Jejunal Lesions Research Articles

Effects of a blend of chestnut and quebracho tannins on gut health and performance of broiler chickens.

Antimicrobial restrictions prompted the search for cost and biologically effective alternatives to replace antimicrobial growth promoters (AGPs) in food-producing animals. In addition, the efficacy of this alternatives needs to be contrasted in field/commercial trials under different challenge conditions. However only a few studies describing the impact of tannins or others AGP-alternatives in commercial poultry production conditions are actually available. The aim of the present work is to study how the inclusion of a blend of chestnut and quebracho tannins can affect broiler productive performance and health under commercial conditions. Three experiments with different approaches were conducted: (1) a trial comparing the effects of both additives (tannins vs AGP) on different commercial farms at the same time; (2) the follow-up of one farm during an entire productive year; and (3) an experimental trial using a C. perfringens challenge model in broiler chickens. Although productive results from field trials were similar among treatments, evaluations of gut health indicators showed improvements in the tannins treated flocks. Frequency and severity of intestinal gross lesions were reduced in jejunum (42% vs 23%; p<0.05–1.37 vs. 0.73; p<0.01, respectively) and ileum (25% vs. 10%; p<0.0.5–1.05 vs. 0.58; p<0.01) in tannins treated birds. Results from 16S studies, show that cecal microbiota diversity was not differentially affected by AGPs or tannins, but changes in the relative abundance of certain taxa were described, including Lactobacillus and Bifidobacterium groups. Results from experimental C. perfringens necrotic enteritis showed that tannins treated birds had reduced incidence of gross lesions in jejunum (43.75 vs. 74.19%; p<0.01) and ileum (18.75% vs. 45.16%; p<0.05) compared with control. These results suggest that AGPs can be replaced by tannins feed additives, and contribute in the implementation of antimicrobial-free programs in broilers without affecting health or performance.

P-EGS03 Curious Case of Life Threatening Gastrointestinal Bleed

Abstract Background Gastrointestinal stromal tumors are mesenchymal in origin, being derived from the interstitial cells of Cajal. These can be found anywhere in the gastrointestinal tract and are commonly found in the stomach followed by the small bowel. Gastrointestinal stromal tumors are usually asymptomatic and are often found incidentally. Chronic bleeding is one of the most common presentation. Gastrointestinal stromal tumors presenting with massive gastro intestinal haemorrhage and mimicking arteriovenous malformation on radiology are rare with only few cases reported. Methods Herein we present such a case of a 45-year-old gentleman with massive gastro intestinal bleeding. At presentation, patient was in congestive heart failure due to severe anaemia with a hemoglobin of 2.9g/dL. CECT Angiography localised the bleed to be from a jejunal mass lesion with radiological features consistent with those of arteriovenous malformation. Patient underwent laparoscopy assisted resection and anastomosis. Results Histopathology examination revealed a low risk jejunal gastrointestinal stromal tumor with no evidence of arteriovenous malformation. The mass was removed completely and the patient was discharged on 5th post-operative day. Patient was followed up in the out-patient department and was found to be doing well. Conclusions Gastrointestinal stromal tumors though relatively uncommon should be kept as important differentials for acute torrential gastrointestinal bleeding. It is highlighted that a presentation of gastrointestinal stromal tumors similar to that of arteriovenous malformations on cross sectional imaging should be kept in mind. The present case is reported in hope of expanding the knowledge of a rare occurrence, its aetiology, clinical impact and treatment.

Effects of dietary glucose oxidase on growth performance and intestinal health of AA broilers challenged by Clostridium perfringens

Arbor Acre (AA) broilers were used as the research object to investigate whether glucose oxidase (GOD) has preventive and relieving effects on necrotic enteritis. The experiment was designed as a factorial arrangement of 2 dietary treatments × 2 infection states. Chickens were fed a basal diet or a diet with 150 U/kg GOD, and were challenged with Clostridium perfringens (Cp) or sterile culture medium. In our study, Cp challenge led to intestinal injury, as evidenced by reducing the average daily gain and the average daily feed intake of AA broilers of 14 to 21 d (P < 0.05), increasing the intestinal jejunal lesion score (P < 0.05), reducing the jejunal villi height and villi height/crypt depth (P < 0.05), upregulating the mRNA expression levels jejunal IFN-γ (P < 0.05). The dietary GOD had no significant effects on the growth performance of each growth period, but significantly decreased the ileal pH, increased the height of villi and the ratio of villi height to crypt depth (P < 0.05) and the expression levels of Occludin and Zonula occludens-1 (ZO-1) at d 21. Moreover, dietary GOD and the Cp challenge significantly altered the composition of 21-d ileal microbiota. The Cp challenge decreased the relative abundance of genus Lactobacillus (P = 0.057), and increased the relative abundance of genus Romboutsia (P < 0.05) and genus Veillonella (P = 0.088). The dietary GOD tended to increase the relative abundance of genus Helicobacter (P = 0.066) and decrease the relative abundance of genus Streptococcus (P = 0.071). This study has shown that the supplementation of GOD could promote the integrity of intestinal barrier and the balance of ileal microbiota, but the effects of GOD on NE broilers and its application in actual production need to be further confirmed.

Effect of organic acids on growth performance, intestinal morphology, and immunity of broiler chickens with and without coccidial challenge

A total of 360-day-old broiler chicks were allocated into six groups in 2 (Coccidial challenge or not) × 3 (dietary treatments) factorial design. Three dietary treatments including: basic diet, basic diet plus organic acids (OAs) in drinking water, and basic diet plus OAs in the feed with and without coccidial challenge. The OAs in water or feed improved (P < 0.01) average body weight (ABW), average body weight gain (ABWG), and feed conversion ratio (FCR) as compared with the control diet during starter, grower, and whole experimental period. Coccidial challenge decreased BW, ABWG, and average feed intake (AFI), as well as resulted in poor FCR during the starter and whole experimental period (P < 0.05). Though there was no interaction between OAs supplementation and coccidial challenge, the OAs supplementation improved the overall performance with and without coccidial challenge birds on 21 d and 35 d. IgG was found higher (P = 0.03) in broilers fed OAs in feed without the coccidial challenge group. On 18 d, OAs supplementation in feed increased TNF-γ (P = 0.006), whereas the coccidial challenge decreases TNF-γ (P = 0.01) and IL-10 (P = < .0001), and increases IgM (P = 0.03), IgG (P = 0.04) and IgA (P = 0.02). On 29 d, the coccidial challenge increases IgM and IgA. On 18 d, jejunal lesion score was found significantly higher in the coccidial challenged group as compared to OAs supplementation with coccidial challenged groups on 18 d (P < 0.0001) and 29 d (P = 0.03). Crypt depth was higher, and Villus-height to Crypt depth ratio was lower in the coccidial challenge group on 18 and 29 d. The Goblet cells were found higher in the non-coccidial challenge on 18 d. After 18 d, 16S rDNA gene sequence analysis of ileal chyme has shown that coccidial challenge decreases Lactobacillus_reuteri species as compared to the non-challenged group (P = 0.02). After 29, Cyanobacteria abundance reduced (P = 0.014) in the challenged group than the non-challenged group at the phylum level. At the genus level, Lactobacillus (P = 0.036) and unidentified Cyanobacteria (P = 0.01) were found higher in the non-challenged group than the coccidial challenge group. The results indicate that the OAs supplementation showed improved responses in a pattern similar to the non-challenged control group by neutralizing the negative effects of the coccidial challenge.

S2290 A What? The Small Bowel Hematoma Presenting as a Jejunal Lesion

S2290 A What? The Small Bowel Hematoma Presenting as a Jejunal Lesion

S2302 From an Unproved Venous Thromboembolism to a Jejunal Cancer: An Unmasking Prompted by Overt Small Bowel Bleeding

Introduction: Of all patients diagnosed with a venous thromboembolism, 2 to 25% will subsequently be diagnosed with malignancy. When considering possible malignancies, a primary small bowel neoplasm is not likely at the top of the list. Small bowel neoplasms may present with nonspecific signs or symptoms such as gastrointestinal bleeding. But even when bleeding does occur diagnosis can be challenging, as the initial work-up for with upper and lower endoscopy may not necessarily visualize the affected region. Small bowel bleeding can be categorized as occult or overt, with the former defined as a positive FIT result with no evidence of visible blood, and the latter implying a clear presentation with melena, hematochezia, or hematemesis. In this case we describe how treating an unprovoked DVT helped in the diagnosis a jejunal adenocarcinoma. Case Description/Methods: This is the case of a 69 year old male who presented to ER with a chief complaint of dark stools 2 weeks prior. Upon further questioning, patient mentioned a history of a fall from standing secondary to associated dizziness. He also noted he had been taking warfarin chronically for a prior diagnosis of a DVT. On initial evaluation patient was found severely anemic and orthostatic, thus admitted for further management. Throughout hospitalization, upper and a lower endoscopy were performed without evidence to explain known anemia. Small bowel bleeding was then suspected, and a pill endoscopy was performed, demonstrating multiple friable and ulcerated lesions distal to the duodenum. Given these findings, a push enteroscopy was subsequently performed and a biopsy was taken from a jejunal lesion with a resultant pathology of a poorly differentiated adenocarcinoma. Discussion: The diagnosis of an uncomplicated unprovoked VTE warrants age-appropriate cancer screening, which in this patient would have included a colonoscopy. If this patient had undergone a screening or surveillance colonoscopy under normal circumstances, this patient’s diagnosis could have gone unnoticed. We believe the use of warfarin for treating the venous thromboembolism was the likely detonator of gastrointestinal bleeding, which ultimately prompted further clinical investigation. The above case presentation not only denotes the classic step-by-step process required to identify a relatively rare small bowel malignancy, but also demonstrates how treating patients sometimes help us “unmask” other diagnoses.Figure 1.: Large, ulcerated, friable, circumferential lesion at proximal jejunum.

A study on fungal defensin against multidrug-resistant Clostridium perfringens and its treatment on infected poultry.

In the present study, we aimed to investigate the antibacterial activity and mechanisms of plectasin-derived peptide NZ2114 in vitro and its therapeutic effects in vivo on broilers challenged with Clostridium perfringens. In vitro assay showed that NZ2114 had potent (minimal inhibitory concentration, 0.91μM) and rapid antibacterial activity (99.9% reduction within 2h), and the dual antibacterial mechanisms (including interfering with the cell membrane and intracellular DNA) against C. perfringens CVCC 2030. In vivo study, NZ2114 tended to increase linearly and quadratically the average daily gain as NZ2114 level increased and was the highest at 20mg/L. NZ2114 at 10 ~ 40mg/L dramatically reduced jejunal lesion score. Besides, the levels of IL-6, TNF-α, and IL-1β tended to downregulate linearly and quadratically as the NZ2114 level increased and were all the lowest at the dose of 20mg/L. NZ2114 significantly upregulated those levels of IgA, IgG, IgM, and sIgA with a linear and quadratic dose effect, with the highest IgA, IgG, IgM, and sIgA at 20mg/L. Finally, NZ2114 tended to linearly and quadratically increase the numerical value of crypt depth, with the lowest value at 40mg/L. Lincomycin only dramatically reduced the jejunal lesion score and increased the numerical value of crypt depth. These results indicate that NZ2114 has the potential as a new alternative to antibiotics for the treatment of C. perfringens-induced necrotic enteritis infection.Key points• NZ2114 could kill C. perfringens by dual antibacterial mechanisms• Broiler necrotic enteritis model induced by C. perfringens was established• NZ2114 treatment could ameliorate C. perfringens-induced necrotic enteritis.

Use of Polyamide (Nylon) Cable Ties for Vascular Ligation of Healthy Equine Jejunal Mesentery.

Jejunal vascular ligation is an essential step in performing jejunojejunostomy. Hand sewn ligation is typically used and can increase operative time with long sections of bowel to be removed. Nylon cable ties (NCT) have been used for vascular ligation in horses but are yet to be investigated for application on the mesenteric vasculature of the gastrointestinal tract. Our objective was to evaluate the efficacy and short-term safety of NCT jejunal mesenteric vessel ligation in healthy horses. Eight healthy adult horses underwent midline celiotomy. A segment of jejunal mesentery was identified (≥4 arcades). Briefly, three fenestrations (proximal, middle, distal) were made 5–10 mm apart adjacent to the first and last vascular arcade to be ligated. Two sterilized NCT were passed to encircle the mesentery through the proximal and middle fenestrations, separated by intact mesentery. NCT were closed tightly and the vascular pedicle transected with Mayo scissors through the distal fenestration. Jejunojejunostomy was then performed and the mesentery sutured closed. The number of vascular arcades and time to ligate using NCT were recorded. At 2 weeks, horses underwent repeat celiotomy to assess the healing of the NCT ligation site and an equal number of vascular arcades were hand sewn double ligated using 2-0 Polyglactin 910 as a timed comparison. NCT mesenteric ligation was significantly faster than hand sewn methods (P < 0.01). Effective hemostasis was achieved in all cases. There was no evidence of local infection or adhesions at 14 days post-operatively. Further investigation in the long-term effects in horses as well as horses with strangulating jejunal lesions are needed for clinical application.

TUMOR DO ESTROMA GASTROINTESTINAL

We report a case of an 87-year-old female patient, admitted to our emergency room with an acute abdomen. Exploratory laparotomy revealed a perforated jejunal lesion, histopathological examination was consistent with a gastrointestinal stromal tumor (GIST). GISTs are rare tumors with nonspecific and variable clinical symptoms. An initial clinical presentation as acute abdomen due to perforation, is very rare.

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.

Potential of blended organic acids to improve performance and health of broilers infected with necrotic enteritis.

Organic acids (OA) and their blends have been shown to positively affect performance and health of broilers. However, the data in the literature are not consistent. This study examined the potential of blended short-chain fatty acids (SCFA) with medium-chain fatty acids (MCFA) as alternatives to antibiotic growth promoters (AGP) on performance, health and welfare of broilers infected with necrotic enteritis (NE). The additives used were: A) a blend of SCFA, MCFA, and a phenolic compound (SMP); B) a blend of free and buffered SCFA with MCFA (SMF); C) a blend of free and buffered SCFA with a high concentration of MCFA (SHM). A total of 1,404 Ross 308 one-day-old male parental chicks were randomly distributed into 78-floor pens with 13 replicates of 18 birds each. Six treatments were the following: T1, unchallenged control (UCC); T2, challenged control (CHC); T3, challenged group plus zinc bacitracin (BAC); T4, challenged group plus additive SMP; T5, challenged group plus additive SMF; T6, challenged group plus additive SHM. Challenged birds were gavaged with Eimeria spp. on d 9 and Clostridium perfringens EHE-NE18 on d 14. Post NE challenge and cumulatively, BWG, FCR, and nutrient digestibility of birds were compromised (P < 0.05) by NE challenge indicating a successful induction of sub-clinical NE. Additive SHM had higher BWG compared to CHC and BAC groups (P = 0.001; d 10 to 24) but not different from SMP and SMF groups (P > 0.05). All the 3 additive groups had lower FCR compared to CHC (P = 0.001; d 0 to 35), and exhibited similar jejunal lesions (d 16) compared to BAC and apparent ileal protein digestibility (d 21) compared to UCC and BAC groups (P > 0.05). Birds in additive SHM group had a higher concentration of serum IgA compared to all groups (P = 0.001) except additive SMF (P > 0.05; d 21). All the additive groups had lower footpad dermatitis and hock burns compared to CHC (P < 0.05). The findings suggest the potential of blended OA as alternatives to BAC to protect broilers from NE indicated by improved FCR, immunity, digestibility, and bird welfare.

Body weight, serum albumin and food intolerance were linked to upper gastrointestinal Crohn's disease: a 7-year retrospective analysis.

BackgroundThe clinical features of upper gastrointestinal (L4) Crohn’s disease (CD) and its subtypes, along with the associated and nutritional status, remain poorly described. Our aim was to evaluate the clinical characteristics of L4 CD phenotype and its subtypes at diagnosis, and their relationship with the nutritional status.MethodsA retrospective study was conducted on 869 CD patients diagnosed between 2013 and 2019, and the association between the clinical characteristics and nutritional status of L4 patients was determined using Random forest importance ranking and logistic regression.ResultsThe majority of the patients (59.72%) presented L4 lesions, of which 335, 158 and 26 had proximal ileal, jejunal and esophago-gastroduodenal (EGD) lesions respectively. L4 patients were predominantly male (OR 2.07), smoker (OR 1.80), and had higher body weight and BMI, longer disease course, and stricturing disease (OR 1.88). Furthermore, the serum albumin level, body weight and disease course showed higher MDG in the random forest importance ranking test for L4 CD and L4-proximal ileal types. According to logistic regression, body weight (OR 1.054), disease course (OR 1.010), stricturing behavior (OR 4.998) and tomato intolerance (OR 1.313) were the independent risk factors for L4. In addition, body weight (OR 1.042) and stricturing behavior (OR 3.152) were the relevant factors for proximal ileal subtype, and stricturing behavior (OR 4.206) and perianal disease (OR 0.339) for jejunal subtype.ConclusionsL4 disease has a higher incidence rate compared to the non-L4 CD, and mainly affects males, and those with prolonged disease course, stricturing behavior, higher weight, BMI, albumin levels and food intolerance (FI).

S2788 When VCE Is Not Enough: It Was the Blebs!

INTRODUCTION: Although not common, accounting 5-10% of gastrointestinal (GI) bleeding, small bowel bleeding can be clinically significant and challenging to locate and treat. If bleeding is not identified on upper endoscopy (EGD) or colonoscopy, a second look can further exclude upper and lower sources. Push enteroscopy, video capsule endoscopy (VCE), and intraoperative endoscopy are next line diagnostic methods. We describe a challenging case of small bowel bleeding. CASE DESCRIPTION/METHODS: A 79 year-old male with atrial fibrillation, on Rivaroxaban, presented with one week of hematochezia. An EGD and colonoscopy did not reveal a source of bleeding. A VCE found numerous vascular blebs throughout the small intestine and fresh blood distally. Based on appearance, blue rubber bleb nevus syndrome was the initial thought, despite it being unlikely given he had no prior GI bleed. Multiple endoscopies, including push enteroscopy, repeat colonoscopy, and bidirectional balloon enteroscopy revealed scattered non-bleeding vascular blebs but no active bleeding source (Figure 1). CT angiography reported a subcentimeter jejunal lesion without active bleeding. Repeat VCE demonstrated active bleeding and submucosal nodules in the jejunum. He then had a laparotomy-assisted endoscopy that found numerous large vascular malformations (Figure 2) concentrated in the mid-jejunum. Full thickness biopsy was consistent with vascular malformation/hemangioma. Given his age and extent of small bowel involvement, octreotide was given. Due to persistent overt bleeding he ultimately underwent resection of the involved small bowel (approximately 100cm). He had no further episodes of GI bleeding on apixaban and was discharged home. DISCUSSION: Vascular malformations, or hemangiomas, are rare lesions that can cause significant GI bleeding. They generally involve the submucosa to mucosa, can involve the small bowel, and can be localized via CT enterography. They can be seen on endoscopy as soft, dark red to purple masses or blebs; biopsy can cause uncontrollable bleeding and surgical resection is often the treatment of choice. This case was unique given the size and involvement of the small intestine. Our patient's findings initially suggested blue rubber bleb nevus syndrome, however a lack of prior history of GI bleeding made this diagnosis unlikely and the management more challenging. This case highlighted the successful role of surgical intervention in a patient with extensive small bowel involvement of vascular malformations.Figure 1.: Vascular malformations in the jejunum found on anterograde balloon enteroscopy.Figure 2.: Numerous vascular malformations in the jejunum found during laparotomy-assisted endoscopy.

Magnetic Resonance Enterography and Capsule Endoscopy in Patients Undergoing Patency Capsule for the Evaluation of Small Bowel Crohn's Disease: A Korean Clinical Experience.

Objective Studies comparing magnetic resonance enterography (MRE) and capsule endoscopy (CE) for the assessment of small bowel (SB) Crohn's disease (CD) are scarce in Korea. In addition, there is no Korean experience of patency capsule (PC) examination prior to CE. The primary aim of this study was to compare diagnostic yields of MRE and CE for the assessment of SB CD. Secondary objectives were to compare the detection rate of proximal SB lesions by each modality in the Montreal classification and evaluate the safety and feasibility of PC in Korean CD patients. Methods MRE was performed as the first examination to assess SB CD. PC examination and CE were then performed. Diagnostic yields of active SB disease by MRE and CE were then analyzed. Results Disintegration of the patency capsule was shown in 5 patients out of 26 patients, who did not undergo CE. These 5 patients were accounted as negative CE findings. Overall, MRE and CE detected 80.8% and 65.4% of active SB lesions of CD in 26 patients, respectively (P = 0.212). MRE and CE detected 0% (0/26) and 19.2% (5/26) (P = 0.051) of jejunal lesions, 30.8% (8/26) and 42.3% (11/26) (P = 0.388) of proximal ileal lesions, and 80.8% (21/26) and 53.8% (14/26) (P = 0.039) of terminal ileal lesions, respectively. According to the Montreal classification, MRE and CE independently detected proximal disease (L4) in 30.8% (8/26) and 53.8% (14/26) (P = 0.092), respectively. Conclusions The diagnostic yields of MRE and CE for the assessment of SB CD including proximal SB lesions were similar. MRE is a more objective tool for detecting clinically relevant stricture than PC although PC examination could be performed safely before CE to prove the patency of SB. This trial is registered with KCT0004305.

Reducing protein and supplementing crystalline amino acids, to alter dietary amino acid profiles in birds challenged for subclinical necrotic enteritis

Necrotic enteritis (NE) is an infection of the gastrointestinal tract and is estimated to cost the global poultry industry billions of dollars annually. A study was conducted to examine whether reducing the crude protein might offset the severity of NE in broilers experimentally challenged with Eimeria spp. on day 9 and Clostridium perfringens on days 14 and 15. Furthermore, increasing the dietary amino acid (AA) density of the diet was also examined owing to identified benefits of improving performance compromised from low protein (LP) diets or NE. A 2 × 2 × 3 factorial arrangement of treatments at 6 replicates per treatment was used with 972 Ross 308 cockerels fed wheat-sorghum-soy-based diets to 35 D. Factors were NE challenge: no or yes; protein: standard (SP) or LP; and AA density: 100% AA, 115% with only essential AA (115% EAA) increased, and 115% AA with both essential and nonessential AA (115% AA) increased. The performance was measured in grower (days 7–21), finisher (days 21–35), and overall (day 7–35) periods. In addition, on day 16, intestinal lesion score and cecal short-chain fatty acids were measured. Only in nonchallenged birds fed LP diets, 115% AA increased grower feed intake (P < 0.01) and body weight gain (P < 0.05) compared to 115% EAA treatments. Challenge increased jejunal lesions (P < 0.001) with no difference between dietary treatments. Finisher body weight gain was greater in nonchallenged birds fed the 115% AA diets than in challenged birds (P < 0.05). Feeding diets with higher nonessential AA encouraged faster recovery from NE challenge. When fed the SP diets, NE challenge increased cecal butyric acid (P < 0.01) and total short-chain fatty acids (P < 0.05). The nutrient matrix used in LP diets does not favor beneficial butyric acid–producing bacteria. Using LP diets to mitigate NE severity does not offset the predisposing effect of E. spp. when attacking the gastrointestinal tract, and NE recovery is favored when feeding SP diets or additional AA.

The effects of dietary Bacillus subtilis supplementation, as an alternative to antibiotics, on growth performance, intestinal immunity, and epithelial barrier integrity in broiler chickens infected with Eimeria maxima

The objective of this study was to investigate the effects of dietary Bacillus subtilis supplementation on growth performance, jejunal lesion scores, oocyst shedding, and cytokine and tight junction protein expression in broiler chickens infected with Eimeria maxima. A total of 196 male day-old Ross 708 broilers were given a nonexperimental diet until 14 D of age. Then, all chickens were randomly assigned to one of seven dietary treatments: 2 basal diets (CON and NC); CON + virginiamycin (AB1); CON + bacitracin methylene disalicylate (BMD; AB2); CON + B. subtilis 1781 (PB1); CON + B. subtilis 747 (PB2); or CON + B. subtilis 1781 + 747 (PB3). At day 21, all chickens except those in the CON group were orally inoculated with E. maxima oocysts. At 7 D after E. maxima infection, the body weight gains of chickens fed PB2 and PB3 increased (P = 0.032) as much as those in chickens fed AB2. The body weight gain and feed efficiency of chickens fed PB2 were significantly increased (P < 0.001), and PB2 chickens showed (P = 0.005) the lowest lesion scores after E. maxima infection. Chickens fed PB2 showed (P < 0.05) lower mRNA expression of IL-1β in infected chicken groups. Chickens in the AB1, AB2, PB1, PB2, and PB3 groups showed (P < 0.05) greater mRNA expression of junctional adhesion molecule 2 in jejunal tissue, whereas occludin expression increased (P < 0.05) in the jejunal tissue of chickens fed AB2 or PB2. Dietary B. subtilis supplementation significantly improved the growth performance of young chickens to a level comparable with that induced by virginiamycin or BMD without E. maxima infection. After infection with E. maxima, dietary virginiamycin and BMD significantly enhanced the epithelial barrier integrity, and the dietary B. subtilis 747 showed significantly enhanced growth performance, intestinal immunity, and epithelial barrier integrity. Together our results indicated that certain strains of B. subtilis provide beneficial effects on the growth of young broiler chickens and have the potential to replace antibiotic growth promoters.

Heterotopic Gastric Mucosa Presenting as Lower Gastrointestinal Bleeding: An Unusual Case Report

Heterotopic gastric mucosa (HGM) is gastric mucosal tissue outside the stomach. It can be discovered anywhere throughout the gastrointestinal tract and is mostly asymptomatic. HGM, although rare beyond the ligament of Treitz, should be included in the differential diagnosis in a young patient with a polyp causing obstructive symptoms or bleeding. Very few cases are published in literature. We describe a case of young male who presented with an episode of large amount of melena, from a bleeding jejunal lesion, diagnosed by endoscopy. Laparotomy and wedge resection of the jejunal lesion was done, and histopathology showed gastric heterotopia in a small jejunal diverticulum.

A rare case of Goodpasture syndrome concomitant with bleeding jejunal Dieulafoy's lesion.

An 81-year-old man was diagnosed with Goodpasture syndrome (GS) because he met the criteria of positive anti-GBM antibodies, rapid progressive glomerulonephritis and pulmonary hemorrhage. After starting plasmapheresis and steroid pulse therapy, he experienced tarry stool and contrast-enhanced CT revealed an aneurysmal finding in the jejunum. Paroral enteroscopy showed a jejunal Dieulafoy's lesion (DL) with gush-out hemorrhage. Hemostasis was successfully achieved by hemoclipping, and he then experienced no re-bleeding events. GS can present as a jejunal DL, and contrast-enhanced CT is useful for investigating the etiology and site of small intestinal bleeding, which can lead to smooth, effective endoscopic hemostasis.

2666 Disseminated Renal Cell Carcinoma Presented as Obscure Gastrointestinal Bleeding

INTRODUCTION: Metastatic disease to the gastrointestinal tract is frequently observed in patient with known disseminated malignancies. Among those, melanoma, breast and lung cancer are commonly reported. Renal cell carcinoma (RCC) metastasis to small bowel is rare and the presentation varies from obstructive symptoms, intussusception, as well as, gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 85 years old male with medical history of pulmonary embolism on apixaban and progressive stage IV RCC despite multiple lines of therapy on lenvatinib, presented with progressive fatigue and melenic stools. Denied abdominal pain, change in bowel habits, prior episodes of bleeding, or NSAIDs use. Vital signs were unremarkable. Physical exam was pertinent for non-tender abdomen, no distention, active bowel sounds, no rebound or guarding, and a rectal exam that revealed melenic stools. Labs: Hemoglobin of 6.8 g/dL (Baseline 10.3 g/dl), electrolytes, kidney and liver function tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed multiple hepatic, retroperitoneal and mesenteric metastases. He received two units of packed red blood cells with appropriate response. Apixaban was held and he was admitted for workup of gastrointestinal bleeding. Esophagogastroduodenoscopy was unrevealing, while colonoscopy showed a few non-bleeding colonic and rectal angioectasias. A subsequent capsule endoscopy demonstrated an actively bleeding jejunal lesion (Figure 1). He continued to have large melenic bowel movements, and his hemoglobin decreased to 5.5 g/dL. A computed tomography angiography showed a blush of contrast in the jejunum, near the site of a tumor implant (Figures 2 and 3). An interventional radiology embolization was performed, with successful hemostasis. DISCUSSION: One autopsy series reported that only 2 out of 44 metastatic tumors to the small intestine were duodenal implants of RCC. In recent years, however, the number of published reports of RCC small bowel metastasis has been increasing. Retrograde venous spread to the paravertebral vessels has been propose as the route of dissemination of RCC to the intestine and solitary, bulky hypervascular lesions might be diagnostic if seen on CT scan. Luminal evaluation may localize the bleeding and offer potential treatment, however, angiography with embolization is the preferred therapeutic approach for small intestine lesions. Small bowel metastases must be considered as an etiology of bleeding when patients with RCC present with melena.

A CASE OF PULMONARY TB AND PERSISTENT INTESTINAL INFLAMMATION AND HEMORRHAGE: TB OR NOT TB?

SESSION TITLE: Chest Infections SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: We present a case of pulmonary tuberculosis with intestinal hemorrhage initially thought to be due to tuberculous enteritis. CASE PRESENTATION: A 68 year-old man presented to the emergency department with two months of productive cough, anorexia, and weight loss. His medical history included untreated latent tuberculosis (TB) infection and nasal NK/T-cell lymphoma, which recurred after chemoradiation and required autologous hematopoietic stem cell transplantation 12 years prior to presentation. He took no medications. He was afebrile and hemodynamically stable with oxygen saturation of 97% breathing room air. He was cachectic and weighed 49 kg. Leukocyte count was 5.9 x 10ˆ9/L and hemoglobin 5.0 g/dL. Renal and liver function tests were normal. Computed tomography of the chest revealed extensive consolidations with cavitation and tree-in-bud opacities (Figure 1). Empiric treatment for TB was initiated with isoniazid, rifampin, pyrazinamide and ethambutol. Shortly after, sputum smear for acid-fast bacilli and GeneXpert were positive, and culture grew M. tuberculosis. Over the next two weeks, the patient developed hematochezia with a drop in hemoglobin to 6.1 g/dL. Computed tomography revealed a 40-cm segment of jejunum with wall thickening, mucosal enhancement, and ulceration (Figure 2). Stool cultures grew M. tuberculosis. Endoscopy revealed gastritis and a duodenal ulcer without bleeding and colonic diverticulosis. Pathology revealed acute inflammation without acid-fast bacilli or dysplasia. Several weeks later, he developed recurrent hematochezia with hemorrhagic shock. Repeat endoscopy revealed a new ulcerated mass in the stomach and several smaller ulcers in the jejunum. Pathology of the gastric lesion revealed diffuse large B-cell lymphoma (positive for CD20, BCL6, and CD10; negative for CD3, CD5, CD7, and CD56) while jejunal lesions revealed acute inflammation and large cells with inclusion bodies consistent with CMV enteritis. Smears and cultures for TB were negative. With chemotherapy and valgancyclovir treatment the patient improved, with weight gain and cessation of bleeding. DISCUSSION: Intestinal TB is difficult to diagnose because of non-specific signs and symptoms. In a patient with pulmonary TB, the presence of TB in the stool is not diagnostic because this may occur as a result of swallowed infected sputum. In this case, intestinal inflammation on imaging with pulmonary TB supported a diagnosis of TB enteritis. However, gastrointestinal hemorrhage necessitating transfusion is unusual in intestinal TB and its persistence for several weeks despite treatment suggested an alternative diagnosis. Eventually, two alternative diagnoses were found: CMV enteritis and lymphoma involving the gastrointestinal tract. CONCLUSIONS: This case underlines the importance of considering a broad differential for gastrointestinal signs and symptoms, even in the presence of pulmonary TB. Reference #1: Debi U, et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol. 2014;20(40):14831-40. Reference #2: Rahman SMM, et al. Evaluation of Xpert MTB/RIF assay for detection of Mycobacterium tuberculosis in stool samples of adults with pulmonary tuberculosis. PLoS One. 2018;13(9):e0203063. DISCLOSURES: Consultant relationship with Cohero Health Please note: $1-$1000 Added 03/14/2019 by Caralee Caplan-Shaw, source=Web Response, value=stock My spouse/partner as a Speaker/Speaker's Bureau relationship with Cook Incorporated Please note: $1001 - $5000 Added 08/05/2019 by Caralee Caplan-Shaw, source=Web Response, value=Consulting fee No relevant relationships by Andrew DeMaio, source=Web Response No relevant relationships by Imran Sulaiman, source=Web Response