Ischemic Enteritis Research Articles

A case of abdominal aortic aneurysm presenting with multiple organs embolization

BackgroundDistal embolization as the first manifestation of an abdominal aortic aneurysm (AAA) is relatively rare. AAAs presenting with multiple organs embolization are rarer and serious systemic conditions. There are no reports of life-saving outcomes in patients with AAAs presenting with multiple organs embolization prior to surgery.Case presentationA 78-year-old man presented with right acute lower limb ischemia (ALLI) and ischemic enteritis coexisting with an 83-mm AAA with a large mural thrombus. Although the patient underwent successful revascularization with endovascular treatment for right ALLI, the manifestation of ischemia of the calf muscles and infection forced right above-knee amputation. The patient also presented with ischemic colitis that resolved with conservative treatment. After receiving appropriate medical therapy and rehabilitation, the patient was successfully treated with open aortic repair for the AAA.ConclusionWe successfully performed open aortic surgery for a rare case of AAA presenting with multiple organs embolization.

Endoscopic Diagnosis and Treatment of Benign Small Bowel Stricture

Benign small bowel strictures can occur in association with various conditions, including small bowel Crohn’s disease, nonsteroidal anti-inflammatory drug-induced enteritis, ischemic enteritis, intestinal tuberculosis, radiation enteritis, postoperative adhesions, and anastomotic strictures. Benign small bowel strictures are classified into two categories, low-grade and high-grade. Low-grade small bowel strictures involve a partial reduction of the internal diameter of the small intestine, causing slight obstruction of the passage of food and digestive fluids without significant bowel obstruction symptoms. By contrast, high-grade small bowel strictures involve a severe narrowing of the intestinal lumen, leading to marked obstruction of the passage of food and digestive fluids and pronounced bowel obstruction symptoms. Small bowel strictures can be diagnosed using various methods, including abdominal plain radiography, abdominal computed tomography, computed tomography enterography, magnetic resonance enterography, balloon-assisted enteroscopy, and abdominal ultrasound. Each diagnostic method has unique advantages and disadvantages as well as differences in diagnostic specificity and sensitivity. Therefore, even if small bowel strictures are not observed using a single imaging technique, their presence cannot be completely excluded. A comprehensive diagnosis that combines clinical information from multiple diagnostic modalities is necessary. Therapeutic approaches for managing small bowel strictures include medical therapy, endoscopic balloon dilation using balloon-assisted enteroscopy, and surgical methods such as strictureplasty and segmental resection. Endoscopic balloon dilation, in particular, can help reduce complications associated with repeated surgeries for strictures.

Efficacy and safety of same-day preparation with sodium picosulfate plus magnesium citrate on the day of colonoscopy for bowel preparation: Multicenter, single-arm, open-label study.

Sodium picosulfate plus magnesium citrate (SP+MC) is a well-tolerated bowel preparation agent. However, Japan currently approves only two methods of taking SP+MC: the day-before and split-dose preparation, without approval of same-day preparations. This study aimed to evaluate the efficacy and safety of same-day SP+MC preparations. This was a multicenter, single-arm, nonrandomized, open-label study. We enrolled 145 Japanese patients between June and December 2023. The patients received two sachets of SP+MC dissolved in 300ml of water and 1200mL or more of clear liquid on the day of colonoscopy. Bowel cleansing efficacy, adverse events (AEs), and patient satisfaction were evaluated. Of the enrolled patients, 137 underwent colonoscopy according to our protocol. Bowel preparation was adequate in 133 patients (97.1%). The mean total Boston Bowel Preparation Score was 8.3±1.2. Five patients experienced AEs (3.6%): two (1.5%), abdominal pain; one (0.73%), ischemic enteritis; one (0.73%), vomiting or nausea; and one (0.73%), headache. All AEs were treated conservatively. None of the patients exhibited abnormal blood test results or clinical symptoms after receiving SP+MC. Regarding patient satisfaction, all patients were able to take SP+MC as directed; 136 (99.2%) expressed a preference for this bowel preparation for future colonoscopies. The same-day SP+MC preparation showed high bowel-cleansing efficacy and satisfaction in Japanese patients without serious AEs.

Diffusely Invasive Mucormycosis of the Small Bowel in a Patient with Microbiologic Cultures and Tissue Biopsies Negative for Fungal Organisms

Abstract Introduction/Objective Invasive mucormycosis can be a swiftly fatal medical emergency occurring in patients with uncontrolled diabetes. This angioinvasive fungus causes tissue necrosis, hemorrhage, and thrombosis and often develops in the sinonasal cavities where it can extend directly to the CNS or spread systemically to visceral sites like the GI tract. Here, we describe a patient whose small bowel resection shortly before death, revealed diffusely invasive mucormycosis despite that blood and body fluid cultures and tissue biopsies were negative for fungal organisms. Methods/Case Report Our patient is a 39 year old male with a history of uncontrolled diabetes, brought to our hospital in cardiac arrest and found to have fentanyl in his system. His labs showed severe metabolic and electrolyte derangements including diabetic ketoacidosis. His blood cultures revealed bacteremia but no fungal growth, and he was placed on antibiotics for sepsis. The patient developed compartment syndrome of his bilateral forearms, which were amputated and showed necrotic skeletal muscle but no fungal infection. The patient also developed facial necrosis concerning for mucormycosis, but nasal endoscopic and facial skin biopsies were negative for mucor. However, his abdominal CT showed diffuse mural thickening of his small bowel concerning for bowel ischemia, which prompted an exploratory laparotomy that revealed large segments of necrotic jejunum and ileum. While peritoneal fluids collected during the surgery yielded no fungal growth on culture, resected segments of necrotic small bowel showed massive presence of mucor with broad, pauci-septate, ribbon-like hyphae branching at right angles. Small bowel and mesenteric vessels showed angioinvasion by mucor with vasculitis and fibrin thrombi causing ischemic enteritis. Mucor was also noted diffusely invading small bowel muscularis propria, adventitia, and mesenteric fat, and small bowel also showed ulceration, hemorrhage, and transmural and mesenteric fat necrosis. Unfortunately, a few days after his surgery, the patient expired from multi-organ failure and septic shock before he could receive anti-fungal therapy for mucormycosis. Results (if a Case Study enter NA) NA Conclusion Mucormycosis is a rapidly growing, angioinvasive, and potentially lethal fungal infection that must be promptly recognized. This report documents an unusual case of invasive mucormycosis of the small bowel that went undetected in a severely ill patient whose blood and peritoneal cultures and tissue biopsies were all negative for fungal organisms.

Oral administration of n-3 fatty acids positively affect the mucosal lesions after experimental ischemic enteritis in the rat

Oral administration of n-3 fatty acids positively affect the mucosal lesions after experimental ischemic enteritis in the rat

Abstract 12186: A Challenging Case of Acute Superior Mesenteric Artery Embolism Diagnosed by Gastroscopy

Introduction: Acute superior mesenteric artery (SMA) occlusion is one of the most lethal causes of acute abdomen that we often experience but mistake for gastrointestinal diseases. The golden time for revascularization in cases of SMA main trunk occlusion is within 5 hours of onset, requiring prompt diagnosis and treatment. We describe a challenging case of acute SMA embolism diagnosed by gastroscopy. Case Summary: A 66-year-old man with a history of hypertension presented to the emergency department for marked epigastric pain after eating raw seafoods. On arrival, electrocardiogram showed atrial flutter with no significant ST-segment changes. Despite the elevation of white blood cell count and lactate dehydrogenase in blood exam, computed tomography (CT) indicated no findings to cause his symptoms. Emergency gastroscopy performed on suspicion of anisakiasis demonstrated pallor findings with hematologic material in the duodenum, suggesting intestinal ischemia (Figure A). Since contrast-enhanced CT revealed an occlusion of SMA (Figure B), we diagnosed acute SMA embolism based on the finding of atrial flutter without anticoagulation. After discussion among cardiologists and gastroenterology surgeons, we selected to perform endovascular treatment. The epigastric pain was improved after reperfusion using a self-expandable stent, but flared up as oral intake progressed. Follow-up CT suggested ischemic enteritis of the proximal jejunum, leading to conduct laparoscopic partial jejunectomy. He was discharged 18 days after the operation with the ability to eat a normal diet. Conclusions: This case highlights that we should keep in mind SMA embolism when examining acute abdomen patients with atrial fibrillation or flutter without anticoagulation.

P074 Interferon-γ promotes antigen processing and presentation pathway in the intestinal epithelium of patients with Crohn’s disease

Abstract Background Interferon-γ (IFN-γ) is a major driver of excessive immune response, leading to intestinal mucosal damage and contributing the pathogenesis of Crohn’s diseases (CD). In contrast to the inflammatory cells and immune system, IFN-γ-induced cellular responses has not been well documented in the intestinal epithelium. The intestinal epithelium consists of multiple cell types and patient-derived intestinal organoid model may be appropriate to evaluate the IFN-γ-induced epithelial cellular responses in patients with CD. Methods To evaluate the IFN-γ-mediated epithelial cellular responses, human small intestinal organoids (enteroids) derived from the controls (n=6) and patients with Crohn’s disease (CD, n=10) were constructed. We focused on the IFN-γ-induced cell death mechanism upregulated in CD enteroids and validated them in surgically resected small intestine in patients with active CD. Results As the concentration of IFN-γ increased in the culture medium, the organoid-forming efficiency decreased steadily, which did not differ between control and CD enteroids. The enteroid viability measured using MTT was estimated to be 83.10 pg/ml for EC50. In control and CD enteroids treated with 100 pg/ml IFN-γ, PANoptosis was the main inflammatory cell death mechanism. Bulk and single-cell RNA sequencing revealed that IFN-γ induced the expression of MHC class II-associated genes, co-inhibitory molecule CD274 (PD-L1), and IDO1 in control and CD enteroids, which may be associated with peripheral tolerance in the absence of exogenous antigens. Gene set enrichment analysis identified an up-regulated antigen processing and presentation pathway with increased expression of MHC class I molecules in IFN-γ-treated CD enteroids compared to IFN-γ-treated control enteroids (normalized enrichment score=2.13, p=0.002, q=0.005). IFN-γ-induced MHC class I pathway could result in T cell-mediated cytotoxicity in CD enteroids. The selective JAK1 inhibitor, upadacitinib, inhibited the IFN-γ-induced PANoptosis and T cell-mediated cytotoxicity in CD enteroids. The expression of HLA-A and B was higher in the inflamed small intestine in patients with CD than those in patients with ischemic enteritis. Conclusion IFN-γ promotes antigen processing and presentation pathway in the intestinal epithelium. In patients with CD, increased expression of MHC class I molecules may induce T cell-mediated cytotoxicity, which could contribute to the development of CD.

Ravulizumab can effectively treat ischemic enteritis caused by paroxysmal nocturnal hemoglobinuria.

Ischemic colitis is a common disease with a good prognosis; however, complications can occur in the presence of a serious underlying disease. Herein, we present a case report in which characteristic findings on lower gastrointestinal endoscopy led to a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). An 82-year-old woman visited our hospital for chronic heart and renal failure. She had a history of breast cancer, myocardial infarction, and hemorrhoidal fistula and was initially hospitalized for ischemic colitis. Subsequent lower gastrointestinal endoscopy revealed extensive ulcerative lesions in the ascending, transverse, and descending colon. Histopathologically, small vessels exhibited multiple fibrin thrombus formations. Based on histopathological and endoscopic results, the presence of an underlying disease was suspected. Flow cytometric analysis showed that erythrocytes and granulocytes had 5.5 and 86.4% CD55- and CD59-negative cells, respectively. The patient was ultimately diagnosed with PNH and considered severely ill, given the ischemic colitis-induced abdominal pain and the need for red blood cell transfusions (4-6 units per month). Accordingly, the patient was administered ravulizumab. Ischemic enteritis did not relapse following ravulizumab administration, and transfusion dependence improved. If a patient with ischemic colitis presents atypical lower gastrointestinal endoscopic findings, it is important to explore the presence of an underlying disease.

OC-025 STRATEGY FOR SURGICAL TREATMENT OF GIANT INGUINOSCROTAL HERNIA - SERIES OF 21 CONSECUTIVE PATIENTS DURING 15 YEARS

Abstract Aim To present our strategy for surgical treatment of patients with giant inguinoscrotal hernia whose hernia defect is ≥10 cm or who have a loss of domain. Material and methods Between January 2006 - January 2022, 21 consecutive patients with giant inguinoscrotal hernia and high risk of postoperative intra-abdominal hypertension were managed. The hernia was repaired in the following manner: modified Rives technique performed through direct inguinal approach in 10 patients; additional procedures were needed to reduce the volume of organs returned to the abdomen in four patients; the primary abdominal cavity was enlarged by various components separation techniques with or without mesh hernioplasty in seven patients. Results The hernia defect size was in range 7–17 cm. In three patients the contents of the hernia sac accounted for more than 50% of the intestines: entire large bowel without the rectum, ileum, jejunum except proximal 15 cm and greater omentum). Postoperative complications occurred in eight patients were: scrotal hematoma, deep mesh infection, seroma and hydrocele. There were three postoperative deaths: 12 hours, 17 and 42 days after the surgery because ischemic enteritis, cerebrovascular stroke and heart failure, respectively. Conclusion Our strategy consisting of modified Rives technique performed through direct inguinal approach with or without additional procedures to reduce the volume of organs returned to the abdomen or to enlarge the primary abdominal cavity can be a good solution for giant inguinoscrotal hernias. Procedure is followed by the risk of deadly complications and requires trained team in intesive care unit.

Similar to Crohn’s Disease, but Diagnosed with Stenotic Ischemic Enteritis or Ischemic Colitis: Case Series and a Systematic Review

Background and Study Aims: Stenotic ischemic enteritis or ischemic colitis, along with transmural inflammation, ulcers and strictures, is extremely similar to Crohn’s disease. We aimed to report relevant cases and perform a systematic review to help distinguish two diseases. Patients and Methods: We reviewed our institutional experience with stenotic ischemic enteritis or ischemic colitis. Besides, we performed a comprehensive literature review using Medline (OvidSP), Web of Science, PubMed, Cochrane Library, and Embase from inception to March 2022. Demographic parameters, serological indexes, imaging markers, histological features and treatment were abstracted from our cases and included literatures. Results: We reported four cases of stenotic ischemic enteritis and one stenotic is chemic colitis in our centre, and they were all male, aging 22-65 years old. Characteristics of the five patients were presented and histological examination played an essential role in discriminating them from CD. Besides, 35 patients of stenotic IE from 17 publications were included in the systematic review and the characteristics of included patients were also presented. Conclusions: The treatment to stenotic ischemic enteritis or ischemic colitis and CD was different. Although they are very similar, but they can be distinguished from each other according to demographic features, radiographic and endoscopic imaging, especially histological evaluation.

A Case of Isolated Superior Mesenteric Artery Dissection with Prolonged Ischemic Enteritis Requiring Reoperation

A Case of Isolated Superior Mesenteric Artery Dissection with Prolonged Ischemic Enteritis Requiring Reoperation

A case of arteriovenous malformation in the inferior mesenteric artery region resected surgically under intraoperative indocyanine green fluorescence imaging.

Introduction and importanceAn arteriovenous malformation (AVM) is defined as a vascular malformation with a short, non-capillary communication between the arteries and veins. Most gastrointestinal AVMs are solitary, occurring predominantly in the stomach, small intestine and right colon, and rarely in the inferior mesenteric artery (IMA) region.Case presentationA 70-year-old man was first diagnosed with ischemic enteritis two years earlier, and was hospitalized several times with the same diagnosis. He visited our hospital because of left lower abdominal pain and melena. Colonoscopy showed findings suggestive of ischemic enteritis, and contrast-enhanced computed tomography (CT) and IMA angiography showed hyperplasia and dilation of blood vessels from the sigmoid-descending colon junction to the upper rectum. We performed conventional laparoscopic low anterior resection using intraoperative intravenous injection of indocyanine green (ICG). The final diagnosis was arteriovenous malformation in the IMA region. The patient had an uneventful postoperative course and was discharged on the 13th day after the operation.Clinical discussionCases of AVM in the IMA region are relatively rare. This is the first reported case of AVM in the IMA region that was resected under intraoperative ICG fluorescence imaging (FI), which provided useful information on the extent of intestinal resection and mesenteric dissection required, and confirmed the adequacy of intestinal blood flow during and after mesenteric dissection and anastomosis.ConclusionIt is advisable to use ICG FI intraoperatively during resection of AVMs in the IMA region, as with colorectal cancer surgery.

Clinical characteristics of paroxysmal nocturnal hemoglobinuria (PNH) complicated with ischemic bowel disease

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematopoietic stem cell disease. Gastrointestinal involvement is rarely seen in PNH. This study aims to analyze the clinical features in PNH patients complicated with ischemic bowel disease. Clinical date of 6 patients were collected at Peking Union Medical College Hospital from January 2010 to December 2020. The clinical manifestations, laboratory tests,imaging, endoscopic,and histopathological features and treatment were analyzed.Five in 6 patients were men, with a median age of 31 years old at onset. Most of disease course were recurrent episodes of chronic disease, with abdominal pain (5/6) and gastrointestinal bleeding (5/6). Laboratory examinations showed pancytopenia, reticulocytosis, elevated serum lactate dehydrogenase, high D-dimer and C-reactive protein levels in all patients. Multiple segments of small intestine were the most commonly involved and colon was also affected. Abdominal CT scan showed thickening and roughness or exudation of the intestinal wall (6/6), increased mesenteric density or "comb sign"(4/6), and cholestasis or gallbladder stones (5/6). Endoscopic manifestations included irregular shallow ulcers in the annular cavity (5/6), swelling mucosa with well-defined margins (6/6). Pathological biopsy revealed chronic inflammation of mucosa. The efficacy of steroids combined with anticoagulant therapy was better than that of steroids alone. Ischemic bowel disease in PNH patients is different from typical ischemic enteritis. Young patients, involvement of intestine with multiple segments are common characteristics. The anticoagulant is an essential agent for these patients.

Smooth muscle degeneration of the mesenteric and branching veins causing ischemic enteritis: a case report

BackgroundIschemic bowel injuries are generally caused by arteriosclerosis, thromboembolism, or vasculitis. Ischemic enteritis is less common than ischemic colitis because of the rich collateral arteries of the small intestine. In the present case, smooth muscle degeneration of the mesenteric to the submucosal veins caused ischemic enteritis and small bowel obstruction.Case presentationAn 85-year-old woman with recurrent enteritis eventually developed small bowel obstruction. We performed laparoscopic partial resection of the small intestine. The pathological findings revealed smooth muscle degeneration of the mesenteric veins that caused ischemic enteritis. Venous changes were detected not only in the injured region, but also in a part of the normal region of the resected specimen. She continued to experience some minor symptoms postoperatively; however, these symptoms subsided in a short period with medicine discontinuation.ConclusionThis report shows the possibility that a disease causes ischemic enteritis with unique venous pathological changes and may recur postoperatively.

Recurrent Takotsubo syndrome complicated with ischemic enteritis successfully treated by hydration: a case report

BackgroundTakotsubo syndrome is a sudden and an acute form of transient cardiac dysfunction, triggered by mental and physical stress. The treatment for Takotsubo syndrome is not well understood and is incompletely established. Takotsubo syndrome is partly thought to be caused by coronary ischemia under sympathetic nerve activation.Case presentationWe report the case of an 80-year-old Japanese woman with recurrent Takotsubo syndrome complicated with ischemic enteritis. In this case, abdominal pain and dehydration due to ischemic enteritis is thought to have triggered Takotsubo syndrome. Her life was saved with rapid, adequate intravenous hydration. She was diagnosed with coronary vasospastic angina using coronary angiography on her second admission. This case highlights the potential of adequate intravenous hydration in increasing coronary blood flow. In our case, it should be noted that pulmonary congestion was mild and may have improved Takotsubo syndrome without the use of diuretics.ConclusionAdequate hydration must be considered for prompt improvement of cardiac function in Takotsubo syndrome. Replenishment of fluid to increase coronary blood flow, improvement of heart load without exacerbating heart failure, and stabilization of circulation dynamics can help treat patients with Takotsubo syndrome without using diuretics.

Oral administration of n-3 fatty acids positively affect the mucosal lesions after experimental ischemic enteritis in the rat.

The purpose of the study was to evaluate the effect of oral administration of n-3 polyunsaturated fatty acids in experimental ischemic enteritis in rats. Forty Wistar rats were submitted to control narrowing of the superior mesenteric artery and were divided in two groups: N3 polyunsaturated fatty acids, which received a high-molecular polymer solution of artificial total enteral nutrition enriched with n-3 fatty acids and CONTROL which received a high-molecular polymer solution of artificial total enteral nutrition. Reduction of the animals' body weight was observed in both groups, but there was no difference between the two groups. Regarding the level of cytokines interleukin (IL)-1b, IL-6, and tumor necrosis factor a (TNF-a) there was no statistically significant difference between the two groups. Ischemic lesions to the small bowel mucosa were observed in both groups. A statistically significant difference in the extent of intestinal lesions was observed between the two groups with the animals that received enteral nutrition enriched with n-3 fatty acid developing fewer lesions. Enteral nutrition enriched with n-3 polyunsaturated fatty acids reduces the mucosal lesions caused by mesenteric ischemia compared to standard enteral nutrition, by modifying the local, but not the systemic, immune, and inflammatory response.

Fatal air embolism during gastrointestinal endoscopy in a 5 -year- old girl

Gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) are generally considered safe procedures with very minimal complications. However, they can be associated with uncommon yet life-threatening complications such as air embolism. A 5-year-old female was referred to our hospital for the evaluation of a left upper quadrant mass. The patient underwent exploratory laparotomy, and a biopsy was obtained. Histopathology confirmed the diagnosis of ganglioneuroblastoma. The patient afterwards underwent laparotomy, and tumor excision resulted in an iatrogenic injury to the superior mesenteric artery, leading to ischemic enteritis requiring multiple small bowel resections resulting in short bowel syndrome and small bowel strictures; gastrointestinal endoscopy was needed for dilatation. Unfortunately, during endoscopy, the patient developed air embolism and went into cardiac arrest. Then an urgent central venoarterial extracorporeal membrane oxygenation (ECMO) was deployed, and the patient was shifted to the intensive care unit and died a few hours later. Air embolism is considered a very rare yet fatal complication of endoscopy. The exact mechanism behind air embolism will differ from one patient to another, making it challenging to identify it. It is important to anticipate such complication in high-risk patients, and all precautions must be taken when performing endoscopic procedures.

Clinical Features and Therapeutic Outcomes of Post-colectomy Enteritis with Ulcerative Colitis.

Objectives: Few reports are available on post-colectomy enteritis (PCE) with ulcerative colitis (UC), which can be severe and sometimes fatal. The clinical characteristics are unclear, and treatment and diagnosis protocols have not been established. We aimed to investigate the incidence, clinical characteristics, diagnostic criteria, and therapeutic outcomes of PCE in this study. Methods: Patients with UC who underwent colectomy between April 2010 and December 2019 were included in this study. We retrospectively analyzed patients who developed PCE and excluded patients with other forms of enteritis. Results: We performed 829 colectomies because of a preoperative diagnosis of UC. Eleven and four patients were diagnosed with Crohn's disease and indeterminate colitis after surgery, respectively; 22 patients developed enteritis in the perioperative period. We excluded six patients with backwash ileitis, five with prepouch ileitis, three with infectious enteritis, and one with ischemic enteritis. In total, 7/814 (0.8%) patients developed PCE. All patients with PCE had pancolitis. PCE was observed a median of 33 (12-248) days after surgery. Endoscopy showed friable and granular mucosa. The extent of disease included various types such as pan-enteritis with diffuse type, pan-enteritis and mild inflammation in the middle ileum, and only ileitis. Gastroduodenitis-associated UC developed in 6/7 cases. All patients improved with tumor necrosis factor alpha (TNFα) antagonists even if TNFα antagonists had not been effective for colitis. Conclusions: PCE was rare. The mucosal endoscopic findings were similar to those of UC, and the extent of disease varied. TNFα antagonist administration for PCE was effective.

S3009 It's Not Always Crohn’s: Parastomal Incarcerated Hernia Causing Distal Ileitis

Introduction: Crohn’s disease is an inflammatory process that can affect any part of the gastrointestinal tract. However, the terminal ileum is the most common site involved. Often, patients present with right lower quadrant pain and bloody diarrhea, which could be acute and complicated by obstruction. However, these symptoms are non-specific, and many other pathologies could affect the terminal ileum. In order to accurately treat these patients, it is imperative to understand the etiology of the inflammatory process before initiating management. Thus, due to the potential for misdiagnosis, we present a case of ileitis initially evaluated for Chron’s disease, later found to be an incarcerated parastomal hernia causing necrotic bowel. Case Description/Methods: A 35-year-old female with a history of colonic diverticulosis status post ileostomy presented with intermittently sharp and crampy right-sided abdominal pain and increasing bloody output from stoma with associated nausea and vomiting. Labs notable for WBC of 18.1, Hb of 14.9 with an acute decrease to 12.7, normal electrolytes, and lactate of 1.1. CT scan of the abdomen revealed dilated, thick-walled small bowel loops without obvious evidence of obstruction concerning for ileitis. Initially, General Surgery was consulted, but due to no concerns for obstruction, supportive management was continued. GI was consulted for ongoing bleeding and concerns for Inflammatory Bowel Disease. The patient underwent ileoscopy, which revealed normal ileal mucosa from stoma to 12-15cm from the stoma, with an abrupt transition to ulcerated, edematous, dusky mucosa, circumferential involvement, most consistent with ischemic injury. Histology revealed small bowel mucosa with ischemic enteritis, ulceration, and necrosis. Subsequently patient underwent a diagnostic laparoscopy with 35cm bowel resection. Discussion: Crohn’s disease is increasing in frequency among a younger population and various ethnicities. However, many clinical conditions that promote ilium inflammation can mimic Chron’s disease, including NSAIDS, infections, and ischemia. Parastomal incarcerated hernia is a common post-surgical complication that can present as ileitis due to ischemia. Ileoscopy will commonly reveal clearly demarcated areas of injury with changes ranging from edematous mucosa to ulcers or even dusky necrotic changes. Thus, clinicians should have a broad differential diagnosis of ileitis in mind to achieve early diagnosis and avoid unnecessary procedures delaying care.Figure 1.: A: Coronal reformatted image of CT abdomen and pelvis with contrast showing dilated small bowel loop and adjacent inflammatory changes B: Axial image of CT abdomen and pelvis with contrast showing thick small bowel wall going into the stoma with adjacent ascites C: Ileoscopy findings of ulcerated, dusky mucosa

Membrane electrode assembly for a water-electrolysis device

Gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) are generally considered safe procedures with very minimal complications. However, they can be associated with uncommon yet life-threatening complications such as air embolism.A 5-year-old female was referred to our hospital for the evaluation of a left upper quadrant mass. The patient underwent exploratory laparotomy, and a biopsy was obtained. Histopathology confirmed the diagnosis of ganglioneuroblastoma. The patient afterwards underwent laparotomy, and tumor excision resulted in an iatrogenic injury to the superior mesenteric artery, leading to ischemic enteritis requiring multiple small bowel resections resulting in short bowel syndrome and small bowel strictures; gastrointestinal endoscopy was needed for dilatation. Unfortunately, during endoscopy, the patient developed air embolism and went into cardiac arrest. Then an urgent central venoarterial extracorporeal membrane oxygenation (ECMO) was deployed, and the patient was shifted to the intensive care unit and died a few hours later.Air embolism is considered a very rare yet fatal complication of endoscopy. The exact mechanism behind air embolism will differ from one patient to another, making it challenging to identify it. It is important to anticipate such complication in high-risk patients, and all precautions must be taken when performing endoscopic procedures.