Ileal Lesion Research Articles

P0424 Utility of superb microvascular imaging for predicting terminal ileal lesion activity in Crohn’s disease

Abstract Background Superb microvascular imaging (SMI) is rarely used in intestinal ultrasonography (IUS) to evaluate Crohn’s disease (CD) activity. This study investigated SMI findings that can predict small or large ulcers in the terminal ileum and compared them with endoscopic findings of patients with CD. Methods Data were retrospectively collected from patients with CD who underwent IUS between September 2020 and April 2024 at our clinic and ileocolonoscopy to evaluate the terminal ileum within 3 months before or after IUS. Patients with a history of small bowel resection were excluded from the study. Based on the endoscopic findings, the lesions in the terminal ileum were classified as follows: no, aphthous (<5 mm), small (5–20 mm) and large (>20 mm) ulcers. IUS was performed using Aplio a550. SMI signals were evaluated using our simplified grading system based on the Limberg score: grade 0, no vascularisation; grade 1, short stretches of vascularity as spots; grade 2, longer stretches of vascularity or grade 3, longer stretches of vascularity reaching the mesentery 1). The modified Limberg score using SMI (mLS-SMI) was applied, with the substituted SMI grade, and the proportion of patients with endoscopic findings indicating small or large ulcers in each mLS-SMI and SMI grades was evaluated. The sensitivity and specificity of the respective mLS-SMI and SMI grades for predicting endoscopic findings of small or large ulcers were also assessed. Results This study included 204 patients (median age, 29.0 years; median disease duration, 5.2 years), 50 of whom were female. The endoscopic findings were as follows: no (n = 96), aphthous (n = 68), small (n = 25) and large (n = 15) ulcers. In total, 164, 14, 13, 11 and 5 patients presented with mLS-SMI grades 0, 1, 2, 3 and 4, respectively. Moreover, 157, 27, 12 and 8 patients exhibited SMI grades 0, 1, 2 and 3, respectively. Further, 10%, 29%, 69%, 64% and 80% of patients with mLS-SMI grades 0, 1, 2, 3 and 4, respectively, and 8%, 52%, 67% and 75% of those with SMI grades 0, 1, 2 and 3, respectively, presented with endoscopic findings indicating small or large ulcers. The sensitivity and specificity of mLS-SMI grades ≥1, ≥2, ≥3 and ≥4 for predicting small or large ulcers were 60% and 88%, 50% and 95%, 28% and 97% and 10% and 99%, respectively. The sensitivity and specificity of SMI grades ≥1, ≥2 and ≥3 for predicting small or large ulcers were 70% and 88%, 35% and 96%, and 15% and 99%, respectively. Conclusion The proportion of patients with endoscopic small or large ulcers increased with mLS-SMI and SMI grades. The sensitivity and specificity of SMI grade ≥1 were comparable to mLS-SMI grade ≥1, suggesting that SMI grade alone may suffice for evaluation. References 1)Nasuno M, Shimazaki H, Nojima M, Hamada T, Sugiyama K, Miyakawa M, Tanaka H. Serum leucine-rich alpha-2 glycoprotein levels for predicting active ultrasonographic findings in intestinal lesions of patients with Crohn’s disease in clinical remission. Medicine (Baltimore). 2023;102(32):e34628. doi: 10.1097/MD.0000000000034628.

Safety of the strategy of minimizing intestinal resection during surgery for pelvic radiation- induced terminal small intestinal stenosis

Objective: To investigate the efficacy of strategies for minimizing small bowel resection during surgery for pelvic radiation-induced terminal small intestinal stenosis in preventing postoperative complications such as anastomotic leakage and short bowel syndrome. Methods: This was a retrospective cohort study. There are two subtypes of chronic radiation enteritis (CRE) with combined intestinal stenosis and intestinal obstruction: (1) Type I: terminal ileal lesions with a normal ileal segment of 2-20 cm between the ileal lesion and ileocecal junction; and (2) Type II: the lesion is located in the small bowel at a distance from the ileocecal region, usually accompanied by extensive damage to the bowel segments outside the lesion. The indications for minimal bowel resection are as follows: (1) diagnosis of Type I small bowel CRE; (2) absence of radiological evidence of rectosigmoid damage; and (3) absence of colonic obstruction. The contraindications are: (1) stenotic, penetrating lesions of the distal cecum; (2) emergency surgery; (3) recurrence of malignant tumor or history of radiotherapy for recurrent malignant tumor; (4) interval between radiotherapy and surgery <6 months; and (5) history of preoperative small bowel resection or abdominal chemotherapy. Case data of 40 patients with Type I CRE who met the above criteria and had undergone minimal bowel resection between April 2017 and December 2019 were retrospectively analyzed (minimal bowel resection group; including 13 patients from Jinling Hospital, 16 from the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, and 11 from the Affiliated Hospital of Xuzhou Medical University). Forty patients with Type I CRE who had undergone resection of intestinal stenosis lesions and the ileocecal region between October 2015 and March 2017 were included as historical controls (conventional resection group; all from Jinling Hospital). The specific strategy for minimal bowel resection was one-stage partial ileal resection+ileo anastomosis+protective small bowel stoma. In contrast, conventional resection comprised ileocecal resection+ileocecal-ascending colon anastomosis. Postoperative complications, intraoperative and postoperative recovery, and changes in postoperative quality of life were analyzed in both groups. The severity of postoperative complications was assessed by Clavien-Dindo and the Comprehensive Complication Index (CCI). Karnofsky performance scores (KPS) were used to evaluate the quality of life of patients in the two groups preoperatively and postoperatively. The higher the KPS score, the better the quality of life. Results: Baseline patient characteristics did not differ significantly between the two groups (P>0.05). Compared with the conventional resection group, the length of small bowel resected in the minimal bowel resection group (51 [20-200] cm vs. 91 [60-200] cm, Z=5.653, P<0.001), duration of postoperative total enteral nutrition [9 (3-18) days vs. 12 (4-50) days, Z=2.172, P=0.030], and duration of postoperative hospital stay [17 (9-24) days vs 29 (13-57) days, Z=6.424, P<0.001] were shorter; all of these differences are statistically significant. The overall incidence of postoperative complications was lower in the minimal bowel resection group than in the conventional resection group [20.0% (8/40) vs. 70.0% (28/40), χ2=19.967, P<0.001], These comprised short bowel syndrome [5.0% (2/40) vs. 25.0% (10/40), χ2=6.274, P=0.012], anastomotic leakage or fistula [2.5% (1/40) vs. 22.5% (9/40), χ2=7.314, P=0.014], and pleural effusion [7.5% (3/40) vs. 25.0% (10/40), χ2=4.500, P=0.034], all of which occurred less often in the minimal bowel resection than conventional resection group. The CCI index was also lower in the minimal bowel resection group than in the conventional resection group [CCI>40: 2.5% (1/40) vs. 12.5% (5/40), Z=18.451, P<0.001]. KPS scores were higher in the minimal bowel resection group 1 and 3 months postoperatively than they had been 1 day preoperatively (79.9±4.7 vs. 75.3±4.1, 86.2±4.8 vs. 75.3±4.1, both P<0.05). In the minimal bowel resection group, seven patients were satisfied with their current quality of life and refused to undergo stoma reduction at follow-up and one deferred stoma reduction because of rectal bleeding. The remaining 32 patients underwent stoma reduction 3 to 12 months after surgery, 26 of whom underwent ileo-cecal anastomosis. The remaining six underwent resection of the stoma and anastomosis of the ileum to the ascending colon. Conclusions: The strategy of minimal small bowel resection in patients with radiation-induced bowel injuries reduces the length of resected small bowel, decreases the risk and severity of postoperative complications, and is associated with a better prognosis and quality of life than conventional resection.

Multipotent Human Neonatal Cardiac‐Derived Mesenchymal Stem Cells Modulate Ileitis In Vivo

AbstractTransmural skip lesions are pathognomonic for Crohn's disease (CD). Despite advances toward CD treatment, disease recurrence remains a problem. CD requires novel therapies to modulate localized intestinal inflammation and promote intestinal epithelium healing. Human neonatal cardiac‐derived mesenchymal stem cells (nMSCs) demonstrate immune cell modulation accompanied by improved cardiac function recovery in myocardial infarction models. In the established CD‐like ileitis SAMP mouse model, direct skip lesion injection of nMSCs prevents ileal skip lesion growth and significantly down‐regulates the pro‐inflammatory milieu. Significant reduction in the percentage of skip lesion CD68+ macrophages (M1 Mφ, pro‐inflammatory) accompanied by an increase of CD206+ macrophages (M2 Mφ, anti‐inflammatory/pro‐regenerative) is observed in skip lesions following nMSCs injection compared to non‐injected and placebo controls (p &lt; 0.05). Skip lesion size is significantly reduced along with pro‐inflammatory cytokines IFN‐y and TNF‐α, with an increase in intestinal tissue anti‐inflammatory cytokine IL‐10 production. nMSCs are also retained within skip lesions 5 weeks post‐treatment. nMSC administration promotes wound remodeling by modulating inflammatory immune cells and by increasing small bowel gastrointestinal transit with concomitant decreased segment gross pathology score compared to placebo control. Data from this study demonstrate that direct injection of nMSCs into ileal skip lesions attenuates inflammation and improves intestinal physiology.

Ileal Neuroendocrine Tumour Causing Carcinoid Syndrome in Absence of Hepatic Metastasis

Carcinoid syndrome consists of the classic symptom triad of flushing, diarrhoea, and valvular heart disease. It occurs in the majority of patients with liver metastases. This report presents a 68-year-old female who suffered from chronic diarrhoea with a history of multiple admissions for the same. On evaluation, a Computed Tomography (CT) scan showed a terminal ileal lesion and bulky ovaries. Suspecting Neuroendocrine Tumour (NET) with carcinoid syndrome, a Gallium 68 DOTANOC (DOTA-1-Nal3- octreotide) scan was done which revealed somatostatin receptor expression in enhancing soft tissue lesion in terminal ileum as well as in bilateral adnexa. This confirmed the diagnosis of NET of the ileum and bilateral ovarian metastases. The patient underwent laparoscopic curative resection of the primary tumour along with bilateral oophorectomy. The patient was diagnosed with ileal NET and presented with clinical symptoms of carcinoid syndrome, yet did not have evidence of hepatic metastasis, but instead had bilateral ovarian metastasis which itself is a rare entity.

EP-565 Four different causes of bowel obstruction in single patient – case report and review of management of small bowel obstruction

Abstract Introduction The most common causes of Small bowel obstruction (SBO) in adults are adhesions, hernias, cancer, Crohn's, Diverticulitis, volvulus, etc; in children, intussusception. Overall mortality is 10%, increasing to 30% with complications. Urgent investigation, aggressive medical management and appropriate timely surgery are key to successful outcome. Aim We present a patient with 4 causes of bowel obstruction due to a single pathology, to highlight different causes and management of SBO with the aim of improving patient outcomes. Case presentation A 55 year old lady presented with SBO, and mass RIF. CT demonstrated subacute SBO. Four causes of obstruction were found at laparotomy 1. intraluminal lesion proximal jejunum 2. intussuscepting ileal lesion 3. terminal - ileal lesion perforated /adherent to pelvic side wall, and 4. RIF mass lesion from ascending colon. Right hemicolectomy + terminal ileal resection (lesions 2, 3, 4) and jejunal resection-anastomosis (lesion 1) were performed. She made a good post- operative recovery. Histology found the morphological appearances and immunoprofile were soft tissue sarcoma arising in the GIT: gastrointestinal clear cell sarcoma/ malignant gastrointestinal neuroectodermal tumour. She is under review with the specialist regional sarcoma team. Conclusion There are over 22 000 admissions for bowel obstruction in England/Wales each year; 6.4% result in death within 90 days. Depending on the cause, SBO may resolve with medical therapy but timely surgery is needed for total obstruction, complications such as bowel perforation, ischaemia, or failure of conservative therapy. Our case report highlights the importance of urgent investigations and appropriate management of SBO.

What is your diagnosis? Ileal lesion in a Labrador Retriever puppy.

What is your diagnosis? Ileal lesion in a Labrador Retriever puppy.

A Case of Small Intestinal Perforation During Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer

Background: For patients with locally advanced rectal cancer, side effects such as nausea, vomiting and loss of appetite may occur during neoadjuvant chemotherapy, but small intestinal perforation is very rare. Case: We present a case of a 62-year-old man who suffered small intestinal perforation in the first cycle neoadjuvant treatment of locally advanced rectal cancer with capecitabine and oxaliplatin. Six days after the start of neoadjuvant chemotherapy, he began to develop intermittent abdominal pain, accompanied by diarrhea and abdominal distension. The CT scan revealed an abscess with free air in the pelvic cavity with proximal intestinal ileus. Then we performed a laparotomy. After enterolysis, the rectum with tumor was carefully examined with no perforative lesion, and the terminal ileum about 15cm from the ileocecum which adhere to the pelvic abscess had one about 0.8cm ulcer. The patient had a radical anterior resection and the morbid small bowel resection with protective ileostomy. The postoperative pathological examination showed the full-thickness necrosis of the intestinal wall in the ileal lesion with peripheral acute suppurative inflammation. AND the final pathological stage of the tumor was pT3N0M0 (American Joint Committee on Cancer, eighth edition). Conclusion: As a chemotherapy regimen based on fluorouracil and oxaliplatin, small intestinal perforation is a very rare complication. The most common complications of these two drugs are gastrointestinal symptoms such as diarrhea. Therefore, when the complications are not relieved during chemotherapy, we should think of a more serious possibility

Are Two Meshes Better than One in Sacrocolpopexy for Pelvic Organ Prolapse? Comparison of Single Anterior versus Anterior and Posterior Vaginal Mesh Procedures

Introduction: Sacrocolpopexy (SC) is the main treatment option for the repair of anterior and apical pelvic organ prolapse (POP). Indications and technical aspects are not standardized, and the question remains whether it is necessary to place a mesh on both anterior and posterior vaginal walls, particularly in cases with only minor or no posterior compartment prolapse. The present study aimed to compare the anatomical and functional outcomes of single anterior mesh only versus anterior and posterior mesh procedures in SC. Materials and Methods: Our prospectively maintained database on POP was used to identify patients who had undergone either abdominal or mini-invasive SC from January 2006 to October 2019. Patients with symptomatic or unmasked stress urinary incontinence (SUI) were not included in the study and were treated using the pubo-vaginal cystocele sling procedure. Objective outcomes included clinical evaluation of pre-existing or de novo POP by the halfway system and POP-q classifications, as well as the development of de novo SUI. Subjective outcomes were assessed using the Pelvic Floor Impact Questionnaire (PFIQ-7) with questions on bladder, bowel, and vaginal functions. Persistent or de novo constipation and overactive bladder were defined as bowel symptoms and urinary urgency/frequency/urinary incontinence after surgery. Results: Ninety-five women with symptomatic anterior and apical POP underwent SC. Forty-one patients were treated with only anterior vaginal mesh (group A), and 54 with anterior and posterior mesh (group B). There were no differences between the pre- and post-operative characteristics of the 2 groups. In group B, there were 2 blood transfusions, 1 wound dehiscence, and 3 mesh erosions/extrusion after abdominal SC (Clavien-Dindo II), and in group A, there was 1 ileal lesion after laparoscopic SC (Clavien-Dindo III). There were no differences between the 2 groups in either anatomical or functional outcomes during 3 years of follow-up. Conclusions: SC with single anterior vaginal mesh has similar results to SC with combined anterior/posterior mesh, regardless of the surgical approach. The single anterior mesh may reduce the risk of complications (mesh erosion/extrusion), and offers better subjective outcomes with improved quality of life. Anterior/posterior mesh may be justified in the presence of clinically significant posterior POP.

Ileal Dieulafoy lesion arose 15\u2009years after partial small bowel resection for meconium obstruction of the neonate: a case report

BackgroundAnastomotic or perianastomotic ulcers present with symptoms such as chronic anaemia and occult bleeding as long-term complications of bowel resection performed in infancy.Case presentationHerein, we describe a 15-year-old girl with a history of surgery for meconium obstruction without mucoviscidosis in infancy who was hospitalized with chief complaints of presyncope and convulsions. Seven hours after admission, she developed melena and went into shock. An emergency laparotomy was performed, and a Dieulafoy lesion was detected near the site of ileal anastomosis from the surgery that had been performed during infancy.ConclusionsAlthough overt massive lower gastrointestinal bleeding necessitating emergency care is rare in the long term after infant bowel resection, Dieulafoy lesions can cause serious bleeding, requiring rapid life-saving haemostatic procedures.

Potential of a mixture of eugenol and garlic tincture to improve performance and intestinal health in broilers under necrotic enteritis challenge.

Plant extracts (PE) are gaining increased attention as potential alternatives to in-feed antimicrobials (AM) due to their known antimicrobial activities. This study was conducted to examine the potential of PE, a microencapsulated product composed of eugenol and garlic tincture as an alternative to AM-agent on performance and intestinal health in broilers under necrotic enteritis (NE) challenge. A total of 960 day-old mixed-sex Cobb 500 chicks were randomly distributed to 48-floor pens with 6 treatments replicated 8 times with 20 birds each. The 6 treatments were as follows: UC, unchallenged control; CC, challenged control; PE, challenged group plus PE; AM, challenged group plus AM; FAP, challenged group plus a full dose of AM with PE; HAP, challenged group plus a half dose of AM with PE in starter, grower and finisher phases. Birds in the challenged groups were inoculated with Eimeria spp. on d 9 and Clostridium perfringens on d 14. The body weight gain (BWG), feed intake (FI), feed conversion ratio (FCR), and livability of birds were compromised, and intestinal lesions and mortality were increased (P < 0.05) by NE challenge, illustrating a successful clinical NE challenge. Birds fed AM had higher BWG and FI, and lower FCR, mortality, and intestinal lesions compared to the CC group (P < 0.05). Birds fed PE had improved FCR (P < 0.05) and livability (5.8%) in an overall period compared to the CC group. On d 16, PE supplementation reduced ileal lesion scores in only male birds (P < 0.05). Birds fed PE had decreased Eimeria maxima and Eimeria acervulina oocyst counts in caecal content (P < 0.05). Birds fed PE had decreased Escherichia brunetti and total oocyst counts in caecal content, and E. acervulina oocyst counts in ileal content in only female birds (P < 0.05). On d 35, PE supplementation reduced variation of BW in both male and female birds and increased yellowness (b∗ value, 14.4%) in the thigh. These findings suggest the potential of PE supplementation in diets to improve the performance and intestinal health of birds under clinical NE as indicated by improved FCR, livability, uniformity, reduced ileal lesions, oocyst counts and increased skin yellowness. However, the protective effect of PE may not be apparent in the presence of AM in the feed.

Lawsonia intracellularis infected enterocytes lack sucrase-isomaltase which contributes to reduced pig digestive capacity

Lawsonia intracellularis is endemic to swine herds worldwide, however much is still unknown regarding its impact on intestinal function. Thus, this study aimed to characterize the impact of L. intracellularis on digestive function, and how vaccination mitigates these impacts. Thirty-six L. intracellularis negative barrows were assigned to treatment groups (n = 12/trt): (1) nonvaccinated, L. intracellularis negative (NC); (2) nonvaccinated, L intracellularis challenged (PC); and (3) L. intracellularis challenged, vaccinated (Enterisol® Ileitis, Boehringer Ingelheim) 7 weeks pre-challenge (VAC). On days post-inoculation (dpi) 0 PC and VAC pigs were inoculated with L. intracellularis. From dpi 19–21 fecal samples were collected for apparent total tract digestibility (ATTD) and at dpi 21, pigs were euthanized for sample collection. Post-inoculation, ADG was reduced in PC pigs compared with NC (41%, P < 0.001) and VAC (25%, P < 0.001) pigs. Ileal gross lesion severity was greater in PC pigs compared with NC (P = 0.003) and VAC (P = 0.018) pigs. Dry matter, organic matter, nitrogen, and energy ATTD were reduced in PC pigs compared with NC pigs (P ≤ 0.001 for all). RNAscope in situ hybridization revealed abolition of sucrase-isomaltase transcript in the ileum of PC pigs compared with NC and VAC pigs (P < 0.01). Conversely, abundance of stem cell signaling markers Wnt3, Hes1, and p27Kip1 were increased in PC pigs compared with NC pigs (P ≤ 0.085). Taken together, these data demonstrate that reduced digestibility during L. intracellularis challenge is partially driven by abolition of digestive machinery in lesioned tissue. Further, vaccination mitigated several of these effects, likely from lower bacterial burden and reduced disease severity.

85 Vaccination Mitigates Performance Losses During a Lawsonia Intracellularis Experimental Challenge

Abstract Lawsonia intracellularis is endemic to swine herds worldwide. Currently, vaccination is one of the few strategies available to mitigate L. intracellularis. Thus, this study aimed to characterize the impact of vaccination on growth performance and disease severity during experimental challenge. Thirty-six L. intracellularis negative barrows were assigned to treatment groups as follows (n = 12/trt): 1) nonvaccinated, L. intracellularis negative (NC); 2) nonvaccinated, L intracellularis challenged (PC); and 3) L. intracellularis challenged, vaccinated (Enterisol® Ileitis, Boehringer Ingelheim) at 1 week postweaning (VAC). On days post inoculation (dpi) 0 (7 weeks post-weaned) PC and VAC pigs were inoculated with L. intracellularis. Individual feed disappearance and BW were recorded weekly and all pigs were euthanized at dpi 21. Post-inoculation, ADG was reduced in PC (P &amp;lt; 0.001) and VAC (P = 0.001) pigs compared with NC pigs. Average daily gain was additionally reduced in PC pigs compared with VAC pigs (P &amp;lt; 0.001). Similarly, ADFI was reduced in PC (P &amp;lt; 0.001) and VAC (P = 0.029) pigs compared with NC pigs, and further reduced in PC pigs compared with VAC pigs (P = 0.032). Overall G:F was reduced in PC pigs compared with NC (P &amp;lt; 0.001) and VAC (P = 0.015) pigs, which did not differ. For antibody response and fecal shedding, NC pigs remained negative. Antibody responses and fecal shedding were lower in VAC pigs compared with PC pigs (P &amp;lt; 0.05). Ileal gross lesion severity was greater in PC pigs compared with VAC (P = 0.018) and NC (P = 0.003) pigs, which did not differ. Similarly, ileal lesion length was greater in PC pigs compared with NC (P = 0.007) and VAC (P = 0.045) pigs. Microscopic lesion severity was greater in PC pigs compared with both PC and VAC pigs (P &amp;lt; 0.05). Taken together, these data characterize the impact L. intracellularis has on growth performance of pigs and highlight the importance of vaccination to prevent disease associated performance losses.

Efficacy of a Dietary Polyherbal Formula on the Performance and Gut Health in Broiler Chicks after Experimental Infection with Eimeria spp.

One-hundred and fifty, one-day-old Ross-308 female chicks were randomly allocated to five equal treatments: NCONTR negative control—not challenged; PCONTR positive control—challenged; PHERB1 and PHERB2 diets were supplemented with phytogenic formula (1 and 2 g/kg feed, respectively)—challenged; PSALIN diet was supplemented with salinomycin (60 mg/kg feed)—challenged. Challenge was made by oral inoculation with 3.5 × 104 E. acervulina, 7.0 × 103 E. maxima and 5.0 × 103 E. tenella oocysts, at 14 days of age. One week post inoculation, bloody diarrhea, oocysts numbers, and intestinal lesions were evaluated, along with intestinal microbiota, viscosity, and pH of digesta, and histopathology. PHERB2 had a comparable (p ≤ 0.001) growth performance and feed conversion ratio to PSALIN. PHERB1 and PHERB2 had similar (p ≤ 0.001) oocyst counts to PSALIN and lower than PCONTROL. PHERB2 and PSALIN had lower (p ≤ 0.001) jejunal, ileal, and cecal lesion scores compared to PCONTR. PHERB1 and PHERB2 had higher (p ≤ 0.001) jejunal and cecal lactobacilli and lower (p ≤ 0.001) coliform counts compared to other treatments. PCONTR had lower (p ≤ 0.001) jejunum villus height, height to crypt ratio, and villus goblet cells. Breast and thigh meat resistance to oxidation was improved (p ≤ 0.001) in PHERB1 and PHERB2 compared to the PCONTR. The polyherbal formula exerted a substantial improvement on growth performance and intestinal health of the Eimeria-challenged birds.

Ovarian metastases of ileal neuroendocrine tumor

A 55-year-old, menopausal woman with history of breast carcinoma was referred for recurrent abdominal pain without diarrhea. Physical examination, routine biological investigation, and serum CA15-3 were normal. Abdominal contrast-enhanced computed tomography (CT) found a 15-mm ileal hyper-vascularized lesion with mild intestinal dilation and a mesenteric mass of about 20 mm. Both ovaries were moderately enlarged without radiological overt signs of malignancy. CT findings were consistent with ileal neuroendocrine tumor (ileal-NET) with mesenteric invasion. Serum value of chromogranin A was normal. 18F-Fluorodihydroxyphenylalanine (18F-FDOPA) positron emission tomography (PET)/CT was added to the preoperative work-up 1 Addeo P. Poncet G. Goichot B. et al. The added diagnostic value of 18F-fluorodihydroxyphenylalanine PET/CT in the preoperative work-up of small bowel neuroendocrine tumors. J Gastrointest Surg. 2017; 22: 722-730 Crossref PubMed Scopus (7) Google Scholar and distinctly identified the primary ileal-NET with the mesenteric involvement. Moreover, intense and pathological 18F-FDOPA uptake was shown in both ovaries and 1 peritoneal nodule of a few millimeters in the Douglas space (Fig 1, A), suggesting ovarian metastases with peritoneal carcinomatosis. Surgical exploration found the primary tumor and the mesenteric lesion that were removed by a 20-cm ileal resection and mesenteric lymphadenectomy. Intervention was completed by bilateral salpingo-oophorectomy, omentectomy, and multiple peritoneal biopsies (Fig 1, B). Postoperative course was uneventful, and pathology confirmed a 20-mm, well-differentiated grade-2 ileal-NET (Ki-67: 4%) with mesenteric invasion, ovarian bilateral spread, and pelvic peritoneal metastases as small as a few millimeters in size (pT4N2M1, UICC 2016).

Leukotriene B4 Receptor Type 2 Accelerates the Healing of Intestinal Lesions by Promoting Epithelial Cell Proliferation.

Leukotriene B4 receptor type 2 (BLT2) is a low-affinity leukotriene B4 receptor that is highly expressed in intestinal epithelial cells. Previous studies demonstrated the protective role of BLT2 in experimentally induced colitis. However, its role in intestinal lesion repair is not fully understood. We investigated the role of BLT2 in the healing of indomethacin-induced intestinal lesions in mice. There was no significant different between wild-type (WT) and BLT2-deficient (BLT2KO) mice in terms of the development of indomethacin-induced intestinal lesions. However, healing of these lesions was significantly impaired in BLT2KO mice compared with WT mice. In contrast, transgenic mice with intestinal epithelium-specific BLT2 overexpression presented with superior ileal lesion healing relative to WT mice. An immunohistochemical study showed that the number of Ki-67-proliferative cells was markedly increased during the healing of intestinal lesions in WT mice but significantly attenuated in BLT2KO mice. Exposure of cultured mouse intestinal epithelial cells to CAY10583, a BLT2 agonist, promoted wound healing and cell proliferation in a concentration-dependent manner. Nevertheless, these responses were abolished under serum-free conditions. The CAY10583-induced proliferative effect was also negated by Go6983, a protein kinase C (PKC) inhibitor, U-73122, a phospholipase C (PLC) inhibitor, LY255283, a BLT2 antagonist, and pertussis toxin that inhibits G protein-coupled receptor signaling via Gi/o proteins. Thus, BLT2 plays an important role in intestinal wound repair. Moreover, this effect is mediated by the promotion of epithelial cell proliferation via the Gi/o protein-dependent and PLC/PKC signaling pathways. The BLT2 agonists are potential therapeutic agents for the treatment of intestinal lesions. SIGNIFICANCE STATEMENT: The healing of indomethacin-induced Crohn's disease-like intestinal lesions was impaired in mice deficient in low-affinity leukotriene B4 receptor type 2 (BLT2). They presented with reduced epithelial cell proliferation during the healing. In contrast, healing was promoted in mice overexpressing intestinal epithelial BLT2. In cultured intestinal epithelial cells, the BLT2 agonist CAY10583 substantially accelerated wound repair by enhancing cell proliferation rather than migration. Thus, BLT2 plays an important role in the intestinal lesions via acceleration of epithelial cell proliferation.

1850 Intestinal Tuberculosis in an Immunocompetent Patient

INTRODUCTION: Intestinal tuberculosis (TB) is a rare disease in western countries usually only affecting immigrants from endemic areas and those that are immunocompromised. Diagnosis is challenging especially when pulmonary symptoms are absent as it can mimic other abdominal pathologies, notably Crohn’s disease. It is especially important to distinguish between Crohn’s and TB since treatments greatly differ. Intestinal TB favors the small bowel, particular the small ileum due to its affinity for Peyer’s patches. Biopsies positive for acid-fast bacilli confirms the diagnosis. Our case describes an immunocompetent patient diagnosed with intestinal TB that was initially thought to be Crohn’s disease. CASE DESCRIPTION/METHODS: A 79-year-old male with a history of TIA, seizure disorder and achalasia presented to the hospital with acute encephalopathy and sepsis. Chest x-ray revealed bilateral infiltrates and the patient was treated for pneumonia. Incidental finding on CT chest, abdomen and pelvis revealed terminal ileitis and an ileocecal valve mass. The patient underwent colonoscopy which showed a terminal ileum and ileal cecal valve lesion with sigmoid stricture and severe left sided diverticulitis. Biopsies were taken that were significant for non-necrotizing granulomas concerning for infectious etiology or Crohn’s disease. The patient was referred to Colorectal Surgery and underwent laparoscopic right hemicolectomy. Surgical pathology revealed extensive granulomas positive for acid-fast bacilli (AFB) secondary to Mycobacterium tuberculosis (TB). Prior to these findings, the patient denied prior TB exposure, travel to TB endemic countries, previous incarceration, pulmonary symptoms, fevers, weight loss, diarrhea, constipation, melena, hematochezia, alcohol or illicit drug use. The patient underwent bronchoscopy with cultures positive for AFB. The patient then began treatment for active TB with a four-drug regimen. DISCUSSION: Though rare, intestinal tuberculosis should be kept on the differential when evaluating chronic intestinal diseases. Proper knowledge and anticipation of intestinal manifestations of systemic disease should be mandatory due to the vast differences in treatment. Though diagnosis is difficult in the absence of active symptoms, intestinal tuberculosis should be considered especially in metropolitan areas. Endoscopic evaluation is the mainstay of diagnosis and should be promptly considered to differentiate it from other abdominal pathologies.

Influence of supplemented coated-cysteamine on morphology, apoptosis and oxidative stress status of gastrointestinal tract

BackgroundCysteamine was coated to cover its odor and maintain the stability. However, coated cysteamine (CC) has not been clearly evaluated for its effects on the gastrointestinal mucosa status. We hypothesize that the appropriate CC supplementation in diet impacts the stomach and intestinal mucosa variously through regulating the morphology, apoptosis, and oxidative stress status in model of pigs.ResultsThe results showed that villus height increased (P < 0.05), and crypt depth decreased (P < 0.05) in the ileum when pigs were fed the diet with low cysteamine (LCS) compared with the control diet. The ileal lesion score in the LCS group was significantly (P < 0.01) lower than that in the control group, while the gastric lesion score in the CC group was significantly (P < 0.01) higher compared with that of the control group. It also showed that the activities of total superoxide dismutase (T-SOD) and diamine oxidase (DAO) were upregulated (P < 0.05) in the LCS group. In addition, Bax and caspase 3 immunore-activity increased (P < 0.01), and Bcl-2 immunoreactivity decreased (P < 0.01) in the gastric mucosa of pigs fed the diet with high cysteamine (HCS). The Bax and caspase 3 immunoreactivity decreased (P < 0.01), and Bcl-2 immunoreactivity increased (P < 0.01) in ileum mucosa of pigs fed the HCS diet.ConclusionsAlthough moderate dietary coated cysteamine showed positive effects on GI mucosal morphology, apoptosis, and oxidative stress status, the excess coated cysteamine may cause apoptosis leading to GI damage in pigs.

Rare case of systemic scleroderma showing full-layer histologic features of an ileal lesion

Rare case of systemic scleroderma showing full-layer histologic features of an ileal lesion

Ileal Dieulafoy Lesion: a rare case report

BackgroundDieulafoy lesion, also known as calibre persistent artery is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). Commonest location is in proximal stomach while occurrence in small intestine, especially ileum is extremely rare.Case presentationA 26 year old female presented with lower gastrointestinal bleeding. Preliminary investigations failed to locate the exact source of bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.8 cm in diameter was identified in distal ileum. Histology revealed it to be Dieulafoy lesion.ConclusionAlthough uncommon, ileal dieulafoy is one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.

A unique case of ileal Dieulafoy's lesion diagnosed and treatedbycap-assisted water immersion colonoscopy.

Ileal Dieulafoy’s lesions are rare causes of GI bleeding and are identified primarily through capsule endoscopy, single-balloon enteroscopy, or double-balloon enteroscopy. We describe a unique case of ileal Dieulafoy’s lesion identified and treated through cap-assisted water-immersion colonoscopy (Video 1, available online at www.VideoGIE.org). An 83-year-old woman with a history of transient ischemic attack on an aspirin regimen presented with a 5-day history of melena and anemia. She had a history of GI bleeding 1 year previously from presumed peptic ulcer and right-sided colonic arteriovenous malformations. Repeated EGD showed retained clips on previous ulcer sites. Colonoscopy showed a 1-cm nonbleeding ascending arteriovenous malformation with more proximal intermittent extrusion of fresh blood from the ileocecal valve. Advancement of a pediatric colonoscope (Evis Exera III PCF-PH190L/l; Olympus Medical Systems, Tokyo, Japan) with distal attachment cap (Reveal; US Endoscopy, Mentor, Ohio, USA) into the ileum revealed a trail of small scattered clots. Further advancement of the colonoscope 30 cm into the ileum (measured by withdrawal from the lesion to the ileocecal valve) demonstrated a 4-mm nonadherent clot. Irrigation of the clot uncovered a 1-mm actively pulsating bleeding vessel. Hemostasis was achieved with 3 hemoclips, and a tattoo was placed (Fig. 1). After discharge, no recurrent bleeding was observed. We highlight the use of cap-assisted water-immersion colonoscopy as a means to advance the colonoscope deeper into the small bowel compared with traditional gas distention colonoscopy. The cap extends the length of the colonoscope 3 to 4 mm, which allows the proximal adjacent intestinal folds to be pushed down ahead of the scope. In some areas where inevitable looping results and advancing the scope even 1 cm is difficult, the cap may assist in pushing down the proximal adjacent fold to help anchor the colonoscope forward and beyond where an otherwise introduced loop has difficulty advancing. Therapeutically, the cap stabilizes lesions into the field of view, preventing inadvertent deflection of the tip. The water-immersion method minimizes excessive looping and lengthening of the colon. The shortened colon length potentially allows more proximal advancement of the colonoscope. Deeper intubation of the ileum allows lesions like this one to be reached without the need for capsule or balloon enteroscopy. Cap-assisted water-immersion colonoscopy may allow more efficient and cost-effective means of identifying and treating ileal lesions thought to be otherwise unreachable by gas distention colonoscopy. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0YmI5NTA1YmQ2ZDcxMzczNmFkNmJiNmU3ZTk5ZGNjZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzQ4OTgwfQ.kUT-cUQDKFui2G-CNZc1qE2Xnpx_8VggXnt8HInPZ1TvsHQOAxBgrnGlQOrXb21rfpZsaBelzmgtc9QugNCH8jIEl0bwzSpqBj-hOyGqwahx7zMmrxqBkbF_XWU0Y-I9h-iyt_OxK_0vxGuPhe7-r4geZhxa-MZR6JSvu4t63wYcweKtN5YC6RadudcV3pjhJjo6B8XLf_lvRkrLMikeprWX06TON7qKuIP7MIFc0oboQmEKmh7you_wYi4YhKJFkAokaXdGUCjWlgAMx_a5xaBb-smXynCQVKSFYbXdhTNq41T5wbpshJJi0VyosoYFQFJGBCqpOVVbzao3upp8eg Download .mp4 (219.31 MB) Help with .mp4 files Video 1. Ileal intubation and endoscopic therapy with cap-assisted water-immersion colonoscopy.