Duodenal Segment Research Articles

Strong Procedure for Superior Mesenteric Artery Syndrome in Children: A Case Report

Superior mesenteric artery syndrome (SMAS) or Wilkie syndrome is a rare anomaly resulting from extrinsic compression of the third duodenal segment by the superior mesenteric artery (SMA) anteriorly and the abdominal aorta posteriorly. Clinically, SMAS is characterized by acute or chronic upper obstruction associated with intermittent abdominal pain. Abdominal computed tomography is the key examination for establishing the diagnosis. Although initial management is medical, surgery is required if this fails. We report the case of a 12-year-old girl admitted for acute occlusive syndrome associated with abdominal pain, in whom the diagnosis of SMAS was retained. Treatment consisted of Strong's surgical technique after failure of medical treatment with good evolution. Our case reports that in cases of SMAS where medical treatment is ineffective, less invasive surgical options such as Strong's technique may be considered to facilitate rapid recovery while minimizing the risk of complications associated with more complex procedures involving bowel resection and anastomosis.

A case of pancreaticoduodenal artery bleeding after laparoscopic right colectomy requiring open hemostasis

BackgroundPancreatic and duodenal-related complications after right colectomy carry a higher risk of mortality.Case presentationA 64-year-old woman underwent laparoscopic right colectomy for a laterally spreading tumor in the cecum. On postoperative day 10, she experienced sudden hematemesis. Contrast-enhanced computed tomography (CT) of the abdomen showed a large amount of hemorrhage in the stomach, but no obvious extravasation. In addition, free air was observed near the duodenal bulb. Despite blood transfusion, vital signs remained unstable and emergency surgery was performed. The abdomen was opened through midline incisions in the upper and lower abdomen. A fragile wall and perforation were observed at the border of the left side of the duodenal bulb and pancreas, with active bleeding observed from inside. As visualization of the bleeding point proved difficult, the duodenum was divided circumferentially to confirm the bleeding point and hemostasis was performed using 4-0 PDS. The left posterior wall of the duodenum was missing, exposing the pancreatic head. For reconstruction, the jejunum was elevated via the posterior colonic route and the duodenal segment and elevated jejunum were anastomosed in an end-to-side manner. Subsequently, gastrojejunal and Brown anastomoses were added. Drains were placed before and after the duodenojejunal anastomosis. Postoperative vital signs were stable and the patient was extubated on postoperative day 1. Follow-up contrast-enhanced CT of the abdomen showed no active bleeding, and the patient was discharged home on postoperative day 21. As of 6 months postoperatively, the course of recovery has been uneventful.ConclusionsWe encountered a case of pancreaticoduodenal artery hemorrhage after laparoscopic right colectomy. Bleeding at this site can prove fatal, so treatment plans should be formulated according to the urgency of the situation.

1214 Wilkie's Syndrome - a Case Report

Abstract Aortomesenteric duodenal compression syndrome (Wilkie’s syndrome) describes compression of the third duodenal segment between the superior mesenteric artery and aorta, causing upper gastrointestinal (UGI) obstruction. Wilkie’s syndrome typically presents with significant weight loss and features of UGI obstruction. It can initially be treated conservatively with decompression and appropriate re-feeding, but occasionally requires surgical correction. In this presentation, we describe a case of Wilkie’s syndrome in a non-English speaking foreign national, disengaged from healthcare. Case Presentation A 47-year-old Romanian national presented with two months of severe epigastric pain, vomiting, inability to tolerate food intake and severe weight loss, with a background of five years of similar symptoms. On examination, the patient was tachycardic (130), severely dehydrated with skin tenting, and cachexic with a distended abdomen and palpable mass in the epigastrium. Computed tomography imaging was performed, excluding an obstructing malignancy, instead demonstrating significant stomach distension (∼50% of the peritoneal cavity), from Wilkie's Syndrome. The patient underwent oesophagogastroduodenoscopy which demonstrated oesophagitis, gastritis and a duodenal ulcer. Biopsies were negative for H pylori and malignancy. Management involved nasogastric tube decompression, intravenous electrolyte collection, fluid resuscitation and high dose PPI. The patient was discharged on day 6 with planned follow-up in one month and assessment for requirement of surgical management for Wilkie’s syndrome. Discussion We present a rare case of Wilkie’s syndrome and discuss conservative and surgical management. We also use this case of late presentation to highlight the challenges of management, and the importance of clearly communicated follow-up plans in vulnerable populations.

Changes of Enterocyte Morphology and Enterocyte: Goblet Cell Ratios in Dogs with Protein-Losing and Non-Protein-Losing Chronic Enteropathies.

This study aimed to assess the morphometry of enterocytes as well as the goblet cell-to-enterocyte ratio in different intestinal segments of dogs with chronic enteropathies (CE). Histopathological intestinal samples from 97 dogs were included in the study (19 healthy juveniles, 21 healthy adults, 24 dogs with protein-losing enteropathy (PLE), and 33 CE dogs without PLE). Healthy adult small intestinal enterocytes showed progressively reduced epithelial cell height in the aboral direction, while juvenile dogs showed progressively increased epithelial cell height in the aboral direction. CE dogs had increased epithelial cell height in the duodenum, while PLE dogs had decreased epithelial cell heights compared to healthy adult dogs. Both the CE and PLE dogs showed decreased enterocyte width in the duodenal segment, and the ileal and colonic enterocytes of CE dogs were narrower than those of healthy adult dogs. CE dogs had a lower goblet cell-to-enterocyte ratio in the colon segment compared to healthy dogs. This study provides valuable morphometric information on enterocytes during canine chronic enteropathies, highlighting significant morphological enterocyte alterations, particularly in the small intestine, as well as a reduced goblet cell-to-enterocyte ratio in the colon of CE cases compared to healthy adult dogs.

Peculiarities of the foregut organic disorders in patients with an acute pancreatitis

Objective. To study the character and peculiarities of structural changes of esophageal, gastric and duodenal wall in patients with an acute pancreatitis.
 Materials and methods. Analysis of the esophago–gastro–duodenoscopy results was conducted in 86 patients with estimation of endoscopic signs of the motor–evacuation and organic disorders of foregut.
 Results. Endoscopic signs of gastrostasis were observed in 17 (20.0%) patients, of duodeno–gastric reflux – in 29 (34.0%), and reflux–oesophagitis – in 14 (16.2%). Reactive inflammatory mucosal gastro–duodenal changes (erythematous and hemorrhagic–erosive gastro–duodenopathy) were determined in 22 (25.6%) patients: in 12 (14.0%) – in moderately severe, and in 10 (11.6%) – in severe acute pancreatitis. In 24 (28.0%) patients an acute erosions of gastric antrum and first duodenal segment were revealed, and in 14 (16.0%) – acute ulcers, which dominated in severe course of the disease.
 Conclusion. The endoscopic signs of the foregut organic disorders established constitute the predictor of the course severity in an acute pancreatitis and serve a criterion of its diagnosis.

Abstract 24: Oncogenic KrasG12D and Cdkn2a/p16 knockout in LGR5 expressing progenitor cells synergize to advance adenoma and adenocarcinoma phenotypes in murine small intestine

Abstract Background: KRAS activating mutations are reported in 42-54% and inactivation of CDKN2A/p16 in 14-30% of human small intestinal adenocarcinomas, suggesting a role in small intestine adenocarcinogenesis. The phenotypic effects of oncogenic KRAS and p16 loss have not been well characterized in small intestine (SI) adenocarcinogenesis. We targeted LGR5-expressing progenitor cells residing in intestinal crypts for conditional activation of Kras and/or Cdkn2a/p16 deletion to generate a murine model to study the single and combined effects of KRAS and p16 alterations driving gastrointestinal tumorigenesis. We hypothesized that oncogenic Kras and loss of Cdkn2a/p16 drives adenoma-adenocarcinoma sequence in murine SI. Methods: We generated mice with conditional knockout of Cdkn2a/p16 (p16del: IL1bwt/tg;Lgr5-Cre+/−;p16fl/fl;Kraswt/wt), conditional expression of oncogenic KrasG12D (IL1bwt/tg;Lgr5-Cre+/−;KrasG12D/wt), or both alterations (p16del+KrasG12D: IL1bwt/tg;Lgr5-Cre+/−;p16fl/fl;KrasG12D/wt), in mice carrying the human interleukin 1 beta (IL1B) and expressing modified Cre under the Lgr5 promoter. Our control murine model expresses wild type p16 and KRAS (p16wt+Kraswt: IL1bwt/tg;Lgr5-Cre+/−;p16wt/wt;Kraswt/wt). These mice were initially generated to study esophageal adenocarcinogenesis and express the IL1b transgene in esophagus but not in SI. All mice were given bile acid in drinking water daily and were treated with tamoxifen to activate Cre in Lgr5-positive gastrointestinal epithelial progenitor cells. Mice were euthanized and gross and histologic alterations in the SI were examined from 4 to 21 months of age. 3D organoids were isolated from the SI of each mouse model. Results: We examined 89 mice from 4 to 12 months of age. Mice with KRAS activation (KrasG12D) alone infrequently developed SI duodenal adenomas (6.25%: 1/16) compared to 50% (9/18) of mice carrying the combined P16del+KrasG12D genotypes (P=0.005). No adenomas were seen in 27 control and 28 p16del mice. Adenomas with high-grade dysplasia, intramucosal adenocarcinoma, and invasive adenocarcinoma were seen only in older p16del+KrasG12D mice (13-21 months). Single or multiple adenomas and adenocarcinomas were observed only in the duodenal segment of SI and not in the colon. 3D organoids isolated from each mouse model reproduce the intestinal histologic phenotype. Conclusions: Loss of Cdkn2a/p16 and KRASG12D expression synergistically advances adenoma-adenocarcinoma tumorigenesis in the SI duodenum, providing a murine model that recapitulates SI adenocarcinogenesis in vivo. 3D SI organoids provide useful in vitro models for mechanistic studies of SI adenocarcinogenesis. These in vivo and in vitro models will enable identification of key molecular pathways that may be targeted with novel therapies for this rare cancer. Citation Format: Tyler Seckar, Jing Sun, Elena V. Komissarova, Jorge L. Sepulveda, Timothy L. Wang, Antonia R. Sepulveda. Oncogenic KrasG12D and Cdkn2a/p16 knockout in LGR5 expressing progenitor cells synergize to advance adenoma and adenocarcinoma phenotypes in murine small intestine [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 24.

Iohexol is an intestinal permeability marker in broilers under coccidiosis challenge

Intestinal integrity losses have been identified as a main driver for poor performance in broilers. The oral administration of markers such as iohexol is a major asset for measuring intestinal permeability (IP) alterations. The aim of the current study was to evaluate oral iohexol administration and serum levels as a quantitative measure for IP in Ross 308 broilers and to identify possible associations with histologic measurements. A total of 40, day-old broiler chickens were randomly divided into 4 groups of 10 broilers and a coccidiosis model was used to induce IP. Three challenge groups received a mixture of different field strains and concentrations of Eimeria acervulina and Eimeria maxima at d 16, and 1 group operated as an uninfected control group. On d 20, 5 birds per group were orally administered the permeability marker iohexol at a dose of 64.7 mg/kg body weight and blood was taken 60 min after the oral gavage. On d 21 these 5 birds per group were euthanized. On d 21, 5 other birds per group were given iohexol where after blood was taken. These birds were euthanized on d 22. During necropsy, birds were scored for coccidiosis lesions and a duodenal segment was taken for histology. The Eimeria challenge had a significant impact on the villus length, crypt depth, villus-to-crypt ratio and CD3+ T-lymphocytes area percentage. Challenged birds had a significant higher concentration of serum iohexol on both sampling days, as compared to the uninfected controls. A significant correlation could be found between the serum iohexol concentration and the histologic parameters (villus length, crypt depth and villus-to-crypt ratio) on the first sampling day. This suggests that iohexol may be used as a gut permeability marker in broilers under Eimeria challenge.

SADI-S with Extended Duodeno-Bulb Preservation: Case Report

Obesity has been growing in Brazil and in the world. It is reaching epidemic proportions, and bariatric surgery is the most effective treatment for patients with this disease. Among the procedures described in the literature, ileal surgeries such as biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) present better long-term results in terms of weight loss and comorbidities control. However, there are concerns regarding long term nutritional problems with these procedures. In this case report the aim is to demonstrate the technical feasibility of preserving an extended duodenal bulb segment, in the SADIS-S procedure, when there are difficulties in dissecting the retrobulbar region, as occurred here, due to fibrosis in this area. This assures the maintenance of the proposed surgical technique, in such a situation. The dissection and transection of the duodenum was done 7 cm distally to the pylorus, under endoscopic view, proximally to the papillae, where the tissue was normal. Additionally, due the importance of the duodenal mucosa on minerals and trace elements absorption and the release of important hormones in this region, this case report elicits the evaluation of the impact of this technical modification, which occurred casually, in the nutritional, hormonal and metabolic results, long term. In this case report, the extended duodenal length has demonstrated reasonable weight loss, adequate comorbidities control and good nutritional status, so far. These aspects must be evaluated in the long term, by clinical trials.

Encapsulation of vitexin-rhamnoside based on zein/pectin nanoparticles improved its stability and bioavailability

To improve the solubility, stability, and bioavailability of vitexin-rhamnoside (VR) isolated from hawthorn, it was encapsulated by the zein-pectin nanoparticles system. When the mass ratio of zein to pectin was 1:4, the particle size of nanoparticles was 222.7 nm, and the encapsulation efficiency of VR was 67%. Analysis with the scanning electron microscope (SEM), fourier transform infrared spectroscopy (FTIR) and atomic force microscopy (AFM) revealed that the zein-VR-pectin nanoparticles were spherical and uniformly distributed. The hydrogen bonding and electrostatic interactions were the main forces to assemble the nanoparticles. The nanoparticle had good stability at pH 3–8.5 with particle sizes ranging from 234 to 251 nm, and the nanoparticles were able to resist the relatively lower ionic strength. In vitro simulated digestion and rat in vivo intestinal perfusion experiments showed that the nanoparticles exhibited significant slow-release properties and the highest absorption rate in the duodenal segment of rats, with Ka and Papp of 0.830 ± 0.11 and 17.004 ± 1.09. These results provided a theoretical and technological approach for the construction of flavonoids delivery system with slow-release properties and improved bioavailability.

Giant gastric polyp mimicking a duodenal tumor

Inflammatory fibroid polyps are very rare gastrointestinal tumors. We present the case of a 66-year-old woman with severe anemia and a giant gastric polyp which had intermittent duodenal intussusception. Ultrasonography showed increased gastric wall thickness and suspected an ampulloma, as revealed also by endoscopy and computed tomography. Ultrasonography reassessment showed later the intragastric mass, which was confirmed by endosonography: giant pediculated hypervascular polyp suggesting malignancy. Challenging phenomena at different investigation methods were due to intermittent protrusion into the first duodenal segment mimicking an ampulloma, but without gastric outlet syndrome or a malignant component, despite the severe anemia. Abnormal US aspect of the stomach in clinical context of anemic syndrome, requires EUS with biopsies in order to confirm underlying lesions. The particularities of this case are the: discordance between imaging aspects and the protrusion into the first duodenal segments with consecutive cholestasis mimicking an ampulloma and the lack of gastric outlet syndrome.

Organic zinc with moderate chelation strength enhances zinc absorption in the small intestine and expression of related transporters in the duodenum of broilers.

Our previous study demonstrated that the absorption of zinc (Zn) from the organic Zn proteinate with moderate chelation strength was significantly higher than that of Zn from the inorganic Zn sulfate in the in situ ligated duodenal segment of broilers, but the underlying mechanisms are unknown. The present study aimed to determine the effect of organic Zn with moderate chelation strength and inorganic Zn on the Zn absorption in the small intestine and the expression of related transporters in the duodenum of broilers. The Zn-deficient broilers (13 days old) were fed with the Zn-unsupplemented basal diets (control) containing 25.72 and 25.64 mg Zn/kg by analysis or the basal diets supplemented with 60 mg Zn/kg as the Zn sulfate or the Zn proteinate with moderate chelation strength (Zn-Prot M) for 26 days. The results showed that the plasma Zn contents from the hepatic portal vein of broilers at 28 days and 39 days of age were increased (p < 0.05) by Zn addition and greater (p < 0.05) in the Zn-Prot M than in the Zn sulfate. On d 28, Zn addition upregulated (p < 0.05) mRNA expression of zinc transporter 1 (ZnT1), Zrt-irt-like protein 5 (ZIP5), y + L-type amino transporter 2 (y + LAT2) and b0,+-type amino acid transporter (rBAT), zinc transporter 4 (ZnT4) protein expression, and zinc transporter 9 (ZnT9) mRNA and protein expression in the duodenum. Moreover, ZnT9 mRNA expression, ZnT4, ZIP5, and rBAT protein expression, zinc transporter 7 (ZnT7), and y + LAT2 mRNA and protein expression in the duodenum of broilers on 28 days were higher (p < 0.05) in the Zn-Prot M than in the Zn sulfate. On d 39, supplemental Zn increased (p < 0.05) peptide-transporter 1 (PepT1) mRNA expression and y + LAT2 protein expression, while the mRNA expression of ZnT7 and Zrt-irt-like protein 3 (ZIP3) were higher (p < 0.05) for the Zn-Prot M than for the Zn sulfate in the duodenum. It was concluded that the Zn-Prot M enhanced the Zn absorption in the small intestine partially via upregulating the expression of ZnT4, ZnT7, ZnT9, ZIP3, ZIP5, y + LAT2, and rBAT in the duodenum of broilers.

Usefulness of indocyanine green fluorescence in laparoscopic resection of choledochal cyst in children

Image-guided surgery using indocyanine green allows the delineation of anatomical structures during laparoscopic surgery. Dye excretion through the bile duct has also facilitated complicated cholecystectomies. However, there have been few reports of its application in children. To date, its use for minimally invasive treatment of choledochal cyst in children has not been reported. The adequate treatment of this condition requires careful dissection to avoid vascular and visceral lesions as well as biliary digestive reconstruction according to the morphology of the hepatic duct. In the presented case, the application of this technique allowed for the complete dissection of the cyst without vascular injury, the safe ligation of the duodenal segment of the cyst, and a successful duodenal hepatic anastomosis. These were accomplished through laparoscopy by visualizing the passage towards the duodenum and ruling out the presence of fistulas. • The use of indocyanine green has allowed for choledochal cyst excision in this case. • Indocyanine green delineated the dilated common bile duct from the normal structures. • Indocyanine green also confirmed the absence of leaks in the anastomosis.

P069 The Unrelenting Ulcer.

Inflammatory Bowel Disease (IBD) is becoming more common in an increasingly diverse population. Exposure history is important, especially when prescribing immunosuppressive therapy. We present a case of suspected disseminated histoplasmosis in a gentleman with longstanding Ulcerative Colitis (UC) on anti-TNF with an atypical, large, non-healing duodenal ulcer. We aim to highlight risks, presentation, and management of histoplasmosis in IBD patients on immunosuppression with anti-TNFs. A 49-year-old-male with a 21-year history of left sided UC in remission on Infliximab (10 years) presented to our ED with orthostatic symptoms and melena. He reported two months of heartburn and epigastric pain refractory to acid suppression. In the ED, vitals were unremarkable. Labs showed BUN 38 mg/dL, hemoglobin 13.3 g/dL, and abnormal AST/ALT. Evaluation of mild chest discomfort revealed normal EKG and calcified nodule in the left lower lobe on chest X-ray. Tuberculosis testing was negative. EGD found a massive, 3-4cm, cratered, medial wall, hemi-circumferential ulcer from duodenal apex into the second duodenal segment (D2). Biopsies revealed acute inflammation, without CMV, dysplasia, malignancy or helicobacter pylori. CT identified a large mass 5x3.1x3.2cm in the pancreaticoduodenal groove from D2 without pancreatic duct dilation. There were prominent right axillary and sub-pectoral lymph nodes and the calcified granuloma seen on X-ray. He denied NSAID use. Symptomatic improvement occurred on aggressive acid suppression. EGD a month later showed persistent ulcer with unchanged pathology. EUS showed significant peri-duodenal thickening without malignant findings. IgG/IgG4 immunostains were negative. CEA and CA 19-9 were normal. Subsequent EGDs and imaging showed no changes. He developed duodenal stenosis requiring dilation. Hematology/Oncology evaluation was unrevealing and hyper-secretory disorder was ruled out. Lack of healing over seven months prompted referral to Infectious Disease. They identified bird dropping exposure with repeated deck pressure washing. Positive Histoplasma immunodiffusion M band indicated prior infection. Given exposure, lab, chest imaging and endoscopic findings, treatment for disseminated histoplasmosis (DH) with Itraconazole was initiated. Infliximab was held and mesalamines were restarted. Histoplasmosis is endemic to the Ohio/Mississippi River Valley and other countries. Disseminated histoplasmosis, typically found in the immunocompromised, presents in many ways with GI involvement in 70%. Diagnosis can be difficult as histoplasmosis mimics other diseases, including IBD. Prognosis is poor if left untreated. Endoscopically, ulcerations, mass-like lesions, or strictures are seen. Aside from identifying yeast, pathology is nonspecific. Severity guides treatment, classically involving Itraconazole. In IBD and diseases managed with immunosuppression (e.g. anti-TNFs), stopping therapy during infections is standard of care. Therapy may resume after treatment response. Treatment may be a year for DH. Prophylaxis for histoplasmosis, the most common fungal infection with anti-TNF use, is controversial. Literature exists where anti-TNF was continued during treatment of histoplasmosis with good outcomes. There were no recurrences with continuation or re-initiation of anti-TNF after treatment. However, many patients switched therapies. Though histoplasmosis rarely causes infection in IBD patients, outcomes can be poor. We must be aware of possible exposures, atypical or presentations mimicking IBD to identify infection early, stop immunosuppression and provide timely treatment.

Characterization of the bacterial microbiota across the different intestinal segments of the Qinghai semi-fine wool sheep on the Qinghai-Tibetan Plateau.

ObjectiveThe intestinal microbiota enhances nutrient absorption in the host and thus promotes heath. Qinghai semi-fine wool sheep is an important livestock raised in the Qinghai-Tibetan Plateau; however, little is known about the bacterial microbiota of its intestinal tract. The aim of this study was to detect the microbial characterization in the intestinal tract of the Qinghai semi-fine wool sheep.MethodsThe bacterial profiles of the six different intestinal segments (duodenum, jejunum, ileum, cecum, colon and rectum) of Qinghai semi-fine wool sheep were studied using 16S rRNA V3–V4 hypervariable amplicon sequencing.ResultsA total of 2,623,323 effective sequences were obtained, and 441 OTUs shared all six intestinal segments. The bacterial diversity was significantly different among the different intestinal segments, and the large intestine exhibited higher bacterial diversity than the small intestine. Firmicutes, Bacteroidetes, and Patescibacteria were the dominant phyla in these bacterial communities. Additionally, at the genus level, Prevotella_1, Candidatus_Saccharimonas, and Ruminococcaceae_UCG-005 were the most predominant genus in duodenal segment, jejunal and ileal segments, and cecal, colonic, and rectal segments, respectively. We predicted that the microbial functions and the relative abundance of the genes involved in carbohydrate metabolism were overrepresented in the intestinal segments of Qinghai semi-fine wool sheep.ConclusionThe bacterial communities and functions differed among different intestinal segments. Our study is the first to provide insights into the composition and biological functions of the intestinal microbiota of Qinghai semi-fine wool sheep. Our results also provide useful information for the nutritional regulation and production development in Qinghai semi-fine wool sheep.

A Case of Duodenal Resection and Duodenojejunostomy for Multiple Small Bowel Infarction in Patient With Inherited Thrombophilia and Vitamin K Antagonist Induced Critical Hypocoagulation

We present a case of the multiple venous intestinal infarction in patient with two inherited thrombophilias: Leiden factor V (LFV) and factor VIII elevation. The patient had a critical hypocoagulation caused by vitamin K antagonist (VKA) overdose. At laparotomy, several intestinal segments were necrotic and ischemic. Coagulopathy was corrected by the transfusion of the fresh frozen plasma. Because of the 4th duodenal segment infarction distal segmental duodenectomy with side-to-side duodenojejunostomy was done, which is a rarely performed procedure. On postoperative day 6 deep vein thrombosis developed, despite nadroparin profillaxes, early mobilisation and compressive stockings.Our case demonstrated that in patients with congenital thrombophilia, development of the mesenteric venous thrombosis is possible even with VKA induced severe hypocoagulation. Venous infarction of the small bowel can be associated with the hemoperitoneum and gastrointestinal bleeding. After resection of the fourth duodenal segment, side-to-side duodenojejunostomy is a feasible method of reconstruction.

Partial Obstruction and Intestinal Bleeding Secondary to a Congenital Duodenal Diverticulum in a Dog

Background: Intestinal diverticulum is an abnormality resulting in the formation of a blind-ended saccular pouch that can be acquired either congenital, true (involving all intestinal layers) or false (involving the mucosa and submucosa), with extraluminal and intraluminal type. In humans, the acquired is more frequent, being the colon is the most affected segment followed by duodenum; most of duodenal diverticulum remains asymptomatic, but biliary obstruction, recurrent acute pancreatitis, hemorrhagic ulcer, proximal intestinal obstruction and perforation may occur. The aim of this report is to present a case of a congenital disease in dogs, prone to misdiagnosis due to non-specific clinical signs.Case: An 8-month-old male Boxer was evaluated due to recurrent hyporexia, vomiting, melena and syncope over three months with signs of a possible intestinal obstruction. Physical examination showed no abnormalities except for pale mucous membranes. Complete blood count revealed anemia and leukocytosis. Platelets and biochemical profiles were normal. Abdominal ultrasound examination indicated a dilated duodenum, measuring approximately 3.36 cm in diameter, with heterogeneous fluid content and hyperechogenic structures with acoustic shadow, peristalsis appeared decreased and non-progressive. The gastrointestinal positive contrast study was performed to better evaluate abnormalities detected at ultrasonography. Images after 30 m of contrast administration demonstrated a marked distension of the duodenum, filled with contrast and a mildly filled stomach displaced to the left. Sixty min after contrast administration a marked distension of the entire duodenum, with tortuous aspect and filled with contrast was seen. The caudal duodenal flexure was connected to a large barium filled saccular structure that measured approximately 7 cm in diameter, consistent with a duodenal diverticulum. A blood transfusion was performed and surgical treatment indicated. The diverticulum and a small portion of the caudal duodenal segment were resected, an end-side enteroanastomosis was made due to the difference in diameter between intestinal segments. The patient was medicated with sucralfate (12.5 mg/kg), ranitidine (2 mg/kg), metronidazole (25 mg/kg), dipyrone (25 mg/kg) and, tramadol (2 mg/kg) and recovered quickly from surgery. Histopathological examination characterized the diverticular tissue as a true diverticulum by the presence of all intestinal layers. Post-operative and follow-up evaluations showed no recurrence of clinical signs.Discussion: In veterinary practice, congenital duodenal diverticulum is a rare condition documented in dogs, curiously all Boxers None of the reported cases in literature had the diagnostic of duodenal diverticulum made exclusively by ultrasonography. Other diagnostic imaging modalities, such as gastrointestinal barium study or endoscopy, were necessary. In one case a diagnostic was made during exploratory laparotomy. The marked dilatation of the duodenal segment impaired ultrasound evaluation, allowing recognition of an obstructive pattern, not the diverticulum itself. At histopathological examination, the diverticular tissue was characterized by a thickened wall with a hypertrophied muscle layer, characterizing a true duodenal diverticulum. The location, breed and age of the dogs affected with duodenal diverticulum was similar in all veterinary cases reported. Dogs presenting signs of gastrointestinal disease and abdominal pain are common in patients referred to ultrasound examination. However, despite the rare reports described, we must consider this affection as a differential diagnosis, whenever boxer puppies present these clinical signs associated with gastrointestinal bleeding and syncope.

Comparison of a simple continuous versus simple interrupted suture pattern for the repair of a large, open duodenal defect with a jejunal serosal patch in a canine cadaveric model

To determine whether jejunal serosal patches could securely seal large, open defects in duodenal segments harvested from canine cadavers and to compare intraluminal pressures at which leakage first occurred and maximal intraluminal pressures for repaired duodenal segments between 2 suture patterns. Duodenal and jejunal segments from 9 canine cadavers. 20 constructs were created through repair of large, open duodenal defects with circumferential suturing of an intact jejunal segment (jejunal serosal patch). Constructs were randomly assigned to have the serosal patch anastomosed to the duodenal segment by a simple continuous or simple interrupted suture pattern. The pressure at which the first leakage was observed and the maximum pressure obtained during testing were recorded and compared between suture patterns. Initial leakage pressure was significantly higher with the simple interrupted pattern (mean ± SD, 68.89 ± 5.62 mm Hg), compared with the simple continuous pattern (59.8 ± 20.03 mm Hg). Maximum intraluminal pressures did not significantly differ between the simple interrupted (91 ± 8.27 mm Hg) and simple continuous patterns (90.7 ± 16.91 mm Hg). All constructs, regardless of suture pattern, withstood supraphysiologic pressures. Jejunal serosal patches adequately sealed large, open duodenal defects and prevented leakage in these constructs. Constructs with simple continuous or simple interrupted suture patterns withstood physiologic and supraphysiologic intraluminal pressures, although constructs with a simple interrupted suture pattern initially leaked at higher pressures. (Am J Vet Res 2020;81:985-991).

S2823 Primary Aortoenteric Fistula as a Rare Cause of Gastrointestinal Bleeding

INTRODUCTION: Aortoenteric fistulas (AEF) are formed by an abnormal connection between the aorta and gastrointestinal tract, usually the duodenum, that can lead to life-threatening gastrointestinal hemorrhages. Fistulas can present de novo, known as primary fistulas, or as secondary AEF, which occur due to surgical aortic interventions such as aortic grafts. The annual incidence of primary AEF is 0.007 per million while the incidence of secondary AEF due to aortic repair is 0.6–2%. We present a case of primary Aortoenteric fistula with no prior surgical interventions. CASE DESCRIPTION/METHODS: A 51-year old patient with a past medical history of hypertension, coronary artery disease, and tobacco use was arrived to the hospital with complaints of bright red blood per rectum. A CT abdomen/pelvis revealed a 6.4 cm infrarenal aortic aneurysm (AA) and a right common iliac artery aneurysm with complete thrombosis of the external iliac artery. An EGD showed the duodenum with an opening and oozing fresh blood suggestive of an AEF, along with a pulsatile mass, most likely the AAA. Patient was then emergently taken to the OR and had an endovascular stent placed with successful exclusion of the infrarenal aortic aneurysm. Thereafter, a colonoscopy performed by colorectal surgery showed a large pulsatile blue mass extrinsically compressing the colon in multiple locations; subsequently aborted at the splenic flexure due to this extrinsic compression. The patient then underwent open repair which found an aortoduodenal fistula in the 4th duodenal segment. The duodenum was resected with primary anastomosis, the aortic stent was explanted, aortic aneurysm resected, and reconstruction performed. After surgery, the patient improved clinically and had no further bleeding. DISCUSSION: Primary AEFs are a devastating condition which are difficult to identify. The likely cause, an abdominal aortic aneurysm, can be clinically silent and typically lack any history of prior aortic surgical interventions. When symptoms do occur, it is typically GI bleeding ranging from mild to an exsanguinating hemorrhage, with other nonspecific symptoms including malaise, weight loss, and abdominal pain. CT angiography is a quick initial diagnostic tool but if there was no prior suspicion of primary AEF, an EGD would reveal a clot or fresh blood in the duodenum. With such findings on endoscopy, it is important to quickly involve vascular surgery for emergent repair via open or endovascular techniques to avoid adverse outcomes.Figure 1.: Endoscopic view of primary Aortoenteric Fistula in the duodenum.

Imaging Spectrum of Duodenal Emergencies.

The duodenum, the first portion of the small bowel, is divided into four segments and extends to both retro- and intraperitoneal spaces. Some conditions arise primarily from the duodenum, but it can be secondarily affected by processes that involve neighboring structures. When duodenal emergencies are not identified and treated promptly, they may result in high morbidity and mortality. Imaging plays an important role in the diagnosis of duodenal conditions in the acute setting. However, the radiologic findings can be subtle, and awareness of relevant patient history and clinical presentation is important as it may increase the index of suspicion and one's ability to diagnose these conditions. Duodenal peptic disease is common and can be complicated by bleeding and perforation. The duodenum can be secondarily involved by pancreatitis and gallbladder pathologic conditions and may be affected by iatrogenic complications following endoscopic procedures. Traumatic injuries to the duodenum are generally uncommon, with penetrating traumatic injury being the most frequent mechanism of injury. Duodenal vascular pathologic conditions such as aortoduodenal fistula are uncommon but can be life threatening. The knowledge of which pathologic condition can involve which duodenal segment can help the radiologist establish a differential diagnosis and achieve a more targeted imaging approach. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.

Correlation of intraoperative donor duodenal-segment swab cultures with the subsequent occurrence of surgical site infections in kidney and pancreas transplant recipients.

Pancreas transplantation is employed for the treatment of type I diabetes mellitus. It is postulated that surgical site infection (SSI), particularly organ-space infections, after pancreas transplantation may arise from microbial contamination arising from the donor duodenal segment. Therefore, some centers have adopted the practice of culturing the donor duodenal segment and subsequently administering antimicrobial therapy to the recipient directed at the microorganisms isolated to prevent SSI. In this retrospective cohort study, we evaluated the correlation between positive donor duodenal-segment cultures and SSIs in the recipients. Data were recorded and analyzed to assess the correlation of the organisms isolated in the donor duodenal cultures with those producing SSI in the recipients. We evaluated 379 consecutive pancreas transplant recipients from January 2000 to December 2015. Donor duodenal swab cultures were performed at the time of pancreas transplantation, and 206 (54.3%) were positive. SSIs occurred in 51 of the 206 recipients (24.8%) with positive duodenal-segment cultures and in 41 of 173 individuals (23.7%) with negative cultures (P = .81; r = 0.00). Notably, deep and organ-space SSIs were observed in 27 of 206 of the positive duodenal culture groups (13.1%) versus 29 of 173 of the negative duodenal culture groups (16.8%; P = 0.31; r = -0.059). No differences were detected in the pathogens producing SSIs between the group with a positive duodenal swab versus the group with a negative swab. Microorganisms producing SSIs matched those found in the positive donor duodenal cultures in only 15 patients (7.8%). Although positive cultures from the donor duodenal segment prompted the administration of antimicrobial therapy in the recipient directed against the pathogen isolated, this practice did not reduce SSIs compared with those transplant recipients with culture-negative duodenal swabs. In addition, the organisms isolated from the donor duodenal segment were not predictive of subsequent SSI.