Duodenal Wall Thickening Research Articles

Efficacy and safety of apraglutide in short bowel syndrome with intestinal failure and colon–in–continuity: A multicenter, open-label, metabolic balance study

BackgroundApraglutide is a novel long-acting GLP-2 analog in development for short bowel syndrome with intestinal failure (SBS-IF). This multicenter, open-label, phase 2 study in SBS-IF and colon-in-continuity (CiC) investigates the safety and efficacy of apraglutide. MethodsThis was a 52-week phase 2 metabolic balance study (MBS) in 9 adult patients with SBS-IF-CiC receiving once-weekly subcutaneous apraglutide injections. Safety was the primary endpoint. Secondary endpoints included changes in absorption parameters (MBS at baseline, after 4 weeks with stable parenteral support (PS), and 48 weeks), PS needs (48-week PS adjustment period based on monthly 48-hour fluid balances) and intestinal morphology and motility (static and cine MRI at baseline and 4, 24 and 48 weeks). ResultsPS volume decreased by -4702mL/week (-52%; p<0.001) at week 52. Seven patients (78%) achieved ≥1 day off PS at week 52. At 4 weeks, fecal output was reduced by 253 g/day (p=0.013). At 48 weeks, increases in wet weight absorption by 316 g/day (p=0.039), energy absorption by 1134 kJ/day (p=0.041) and carbohydrate absorption by 56.1 g/day (p= 0.024) were observed. Moreover, small bowel length increased from 29.7 to 40.7 cm (p=0.012), duodenal wall thickness increased by 0.8 mm (p=0.02) and motility in the proximal colon was reduced (p=0.031). A total of 127 adverse events was reported, which were mostly mild to moderate. ConclusionApraglutide had an acceptable safety profile and was associated with significant reductions in PS needs and days off PS, improvements in intestinal absorption, and structural and functional intestinal changes in patients with SBS-IF-CiC.ClinicalTrials.gov, Number NCT04964986

Peri-Ampullary Tumour; An Unusual Cause of Upper Gastrointestinal Bleeding

Periampullary tumors are cancers that arise in the region of the around the ampulla of Vater, where the bile duct and pancreatic duct converge and empty into the small intestine. This region is very critical for digestive enzyme and bile secretions. This may be associated with slow disease progression, age related changes delayed onset of symptoms and lack of screening and diagnostic facilities. These tumours can be challenging to diagnose and manage due to their proximity to several vital structures. Upper gastrointestinal bleeding may be a rare clinical presentation following tumoral ulceration, erosion into blood vessels or nearby structures or secondary complications like pancreatitis or portal hypertension. Identifying the anatomical origin of these malignancies is usually a herculean task. This will require prompt oesophagogastroduodenoscopy and imaging to determine the source and appropriate management. This is especially true given the region's transitional character, closeness to various structures, and overlapping features among them. We present periampullary tumour an unusual cause of upper gastrointestinal bleeding in a resource limited setting. A52 year old Nigerian male was admitted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto for evaluation following a 3 months history of progressive weight loss, generalized body weakness and a burning and occasionally colicky, persistent, non-radiating epigastric pain, loss of appetite, easy fatiguability, occasional dizziness and recurrent non-projectile post-prandial non-billous vomiting. Though he had no hematemesis, he had history of passage of malaena. The patient was fully conscious on admission, pale, wasted with a markedly tender epigstric region. He was tachycardic with a minimal elevation in blood pressure level of 138/94mmHg. He had an international normalized ratio (INR) of 1.0. Oesophagogastroduodenoscopy was performed which showed a polypoid fungating mass at the1st extending to the 2nd part of the duodenum. A Computerized Tomogram scan of the abdomen showed a diffuse circumferential duodenal wall thickening of 1st and 2nd parts (more in 2nd part) with reduction in luminal calibre of duodenum and mildly dilated pancreatic, common bile, common hepatic ducts. Multiple biopsies were taken for histology which showed moderately differentiated aadenocarcinoma. Surface epithelium composed of columnar epithelial cells which can be seen in the top right of the image below with an invasive tumour, seen infiltrating the lamina propria in the lower left. He went on to have an exploratory laparotomy with triple bypass involving a side to side gastrojejunal anastomosis and cholecystojejunostomy and entero-enterotomy folowing which he went on to receive chemotherapy. As of the time of this write up the patient has recuperated well following his treatment.

Groove pancreatitis – an unusual case of pancreatitis, case report

Groove pancreatitis is a rare form of chronic pancreatitis affecting the pancreaticoduodenal groove, leading to ductal stenosis and symptoms like abdominal pain, vomiting, and jaundice. It often coexists with cystic dystrophy of the duodenal wall (CDDW), marked by duodenal wall thickening and cyst formation. We report a case of a 36-year-old male with persistent abdominal pain and a history of acute pancreatitis, diagnosed with CDDW via MRI. Despite multiple endoscopic interventions, ductal access was challenging due to inflammation and conservative management with proton pump inhibitors and pancreatic enzymes provided symptom relief. Diagnostic tools include MRI, endoscopy, and EUS were administered. Management of groove pancreatitis still remains a challenge consisting of treatment ranging from conservative methods to surgical intervention for refractory cases, emphasizing a cautious, stepwise approach and lifestyle changes.

Groove pancreatitis: From enigma to future directions-A comprehensive review.

Groove pancreatitis (GP) is a rare and clinically distinct form of chronic pancreatitis affecting the pancreaticoduodenal groove comprising the head of the pancreas, duodenum, and the common bile duct. It is more prevalent in individuals in their 4-5th decade of life and disproportionately affects men compared with women. Excessive alcohol consumption, tobacco smoking, pancreatic ductal stones, pancreatic divisum, annular pancreas, ectopic pancreas, duodenal wall thickening, and peptic ulcers are significant risk factors implicated in the development of GP. The usual presenting symptoms include severe abdominal pain, nausea, vomiting, diarrhea, weight loss, and jaundice. Establishing a diagnosis of GP is often challenging due to significant clinical and radiological overlap with numerous benign and malignant conditions affecting the same anatomical location. This can lead to a delay in initiation of treatment leading to increasing morbidity, mortality, and complication rates. Promising research in artificial intelligence (AI) has garnered immense interest in recent years. Due to its widespread application in diagnostic imaging with a high degree of sensitivity and specificity, AI has the potential of becoming a vital tool in differentiating GP from pancreatic malignancies, thereby preventing a missed or delayed diagnosis. In this article, we provide a comprehensive review of GP, covering the etiology, pathogenesis, clinical presentation, radiological and endoscopic evaluation, management strategies, and future directions. This article also aims to increase awareness about this lesser known and often-misdiagnosed clinical entity amongst clinicians to ultimately improve patient outcomes.

Aetiological Spectrum of Pancreaticobiliary Diseases in Adult Nigerians on Magnetic Resonance Cholangiopancreatography.

Imaging is vital for assessing pancreaticobiliary diseases. The aim of the study was to investigate the spectrum and pattern of pancreaticobiliary diseases in adult Nigerians using magnetic resonance cholangiopancreatography (MRCP). This was a retrospective, descriptive cross-sectional study. The electronic radiological records of 110 adult Nigerians who had undergone MRCP were reviewed. The MRCP images were evaluated for bile duct dilatation, intraluminal filling defects, strictures, calculi, and other abnormalities. There were 45 males (40.9%) and 65 females (59.1%) aged 18-83 years, with a mean age of 51.93 ± 15.22 years. Jaundice (59.1%) and right hypochondrial pain (31.8%) were the most common presenting complaints. Gallstones (32.7%), common bile duct strictures (15.5%), choledocholithiasis (11.8%), pancreatic head carcinoma (10.9%), and gallbladder carcinoma (2.7%) were the most frequent abnormalities. There was biliary obstruction in 56.4% of participants, mostly at the distal and proximal common bile duct. Other findings include hepatomegaly (23.6%), hepatic cysts (6.4%), hepatic steatosis (0.9%), duodenal wall thickening (1.8%), and ascites (5.5%). MRCP was normal in 25 (22.7%) participants. Gallstones were the predominant pathology of the various pancreaticobiliary diseases, while Pancreatic head and gallbladder carcinoma were the most common malignant diseases.

Theory of the Leaky Intestine: Sex Differences in Intestinal Parasitic Infections, Cytoskeletal Wall Dysfunctions, and Hypertension

BACKGROUND: Intestinal parasitic infections (IPIs) impact approximately 3.5 billion individuals globally. Protozoan IPIs may influence the intestinal microbiome. This research investigates IPI effects on intestinal wall thickness and their potential links to sex-specific hypertension. It also explores the impact of alterations in intestinal wall permeability on sodium and blood glucose levels. METHODS: The study enrolled 108 subjects, including 83 consecutive patients with confirmed symptomatic IPIs (48 males, 35 females) and 25 healthy volunteers used as controls (9 males, 16 females). B-mode ultrasound grayscale images of the duodenum and colon were taken with and without water contrast. RESULTS: Patients with parasites exhibited a higher BMI (mean = 28.9 ± 7.4) compared to controls (mean = 24.68 ± 7.2), F (1, 96) = 5.78, _p _&lt; 0.05. IPI patients showed a tendency towards increased duodenal wall thickness (DUOTHICK = 0.88 ± 0.7 cm) versus controls (0.6 ± 0.1 cm), _p = _0.05. Additionally, IPI patients had significantly greater thickness in the ascending colon (ASCTHICK = 1.1 ± 0.3 cm) and descending colon (DSCTHICK = 1.2 ± 0.4 cm) compared to controls (ASCTHICK = 0.6 ± 0.2 cm, DSCTHICK = 0.6 ± 0.1 cm), _p _&lt; 0.05. Men over 50 years exhibited greater DSCTHICK (1.25 ± 0.434 cm) than postmenopausal women (0.986 ± 0.389 cm), _p _&lt; 0.05. DSCTHICK significantly predicted diastolic blood pressure (β = −0.295, _p _&lt; 0.05) and blood sodium level (β = −0.300, _p _&lt; 0.05). DUOTHICK in diabetic IPI patients exceeded that in nondiabetic patients. Effective antiparasitic and antidiabetic treatments induced changes in the echoanatomy of the intestinal wall, suggesting the sealing of ‘the leak’. CONCLUSIONS: IPIs disrupted the intestinal cytoskeleton, leading to “leaky gut syndrome” development.

Duodenal tuberculosis with gastric outlet obstruction: a case report of successful diagnosis and treatment, with review of literature

BackgroundDuodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked.Case presentationA 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl–Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic.ConclusionsAn aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO.

Theory of the Leaky Intestine: Gender Differences in Intestinal Parasitic Infections, Cytoskeletal Wall Dysfunctions, and Hypertension

BACKGROUND: Intestinal parasitic infections (IPIs) impact approximately 3.5 billion individuals globally. Protozoan IPIs may influence the intestinal microbiome. This research investigates IPI effects on intestinal wall thickness and their potential links to gender-specific hypertension. It also explores the impact of alterations in intestinal wall permeability on sodium and blood glucose levels. METHODS: The study enrolled 108 subjects, including 83 consecutive patients with confirmed symptomatic IPIs (48 males, 35 females) and 25 healthy controls (9 males, 16 females). B-mode ultrasound grayscale images of the duodenum and colon were taken with and without water contrast. RESULTS: Patients with parasites exhibited a higher BMI (mean = 28.98 ± 7.43) compared to controls (mean = 24.68 ± 7.2), F (1, 96) = 5.78, _p _&lt; 0.05. IPI patients showed a tendency towards increased duodenal wall thickness (DUOTHICK = 0.88 ± 0.73 cm) versus controls (0.6 ± 0.1 cm), _p = _0.056. Additionally, IPI patients had significantly greater thickness in the ascending colon (ASCTHICK = 1.1 ± 0.3 cm) and descending colon (DSCTHICK = 1.2 ± 0.4 cm) compared to controls (ASCTHICK = 0.6 ± 0.2 cm, DSCTHICK = 0.6 ± 0.1 cm), _p _&lt; 0.05. Men over 50 years exhibited greater DSCTHICK (1.25 ± 0.434 cm) than postmenopausal women (0.986 ± 0.389 cm), _p _&lt; 0.05. DSCTHICK significantly predicted diastolic blood pressure (β = −0.295, _p _&lt; 0.05) and blood sodium level (β = −0.300, _p _&lt; 0.05). DUOTHICK in diabetic IPI patients exceeded that in nondiabetic patients. Effective antiparasitic and antidiabetic treatments induced changes in the echoanatomy of the intestinal wall, suggesting the sealing of ‘the leak’. CONCLUSIONS: IPIs disrupted the intestinal cytoskeleton, leading to “leaky gut syndrome” development.

IgG4-related disease of duodenal obstruction due to multiple ulcers in a 12-year-old girl

BackgroundImmunoglobulin G4-related disease (IgG4-RD) is a systemic inflammatory disease and affected individuals typically present with an increased infiltration of IgG4-positive plasma cells in the pancreas, hepatobiliary tract, and liver but rarely in the gastrointestinal tract.Case presentationA 12-year-old girl presented with vomiting and poor weight gain. Gastroscopy revealed duodenal stenosis and ulceration. Computed tomography revealed edematous duodenal wall thickening and air-fluid levels on the right side of the duodenum, which suggested duodenal perforation or penetration. She underwent pancreaticoduodenectomy, and IgG4-RD was diagnosed via histopathology.ConclusionsThis is the first pediatric case of isolated duodenal IgG4-RD resulting in duodenal obstruction after multiple ulcers. Gastrointestinal IgG4-RD should be among the differential diagnoses of unexplained gastrointestinal obstruction or ulceration even in children.

Imaging of paraduodenal pancreatitis: A systematic review.

Paraduodenal pancreatitis (PP) represents a diagnostic challenge, especially in non-referral centers, given its potential imaging overlap with pancreatic cancer. There are two main histological variants of PP, the cystic and the solid, with slightly different imaging appearances. Moreover, imaging findings in PP may change over time because of disease progression and/or as an effect of its risk factors exposition, namely alcohol intake and smoking. To describe multimodality imaging findings in patients affected by PP to help clinicians in the differential diagnosis with pancreatic cancer. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses 2009 guidelines. A Literature search was performed on PubMed, Embase and Cochrane Library using (groove pancreatitis [Title/Abstract]) OR (PP [Title/Abstract]) as key words. A total of 593 articles were considered for inclusion. After eliminating duplicates, and title and abstract screening, 53 full-text articles were assessed for eligibility. Eligibility criteria were: Original studies including 8 or more patients, fully written in English, describing imaging findings in PP, with pathological confirmation or clinical-radiological follow-up as the gold standard. Finally, 14 studies were included in our systematic review. Computed tomography (CT) findings were described in 292 patients, magnetic resonance imaging (MRI) findings in 231 and endoscopic ultrasound (EUS) findings in 115. Duodenal wall thickening was observed in 88.8% of the cases: Detection rate was 96.5% at EUS, 91.0% at MRI and 84.1% at CT. Second duodenal portion increased enhancement was recognizable in 76.3% of the cases: Detection rate was 84.4% at MRI and 72.1% at CT. Cysts within the duodenal wall were detected in 82.6% of the cases: Detection rate was 94.4% at EUS, 81.9% at MRI and 75.7% at CT. A solid mass in the groove region was described in 40.9% of the cases; in 78.3% of the cases, it showed patchy enhancement in the portal venous phase, and in 100% appeared iso/hyperintense during delayed phase imaging. Only 3.6% of the lesions showed restricted diffusion. The prevalence of radiological signs of chronic obstructive pancreatitis, namely main pancreatic duct dilatation, pancreatic calcifications, and pancreatic cysts, was extremely variable in the different articles. PP has peculiar imaging findings. MRI is the best radiological imaging modality for diagnosing PP, but EUS is more accurate than MRI in depicting duodenal wall alterations.

CT imaging patterns of paraduodenal pancreatitis: a unique clinicoradiological entity

To analyse the computed tomography (CT) findings of paraduodenal pancreatitis (PP) in patients treated at Amrita Institute of Medical Sciences. Clinical, laboratory, and CT findings of 30 patients with PP treated from July 2007 to December 2020 were reviewed retrospectively. The average age of the patients was 45.9 years (19-60 years), which included 29 (96.7%) men, and 90% had a history of alcohol abuse. The majority [22 (73.3%)] presented with recurrent abdominal pain. Serum amylase was elevated in 21 (70%) patients and serum lipase was elevated in 25 (83.3%) patients. Carbohydrate antigen (CA 19-9) was elevated in three (10%) patients. The cystic pattern was seen in three (10%), solid pattern in 13 (43.3%), and solid-cystic pattern in 14 (46.7%) patients. The pure form of the disease was seen in seven (23.3%) patients, whereas the segmental form was seen in 23 (76.7%) patients. Descending duodenal wall thickening and enhancement was seen in 25 (83.3%) and 18 (60%) patients, respectively. The gastroduodenal artery was displaced medially in 12 (40%) patients and encased in five (16.7%) patients; however, it was not occluded in any of the patients. Calcifications were seen in the groove lesion in nine (30%) patients. The pancreas showed atrophic changes in 14 (46.6%) patients and calcifications in 12 (40%) patients. Distal common bile duct strictures were seen in three (10%) patients. The presence of sheet-like soft-tissue thickening in the groove with diffuse duodenal thickening and intramural/paraduodenal cysts are highly suggestive of PP. Identifying characteristic imaging findings of PP may help in prospective diagnosis and lead to conservative management of most of these patients avoiding unnecessary invasive procedures.

Ultrasonographic evaluation of the coelomic cavity in Rhode Island Red hybrid hens (Gallus gallus domesticus).

Backyard chickens are gaining popularity, and so is individual veterinary care for their health and management. Ultrasonography represents an important part of the imaging diagnostic arsenal in veterinary medicine; however, published data on its use in chickens are scarce and mostly focus on the reproductive tract. The objectives of this prospective, reference interval study were to describe a standard protocol for a full coelomic evaluation and the normal ultrasonographic appearance and measurements of the coelomic organs in awake and anesthetized healthy hens. The liver, gallbladder, gonad, gastrointestinal tract, pancreas, and spleen were clearly visualized in 21 Rhode Island Red hybrid hens (8 immatures, 13 adults) included in this study. In all animals, there was a scant amount of coelomic fluid, which was more visible at the cardiac apex. The cysticoenteric duct and hepatoenteric duct were visualized in 57% (12/21) of the hens. Seven hens were anesthetized and placed in dorsal decubitus, as the kidneys were not visualized in the hens while standing. Reference intervals were calculated for the splenic short and long axes, proventricular wall thickness, ventricular wall thickness, and duodenal wall thickness. Reference values were measured for the thickness of the pancreas, gallbladder wall, and kidneys, as well as the diameters of the biliary ducts. Moreover, five hens of different breeds were examined, and the results obtained were comparable to those of previous studies. The results of this study support the use of ultrasonography as a diagnostic tool in Rhode Island Red hybrid hens and provide reference ranges for use in hens with clinical diseases involving coelomic organs.

An unexpected cause of proximal small intestinal obstruction

A 63-year-old caucasian male with history of tonsil cancer, under induction chemotherapy, reported food intolerance and vomiting with duration of one month. Symptoms had increased over the last days and were associated with a weight loss of 10 Kg during the past three months. The patient lived all of is life in an urban environment. General physical examination revealed cachexia and dehydration. Gastrointestinal symptoms persisted despite intravenous pantoprazole, prokinetic drugs and nasogastric tube insertion. On investigation, patient presented normocytic and normochromic anemia (9.2 g/dL), lymphocytosis (11.78 x109/L) with neutrophilia (70.7%) and eosinophilia (7.7%), hypoalbuminemia (2.8 g/dL) and elevated C-reactive protein (25.5 mg/dL). Upper endoscopy revealed deformation of bulb and second part of the duodenum with mucosal edema, superficial ulceration and friability (Figure 1a). Biopsies were taken from the bulb and second portion of the duodenum. Computer tomography demonstrated gastric distention, duodenal wall thickening and lumen narrowing in the second and third portion of the duodenum (Figure 2). These findings were indicative of a functionally relevant duodenum stenosis. Histopathologic evaluation of biopsy specimens from the duodenum revealed moderate accumulation of eosinophilic granulocytes and nematode larvae within mucosal crypts (Figure 1b). What is the diagnosis?

Paraduodenal pancreatitis – problem in the groove

Background Paraduodenal pancreatitis (PDP) is a particular form of chronic pancreatitis (CP) occurring in and around the duodenal wall. Despite its low prevalence, this rare condition presents a significant challenge in clinical practice. Methods We retrospectively analysed the electronic medical charts of all patients with a diagnosis of chronic pancreatitis and identified those with PDP, between January 1999 and December 2020. Results There were 35 patients diagnosed with PDP (86% males and 14% females); median age of 56 ± 11 (range 38–80). Alcohol overconsumption was reported in 81% and smoking in 90% of patients. Abdominal pain was the leading symptom (71%), followed by weight loss, nausea and vomiting, jaundice, and diarrhoea. In 23 patients (66%), recurrent acute pancreatitis attacks were noted. Focal duodenal wall thickening was present in 34 patients (97%), cystic lesions in 80%, pancreatic duct dilatation in 54% and common bile duct dilatation in 46%. Endoscopic treatment was performed on nine patients (26%) and five patients (14%) underwent surgery. Complete symptom relief was reported in 12 patients (34%), partial symptom relief in three (9%), there was no improvement in five (14%), data were not available in three (9%) and 12 (34%) patients died before data analysis. Conclusions PDP is a rare form of pancreatitis, most commonly occurring in the 5th or 6th decade of life, with a predominance in males and patients with a history of smoking and high alcohol consumption. Focal thickening and cystic lesions of the duodenal wall are the most common imaging findings, followed by pancreatic duct and common bile duct dilatation. A minority of patients requires surgery.

Intestinal parasitic infection-induced intestinal wall cytoskeleton dysfunction in diabetes mellitus

Background: The gastrointestinal tract (GIT) could harbor intestinal parasitic infections (IPIs) alongside a dense and diverse microbial community, termed GIT microbiome. We examined the role of IPI-related changes in intestinal echoanatomy in the pathophysiology of type 2 diabetes mellitus (T2DM). Methods: The study included 95 subjects (44 males and 51 females). The diagnosis was based on clinical presentation and laboratory tests, including serial stool microscopy for IPIs, and for diabetes, measurement of hemoglobin A1C, fasting or random blood glucose level, or oral glucose tolerance testing. The B-mode ultrasound grayscale and color images using a high-frequency phased array transducer of 7.5 MHz of the duodenum and colon were obtained with and without water contrast. The duodenal wall thickness was used as measurement endpoint. Results: Eighty consecutive patients had at least one type of IPIs in serial stool microscopy, and 15 were healthy persons. Among the 80 IPI patients, 52 (65%) were diabetic, and 28 (35%) patients were nondiabetic. We demonstrated normal duodenum and colon echoanatomy in healthy persons. In patients with IPIs, the duodenal wall thickness (6.87 ± 2.09 mm) was greater than that in healthy persons (3.5 ± 1.07 mm) (P < 0.001). In diabetic patients, the duodenal wall thickness (7.23 ± 2.1 mm) was greater than that in nondiabetic patients (5.26 ± 2.07 mm) (P < 0.001). There were main effects of age and obesity but not sex. Antiparasitic treatment of IPIs alongside antidiabetic drugs improved control of fasting blood sugar. Conclusion: Ultrasound duodenography and colonography demonstrated IPI-induced intestinal wall thickening with rearrangement of the cytoskeleton, causing malfunction of the glucose transporter system which resulted in T2DM.

S2498 Lemmel Syndrome: An Unusual Presentation with Gastric Outlet Obstruction

Introduction: Lemmel syndrome is a rare clinical entity characterized by a periampullary duodenal diverticulum causing compression and dilatation of the pancreatic and common bile ducts, classically accompanied by obstructive jaundice. Gastric outlet obstruction (GOO) is not a known complication of this syndrome, nor are there standardized approaches to its treatment. We present the first documented case of Lemmel syndrome presenting as GOO and its successful treatment with endoscopic diverticular lavage. Case Description/Methods: An 82-year-old woman presented with abdominal pain and non-bloody non-bilious emesis. On arrival, she was hemodynamically stable and anicteric. Computed tomography (CT) with contrast revealed a 2.7x3.7x5.2 cm complex pancreatic head mass containing air and debris, contiguous with the duodenum at the junction of the 2nd and 3rd segments with dilatation of the common bile (1 cm) and main pancreatic duct (0.6 cm), concerning for a pancreatic neoplasm. There was also GOO manifested as a markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography (EUS) showed no signs of significant abnormalities within the pancreas. However, a large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris was visualized and was found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation. Endoscopic diverticular lavage with removal of food debris was performed. Her diet was quickly escalated, her symptoms resolved, and she was discharged the following afternoon. Repeat CT 11 days post-procedure showed resolution of GOO and reduced biliary ductal dilation and diverticular size. At 1-month follow-up, she remained asymptomatic and was tolerating high-fiber diet without clinical signs of gastric outlet or biliary obstruction. Discussion: Lemmel syndrome is a rare cause of GOO in the setting of pancreatic and common bile duct compression and dilatation with or without the presence of jaundice. Until now, there have been no reported cases of GOO secondary to Lemmel syndrome, nor its successful treatment with a simple diverticular lavage. It is important that physicians consider this diagnosis and treatment strategy in order to deliver cost-effective and appropriate care to patients presenting with GOO in the setting of a periampullary diverticulum with evidence of dilated biliary and pancreatic ducts.Figure 1.: CT abdomen pelvis demonstrating a 2.7 x 3.7 x 5.2 cm complex pancreatic head mass containing air and debris (A), contiguous with the duodenum at the junction of the second and third segments (B) with moderate 1.0 cm dilatation of the common bile duct (C) and 0.6 cm dilatation of the main pancreatic duct (D, E). CT abdomen pelvis demonstrating gastric outlet obstruction manifested as markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement (F).Figure 2.: Endoscopic ultrasonography (EUS) of the head (A), neck (B), and body (C) of the pancreas without signs of significant endosonographic abnormalities.Figure 3.: Large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris visualized and found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation.Figure 4.: CT abdomen pelvis demonstrating improvement in common bile duct dilation (A) and diverticular size with resolution of radiographic evidence of gastric outlet obstruction (B, C) 10 days after endoscopic diverticular lavage. Bile duct measuring 0.7 cm, previously 1.0 cm. Diverticular dimensions measuring 1.9 x 3.6 x 3.7 cm (AP by transverse by craniocaudal), previously 2.7 x 3.7 x 5.2 cm. Pancreatic duct was poorly visualized, and comparison could not be made.

Ultrasonography of the gastrointestinal tract of toco toucans (Ramphastos toco)

Baseline data for wall thickness in healthy toucans can be used to diagnose disease in sick individuals. This study aimed to evaluate the use of ultrasonography for the examination of the gastrointestinal tract of healthy toco toucans (Ramphastos toco). Ten non-anaesthetized healthy adult toco toucans were evaluated. Food was withheld for 3h prior to the ultrasound examination. Longitudinal and transverse images of the gastrointestinal tract were obtained using ventromedian cranial and ventromedian caudal approaches to evaluate the morphology and stratification. The wall thickness of the sections was measured: proventriculus and ventriculus, duodenum, jejunum/ileum, and cloaca. Additionally, the thickness of the mucosal layer of the duodenum and jejunum/ileum was also measured. Subsequently, the ratios of the duodenal wall thickness to the duodenal mucosa layer and the total wall thickness of the jejunum/ileum to the jejunum/ileum layer mucosa were stablished. The wall thickness of the proventriculus was significantly higher than the wall thickness of ventriculus. The wall thickness of the duodenum was significantly higher than the wall thickness of jejunum/ileum. The mean ratios of the duodenal wall thickness to the duodenal mucosa layer and the wall thickness of the jejunum/ileum to the jejunum/ileum layer were 83.15% and 80.07%, respectively. In conclusion, it was possible to assess the stomach and intestines using ultrasound examination in healthy toco toucans, due to their medium body size and no interference by surrounding air sacs.

Diagnostic Accuracy of Ultrasound for Detecting Gastric or Duodenal Ulcers in Pediatric Patients.

Direct ultrasound imaging findings alone have low sensitivity for diagnosing duodenal (65%) and gastric ulcers (40%). This retrospective study evaluated the efficiency of ultrasound in detecting gastric/duodenal ulcers in pediatric patients through direct and indirect findings. We evaluated 244 children who underwent ultrasound and subsequent endoscopy within 4 weeks for direct and indirect imaging findings indicative of gastric/duodenal ulcers. Positive direct imaging findings revealed gastric or duodenal wall thickness >8 or 5 mm, respectively, and indirect findings revealed inflammatory changes, hyperechogenicity, and presence of lymph node around ulcers. Correspondingly, we calculated the sensitivity and specificity for diagnosing gastric/duodenal ulcers and used the Fisher's exact and Mann-Whitney U tests to compare the frequency of findings and gastroduodenal wall thicknesses in pediatric patients with gastric/duodenal ulcers. Overall, 6 and 24 were diagnosed with gastric and duodenal ulcers, respectively. The sensitivities of direct and indirect findings were 60.0% (18/30) and 80.0% (24/30), respectively; the corresponding specificities were 98.1% (210/214) and 97.2% (208/214). The frequency of direct and indirect sonographic findings differed significantly between patients with gastric or duodenal ulcers (18/30 versus 24/30, P=.002). Gastric and duodenal wall thicknesses were greater in patients with gastric (6.6 ± 2.6 mm versus 3.6 ± 1.4 mm; P=.003) or duodenal ulcer (5.0 ± 1.4 mm versus 2.2 ± 1.0 mm; P <.0001), respectively, than in those without. The frequency of indirect finding was greater than that of direct finding in pediatric patients with gastric/duodenal ulcers. Therefore, sonographers should carefully evaluate indirect findings around the stomach or duodenum.

Endoscopic Removal of Ingested Wire Bristle from the Pancreas

A 78-year-old woman presented to the emergency department with a 5-day history of upper abdominal pain and nausea. Computed tomography revealed a 3.5 cm × 0.1 cm hyperdensity extending from the duodenal wall into the uncinate process of the pancreas, associated with duodenal wall thickening, intramural air, and a 3.1-cm pancreatic fluid collection (Figure A). The patient was initially seen by the surgical service, which recommended gastroenterology consultation for attempted endoscopic foreign body removal.

Study of role of computerized tomography (CT) in evaluation of groove pancreatitis

Background: Groove pancreatitis is a rare form of chronic pancreatitis affecting the groove between the pancreatic head, duodenum and common bile duct. The exact cause of the disease is not known, although there are strong associations with long term alcohol abuse, functional obstruction of duct of Santorini and brunner gland hyperplasia. The purpose of this study was to describe the imaging findings of groove pancreatitis (GP) on Contrast enhanced CT Abdomen. Material and Methods: Present study was retrospective study conducted, with help of medical records of 16 patients with a final diagnosis of Groove pancreatitis. CT, MRI and MRCP findings were analysed. Statistical analysis was done using descriptive statistics. Results: In present study, two types of groove pancreatitis (GP) as pure type (50%) and segmental type (50%) were noted. Other important findings were focal duodenal wall thickening (62.5%) and cysts in the duodenal wall itself or in groove between the pancreatic head and the duodenum (37.5%), CBD dilatation and distal smooth tapering (62.5%) including all the segmental types and 2 of the pure type leading to intra- and extra-hepatic biliary system dilatation. MRI and MRCP were available in 6 patients in our study. There was a CT similarity regarding the sheet of tissues within the pancreaticoduodenal groove. These were seen expressing T1 hypo-intense and T2 slightly hyperintense signal in 3 patients with depiction of mild enhancement in the delayed phases in three of them (50%). On the MDCT examinations hypodense sheet at the PD groove was seen in 12 patients with modest enhancement identified in delayed phase seen in 6 of the them. Duodenal wall thickening was seen in 10 patients while associated cysts within the duodenal wall or in PD groove were seen in 6 patients. Pancreatic head enlargement with diffuse enhancement was seen in 8 patients. Mild pancreatic duct dilatation was seen in 8 patients while dilatation of the CBD was seen in 10 patients with distal tapering and intra-hepatic biliary dilatation. Conclusion: Groove pancreatitis (GP) is a disease that should be considered in the list of differential diagnosis of masses implicating the pancreatic head and medial duodenal wall. Imaging findings that are suggestive of GP include chronic inflammatory changes with fibrosis in the PD groove with or without implication of the nearby head of the pancreas, duodenal medial mural thickening with luminal stenosis and cysts at the PD groove or within the duodenal wall.