Infiltration Of Bowel Research Articles

Unusual ascites following ingestion of spicy food in a young woman.

Eosinophilic enteritis, one type of eosinophilic disorders, is a rare disease characterised by infiltration of the small bowel with numerous mucosal eosinophils or/and eosinophilic ascites pathologically. The prevalence of eosinophilic enteritis is fewer than ten in100,000 people, frequently occurred in female1. The pathogenesis of the disease is poorly known, but allergic diseases, autoimmune connective reaction and intestinal dysbiosis have been implicated.

Spiliotis-Farfarelos Maneuver for the Management of Small Bowel Obstruction and Frozen Pelvis in Patients With Peritoneal Metastasis.

The management of the advanced peritoneal disease is demanding especially in cases of extensive bowel infiltration and the obstruction of the gastrointestinal tract in different sites. Patients with bowel obstruction due to peritoneal carcinomatosis have an overall survival that ranges from three to eight months to four to five weeks based on the operability or not of the disease, respectively. The decision to operate should carefully consider the balance between the probability of symptomatic relief and the risk of severe perioperative complications and survival after surgery. The extent of the disease and postoperative malnutrition could further complicate patients' postoperative course. We aim to present an operative maneuver of bowel preparation and fixation in cases of extensive infiltration of the small bowel by peritoneal carcinomatosis (PC) in order to eliminate the risk of postoperative fistula formation or anastomotic leakage.

The potential role of FDG PET-CT in the characterization of the activity of Crohn’s disease, staging follow-up and prognosis estimation: a pilot study

Objectives: FDG PET-CT is a global, noninvasive, sensitive method to determine the location and activity of inflammatory lesions. Segmental FDG uptake is proportional with immune cell infiltration of bowel. Our aim was to evaluate prospectively the role of PET in patients with active Crohn’s disease (CD) before and after one year’s biological therapy, and to compare simple endoscopic score for CD (SES-CD), CD activity index (CDAI) and global PET scores. We also analyzed the prognostic value of initial PET scores.Patients: Twelve patients were selected: six male/six female, ages between 18 and 39, average: 24 years, with CDAI values >300.Methods: We scored the FDG uptake in the small intestine and the four colon segments (on a scale 0–3 for each), and summed them thus forming a global PET score. The scoring was based on the maximal standardized uptake value of the intestinal segment, related to the SUVmax of the liver (as a reference for normal tissue activity). The SES-CD, CDAI and global PET scores before and after treatment were statistically compared.Results: There were significant changes in CDAI and SES-CD after therapy, PET scores improved only in patients’ subgroup with high (>4) initial PET score, indicating good prognosis of biological treatment. In active disease, PET was more informative than endoscopy to access the extent of the inflammation, and small intestine involvement.Conclusions: FDG PET-CT score is a promising, noninvasive complementary method in the staging, treatment planning and follow-up of CD. Limitation of the study is the small number of patients.

Isolated Enteric Mastocytosis Causing Recurrent Small Bowel Obstruction

Mast cells are involved in many allergenic and non-allergenic inflammatory events in the gastrointestinal (GI) tract. Local proliferation of mast cells can lead to alteration of GI function and systemic symptoms. GI symptoms may include abdominal pain, nausea, vomiting and diarrhea. We report a rare case of isolated mastocytosis of the small bowel causing recurrent small bowel obstruction (SBO). Case Presentation: A 37-year-old male with no significant past medical or surgical history was referred to our center for evaluation of recurrent SBO of unclear etiology. His usual “attacks” presented with abdominal pain and CT scans of abdomen intermittently concerning for a possible small bowel stricture, terminal ileum thickening with upstream dilation of the small bowel. His symptoms would resolve with conservative management. He had no known drug or seasonal allergies. Extensive laboratory and endoscopic evaluations were non-diagnostic and he continued to have 1-2 such episodes per month with no precipitating factors. After 2 years of these “attacks” he was hospitalized again with another episode of SBO. He underwent a proximal ileal segmental resection and primary anastomosis. Pathology revealed significant mast cells infiltration of the small bowel, up to 20/hpf. These results were thought to be suspicious for mastocytic enteritis. His PPI therapy was switched to an H2 blocker to prevent histamine release. The patient has remained symptom free since then for the last 9 months with no further attacks of SBO. Discussion: Mast cells play an important role in the regulation of gastrointestinal visceral sensitivity and vascular permeability. Increased number of mast cells can be seen in the mucosa of patients with inflammatory bowel disease, irritable bowel syndrome, mastocytic enterocolitis, systemic mastocytosis and parasitic infections. Features of mastocytosis in GI biopsies are not well described and difficult to diagnose. In our case, the presentation was very rare with only isolated mastocytosis of the GI tract causing recurrent SBO. Management is aimed at stabilizing mast cells and controlling mediator release with antihistamines and antileukotrienes to prevent symptoms. Conclusion: We present a rare case of recurrent SBO caused by isolated small intestinal mastocytosis without any systemic mastocytosis. This entity should be in the differential diagnosis for potentially rare causes of unexplained, recurrent SBO.

P28.11: How reliable is office gel sonovaginography in predicting depth of infiltration of bowel DIE?

<scp>P</scp>28.11: How reliable is office gel sonovaginography in predicting depth of infiltration of bowel <scp>DIE</scp>?

Concealed enterovesical fistula associated with forgotten intra-abdominal haemostat and intravesical towel.

Introduction. Enterovesical fistula is rare and is often caused by bowel inflammatory diseases and tumours in the urinary bladder or the intestine with local infiltration of bowel or bladder, respectively. The fistula usually presents with lower urinary tract symptoms, pneumaturia, and faecaluria or with food particles in the urine. Intra-abdominal retained surgical foreign bodies have also been reported as causes. Case Presentation. A case of atypical presentation in a woman with enterovesical fistula following abdominal hysterectomy. Investigations confirmed the presence of surgical towel in the urinary bladder and a pair of artery forceps in the abdomen. The towel was removed at cystoscopy after which she presented with food particles in the urine. She later had laparatomy to remove the haemostat and to repair the fistula. Discussion. A typical presentation of enterovesical fistula delayed the diagnosis and treatment in this patient. Conclusion. Managing patients with recurrent urinary tract infection after abdominal operation should include appropriate imaging of the abdomen with emphasis on pelvic organs. Also, surgical operation should always be given the best shot the first time and strict operation room standards and guidelines should always be followed.

Anatomic Significance of a Positive Barium Enema in Deep Infiltrating Endometriosis of the Large Bowel

The anatomopathological significance of a positive double-contrast barium enema (DCBE) for suspicion of deep infiltrating endometriosis of the large bowel was studied. This is a retrospective study of a prospective database. A large-bowel resection was proposed for patients who were suspicious for large-bowel endometriosis and had a positive DCBE. In a series of 73 patients, 71 large-bowel resections were performed. Histology and immunohistochemistry with the monoclonal antibody CD-10 were performed on the resection specimen. Outcome measures were the length of the resected specimen, the largest diameter of the lesion, the positivity of the resection margins, and the degree of infiltration of the large bowel. We also compared the mean largest diameters of the lesions with the degree of infiltration of the large bowel. Between December 1997 and October 2005, 80 patients were suspicious for large-bowel endometriosis: 73 (91%) had positive DCBEs, and 7 (9%) had negative DCBEs. Of the 73 with positive DCBEs, 4 (5%) refused digestive resection and 1 (1.4%) was excluded. Three patients underwent two large-bowel resections because of the presence of bifocal lesions (left and right colon). A total of 71 resections were performed. In case of positive DCBE, the perivisceral fat and the whole muscularis were infiltrated in 100% of cases. The infiltration reached the submucosa and the mucosa respectively in 82% and 18% of cases. A total of 9.9% of resection margins were positive at histology but only focally. The mean largest diameter of the lesions infiltrating the whole thickness of the large bowel was not statistically different from the mean largest diameter of more superficial lesions. Findings of mass effect with indentations and ridging of the mucosa on DCBE in a setting suspicious for large-bowel endometriosis correspond well with pathologic findings of deep infiltration of the large-bowel wall. Clinicians dealing with deep infiltrating endometriosis should be aware of these findings, which could influence their choice of surgical treatment.

Clostridium, Strongyloides, Lymphoma – from Common to Rare Causes of Diarrhea in One Patient

Purpose: We present the case of a 71 year old female of Japanese descent who presented with five months of chronic, watery diarrhea of up to 20 bowel movements daily. Her diarrhea was large volume without cramping, pain, or fevers, and persisted during the night and despite fasting. She also had a 20 pound weight loss and dehydration requiring eight hospitalizations for intravenous fluid administration and symptom control. Her past medical history was significant for human T-lymphotropic virus type I-associated adult T cell leukemia/lymphoma (HTLV-1 ATLL) diagnosed two years prior to admission. At that time, she also was diagnosed with Strongyloides stercoralis infection via small bowel biopsies. Though the parasite was successfully eradicated with ivermectin, strongyloides recurred four months prior to presentation, requiring further ivermectin treatment in addition to lifelong suppressive therapy. Past history also was remarkable for Clostridium difficile infection detected six months prior to presentation, successfully treated with a combination of oral metronidazole and vancomycin. A 72 hour stool collection confirmed large volume diarrhea of greater than 5000 grams. Investigation of the diarrhea was largely unremarkable, including evaluation of infectious (negative Clostridium difficile and enteric pathogen cultures, hepatitis serologies, strongyloides culture, ova and parasite studies, and small bowel aspirate), neuroendocrine (normal vasoactive intestinal peptide, thyroid studies, pancreatic polypeptide, calcitonin, 24 hour urine collection of 5-HIAA and histamine, gastrin and gastric pH level), anatomic (normal endoscopies, abdominal CT and MRI scans), and autoimmune (normal TTG, ANA, AMA, serum IgG/IgA levels, SPEP and UPEP) causes. She had little improvement with loperamide, octreotide, cholestyramine, or tincture of opium. Duodenal biopsy revealed intraepithelial lymphocytosis and an atypical CD4 positive T cell infiltrate, consistent with HTLV-1/ATLL infiltration of the small bowel. Chemotherapeutic treatment with alemtuzumab was recommended. HTLV-1 infection is endemic in many parts of the world, including southern Japan. It is a risk factor for strongyloides infection, which can present with diarrhea. Any patient with HTLV-1 infection and chronic diarrhea should be evaluated for strongyloides infection. Though there are few examples describing HTLV-1 lymphomatous infiltration of the small bowel, our case demonstrates it does occur. Refractory diarrhea in patients with HTLV-1 lymphoma requires extensive evaluation, and may even be an indication for chemotherapeutic treatment of ATLL, as in this case.

Acute small bowel obstruction caused by endometriosis: A case report and review of the literature

Gastrointestinal involvement of endometriosis has been found in 3%-37% of menstruating women and exclusive localization on the ileum is very rare (1%-7%). Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction, ranging from 7% to 23% of all cases with intestinal involvement. We report a case in which endometrial infiltration of the small bowel caused acute obstruction requiring emergency surgery, in a woman whose symptoms were not related to menses. Histology of the resected specimen showed that endometriosis was mainly prevalent in the muscularis propria and submucosa and that the mucosa was not ulcerated but had inflammation and glandular alteration. Endometrial lymph node involvement, with a cystic glandular pattern was also detected.

Large mesenteric gastrointestinal stromal tumor in a patient with familial adenomatous polyposis syndrome

We report a case of a 30-year-old man who presented with severe debilitation, anemia and diarrhea over two months. Colonoscopy revealed many (>100) polyps (familial adenomatous polyposis syndrome). Abdominal CT scan showed a large mass at the left upper abdomen in conjunction with the splenic flexure. Total colectomy with mesenteric mass and adjacent small bowel removal and ileoanal pouch was performed. Examination of the resected mesenteric mass showed a gastrointestinal stromal tumor (GIST) with scarce mitosis and infiltration of the adjacent small bowel. We describe for the first time in medical literature the coexistence of familial adenomatous polyposis syndrome and GIST in a 30-year-old man.

Leukemia infiltration of bowel in chronic lymphocytic leukemia

Leukemia infiltration of bowel in chronic lymphocytic leukemia

Familial autoimmune enteropathy with circulating anti-bullous pemphigoid antibodies and chronic autoimmune hepatitis

In a family of four children (two boys and two girls), the two brothers had severe, protracted watery diarrhea beginning at 2 and 3 weeks of life, respectively. Duodenal mucosa in both patients showed total villous atrophy and severe inflammatory infiltration of the entire bowel. The first patient also had lymphoid cell infiltration of the pancreas and died at 6 weeks of age. The second boy is alive at 2 years of age and is immunocompetent, but still receives total parenteral nutrition. Indirect immunofluorescence studies revealed circulating antibodies to enterocytes, smooth muscle, thyroid, and islet cells. Bullous pemphigoid antibodies (230 and 180 kd), specific for hemidesmosomal proteins and usually associated with a subepidermal blistering skin disease, were detected by direct and indirect immunofluorescence studies and by Western immunoblot. A diagnosis of autoimmune hepatitis was made, based on evidence of chronic active hepatitis and circulating anti-smooth muscle antibody. Immunosuppressive treatments induced partial clinical remission of the diarrhea but no resolution of the small bowel injury. At 16 months of age, remission of the diarrhea occurred, but persistent autoimmune hepatitis led us to maintain treatment with prednisone and azathioprine, and later with cyclosporine. In this child, as in other patients with autoimmune disease, the link between autoantibodies and organ damage remains uncertain but immunosuppressive treatment is indicated. (J P EDIATR 1994;125:858-62)

Immunoproliferative Small-Intestinal Disease

Experience with 30 patients with immunoproliferative small intestinal disease followed prospectively between 1971 and 1986 is described. All presented with malabsorption or growth retardation and had similar clinical, biochemical, and radiological features, irrespective of the presence of lymphoma or immunological abnormality. Alpha-chain disease protein was detected in 4 of the 11 patients who had a non-lymphomatous, predominantly plasmacytic infiltration of the small bowel; and in 5 of the 19 cases with diffuse intestinal lymphoma. The importance of exploratory laparotomy to include full-thickness intestinal biopsy in patients who have a benign infiltrate on peroral biopsy is demonstrated by the finding of lymphoma in operative specimens in 9 of 15 patients with mature, lymphoplasmacytic cells, and 5 of 8 patients with atypical, lymphoplasmacytic cells. The majority of patients with fully established benign disease, even those elaborating alpha-chain disease protein, appeared to have a good prognosis. No patient with immunoproliferative small intestinal disease developed immunologically demonstrated alpha-chain disease or frank lymphoma, when this was not found initially at explorative laparotomy.

Plasma cell infiltration of the small bowel: lack of evidence for a non-secretory form of alpha-heavy chain disease.

Eight patients with diffuse plasma cell infiltration of the small bowel who had the clinical features of immunoproliferative small intestinal disease (IPSID), but whose serum was negative for free alpha-heavy chains, were investigated for evidence of a non-secretory form of alpha-chain disease (alpha-CD). Molecular sieving and immunoblotting of serum, immunoperoxidase staining of biopsy specimens, and in vitro protein synthesis studies utilising an immunoprecipitation technique and polyacrylamide gel electrophoresis, failed to detect any new cases of alpha-CD. Four of the eight cases were found to have diffuse intestinal lymphoma. The remaining four patients, who were unsuccessfully investigated for evidence of a significant abnormality in cellular immunity, have not developed detectable alpha-CD protein or lymphoma over a mean of 143 months. Despite continuing exposure to possible environmental stimuli, it is concluded that not all cases of IPSID elaborate detectable alpha-CD protein or evolve to lymphoma.

Peritoneal mesothelioma

The clinical and radiological features of peritoneal mesothelioma in four patients with an industrial history of asbestos exposure are described. The radiological features of intestinal obstruction, soft tissue masses and displacement and infiltration of bowel are stressed. A normal chest radiograph does not exclude the diagnosis. More sensitive diagnostic imaging and perhaps the use of laparoscopy may help to improve the accuracy of pre-mortem diagnosis.

Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis consists histologically of a purely eosinophilic infiltration of small bowel and stomach walls. This is manifested radiologically in the small bowel as a thickening of the circular folds and wall without mucosal ulceration or any other local abnormality, either over much of its length or in a shorter segment. Many of the other causes of pure fold and wall thickening can be excluded by correlation with the clinical presentation so that this condition, although rare, should in the right clinical setting be considered by the radiologist. The typical clinical features consist of cramps, diarrhoea, distension, nausea and vomiting, either as a single subacute episode or with an intermittent history going back months or years, and frequently in a patient with a personal or family history of asthma or other allergic disorders. The eosinophilic infiltration may spare the mucosa in which case per-oral biopsy methods would give negative results. The only means of proving the diagnosis would then be by laparotomy to obtain a full thickness biopsy. However the radiological and clinical features, combined with a therapeutic trial of corticosteroids which rapidly reduce the clinical, radiological and haematological abnormalities, may be sufficient to avert this. The two cases described illustrate many of these features but in addition, unlike most other published cases, they showed neither radiologically visible gastric involvement nor peripheral blood eosinophilia.

Acute leukemic infiltration of the small bowel diagnosed by suction biopsy

A case of acute lymphoblastic leukemia presenting with abdominal symptoms is reported. Diffuse leukemic infiltration of the small bowel was suggested by the small-bowel X-rays and confirmed through jejunal biopsy. With steroid therapy the patient's abdominal symptoms ceased and his small-bowel X-rays, biopsy, and function improved.