be severe and life-threatening. Active hemorrhage from the duodenal ampulla is a rare endoscopic finding and bleeding in cases of hemosuccus pancreaticus is frequently intermittent. In patients with obscure upper GI bleeding and the appropriate risk factors, a high index of suspicion is required to ultimately make the diagnosis. (Figure) Given the frequency of associated vascular abnormalities, all patients with suspected or confirmed hemosuccus pancreaticus merit dedicated vascular imaging and if a vascular lesion is identified, angiography and coil embolization are the preferred definitive management.Figure 1.: Intermittent active bleeding from ampulla consistent with endoscopic diagnosis of hemosuccus pancreaticus.

S2666 Three Simultaneous Sources of Upper GI Bleeding

Introduction: Acute upper GI bleeding is one of the most common causes of gastrointestinal related hospitalizations. Presentation of these patients commonly includes melena, hematemesis, or unstable hematochezia. One of the most common etiologies for this presentation is peptic ulcer disease. However less common causes include Dieulafoy lesions and iatrogenic gastric fistulas. The following case discusses three simultaneously diagnosed causes of upper GI bleeding. Case Description/Methods: An 82-year-old male with a history of splenectomy presented with melena and syncope. The day of arrival patient had syncopized after having multiple large bouts of black stool. On presentation, he was hypotensive, and tachycardic. His hemoglobin was 6.3 g/dL with a BUN of 62 mg/dL. An EGD was planned following patient stabilization. Initial EGD revealed a single 8mm ulcer in the duodenal bulb with no stigmata of bleeding. Just distally to the ulcer in the duodenal sweep was an actively bleeding Dieulafoy lesion. Hemostasis was achieved with bipolar cautery and the active bleed was stopped. Retroflexion during the initial procedure showed retained clot and old blood in the fundus that was presumed from the Dieulafoy lesion. Despite intervention, patient continued to have large bouts of melena the evening after the procedure. A 2nd EGD was performed and showed a stable ulcer and no signs of recurrent Dieulafoy. The fundus was now more visible and revealed ischemic damage. Careful inspection revealed a fistula with suture material free floating. Review of the operative note from the splenectomy revealed patient suffered a small laceration to the gastric fundus during the procedure which was repaired with an inner row of sutures. Given the size of the fistula, decision made for a CT scan to better define the anatomy. Unfortunately, the patient continued to decompensate, and family ultimately elected for comfort care. (Figure) Discussion: Dieulafoy lesions and gastric fistulas are both relatively rare, but potentially life-threatening, conditions. A Dieulafoy is a narrow artery that bleeds through a small mucosal defect. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as an alternative to endoscopy for inaccessible lesions. The most common site for a Dieulafoy lesion to appear is in the lesser curvature. Gastric fistulas status post splenectomy occur in less than 1% of cases with the usual site along the greater curvature near the fundus.Figure 1.: Top left: Index EGD showing a single cratered 8mm ulcer in the duodenal cap. Top right: Index EGD with active Dieulafoy bleed in the duodenal sweep, just distal to ulcer. Bottom left: 2nd EGD showing free floating suture material and ischemia in the fundus Bottom right: 2nd EGD showing obvious fistula with ischemic changes, obscured by clot and old blood during index endoscopy.

Morphological investigation of intestine structure of the Sunda Porcupine (Hystrix javanica)

Abstract. Yuliastuti, Prawira AY, Wahid ME, Nisa’ C, Agungpriyono S. 2022. Morphological investigation of intestine structure of the Sunda Porcupine (Hystrix javanica). Biodiversitas 23: 4793-4799. The intestine is an important part of the digestive system, which plays a role in the enzymatic process of food and the absorption of nutrients for survival. Sunda porcupine is one of the wild and protected animals in Indonesia and belongs to the group of rodents that have hindgut fermenter characteristics. Therefore, this study aims to investigate the intestine structure of the Sunda porcupine as an important part of the digestive system. Three adults of Sunda porcupine were euthanized in accordance with ethical approval of the Animal Care and Use Committee (ACUC) of IPB University (No. 92-2018 IPB). Gross anatomy of the macrostructure and length of the intestine, as well as histology features, such as general structure and carbohydrate content using PAS and AB pH 2.5 staining method, were observed. The organ consisted of the small and large intestine, with the duodenal ampulla and large caecum as the prominent structure. In this study, body weight and length correlated positively to intestinal length. The histological observation showed the presence of Brunner’s gland in the duodenum and it has the highest villi compared to others, while villi was absent in the large intestine. Furthermore, the small intestine exhibited various intensities with PAS and AB stain, while the large intestine had strong intensity in the goblet cell. Brunner gland in duodenum demonstrated the moderate intensity of PAS stain compared to the goblet cell in the mucosa. This study provides information about the intestine structure of Sunda porcupine as the herbivore and hindgut fermenter

Comparison of acute gastrointestinal toxicities between 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy including prophylactic regions in chemoradiotherapy with S-1 for pancreatic cancer-importance of dose volume histogram parameters in the stomach as the predictive factors.

The purpose of this study was to compare acute gastrointestinal (GI) toxicities in patients who underwent 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) in chemoradiotherapy (CRT) with S-1 including prophylactic regions for pancreatic cancer. We also investigated the predictive factor of acute GI toxicities in dose volume histogram (DVH) parameters. Patients who received CRT with S-1 for pancreatic cancer between January 2014 and March 2021 were included. Radiotherapy (RT) with a total dose of 50-54 Gy was delivered. We examined the differences in the frequencies of acute GI toxicity of grade 2 or higher and DVH parameters of the stomach (ST) and duodenum (DU) between the 3DCRT group and the IMRT group. The RT-related predictive factors of acute GI toxicities were investigated by univariate and multivariate analyses. There were 25 patients in the 3DCRT group and 31 patients in the IMRT group. The frequencies of acute GI toxicity of G2 or higher were 36% in the 3DCRT group and 9.7% in the IMRT group (p = 0.035). ST V50 was the most predictive factor (p = 0.001), and the incidences of acute GI toxicity of G2 or higher in ST V50 ≥ 4.1 cc and < 4.1cc were 43.7% and 7.7%, respectively. ST V40 was also a significant predictive factor of acute GI toxicity (p = 0.002). IMRT could reduce acute GI toxicities in CRT with S-1 including prophylactic regions for pancreatic cancer. Acute GI toxicities may be affected by moderate to high doses to the ST.

Comprehensive genomic and transcriptomic characterization of small bowel adenocarcinoma.

4018 Background: Small bowel adenocarcinoma (SBA) is a rare cancer with rising incidence and worse overall survival (OS) compared to other intestinal cancers. Clinical management of SBA is primarily extrapolated from colorectal cancer (CRC). Comprehensive genomic and transcriptomic profiling of SBA will facilitate development of disease-specific therapeutic strategies. We investigated molecular alterations and association with clinical outcomes in a large cohort of SBA pts. Methods: Tumors were analyzed using 592 gene next-generation sequencing of DNA (592 genes or WES), RNA (WTS) and IHC (Caris). Immune infiltration was calculated by QuantiSeq. OS was calculated from treatment start/tissue collection to last contact from insurance claims. Results: We analyzed 823 SBA tumors: 448 primary/312 metastases, 586 duodenal (DA)/95 jejunal (JA)/38 ileal (IA). Median age of JA pts was lower (57yo) than DA (67yo) and IA (68yo). Upon subsite comparison, HER2 overexpression (2.5%) and amplification (3.6%) was only seen in DA, while HER2 mutations (mts) were most common in JA (10%) and absent in IA. IA had the lowest rate of KRAS (30%) and APC (11%) mts and highest rate of DDR mts (37%). JAs were enriched in RSPO3 fusion (19%) and BRAF mts (21%). Among BRAF mts in SBA, class 3 comprised 53%, class 2 37% and class 1 10%. MSI/dMMR was seen in 8% SBA and TMB-H in 11% with no difference among subsites. Compared to 14000 CRC tumors, SBA had significantly higher immune infiltrates regardless of MSI status (p&lt;0.001), with highest fold change in myeloid dendritic cells (15.5), Tregs (9.4), neutrophils (3.6) and M2 Macrophages (3.5). When investigating clinical outcome of SBA pts (n=751), favorable prognostic markers included TMB³8 mts/Mb (HR: 0.65, 95%CI: 0.50-0.85), mts in APC (HR: 0.76, 95% CI: 0.62-0.93), MSH6 (HR: 0.45, 95% CI: 0.20-0.99), HNF1A (HR: 0.268, 95% CI: 0.11-0.65), PRKDC (HR: 0.45, 95% CI: 0.20-1.01) and ERBB3 (HR: 0.46, 95% CI: 0.26-0.82), while TP53 (HR: 1.32, 95% CI: 1.10-1.59) and CDKN2A (HR: 1.7, 95% CI: 1.25-2.3) mts and positive PD-L1 (HR: 1.44, 95% CI: 1.09-1.90) predicted worse OS. Among SBA pts treated with chemotherapy (n=258), DA had worse OS than IA/JA (HR: 1.44, 95% CI: 1.05-1.98), which had worse OS than left-sided [LS] (HR: 1.86, 95% CI: 1.39-2.46) and right-sided [RS] CRC pts (HR: 1.35, 95% CI: 1.01-1.79). DA pts had significantly worse OS compared to LS (HR=2.97, 95% CI: 1.73-5.08) and RS (HR=1.88, 95% CI: 1.08-3.24) CRC pts. Conclusions: This study represents the largest SBA cohort with comprehensive genomic and transcriptomic profiling. We identified subsite-specific enrichment in targetable alterations, including HER2 overexpression/amplification in DA, BRAF/HER2 mts and RSPO3 fusions in JA, and DDR mts in IA. SBAs harbor higher immune infiltrates than CRC, suggesting active immune modulation. DA is characterized by poor overall outcomes and decreased therapeutic benefit from chemotherapy compared to LS- and RS- CRCs.

Estimation of the organ of origin of peri-ampullary malignancy by preoperative CT scan.

Tumors occurring within the pancreatic head commonly arise from the pancreas, duodenal ampulla, distal bile duct, or duodenum. However, they are difficult to distinguish on standard preoperative imaging. To assess the ability of specialist reporting of preoperative computed tomography (CT) scans to determine the organ of origin of pancreatic cancer (PC). Blinded re-reporting of preoperative imaging from five hospitals was undertaken of a consecutive cohort of 411 patients undergoing surgery for PC between January 2006 and May 2014. Radiological identification of tumor site was determined by the presence of the main tumor bulk within the pancreatic head parenchyma and estimation of the pathological organ of origin of the PC was based on all the reported features. Each pathological tumor type was noted to have distinct radiological features. Localization of a visible tumor within the pancreatic parenchyma was seen most commonly in PC (92%) than other tumor types (P < 0.0001). Local invasion into the duodenum was a characteristic feature seen in 79% of patients with ampullary tumors and isolated dilation of the bile duct without dilation of the pancreatic duct was seen most commonly in patients with ampullary or bile duct cancer. In the assessment of tumor origin, good agreement (kappa = 0.6, 0.51-0.68) was noted between the consensus radiology opinion and the final histology result. Overall accuracy was greatest for ampullary cancer (88.1%) and lowest for PC (83.2%). Radiological assessment of preoperative imaging provides a high degree of accuracy in predicting the organ of origin of peri-ampullary cancer.

Concentration of alpha-defensins in the blood plasma of children with Helicobacter pylori – associated peptic ulcer of the duodenum

Introduction. Various gastrointestinal and extragastric diseases are associated with H. pylori in children and adolescents, but the strongest testing and treatment guidelines are only for children and adolescents with peptic ulcer. The most promising developments now are the study of the antibacterial effect of endogenous antimicrobial peptides (AP), among which the most important are defenses 1-3 (human neutrophil peptides, HNPs1-3). Objective. To investigate the concentration of HNPs 1-3 in children with H. pylori-associated peptic ulcer of the duodenum (DU). Methods. A study of 65 children with DU (47 children with H. pylori-associated DU, 18 children with H. pylori-negative DU) and 25 healthy children aged 7-18 years with the determination of HNPs 1-3 levels in plasma. Results. More common was H. pylori in the group of children with III grade of inflammation than in the group of children with II grade (χ2:p&lt;0.0001). A significant association was found between mucosal inflammation activity and the presence of H. pylori (r=0.66, p&lt;0.0001). The mean level of HNP1-3 in healthy children was 13.67±0.96 ng/ml, in children with DU it was probably higher and was 104.88±11.5 ng/ml (p=0.005). There is a direct correlation between the level of HNP1-3 and the severity of DU in children (r=0.67, p&gt;0.05), as well as between HNP1-3 and the activity of the inflammatory process (r=0.73, p&gt;0.01). In children with H. pylori-associated DU, HNP1-3 values were significantly higher (107.34±16.18 [98.45-119.22]) ng/ml than those in children with DU not associated with H. pylori infection (66.70±11.31 [59.54-73.29]) ng/ml and in healthy children (13.67±0.96 [7.27-18.91] ng/ml). Conclusion. Elevated plasma HNP1-3 levels in children with DU in the presence of H. pylori are likely to be a protective response to limit infection that can be used as a potential biomarker of adverse events.

The leukocyte formula of blood in helminthic invasions

The blood picture in helminthic invasions and its significance in the clinic of these diseases have already been sufficiently covered in print. Nevertheless, our material, it seems to us, is of some interest due to the fact that we studied the blood picture in those patients who, in addition to coprological research, also had the expulsion of worms per duode num. Thus, our results relate to a certain type of worm, precisely established. We took blood smears a few days before or on the eve of the expulsion of the worms. In total, the blood was examined in 117 invasive patients, which are distributed according to the genus of worms as follows.

S1650 Severely Elevated CA19-9: Benign or Malignant?

Introduction: CA 19-9 is a carbohydrate antigen and a widely used biomarker for pancreatic cancer, however it can be elevated in extra-pancreatic malignancies and benign conditions. Generally, CA 19-9 levels are significantly lower in benign than in malignant conditions, and levels resolve once the primary obstruction or inflammatory offense is treated. We present a case of a male who was found to have critically elevated CA 19-9 without evidence of pancreatic malignancy. Case Description/Methods: A healthy 51-year-old male presented to the emergency room with generalized itchiness and painless jaundice for two weeks. Symptoms originally began with abdominal pain that quickly resolved, but was followed by jaundiced skin, dark urine, and clay colored stools. His physical exam was positive for scleral icterus and jaundice, with a negative abdominal exam. His laboratory values in the emergency room were significant for an elevated total bilirubin of 15.8 mg/dl, direct bilirubin of 11.8 mg/dl, elevated alkaline phosphatase 521 U/L, elevated AST of 56 U/L and ALT of 103 U/L without leukocytosis. The MRCP revealed choledocholithiasis and the patient was planned for an endoscopic retrograde cholangiopancreatography (ERCP) for further evaluation of the obstructive jaundice. While pending ERCP, a critically elevated CA 19-9 came back at 23,398.5 U/ML. He subsequently had an ERCP that confirmed the presence of the choledocholithiasis, and he underwent a biliary sphincterotomy with biliary stent placement. No masses were appreciated during either MRCP or ERCP. Pathology from duodenal ampulla was negative for dysplasia. The patient was discharged home the next day with outpatient follow-up. Discussion: CA 19-9 is not specific for pancreatic carcinoma, as it has been found elevated in extra-pancreatic malignancies and benign conditions such as disease of the hepatobiliary system, pneumonia, pleural effusion, renal failure and SLE. In a retrospective review of all patients who had CA 19-9 levels measured, markedly raised levels of more than 10,000 U/ml were observed in patients with advanced stages of colorectal, pancreatic and lung carcinoma. In benign conditions, no patients had a CA 19-9 level greater than 500 and only 2 cases of cirrhosis and cholecystitis had a level between 200-500. Although our patient did not have any evidence of malignancy, it should be kept on the differential if his outpatient work-up reveals persistently elevated CA 19-9 levels despite resolution of biliary obstruction.

Glycopatterns of the foregut in the striped dolphin Stenella coeruleoalba, Meyen 1833 from the Mediterranean Sea

AbstractThe glycopatterns of the glycans secreted by the mucosa of stomach and duodenal ampulla of the striped dolphin, Stenella coeruleoalba were studied by histochemical (Periodic acid‐Schiff, Alcian Blue pH 2.5, High Iron Diamine) and lectin‐binding (SBA, DBA, PNA, WGA, MAA‐II, SNA, ConA, UEA‐I, AAA, LTA) techniques. The stomach can be divided into four compartments: main stomach, two connecting chambers and pylorus. The pylorus is followed by the duodenal ampulla. Mucins are secreted by surface cells and intramucosal glands specific for each compartment. In the main stomach glands, neck cells were weakly sulphated, with prevailing glycosaminylated, glycosylated/mannosylated, and fucosylated residuals. Parietal and chief cells in general were scarcely reactive. In the connecting chambers glands, there were high levels of sulphation, glycosaminylation, glycosylation/mannosylation, and fucosylation, the latter with more complex patterns than those observed in the main stomach glands. In the pyloric glands sulphated, glycosaminylated and fucosylated residuals decreased, whereas the opposite was observed for galactosyl/galactosaminylated residuals. Glycosylation patterns in the glands of the duodenal ampulla differed from those of the pyloric ones, with similar levels of sulphation, lower levels of galactosyl/galactosaminylation and glycosaminylation, and higher level of fucosylation. The results are compared with those available in literature.

Ampullary neoplasms: surgical management

Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth. Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors. Areview of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry arisk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and levelII dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.

A Pilot Study of Synchronization of Respiration-Induced Motions in the Duodenum and Stomach for the Primary Tumor in Radiation Therapy for Pancreatic Cancer Using 4-Dimensional Computed Tomography

PurposeWe investigated the synchronization of respiration-induced motions at the primary tumor and organs at risk at radiation planning for pancreatic cancer. Methods and MaterialsFour-dimensional computed tomography images were acquired under the condition of shallow free breathing in patients with pancreatic cancer. The gross tumor volume (GTV), duodenum (DU), and stomach (ST) were contoured. The center of mass was computed for each 4-dimensional volume of interest. The respiration dependence of coordinates for the center of each volume of interest was computed relative to its location at the 50% (maximum exhalation) phase. Based on the shift of the GTV, we investigated the synchronization of respiration-induced motions between each contouring target. We examined the differences in the volume averaged dose to the ST and DU in each respiratory phase. ResultsNine patients with pancreatic cancer were analyzed in this study. The mean maximum 3-dimensional excursions at the GTV, DU, and ST were 9.6, 9.8, and 11.4 mm, respectively. At phase 0% and 90% (inhale phases), mean distance changes in the positional relationship with the GTV were 0.3 and 0.7 mm respectively for the DU and −2.5 and −2.4 mm respectively for the ST. There was no significant respiration associated change (RAC) between each respiratory phase in the DU (P = .568), and there was a significant RAC in the ST (P < .001). There was a significant RAC of the volume averaged dose to the ST (P = .023). ConclusionsOur results indicate that the DU but not the ST might move synchronously with GTV due to respiration.