Gastrointestinal Necrosis Research Articles

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults

Objectives Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. Methods A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. Results Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47–100%, and 54–100%, which increased to 53–100%, and 60–100%, respectively, when considering only radiologists’ reinterpretations. Conclusions In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

Non-occlusive mesenteric ischemia in reconstructive digestive tract surgery

To analyze the mechanisms of non-occlusive mesenteric ischemia (NOMI) after digestive tract surgery. NOMI occurred in 10 (0.4%) patients after reconstructive digestive tract surgery between 2015 and 2021. There were 4 women and 6 men aged 29-92 years (67 [60; 71]). Patients differed from each other in the nature of baseline disease and surgical approach. All patients underwent standardized surgical interventions. There were no intraoperative complications. Median of surgery time was 372.5 (246.25; 548.75) min, blood loss - 450 (200; 725) ml. These parameters conformed to the type of surgery. There were no specific clinical signs of NOMI. Lactic acidosis (>4 mmol/L) occurred in 7 patients after 1-3 postoperative days. In 6 patients, fulminant NOMI developed after 1-2 postoperative days with subsequent multiple organ failure syndrome and septic shock. All patients underwent emergency redo surgery. Multivisceral gastrointestinal necrosis occurred in 5 patients, gastric conduit necrosis - 3, colon necrosis - 1, gastric stump necrosis - 1 patient. Mortality rate was 80%. Two patients survived. NOMI manifested as a septic shock in 60% of patients that was due to fulminant development of multivisceral necrosis after 1-2 postoperative days. Timely diagnosis of reversible NOMI in these cases was impossible. Extensive visceral necrosis in early postoperative period is probably associated with intraoperative critical ischemia of digestive organs.

BACTERIAL INTESTINAL INFECTIONS OF YOUNG CATTLE

Gastrointestinal infections of bacterial etiology occupy one of the main places in the pathology of young cattle. The article presents a literature review on the etiology, pathogenesis and clinical diagnosis of major bacterial intestinal infections in young cattle.
 The body of animals is constantly affected by a set of causes, which, due to violations of the technology of maintenance, care and feeding, playing the role of stress factors, leading to reduced nonspecific resistance, increased reactivity and bacteriosis in animals associated with gastrointestinal lesions. Up to 75 % of diseases of the digestive tract of young cattle are more likely to occur as associated infections caused by both viruses and bacteria. Viruses, multiplying in the mucous membrane of the gastrointestinal tract, cause dystrophy, necrosis and desquamation of epithelial cells, what promotes the colonization and penetration into the blood of pathogenic bacteria or their metabolites and the development of severe pathological processes.
 Bacterial agents that cause diarrhea or complicate viral infections include pathogenic Escherichia coli, Salmonella, Clostridium, Citrobacter, Enterococci, Yersinia, Pseudomonas, Campylobacter and others. A special role in the occurrence of diseases of the digestive tract in young cattle is played by opportunistic pathogens, which include bacteria of the family Enterobacteriaceae.
 The main intestinal infections of bacterial etiology of young cattle are colibacillosis, salmonellosis, anaerobic enterotoxemia of calves and campylobacteriosis. Calf colibacillosis is an acute infectious disease caused by enteropathogenic Escherichia coli, which is characterized by profuse diarrhea, septicemia, intoxication, dehydration and significant animal death. The causative agents of salmonellosis are bacteria of the family Enterobacteriaceae Salmonella dublin, S. enteritidis and S. typhimurium. Calves suffer from salmonellosis from the first days of life and up to 6 months of age, with a characteristic acute fever and diarrheal symptom complex. Anaerobic enterotoxemia of calves is an acute toxic-infectious disease of mainly newborn young, caused by the obligate anaerobic bacterium Clostridium perfringens, characterized by hemorrhagic-necrotic inflammation of the intestine, diarrhea and intoxication of the body. Campylobacter jejuni can cause diarrhea in calves. Campylobacteriosis with symptoms of enteritis mainly affects dairy calves, although C. jejuni can also cause enteritis in ruminant calves.
 Other bacteria that can cause enteritis in calves are Bacteroides fragilis, Chlamydophila psittaci, Klebsiella spp., Proteus spp., Yersinia enterocolitica and others.

Successful Treatment with Metronidazole and Paromomycin for Fulminant Amoebic Colitis During Cytotoxic Chemotherapy in a Patient with Small-Cell Lung Cancer

We report the case of a 64-year-old man with advanced small-cell lung cancer who developed fulminant amoebic colitis during cytotoxic chemotherapy. During the first cycle of carboplatin/etoposide treatment, febrile neutropenia and grade 4 neutropenia developed. Because diarrhea, abdominal pain, and bloody stool were observed, abdominal computed tomography was performed, showing intussusception, and surgery was performed. Histopathology of the colon revealed gastrointestinal necrosis and perforation due to Entamoeba histolytica infection. Amoebiasis improved after treatment with metronidazole and paromomycin. The second cycle of carboplatin/etoposide with dose reduction was completed, resulting in a partial response to small-cell lung cancer. The results of this case suggest that paromomycin is an additional option for amoebiasis during cytotoxic chemotherapy, and persistent diarrhea during cytotoxic chemotherapy should alert clinicians to consider the development of amoebiasis. Funding declaration: None Conflict of Interests: None Consent: Written informed consent was obtained from the parents of the patient for the publication of this report and accompanying images

Multicenter investigation of pediatric gastrointestinal tract magnets ingestion in China

PurposeTo describe the incidence and management of gastrointestinal tract Buckyball magnets ingestions in a multicenter Chinese pediatric patient population, and discuss the preventive measures.MethodsMedical records of 74 pediatric patients from 9 large Chinese hospitals during the past 10 years, who were diagnosed as buckyball magnets ingestion and got invasive treatment, were retrospectively studied. The follow-up was through telephone and outpatient service to estimate the post-surgery condition. Information collection was through online questionnaire.ResultsAmong the 74 cases, there were 50 boys (68%) and 24 girls (32%). The median age was 36 (interquartile range (IQR) 22–77) months, with a range of 7 months to 11 years, and it showed two peaks, the first between 1 and 3 years, and the second between 6 to 11 years. The annual case number showed a sharp increase over time, and the total case number in the last 2 years (2017 and 2018) showed a greater than 9-fold increase when compared with the first 2 years (2013 and 2014). The majority of ingestions were unintentional, with only 3 patients deliberately swallowing the Buckyball magnets. The median time of ingestion until the onset of emergent symptoms was 2 (IQR 1–5) days, and ranged from 4 h to 40 days. Twenty-one patients had no symptoms, and the remaining cases presented with abdominal pain, vomiting, fever, abdominal distension, excessive crying, melena, and the ceasing of flatus and defecation. Gastroscopy, colonoscopy, laparoscopic surgery and laparotomy surgery were performed in accordance with the algorithm from the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Procedural and operative findings included gastrointestinal mucosa erosion, ischemia and necrosis, perforation, and abdominal abscess, fistula and intestinal obstruction. The median number of Buckyball magnets ingested was 4 (IQR 2–8), with a range from 1 to 39. During the median follow-up period of 6 (IQR 1–15) months, 3 patients had intestinal obstruction, and one underwent a second operation. The remaining 71 patients courses were uneventful during the follow-up period. None of the 74 patients reported a second swallowing of foreign bodies.ConclusionsThe incidence of pediatric gastrointestinal tract magnets ingestion in China is increasing. Management of such patients should follow the NASPGHAN algorithm. Preventive measures to limit children’s access to Buckyball magnets should be taken from three levels, namely the national administration, producer, and consumer.

Clozapine: why wait to start a laxative?

SUMMARYClozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.LEARNING OBJECTIVES:After reading this article you will be able to: •understand the mechanism of gastrointestinal hypomotility in those taking clozapine•improve the monitoring of clozapine-induced constipation•understand prophylactic laxative treatment and the use of less commonly prescribed laxatives in patients who experience clozapine-induced constipation.

Chronic Oral Administration of Ocimum gratissimum Leaf Extract Induced Gastrointestinal Necrosis in Treated Albino Rats

Aim: This study was designed to investigate the effect on of Ocimum gratissimum leaves extract on the histology of the gastrointestinal tract in rats.
 Study Design: Adult rats of both sexes were used for the work. The study was carried out at the Departments of Physiology and Histology, College of Veterinary Medicine, Michael Okpara University of Agriculture, Umudike, Nigeria between September 2014 and January, 2015.
 Methodology: Fifty adult albino rats and 35 Mice were used for the study. The mice were used for acute toxicity study while the rats were divided into five groups of 10 rats each and were used for the histological study. Groups 2-5 were assigned different dose levels of OGLE in the order 100, 200, 400 and 800 mg/kg respectively while group 1 was given only feed and water. Treatment was given by the oral route and lasted for 28 days.
 Results: Phytochemical compounds identified in the extract include protein and carbohydrate which occurred in high amounts, tannins, flavonoids and glycosides in moderate quantities, saponins, steroids and phenolic compounds in low amounts while tannins and alkaloids were absent. An LD50 and ED50 values of 2075 mg/kg and 850 mg/kg body weight respectively were obtained for the extract with a Therapeutic Index value of 2.44. Chronic oral administration of the extract also caused various degrees of histological changes in the gastrointestinal tract in all treated animals with significant erosions of the mucosa and submucosa. The gastrointesinal necrosis produced by Ocimum gratissimum leaf extract after long term treatment was dose dependent with 100 mg/kg inducing only mild necrosis of the villi, 200 mg/kg, a higher necrosis of the villi, while 400 mg/kg and 800 mg/kg induced severe necrosis of both the villi and the intestinal mucosa.
 Conclusion: Results obtained from this study therefore suggest that Ocimum gratissimum leaf extract is rich in bioactive compounds and may be well tolerated at low to moderate doses during short term treatment but may cause gastrointestinal erosions when used continuously over a long period.

An Eye on Necrosis

We present a case of acute esophageal necrosis (black esophagus) caused by iron pill esophagitis in a patient thirteen days status post combined heart and bilateral lung transplant who was supplemented with oral iron for anemia due to intraoperative blood loss. This case illustrates an unusual cause of acute esophageal necrosis and should be on the differential for patients with unexplained findings of esophageal necrosis who are also on iron supplementation. Case A 52 year old man with chronic right ventricular failure due to class I pulmonary hypertension and unrepaired total anomalous pulmonary venous return with Eisenmenger physiology underwent combined heart and bilateral lung transplantation. He received standard infectious prophylaxis, and started oral ferrous sulfate for anemia after passing a swallow evaluation. On postoperative day (POD) 11, he developed dysphagia and odynophagia. Esophagogastroduodenoscopy (EGD) performed on POD 13 showed circumferential necrosis of the esophagus with tongues of esophagitis proximally (Figure 1), and a stricture with luminal diameter of 6mm. Biopsies revealed necrotic tissue and brown pigment/crystalline material consistent with iron pill-induced esophageal necrosis (supported by positive iron stain) (Figure 2). Ischemia and infection were ruled out. Four months after discharge, EGD showed a 3 cm long fibrotic stricture 25 cm from the incisors 6 mm in diameter. There was mild erythema adjacent to the stricture with otherwise normal esophageal mucosa. Biopsies demonstrated normal squamous mucosa. He will undergo temporary esophageal stenting to treat the stricture. Discussion Ferrous sulfate was first reported to cause ulcerations of the hypopharynx and cervical esophagus in 1976. Severe gastrointestinal necrosis has been seen with iron overdose, however, not with therapeutic doses. In one series of 33 patients with iron pill induced upper gastrointestinal injury, 83% of biopsies contained ulcerative or erosive mucosal injury, but none contained necrosis. Acute esophageal necrosis remains a rare entity with well characterized clinical manifestations but poorly understood pathophysiology. It is suspected to result from ischemia and decreased mucosal defenses. Currently there are no reported cases of iron pill induced acute esophageal necrosis in the literature. This was a surprising finding and should be considered in patient with severe esophagitis or acute esophageal necrosis taking oral iron supplements.1770_A Figure 1 No Caption available.1770_B Figure 2 No Caption available.

Clozapine-induced acute gastrointestinal necrosis: a case report

BackgroundClozapine is known to cause fecal impaction and ileus with resultant colonic necrosis due to compression of colonic mucosa. There are rare reports of clozapine causing necrosis of other portions of the gastrointestinal tract unrelated to constipation. We describe a case of acute necrosis of the upper gastrointestinal tract and small bowel to due to clozapine and quetiapine.Case presentationA 66-year-old white man with a past medical history of schizophrenia, maintained on clozapine and quetiapine, presented with hypoxic respiratory failure caused by aspiration of feculent emesis due to impacted stool throughout his colon. His constipation resolved with discontinuation of clozapine and quetiapine, and his clinical condition improved. These medicines were restarted after 2 weeks, resulting in acute gastrointestinal necrosis from the mid esophagus through his entire small bowel. He died due to septic shock with Gram-negative rod bacteremia.ConclusionsClozapine may cause acute gastrointestinal necrosis.

Kayexalate (Sodium Polystyrene Sulfonate) as a Hallmark and Cause of Gastrointestinal Tract Injury: Two Case Reports and a Review of the Literature

Kayexalate (sodium polystyrene sulfonate) is a cation exchange resin that is commonly used for the treatment for hyperkalemia. With the increasing prevalence of type II diabetes mellitus in developed nations, there has been a concordant rise in renal disease and hyperkalemic patients receiving Kayexalate therapy. Gastrointestinal necrosis is a rare but major complication associated with Kayexalate use that has not been previously well characterized in the forensic literature. Kayexalate crystals have a distinctive “mosaic” appearance on hematoxylin and eosin stained sections and a characteristic coloration with periodic acid-Schiff (PAS) and acid-fast stains. As they are relatively easily identified in histologic sections, and may represent a primary or contributory cause of death, it is suggested that forensic pathologists become familiar with these features. We present two cases in which Kayexalate crystals were detected at autopsy. In one case, the crystals were located within the intestinal lumen and mucosa in areas of mucosal ulceration, while in the other, crystals were located on the intestinal serosal surface without apparent mucosal ulceration. We discuss how to interpret the significance of Kayexalate crystals, review prior literature on Kayexalate therapy-related gastrointestinal necrosis, and explain how to notify the Food and Drug Administration of an adverse Kayexalate reaction detected at autopsy.

Pathologic Characterization of Genotypes XIV and XVII Newcastle Disease Viruses and Efficacy of Classical Vaccination on Specific Pathogen-Free Birds

To characterize the clinicopathologic features of recently described genotypes of Newcastle disease virus (NDV), 1 representative strain of genotype XIV and 2 of genotype XVII, all isolated from West Africa, were used to infect groups of ten 4-week-old specific pathogen-free chickens. The pathobiology of these 3 strains was compared to a South African NDV strain classified within genotype VII. All chickens infected with the 4 viruses died or were euthanized by day 4 postinfection due to the severity of clinical signs. Gross and histologic lesions in all infected chickens included extensive necrosis of lymphoid tissues (thymus, spleen, bursa of Fabricius, cecal tonsils, gut-associated lymphoid tissue), gastrointestinal necrosis and hemorrhages, and severe hemorrhagic conjunctivitis. Immunohistochemical staining revealed systemic viral distribution, and the most intense staining was in the lymphoid organs. Results demonstrate that the 3 West African strains from the previously uncharacterized genotypes XIV and XVII are typical velogenic viscerotropic NDV strains with lesions similar to the South African strain. Under experimental conditions, QV4 and LaSota NDV vaccine strains successfully protected chickens from morbidity and mortality against the genotype VII and one genotype XVII NDV strain, with no significant differences in the amount of virus shed when 2 vaccine schemes were compared.

MLN4924, a Novel Investigational Inhibitor Of NEDD8-Activating Enzyme (NAE), In Adult Patients With Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS): Results From Multiple Dosing Schedules In a Phase 1 Study

Abstract Background NEDD8-activating enzyme (NAE) regulates the NEDD8 conjugation pathway, and is required for activity of the cullin-RING E3 ligases (CRLs). CRLs control proteasomal degradation of several substrates involved in cell-cycle regulation, signal transduction, DNA replication and stress response including proteins important for survival of AML cells. MLN4924, a first-in-class NAE inhibitor, has shown antitumor activity in preclinical AML models. This study evaluated safety and tolerability of MLN4924 given on multiple dosing schedules. A maximum tolerated dose (MTD) of 59 mg/m2 given on days 1, 3 and 5 of a 21-day cycle (schedule A) was previously reported (Erba et al, EHA 2011); complete responses were observed in 4/27 patients for this schedule (most common AE: diarrhea [44%], most common Gr ≥3 AE: febrile neutropenia [33%]). Here we report on two additional schedules. Methods Adults with AML or MDS and good performance status received MLN4924 as a 60-min IV infusion on one of two schedules for up to 1 year or until disease progression. Schedule B patients received escalating doses of MLN4924 on days 1, 4, 8 and 11 every 21 days. Schedule E patients received a fixed dose of MLN4924 on days 1, 3 and 5 every 21 days. Adverse events (AEs) and responses were graded according to published guidelines. Serial blood samples were obtained during cycle 1 for pharmacokinetic (PK) and pharmacodynamic analyses. Results On schedule B: 26 patients were enrolled (77% male), median age was 70.5 yrs, 23 had AML and 3 had MDS (2 had advanced disease with marrow blasts exceeding 10%). Patients received MLN4924 at 83 (n=19), 110 (n=4), and 147 mg/m2 (n=3). On Schedule E: 16 patients (69% male) received 50 mg/m2 MLN4924, median age was 70.5 yrs, 14 AML and 2 MDS (1 with advanced disease). Three patients on schedule B had dose-limiting toxicities (DLTs): 1 patient at 110 mg/m2; orthostatic hypotension (Gr 3); 2 patients at 147 mg/m2; cardiac failure (Gr 4; n=1), fatal lactic acidosis, hypotension, gastrointestinal necrosis, acute renal failure and myocardial ischemia (each Gr 4; n=1). On schedule E, 2 patients had DLTs: morbilliform rash (Gr 3; n=1); and increased aspartate/alanine aminotransferases (Gr 2/3; n=1). Most common all-grade and Gr ≥3 AEs are shown in the table. The MTD for Schedule B was determined as 83 mg/m2. On schedules B/E, 3/2 patients received ≥4 cycles, 0/4 remain on treatment; discontinuations were due to progressive disease (11/10), AEs (8/0), and other reasons (7/2) respectively. In 17 patients treated at 83 mg/m2 on schedule B and 16 patients on schedule E, individual PK profiles showed a biphasic disposition phase following completion of the first infusion. MLN4924 plasma concentrations were detectable 24–48 hours (schedule B) and 24 hours (schedule E) post dosing. Schedule B geometric mean (%CV) Cmax was 1255 ng/mL (25.1%), AUC24hr was 3936 ng•h/mL (22.6%); schedule E values were Cmax of 669 ng/mL (24.4%) and AUC24hr of 2614 ng•h/mL (21.4%). Observed increases in mean Cmax and AUC24hr were dose-proportional between 50 and 83 mg/m2 after single dosing. Pharmacodynamic data demonstrated evidence of target and pathway inhibition for all patients on both schedules. On schedule B, of 20 response-evaluable patients (18 AML, 2 MDS), 2 (11%) AML patients had partial responses (PR), 13 (72%) had stable disease. On schedule E, of 12 response-evaluable patients (11 AML, 1 MDS), 1 (8%) AML patient had a PR, 7 (59%) maintained stable disease and the MDS patient (8%) had a response. Conclusions Both schedules appeared to be generally well tolerated and NAE inhibition with MLN4924 resulted in clinical activity in highly refractory/multiply relapsed patients. Based on safety and observed clinical activity across schedules, the recommended phase 2 dose for single agent MLN4924 in AML/MDS is 50 mg/m2 given on days 1, 3 and 5 of a 21-day cycle. A study of MLN4924 with azacitidine in treatment-naïve AML patients older than 60 years is ongoing (NCT01814826). Disclosures: Off Label Use: Investigational agent MLN4924 for the treatment of patients with AML and high-grade or low-grade MDS. Hua:Millennium: The Takeda Oncology Company: Employment. Blakemore:Millennium: The Takeda Oncology Company: Employment. Faessel:Millennium: The Takeda Oncology Company: Employment. Dezube:Millennium: The Takeda Oncology Company: Employment. Medeiros:Millennium: The Takeda Oncology Company: Research Funding.

消化管壊死，穿孔を合併した肺癌の3例

背景．肺癌患者において，消化管壊死や穿孔を合併することは稀である．症例．当院で発症した例は小腸転移の壊死穿孔，アメーバ赤痢，非閉塞性腸管梗塞と，原因は多様であった．結論．肺癌診療中に様々な原因で消化管壊死，穿孔を合併した3例を経験した．その予後は不良で時に致死的な経過をたどるため，多様な原因を念頭に置いた検索が重要であると考えられた．

Cetuximab Plus Cisplatin, Irinotecan, and Thoracic Radiotherapy as Definitive Treatment for Locally Advanced, Unresectable Esophageal Cancer: A Phase-II Study of The SWOG (S0414)

The specific aims of the study were to evaluate the 2-year overall survival (OS) and progression-free survival (PFS), toxicity profile, and best objective response rate in patients with locally advanced, clinically unresectable esophageal cancer receiving cetuximab, cisplatin, irinotecan, and thoracic radiotherapy (TRT) within a multi-institutional cooperative-group setting. Eligible patients (cT4 M0 or medically unresectable, biopsy proven, and noncervical esophageal cancer) were to receive four 21-day cycles of cetuximab 400 mg/m (day 1, cycle 1), cetuximab 250 mg/m (day 8, 15, cycle 1; then days 1, 8, and 15 for subsequent cycles), cisplatin 30 mg/m (days 1 and 8, all cycles), and irinotecan 65 mg/m (days 1 and 8, all cycles). TRT was administered at 1.8 Gy in 28 daily fractions to a total dose of 50.4 Gy, to begin with on day 1 of cycle 3. The primary endpoint was 2-year OS, with an accrual goal of 75 patients with adenocarcinoma. The study was closed because of slow accrual, with 21 eligible patients (11 squamous, 10 adenocarcinoma) enrolled from May 2005 to September 2007. Two-year OS and PFS (95% confidence interval [CI]) were 33.3% (14.6-57.0%) and 23.8% (8.2-47.2%), respectively. Kaplan-Meier estimates of median (95% CI) OS and PFS were 11.2 (6.4-43.6) and 6.4 (3.7-12.0) months, respectively. The overall response rate (95% CI) among 17 evaluable patients was 17.6% (3.8-43.4%), including 6% confirmed complete responders and 12% unconfirmed partial responders. Two deaths resulted from protocol treatment (sudden death and gastrointestinal necrosis). Ten (47.6%) and 6 (28.6%) patients had grade-3 or -4 toxicity, respectively: 52.4% were hematologic, 23.8% had fatigue, 19.0% had nausea, 19.0% had dehydration, and 19.0% had anorexia. Concomitant cetuximab, cisplatin, irinotecan, and TRT were poorly tolerated in the first North American cooperative group trial testing this regimen for locally advanced esophageal cancer as treatment-related mortality approached 10%. Single-institution phase-II cetuximab-based combined modality trials have yielded encouraging results in preliminary analyses. The SWOG GI Committee endorses enrollment to open clinical trials to clarify the therapeutic ratio of cetuximab-based combined modality approaches for esophageal cancer.

The importance of ultrasonographic pneumatosis intestinalis in equine neonatal gastrointestinal disease

Summary Reasons for performing study: Recognising the presence of a necrotising component of the gastrointestinal disease may be clinically useful in ill equine neonates. Objectives: To study the importance of abdominal sonograms in neonatal foals suffering from gastrointestinal conditions and to describe the clinical features of necrotising gastrointestinal disease. Hypothesis: There is a subgroup of neonates with sonographically detectable pneumatosis intestinalis (PI), reflecting a necrotising disease. Methods: Records of foals aged ≤7 days hospitalised from 2005 to 2009 with signs of gastrointestinal disease were evaluated (n = 89). The association of sonographic, clinical and clinicopathological signs with necrotising gastrointestinal disease and outcome was determined. Results: PI was imaged in 19 foals. Twenty‐seven foals were classified as having necrotising gastrointestinal disease based on the presence of gastrointestinal signs (colic, diarrhoea, gastric reflux or abdominal distension) and sonographic PI (n = 19), surgical (n = 2) or pathological (n = 6) evidence of gastrointestinal necrosis. There was a difference between survival rate in foals with and without necrotising disease (33.3 and 69.4%, respectively, P = 0.005) or foals with and without PI detected sonographically (36.8 and 72.1%, respectively, P = 0.023). PI was the only sonographic finding associated with outcome. Prematurity, the presence of blood in the faeces, gastric reflux, abdominal distension, abnormal echogenicity of the colon and the lowest white blood cell count during hospitalisation were associated with necrotising gastrointestinal disease (P<0.05). Conclusions and potential relevance: Abdominal sonograms have prognostic value in neonatal gastrointestinal disease. PI and the presence of necrotising gastrointestinal disease were common and associated with a poor prognosis.

Extensive Pneumatosis Intestinalis in Association With Celiac Disease: A Case Report

Pneumatosis intestinalis (PI) is generally regarded as a worrying sign due to its relatively frequent association with serious conditions such as acute gastrointestinal necrosis. While PI can also be associated with a wide spectrum of benign conditions, its diagnosis as benign is usually accepted with the exclusion of gangrenous bowel, even in the absence of other clinical signs suggesting ischemia. We report a case of extensive PI in a patient with celiac disease and discuss its management and the role of diagnostic laparoscopy in this condition with emphasis on the different etiologies of PI. doi:10.4021/jmc63w

Duodenal Perforation Caused by Rhizomucor Species in a Cat

CLINICAL SUMMARY: A 7-month-old female Persian cat presented with gastrointestinal (GI) necrosis and perforation caused by Rhizomucor species. Unfortunately, the cat died of bacterial peritonitis and sepsis before a definitive diagnosis, based on histopathology and fungal culture, was achieved. This appears to be the first reported case of GI disease caused by Rhizomucor species in a cat. Mucorales infections typically cause acute and rapidly progressive disease. As illustrated by this case, clinicians should be alert to the potentially fatal consequences of an opportunistic Rhizomucor species infection in their feline patients.

Extensive Pneumatosis Intestinalis in Association With Celiac Disease: A Case Report

Pneumatosis intestinalis (PI) is generally regarded as a worrying sign due to its relatively frequent association with serious conditions such as acute gastrointestinal necrosis. While PI can also be associated with a wide spectrum of benign conditions, its diagnosis as benign is usually accepted with the exclusion of gangrenous bowel, even in the absence of other clinical signs suggesting ischemia. We report a case of extensive PI in a patient with celiac disease and discuss its management and the role of diagnostic laparoscopy in this condition with emphasis on the different etiologies of PI. J Med Cases. 2011;2(2):39-43 doi: https://doi.org/10.4021/jmc63w

Failure of liver function tests in predicting drug clearance of chemotherapeutic agents in a patient who had recovered from hepatic congestion

Failure of liver function tests in predicting drug clearance of chemotherapeutic agents in a patient who had recovered from hepatic congestion

A case of gastrointestinal tract necrosis with disseminated intravascular coagulopathy after ingesting large amount of strong acid treated surgically by damage control surgery

大量の高濃度塩酸を内服し，ショック・凝固障害が強いためダメージコントロール手術を施行した症例を報告する。症例は70歳の男性で，35%塩酸250mlを経口摂取した。摂取後7時間でショック状態となり，消化管壊死と診断し，緊急手術を施行した。術中著しい凝固障害のため，胃全摘・膵温存十二指腸切除のみとし，vacuum pack closureにて閉腹とした。術後，ICUにて循環動態・凝固障害を改善させ，食道摘出・膵胆管空腸吻合を予定としていた。しかし，家族の同意が得られず，ガーゼ抜去のみの姑息的手術となったが，再手術時には全身状態良好であった。術後，壊死食道を残しており，第28病日，縦隔炎のため死亡した。外傷患者でなくても，ダメージコントロール手術は全身状態不良な患者における手術にも十分応用できる。