Jejunal Loop Research Articles

Successful treatment using balloon-assisted enteroscopy for jejunal loop variceal bleeding after pancreaticoduodenectomy.

Management of jejunal variceal bleeding after pancreaticoduodenectomy can be difficult. Previously, these cases were treated by portal vein stenting or shunt operations, resulting in a high likelihood of rebleeding. Endoscopic management could provide an alternative to invasive surgery; however, few reports have demonstrated endoscopic treatment [1] [2] [3] [4]. We report a successful case of balloon-assisted enteroscopy for jejunal loop variceal bleeding.

Duodenal intussusception due to periampullary duodenal adenoma: A case report

Duodenal intussusceptions are uncommon due to their fixed location in retroperitoneum except when associated with bowel malrotation abnormalities. We present a case of recurrent duodenojejunal intussusception in a 34-year-old female diagnosed on imaging. The lead point, in our case, was periampullary duodenal tubulovillous adenoma which was confirmed on endoscopy and subsequent punch biopsy. The patient underwent segmental duodenal resection anastomosis preserving the ampulla with reduction of the intussuceptum and fixation of the jejunal loops and its mesentery.

Surgical disconnection of high delineated immature debilitating jejunal fistulas using posterolateral access

Objective. The aim of the study was to develop the safest technique for surgical disconnection of high, unformed jejunal fistulas, so as to avoid problems with detection the intestine leading to the fistula and to avoid complications of viscerolysis. Material and methods. The authors present their experience in surgical management of 35 patients with high delimited unformed debilitating jejunal fistulas. Of these, 22 patients were included in the comparison group; their fistulas were closed or disconnected with the known methods. Findings obtained from other 172 patients with adhesive intestinal obstruction after infectious complications of laparotomic wounds and topography of visceroparietal planar adhesions of the peritoneum were analyzed. After studying the nature and location of visceroparietal adhesions, the authors could develop a technique for proximal disconnection of high delimited unformed debilitating jejunal fistulas using posterolateral access which was applied in 13 patients from the studied group. Research results. The proposed technique of unilateral disconnection of high unformed jejunal fistulas reduces duration, damage and risk of prolonged bowel deserosing. As a result, a significant decrease in postoperative mortality from 59.1 ± 9.2% to 23.1 ± 11.2% (t=2.5; p<0.05) was registered. Due to the preoperative endoscopic marking showing direction to the fistula of intestinal loop and duodenojejunal junction, intraoperative orientation was more accurate and took much less time than in the comparison group. The posterolateral surgical approach to the fistula in the jejunal loop reduced the risk of its damage, since there was no need for extensive enterolysis anymore. Therefore, postoperative period in patients of the studied group was better and with fewer complications than in the comparison group. Conclusion. The posterolateral access prevented extended viscerolysis and allowed to put a reliable and atraumatic interintestinal anastomosis so as to disconnect the fistula. The unilateral disconnection of the jejunal fistula at postoperative intestinal paresis unloaded the interintestinal anastomosis, similar to Meidl’s definitive jejunostomy. The abovementioned positive aspects of the proposed surgical intervention allowed to significantly decrease postoperative complications and mortality rate, if to compare with outcomes after known surgical interventions with a similar purpose.

Plant-oriented microbiome inoculum modulates age-related maturation of gut-mucosal expression of innate immune and barrier function genes in suckling and weaned piglets.

In the immediate time after weaning, piglets often show symptoms of gut inflammation. The change to a plant-based diet, lack of sow milk, and the resulting novel gut microbiome and metabolite profile in digesta may be causative factors for the observed inflammation. We used the intestinal loop perfusion assay (ILPA) to investigate jejunal and colonic expression of genes for antimicrobial secretion, oxidative stress, barrier function, and inflammatory signaling in suckling and weaned piglets when exposed to "plant-oriented" microbiome (POM) representing postweaning digesta with gut-site specific microbial and metabolite composition. Two serial ILPA were performed in two replicate batches, with 16 piglets preweaning (days 24 to 27) and 16 piglets postweaning (days 38 to 41). Two jejunal and colonic loops were perfused with Krebs-Henseleit buffer (control) or with the respective POM for 2 h. Afterward, RNA was isolated from the loop tissue to determine the relative gene expression. Age-related effects in jejunum included higher expression of genes for antimicrobial secretions and barrier function as well as reduced expression of pattern-recognition receptors post- compared to preweaning (P < 0.05). Age-related effects in the colon comprised downregulation of the expression of pattern-recognition receptors post- compared to preweaning (P < 0.05). Likewise, age reduced the colonic expression of genes encoding for cytokines, antimicrobial secretions, antioxidant enzymes, and tight-junction proteins post- compared to preweaning. Effect of POM in the jejunum comprised an increased the expression of toll-like receptors compared to the control (P < 0.05), demonstrating a specific response to microbial antigens. Similarly, POM administration upregulated the jejunal expression of antioxidant enzymes (P < 0.05). The POM perfusion strongly upregulated the colonic expression of cytokines and altered the expression of barrier function genes, fatty acid receptors and transporters, and antimicrobial secretions (P < 0.05). In conclusion, results indicated that POM signaled via altering the expression of pattern-recognition receptors in the jejunum, which in turn activated the secretory defense and decreased mucosal permeability. In the colon, POM may have acted pro-inflammatory via upregulated cytokine expression. Results are valuable for the formulation of transition feeds for the immediate time after weaning to maintain mucosal immune tolerance towards the novel digesta composition.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Safety and Efficacy of Sleeve Gastrectomy with Sleeve Jejunal Bypass: An Advantage over Other Bypass Procedures – Multicenter 3 and 5 year Data

Abstract Background: The sleeve gastrectomy with sleeve jejunal (SG + SJ) bypass is a single anastomosis, sleeve plus procedure which was introduced as a loop modification of the transit bipartition and the single-anastomosis sleeve-ileal bypass, continuing with the original idea of maintaining biliary access by avoiding duodenal transection, while creating a functional bypass to achieve weight loss and resolution of the metabolic syndrome. Objectives: This study was done to evaluate the extent of weight reduction, control of type 2 diabetes mellitus (T2DM), their maintenance up to 5 years, nutritional stability, and documentation of any complications, following this procedure. Methods: This is a retrospective analysis of prospectively collected data of patients who underwent SG + SJ bypass, with a follow-up of 1–5 years, in three centers, amounting to 112 patients. A SG is followed by anastomosis of a loop of jejunum, usually at 200 cm distal to the duodenojejunal flexure (sometimes at 150 cm or even 100 cm depending on total small bowel length [TSBL]), with the antrum. The cohort included 41 male and 71 female patients with a mean age of 42 years and mean preoperative body mass index (BMI) of 45.8 kg/m2 (range: 30.15–74.6 kg/m2). Seventy-three (65.2%) patients had T2DM, with mean glycated hemoglobin (HbA1c) of 7.5% (range: 4.9%–16%). The primary outcome of this study was weight loss and remission of T2DM, and the secondary outcome was its safety and nutritional stability. Results: Of these 112 patients analyzed in this study, 110 (98.2%) followed up at 1 year, 45 out of 58 (77.6%) at 3 years, and 14 out of 25 (56%) at 5 years. Operative duration was 120–180 min with an average hospital stay of 2–4 days with no postoperative problems. The mean TSBL was 793 cm (range: 530–1035 cm); the mean common channel (CC) was 587 cm (range: 330–835). Reduction in BMI was observed from 45.8 to 28.2 kg/m2 at 1 year, 27.4 kg/m2 at 3 years, and 27.3 at 5 years. The mean percentage of total body weight loss was 37.9% at 1 year, 40.7% at 3 years, and 40.6% at 5 years. Remission of diabetes was seen in 98.6% at 1 year, 97% at 3 years, and 91.7 at 5 years, with a mean fall in HbA1c from 7.5% to 5.2% at 1 year, 5% at 3 years, and 4.96% at 5 years. No mortality was seen in any of these 112 patients. Four patients had complications such as nausea, vomiting, diarrhea, dumping syndrome, hypoproteinemia, and hypoalbuminemia. Two patients required a partial reversal of the procedure (disconnection of the jejunal bypass while retaining the sleeve), while the rest were managed conservatively. Conclusions: This procedure was found to be safe and effective in achieving and maintaining weight loss and diabetes remission, along with nutritional stability, even at 3 and 5-year follow-up; long-term data are awaited. It has the advantage of maintaining biliary access and if necessary a partial reversal can be done in a simpler manner compared to other bypass procedures.

Obstructed Left Paraduodenal Hernia with Spontaneous Reduction Demonstrated on Computed Tomography: A Case Report

Paraduodenal hernias (PDH) are the most frequently occurring internal hernia, caused due to nonfusion between inferior mesentery and parietal peritoneum. The herniation of the bowel through the fossa of Landzert results in the left paraduodenal hernia which constitutes 75% of PDH. A case of a 34-year-old male with obstructed left PDH and a spontaneous reduction is demonstrated on Computed Tomography (CT). The patient had a cluster of jejunal loops forming a sac-like mass in the left anterior pararenal space, with surrounding mass effect with twisting and stretching of the mesenteric vessels at the hernia orifice, which showed a spontaneous reduction on subsequent contrast-enhanced and delayed CT studies. Despite the imaging evidence of spontaneous reduction of left PDH in our case, surgery remains the mainstay in terms of management for left paraduodenal hernia.

Submucosal infiltrate of anisakis larvae. Rare cause of intestinal obstruction.

Patient aged 71 with a history of type 2 diabetes mellitus. He came to the emergency department for abdominal pain and vomiting. Laboratory tests showed an increase in acute phase reactants. Abdominal CT scan showed dilated jejunal loops, compatible with intestinal occlusion. Urgent intervention was performed, resecting the affected segment. The pathology report showed a prominent transmural inflammatory infiltrate and interstitial oedema, with moderate villous atrophy, identifying parasitic structures compatible with anisakis larvae (family Anisakidae). Given the mechanism of tissue invasion, the larvae are surrounded by a predominantly eosinophilic inflammatory infiltrate, organised as granulomas or abscesses.

Mesenteric Cyst Lymphangiomas in 6 years Old Boy (A Case Report)

mesenteric cyst lymphangioma is a rare benign intra-abdominal tumour, It is located in the mesentery of the gastrointestinal tract and may extend from the base of the mesentery into the retroperitoneum. chylous ascites is an uncommon form of ascites due to leakage of lipid-rich lymph into the peritoneal cavity, it is diagnosed by the presence of milky-appearing ascites fluid and white triglyceride content &gt;200mg/dl. We report 6-year-old boy presented progressive Vega abdominal pain over one month associated lately with abdominal distention and vomiting, abdominal ultrasound and NON-CONTRAST computed tomography (CT) revealed a large cystic abdominal lesion demonstrating multiple septations involving the retroperitoneal region. The intra-operative finding was a large yellowish septate mesenteric cyst arising from both mesenteric borders of jejunal loop extending retroperitoneal with white mesentery and multiple reactionary lymph node and chylous acites.

Current treatment strategies for postoperative intrahepatic bile duct stones in congenital biliary dilatation: a single center retrospective study

BackgroundIntrahepatic bile duct (IHBD) stones are one of the most common late complications of Roux-en-Y hepaticojejunostomy for congenital biliary dilatation (CBD). We report the current treatment strategies for IHBD stones and their outcomes in our institute.MethodsBetween 1983 and 2021, 117 patients with CBD were surgically treated in our institute. Our treatment strategies included oral ursodeoxycholic acid (UDCA), double-balloon endoscopic retrograde cholangiography (DB-ERC), percutaneous cholangio-drainage (PTCD), and open surgery. A retrospective study was conducted using medical charts.ResultsPostoperative IHBD stones were identified in 12 of 117 patients with CBD (10.2%). Five patients received UDCA, and small stones were successfully resolved in two cases. DB-ERC was performed eight times in five patients, but the endoscope could not reach the porta hepatis due to a long jejunal loop in two of five patients. One patient presented with severe acute pancreatitis induced by prolonged DB-ERC. PTCD was performed in three patients, two of whom finally underwent open surgery due to unsuccessful lithotomy. Open surgery was eventually performed in three patients. Lithotomy was performed in one patient; lithotomy with strictureplasty was performed in another patient. The other patient was diagnosed with intrahepatic cholelithiasis with adenocarcinoma. He underwent left lobectomy and died of carcinomatous peritonitis.ConclusionsOral UDCA may be effective for small stones. Although DB-ERC should be considered as a first-line interventional therapy for lithotomy, it may not be feasible due to a long jejunal loop, and pancreatitis may occur. Long-term follow-up and early detection and treatment for IHBD stones may yield a good prognosis.

Jejunal obstruction due to jejunocolic congenital band in a 12-year-old child: a case report

BackgroundA congenital band is an uncommon abnormality that can be found anywhere along the gastrointestinal tract. Intestinal obstruction caused by an anomalous congenital band is very rare in children. To the best of our knowledge, no cases of congenital bands extending from the descending colon to the jejunum have been reported in the English literatureCase presentationHerein, we present the case of a 12-year-old Syrian patient with intestinal obstruction due to a congenital band extending from the mesentery of the descending colon to the mesentery of the jejunum with an entrapped loop of jejunum between the band and the mesentery. The location of the obstruction was determined by upper gastrointestinal contrast radiography, but the cause of the obstruction was diagnosed intraoperatively. The band was excised without intestinal resection.ConclusionPrediagnosis of congenital bands can be challenging, and surgery is required. When making a bowel obstruction differential diagnosis, it is important to keep this type of band in mind.

Case report on Management and Complication of Peutz Jegher Syndrome

Introduction: Infrequent and characterized by mucocutaneous pigmentations, gastrointestinal polyposis, and an increased risk of malignancy, Peutz-Jeghers syndrome is an autosomal dominant genetic condition. The usual perioral macules and patches that are colored in the buccal mucosa are present in 90% of patients, and numerous but not continuously contiguous lesions, primarily in the gastrointestinal (G.I.) tract, with rarely more than 20 hamartomata's polyps, are the characteristics of Peutz-Jeghers syndrome (P.J.S.). Present complaints and Investigation:-Suddenly felt sick to my stomach and started to puke. Abdominal pain, Black stools, repeated vomiting, weight loss of 5 kg in 15 days, loss of appetite, and Intussusception were discovered during examinations in the upper small bowel. A thorough study of the gastrointestinal tract was conducted. Endoscopically, the enormous polyps of the stomach and duodenum were discovered and biopsied. Resulting of bleeding due to the G.I. polyps, she became anemic. There were polyps. Later removed endoscopically while being sedated, C.T.'s Abdomen and pelvis found multiple mildly enhanced polypoidal lesions notes attached to the pyloric part of stomach and duodenum proximal jejunal loops, similar lesions of Ascending colon, transverse colon, and advice colonoscopy. History: The patient was admitted in 2015 And Operated on 26/12/2015, the year Jejunoileal intussusception. The primary diagnosis, therapeutic intervention, and outcomes: After physical examination and investigation, Hamartomatous polyp (P-J Secondary Intussuseception ) Conclusions: The following primary complaints were the reason for the patient's hospital admission. Upon entry to the hospital, the patient's main complaint was that Peutz Jegher Syndrome was identified as the patient's condition once all investigations were complete. The patient now needs appropriate medical attention and quality nursing care.

Rapunzel Syndrome in a Teenage Girl: A Case Report

Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis. We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful. An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms. In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes.

S352 Presidential Poster Award Light at the End of the Tunnel: Pipeline to the Jejunum

Introduction: Small intestinal strictures that are distal to the duodenum, particularly the jejunum, are uniquely complicated to manage. Adult endoscopes are often too short or too rigid to reach this region of the small bowel. Furthermore, duodenal stents are not flexible enough and are uncovered. In this case, we were able to place several esophageal stents in the proximal jejunum using a pediatric colonoscope that could not be placed previously. Case Description/Methods: A 56 year-old woman with hypertension, obstructive lung disease, and a prior ischemic stroke presented to the hospital for four days of postprandial emesis, abdominal distention, epigastric pain, and constipation. She previously underwent appendectomy and hysterectomy, and had no prior endoscopic studies. Computed tomography (CT) was performed demonstrating mural thickening of the distal duodenum and partial occlusion of the small bowel with regional lymphadenopathy, and a large left adrenal mass. Esophagogastroduodenoscopy (EGD) showed an intrinsic severe stenosis in the distal duodenum. After biopsies were taken, the tissue was found to be a primitive neuroectodermal tumor. Because of the presence of mesenteric adhesion and extensive stenosis, it was decided to correct the stricture endoscopically rather than with surgical intervention. Using a pediatric colonoscope and fluoroscopic guidance, three stents were placed sequentially and telescoping each other from the proximal jejunum to the distal duodenum: a fully covered 20 mm x 120 mm esophageal stent, a partially covered 18 mm x 97 mm esophageal stent, and a fully covered 20 mm x 60 mm esophageal stent (Figure). There were no immediate complications with the procedure and repeat imaging demonstrated luminal patency. Due to the expansion of the stents through a tight stricture, the abdominal pain and pressure was present despite no evidence of perforation on CT. Discussion: This demonstrates the feasibility of utilizing multiple esophageal stents to help relieve more distal gastrointestinal obstructions that were not feasible in the past. The covered esophageal stents are extremely useful when there is discontinuity in the lumen of the small bowel to keep the natural flow of food and help prevent surgical interventions. Watch the video at https://tinyurl.com/ACGAbstractS352Figure 1.: (A) Coronal CT image of a large abdominal mass involving loops of bowel and jejunum. (B) Abdominal x-ray showing interval placement of stents from the distal duodenum to the proximal jejunum.

S3493 Two Cases of Perforated Jejunal Diverticulum With Severe COVID-19

Introduction: Jejunoileal diverticulitis is very rare with a high mortality rate of 21-40%. The rates of small bowel diverticulitis with perforation associated with COVID are unknown. Here, we present cases of complicated jejunal diverticulitis with perforation in two patients with severe COVID infection. Case Description/Methods: The first patient is a 69-year-old man who presented to our Emergency Department with shortness of breath, cough, and diarrhea. He was diagnosed with severe COVID-19 despite being vaccinated. He was started on methylprednisolone and remdesivir. 13 days into admission, the patient developed pneumomediastinum. Computed Tomography Abdomen/Pelvis (CT A/P) for further evaluation showed pneumoperitoneum and perforated jejunal diverticulitis. Given the severity of COVID pneumonia requiring high-flow oxygen, continued use of corticosteroids (methylprednisolone 40mg BID), and risk of surgical complications with COVID, conservative management with antibiotics and bowel rest was pursued. The patient developed an abscess in the mesentery and pelvis for which a drain was placed percutaneously by Interventional Radiology. He unfortunately developed progression of the perforation and passed away from septic shock. The second patient is a 57-year-old male with hypertension, deep vein thrombosis who presented with worsening shortness of breath, cough, fever. He was diagnosed with severe COVID (unvaccinated) and started on baracitinib, remdesivir, methylprednisolone. Ten days into admission he developed severe abdominal pain, nausea, vomiting, and worsening leukocytosis. CT A/P showed new abscess involving the left upper quadrant with a contained jejunal perforation. The patient was initially managed with bowel rest, antibiotics and pain control. However, he developed worsening leukocytosis and pain with peritonitis on exam. He was taken emergently to the operating room and had proximal perforated jejunum resection and lysis of adhesions. He ultimately had small bowel re-anastomosis. He continued to improve clinically and was discharged home. (Figure) Discussion: It is unclear if the complication of perforated diverticulum in these cases is due to the underlying inflammatory response due to COVID, steroid-induced disruption of intestinal mucosal barrier or incidental diverticulitis with evolution to complicated perforation. However, each case reminds us how important it is to take abdominal complaints in COVID seriously as jejunoileal diverticulitis has a high mortality rate.Figure 1.: Left panel- Patient 1 CT Abdomen/Pelvis transverse view showing jejunal perforation with surrounding inflammation (arrow). Right panel- Patient 2 CT Abdomen/Pelvis transverse view showing thickened loops of jejunum with interloop abscess (arrow).

S1770 Neuroendocrine Tumor in the Biliary Tract Presenting With Cholangitis

Introduction: Neuroendocrine tumors (NETs) of the biliary tract account for less than 2% of all gastrointestinal cancers with an incidence of 0.32%.1,2 Extrahepatic biliary NETs are mostly found incidentally in the distal common bile duct (CBD) but in rare cases they may present with obstructive jaundice. We present a case of an elderly male with symptoms of biliary obstruction and acute cholangitis secondary to a NET in the proximal bile duct. Case Description/Methods: A 64-year-old male with hypertension presented with epigastric abdominal pain, vomiting and fever. Patient reported an unintentional 50-pound weight loss over the past year. Vital signs were remarkable for heart rate of 118 beats/min. Labs revealed White blood cell count of 21,000 uL, AST 303 U/L, ALT 563 U/L, alkaline phosphatase 300 U/L, total bilirubin 1.9 mg/dL. CT abdomen showed intrahepatic ductal dilatation to 1.1 cm, and a 1.2 x 1.1 cm low attenuating lesion within the left lobe of the liver and wall thickening of the proximal jejunal loops. Piperacillin-tazobactam was started for acute cholangitis. Endoscopic ultrasound showed duct dilation in the left hepatic lobe and ERCP showed ulceration of major papillae. Following biliary sphincterotomy, exploration revealed severe stenosis of the main bile duct and a 12 mm polypoid lesion in the upper third of the CBD. Histology showed well differentiated NET with trabecular and organoid pattern, positive chromogranin and synaptophysin with Ki-67 index of 3%. Special staining was also positive for reticulin and trichrome. A 10fr x 9cm stent was placed. Following a 7-day course of antibiotics and symptom resolution, the patient was discharged with a plan for elective surgery. Left hepatectomy, CBD resection, and Roux-en-Y hepaticojejunostomy were performed 6 months after hospitalization. At 2 months follow up in clinic, the patient was asymptomatic. Discussion: Biliary NETs are found in the common hepatic duct, CBD and the cystic duct.3 Biliary NETs are twice more common in females, with a mean age of 47 years old. Although most cases are incidental, presenting symptoms are jaundice and pruritis. Diagnosis requires histologic evidence and positive expression of chromogranin A, synaptophysin, CD56, or neural cell adhesion molecule.4 Treatment is surgical excision with Roux-en-Y hepaticojejunostomy. Since biliary NETs uncommonly present with obstructive jaundice, this case presentation highlights the need for a broad differential diagnosis in evaluating patients with obstructive jaundice.

S355 Presidential Poster Award Recurrent Obstruction After Surgical GJ in a Rare Case of Gastric Outlet Obstruction: EUS to the Rescue

Introduction: Eosinophilic enteritis is a rare cause of gastric outlet obstruction and if not recognized early can be very difficult to manage. Endoscopic ultrasound (EUS) guided gastrojejunostomy (GJ) is most often used for malignant disorders. However, it can act as a very effective temporary tool in benign disorders for effective medical therapy to take its course. Case Description/Methods: A 49-year-old man presented to us with features of recurrent vomiting and pain abdomen for 5 months. He had alcohol-related chronic calcific pancreatitis. Three years prior to current presentation he had features of gastric outlet obstruction for which he underwent oesophagogastroduodenoscopy (EGD) revealing a circumferential ulcer in antropyloric region with swelling. He underwent truncal vagotomy with antecolic gastrojejunostomy. Biopsy from the specimen had revealed eosinophilic gastroenteritis (EE). He again had some symptoms of obstruction 2 months after surgery which responded to proton pump inhibitors. He remained apparently well with regular follow up for chronic pancreatitis. Now he was symptomatic with progressive symptoms of gastric outlet obstruction since last 4 months. On endoscopy he was found to have both afferent and efferent loop strictures. He was also having a few geographic ulcers and psuedopolyps near stricture mouth. He underwent balloon dilatation twice upto 13.5 mm but symtoms did not improve. Repeat biopsies were taken from the ulcer and stricture site revealed EE with eosinophilic abscesses. Barium meal follow-through and Contrast enhanced CT was done for evaluation of stricture. A nasoduodenal (ND) tube of 10 french was negotiated over guidewire through the stricture using a cannula. It was used to continue enteral feeding. Surgical consultation was taken and poor surgical outcome was predicted in view of both loop involvement. He was started on oral budesonide and planned for an endoscopic bypass procedure. The ND tube was used to distend the normal jejunal loops beyond stricture and endoscopic ultrasound was used for gastrojejunostomy using a lumen apposing metal stent. Discussion: EUS-GJ is a viable option for gastric outlet obstruction even in benign cases for bridging for further surgical or medical therapy. Post-surgery complications may be difficult to manage and EUS-GJ appears more lucrative for the short time period. It requires a carefully selected patient with preset managment plan and a learning curve for successful implementation. Watch the video at https://tinyurl.com/ACGAbstractS355

S2557 An Unusual Cause of Obscure Gastrointestinal Bleeding

Introduction: Obscure gastrointestinal bleeding is bleeding of unknown origin, that persists or recurs, after a negative initial or primary endoscopy. It accounts for approximately 5% of all cases of gastrointestinal bleeding and is usually due to a lesion in the small bowel. We present a case of rare cause of obscure gastrointestinal bleeding. Case Description/Methods: 68 year old male, was admitted with history of passing black coloured stools since last 2 weeks. History of weightloss was present. History of squamous cell carcinoma vocal cord in the past and he underwent radiation therapy. Blood investigations showed anemia. Endoscopy showed antral erosions. Colonoscopy revealed caecal angiodysplasia and was treated with Argon plasma coagulation. In view of persistent melena, patient underwent CT angiography, which revealed bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum (Fig 1). Spiral enteroscopy revealed an ulceroproliferative neoplasm about 4 x 3 cm, involving more than half the circumference of jejunum (Fig 2). He was discharged after stabilisation. Two weeks later, patient was admitted with abdominal pain. CT abdomen revealed dilated jejunal loops with bowel wall thickening and eccentric cavitation. A small loculated collection of size 3.6x1.8cm with a tiny air foci was seen along with minimal free fluid (Fig 3). On laparotomy, a perforated tumor in proximal jejunum, 25 cm away from DJ flexure, was identified. He underwent resection and end to end anastomosis. On histopathology, sections from jejunum showed transmural infiltration by a tumour arranged in sheets. The tumour cells were polygonal to epithelioid, with heterogeneously clumped chromatin. Interspersed proliferated blood vessels were noted. The neoplastic cells show diffuse strong positivity for Pan CK , Vimentin and patchy positivity for CK 7,CD31. CD34 highlighted the vessels. They were negative for p40, CDX2, CK20, CK 5/6, WT1, HMB45, SMA, CD117 and DOG 1. Histopathology was suggestive of a poorly differentiated sarcoma, with IHC suggestive of epitheliod angiosarcoma. Discussion: Primary angiosarcoma of small intestine is very rare. Epithelioid angiosarcomas are rare tumors, accounting for less than 1%. Angiosarcoma of small bowel may be associated with previous radiation treatment, chemotherapy, and chemical toxin exposure, specifically polyvinyl chloride. Angiosarcoma of small intestine can be considered as a rare cause in a patient who presents with obscure gastrointestinal bleed.Figure 1.: Bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum, Fig 2: Spiral enteroscopy , Fig 3: Dilated jejunal loops with bowel wall thickening and eccentric cavitation, Fig 4/5 Histopathology , Fig 6: Immunohistochemistry.

S2677 A Case of Blue Rubber Bleb Nevus Syndrome in an Elderly Patient

Introduction: Blue Rubber Bleb Nevus Syndrome (BRBNS) is an uncommon disorder with only about 200 cases reported worldwide. It is defined by the formation of soft rubbery venous blebs that mostly involve the skin, gastrointestinal (GI) tract, central nervous system, spleen and other visceral organs. BRBNS is mostly diagnosed in children with only 4% incidence noted in adult age groups. Herein we describe the case of the oldest reported individual newly diagnosed with BRBNS who was a 90 year-old lady presenting with small bowel bleeding. Case Description/Methods: A 90-year-old woman with history of atrial fibrillation on apixaban presented to the emergency room with a few week history of melena. Vital signs were significant for tachycardia with a heart rate of 110 beats/min. Physical exam showed pale conjunctiva with no noted cutaneous lesions. Laboratory tests were significant for a hemoglobin of 7.2 g/dL down from a normal baseline (normal range 12-16 g/dL). Upper endoscopy showed non bleeding submucosal venous structures in the esophagus and duodenum (panel A, B). Colonoscopy showed coffee ground blood with no noted source of bleeding. Capsule endoscopy revealed numerous venous structures in the small bowel with active oozing in the jejunal loops suggestive of BRBNS (panel C). A single-balloon assisted deep enteroscopy was offered to attempt to control the bleeding however the patient preferred to avoid any further endoscopic or surgical interventions and chose to receive palliative care. (Figure) Discussion: Most BRBNS cases are sporadic however inheritance through autosomal dominance fashion via TEK gene mutations have been reported in a minority of cases. GI involvement by BRBNS usually manifests as GI bleeding that can range from a chronic slow rate to a massive and life-threatening hemorrhage. Presentation with bowel volvulus, intussusception, infarction and gangrene have been reported. Direct examination through endoscopic visualization is the diagnostic and potentially therapeutic intervention of choice. Management depends on the initial presenting symptoms and extent of involved areas and include iron supplementation, blood transfusion and endoscopic control of bleeding. Surgical resection of affected bowel loops is reserved for complicated and refractory cases. Ongoing clinical trials evaluating the efficacy and safety of sirolimus, interferon-beta and octreotide are underway for the management of complex cases. Recurrence is common and no curative treatment is currently available.Figure 1.: Panel A: Upper endoscopy showing non-bleeding venous structures in the esophagus. Panel B: Upper endoscopy showing non-bleeding venous structures in the duodenum. Panel C: Capsule endoscopy revealing numerous venous structures in the small bowel.

Management Strategies for Choledochal Cysts in Infants and Children Our Experience at Department of Pediatric Surgery ,L.R.H, Peshawar

Objective: This study aims to understand more about choledochal cysts and how they are managed in children under 12 years old. Setting and Design: A Descriptive Study at Department of Pediatric surgery L.R.H. Hospital Peshawar. Method and Material: The most common kind of malformation of the biliary tree in Pakistan is choledochal cyst malformation (C.C.M.). Congenital choledochal anomalies range from asymptomatic to life-threatening cholangitis or pancreatitis. Surgeons now recommend total cyst ectomy and bilioentenric anastomosis. This five-year research examines. Clinical presentation, blood and laboratory testing, imaging, surgery, and predictive data were evaluated from case records. Twenty-three children with choledochal cysts were treated between January 2019 and December 2021, and their clinical presentation, diagnostic tests, and treatments were recorded. ERCP or a cholangiogram confirmed choledochal cysts after ultrasound diagnosis (P.O.C.). Before surgery, children with cholangitis received antibiotics and percutaneous transhepatic biliary drainage (excision of the cyst and jejunal loop interposition hepaticoduodenostomy) Results: Twenty-three patients were analyzed; eight presented with chronic abdominal pain, five with a history of cholangitis, two with acute cholangitis, four with biliary peritonitis, and one with a history of pancreatitis. Following cyst excision, Roux-en-Y hepaticojejunostomy (RYHJ) was performed in 13 patients, and hepaticoduodenostomy (H.D.) was performed in 4 patients. One example of congenital choledochal malformation type II was treated with cyst excision and drainage because cholangitis and jaundice threatened the patient's life. The median age was 3, and the gender distribution was about even. Of the patients who sought care, 18 presented with jaundice, 15 with abdominal discomfort, 12 with fever, and 9 with a mass in their stomach. Only four people had all three symptoms of characteristic jaundice, pain, and lump. Overall, the results of both ERCP in 7 patients and P.O.C. in 14 cases were favorable. There were two distinct clinical presentations: I infantile form (less than a year), which included nine infants with jaundice in all, acholic stool in 7, lump abdomen in 4, but only one with classical triad; and (ii) childhood form (more than a year), which included twelve patients with abdominal pain, jaundice, and cholangitis. Twenty patients had a type I cyst, and three had a type Iva cyst. Only two kids said no to surgery, while the rest went through with it. Only three newborns were lost during surgery, but the other 18 did well following their follow-up visits (median 25 months). Six had extrahepatic biliary atresia, two had congenital hepatic fibrosis, and one had congenital biliary cirrhosis. Practical implication: Our study will provide a new data to the health care providers about choledochal cysts and how they are managed in children under 12 years old Conclusions: However, total cyst removal and Roux en Y hepaticojejunostomy (RYHJ) anastomosis is the definitive treatment of Congenital Choledochal Malformation. However, several other temporary therapies are also necessary at various phases of the illness. Their criticality—evolutionary stages may differentiate two types of choledochal cysts from infancy through adulthood. The prognosis is favorable following surgery, but early identification and referral are critical for reducing the risk of complications and mortality. Keywords: Choledochal cyst, ERPC, H.D., RYHJ, and C.C.M. (Endoscopic retrograde cholangiopancreatography)