Jejunoileal Junction Research Articles

A rare case of jejunal atresia.

IntroductionIntestinal atresia more common in the small bowel, apart from large intestine. Jejunal atresia characterized by complete occlusion of the intestinal lumen, is a rare congenital anomaly occurring in 1 in 12,000 live births.ImportanceThe jejunal atresia can be single or multiple occurring anywhere from the ligament of Treitz to the jejuno-ileal junction, requiring immediate surgical attention to prevent mortality and morbidity among these neonates.Case presentationA rare case of jejunal atresia in neonate and its management has been discussed here.Clinical discussionSurgical excision of the involved bowel and end to end anastomosis of the normal bowel is definitive treatment.ConclusionThe morbidity associated with post-operative hypo persistaltic bowel can be minimised by adding oral prokinetics in controlled manner.

Types and site distributions of intestinal injuries in seat belt syndrome

Objective Intestinal injuries in seat belt syndrome are relatively uncommon but can be potentially lethal due to accompanying peritonitis and hemorrhaging. It can be difficult to identify the exact injury sites of the intestine as multiple areas are often damaged and massive intraperitoneal hemorrhaging may make it challenging to determine causal bleeding points of mesenteric injuries. This study aimed to clarify the incidence and distribution of intestinal injuries in seat belt syndrome. Methods We retrospectively reviewed the clinical records of 25 patients who underwent laparotomy for suspected intestinal injuries due to seat belt syndrome during a frontal impact. The incidence and distribution of the sites of intestinal injuries, as well as associated injuries, were investigated. Intestinal injuries were divided into bowel and mesenteric injuries. Additionally, bowel injuries were classified into two types: perforation and non-perforation (seromuscular tears/intramural hematomas). Regarding the injured sites, the small intestine was divided into the following three parts: (1) the ligament of Treitz (100-cm distal from the ligament [proximal jejunum]), (2) the ileocecal valve (100-cm proximal from the valve [distal ileum]), and (3) the intermediate area between those two regions (jejunoileal junction). Results In total, there were 64 major injuries among 25 patients requiring surgical intervention: 34 bowel injuries (20 perforations and 14 non-perforations) and 30 mesenteric injuries. Significantly more bowel perforations occurred in the small intestine (1 [interquartile range (IQR), 0–1]) than in the large intestine (0 [IQR, 0–0]) (p = 0.003). Similarly, significantly more mesenteric injuries occurred in the small intestine (1 [IQR, 0–1.25]) than in the large intestine (0 [IQR, 0–0]) (p < 0.001). Specific sites of the mesenteric injuries in the small intestine included the jejunoileal junction (0 [IQR, 0–1]) and distal ileum (0 [IQR, 0–1]); the jejunoileal junction was significantly more vulnerable than the proximal jejunum (0 [IQR, 0–0]) (p = 0.015). Conclusions In patients with seat belt syndrome, the small intestine was more vulnerable to perforation and mesenteric injury than the large intestine. Additionally, for mesenteric injuries, the jejunoileal junction was more likely to be damaged than the proximal jejunum.

HB-EGF Protects the Lungs after Intestinal Ischemia/Reperfusion Injury

Acute respiratory distress syndrome continues to be a major source of morbidity and mortality in critically-ill patients. Heparin binding EGF-like growth factor (HB-EGF) is a biologically active protein that acts as an intestinal cytoprotective agent. We have previously demonstrated that HB-EGF protects the intestines from injury in several different animal models of intestinal injury. In the current study, we investigated the ability of HB-EGF to protect the lungs from remote organ injury after intestinal ischemia/reperfusion (I/R). Mice were randomly assigned to one of the following groups: (1) sham-operated; (2) sham+HB-EGF (1200 microg/kg in 0.6 mL administered by intra-luminal injection at the jejuno-ileal junction immediately after identification of the superior mesenteric artery); (3) superior mesenteric artery occlusion for 45 min followed by reperfusion for 6 h (I/R); or (4) I/R+HB-EGF (1200 microg/kg in 0.6 mL) administered 15 min after vascular occlusion. The severity of acute lung injury was determined by histology, morphometric analysis and invasive pulmonary function testing. Animal survival was evaluated using Kaplan-Meier analysis. Mice subjected to intestinal I/R injury showed histologic and functional evidence of acute lung injury and decreased survival compared with sham-operated animals. Compared with mice treated with HB-EGF (I/R+HB-EGF), the I/R group had more severe acute lung injury, and decreased survival. Our results demonstrate that HB-EGF reduces the severity of acute lung injury after intestinal I/R in mice. These data demonstrate that HB-EGF may be a potential novel systemic anti-inflammatory agent for the prevention of the systemic inflammatory response syndrome (SIRS) after intestinal injury.

End-to-end jejuno-ileal anastomosis following resection of strangulated small intestine in horses: a comparative study

Small intestinal resection and anastomosis is a relatively common procedure in equine surgical practice. This study was designed to test objectively the subjective opinions of surgeons at the Liphook Equine Hospital that an end-to-end jejuno-ileal anastomosis (JIA) is an effective and clinically justifiable procedure, contrary to conventional recommendations. An end-to-end JIA carries no greater risk of morbidity and mortality than an end-to-end jejunojejunal anastomosis (JJA). A retrospective observational study was performed on a population of 100 horses that had undergone small intestinal resection and end-to-end anastomosis. Two groups were identified; Group 1 (n = 30) had undergone an end-to- end JIA and Group 2 (n = 70) an end-to-end JJA. The 2 populations were tested for pre- and intraoperative comparability and for their equivalence of outcomes. The 2 populations were comparable in terms of their distributions of preoperative parameters and type of lesion present. The observations used as outcome parameters (incidence risk of post operative colic, incidence risk of post operative ileus, duration of post operative ileus, rates of functioning original anastomoses at the time of discharge and at 12 months, survival rates at 6 months and 12 months) were equivalent between the 2 groups. End-to-end JIA carries no greater risk of morbidity and mortality than an end-to-end JJA. Surgeons faced with strangulating obstructions involving the jejuno-ileal junction in which there remains an accessible length of viable terminal ileum may reasonably perform an end-to-end JIA. This has the potentially significant advantage over a jejunocaecal anastomosis of preserving more anatomical and physiological normality to the intestinal tract. The study was, however, relatively small for an equivalence study and greater confidence would be gained with higher numbers.

Diagnosis and treatment of gastrointestinal stromal tumor: an analysis of 23 cases

Objective To evaluate the clinical diagnosis and treatment of gastrointestinal stromal tumors (GISTs). Methods The clinical data of patients with GISTs admitted into surgical department from July 2000 to Oct 2005 were retrospectively analyzed. Rusults Twenty-three patients received operation. Twenty-one patients underwent complete tumor resection, two did laparotomy only. Among the patients 7 cases were benign ,6 potential malignant, and 10 malignant . All patients were followed-up from 10 to 72 months. Three of the patients had local recurrence and metastasis, and 5 patients died. Conclusion It was difficult the diagnosis of GISTs because of the lack of clinical feature. Endoscopy and imaging examination are main methods to detect GISTs. Final diagnosis should be based on pathology. Surgical rection is the main treatment. Key words: gastrointestinal stromal tumors; diagnosis; operative

Traumatic bowel perforation: Analysis of CT findings according to the perforation site and the elapsed time since accident

Abdominal CTs of 57 patients with bowel perforation after blunt abdominal trauma were retrospectively analyzed to determine: the diagnostic accuracy of the perforation site, and the differential findings according to the elapsed time from the trauma. Diagnostic accuracy of the perforation site was as follows: duodenum (100%), jejunum (81%), jejunoileal junction (100%), ileum (93%), and colon (20%). Extraluminal air was the only significant differential findings according to the elapsed time, and was seen more commonly on late stage of bowel perforation ( P<.05).

Evaluation of laparoscopic adhesiolysis for the treatment of experimentally induced adhesions in pony foals.

To assess the efficacy of laparoscopic adhesiolysis in the treatment of experimentally induced adhesions in foals. 8 healthy pony foals. Celiotomy was performed and adhesions created at the jejunoileal junction and at sites 0.5 and 1 m proximal to this junction, using a serosal abrasion method. Ten days after celiotomy, exploratory laparoscopy was performed. Laparoscopic adhesiolysis was performed in the treatment group only (4 foals, randomly selected). Thirty days after the exploratory laparoscopy, a final laparoscopic examination was performed, and the foals were euthanatized. The number and characteristics of abdominal adhesions were recorded during laparoscopy 10 and 30 days after celiotomy and during necropsy. At 30 days after celiotomy, the number of adhesions in the control group was significantly higher than the number in the treatment group. In the control group, all adhesions observed during the exploratory laparoscopy were still evident at the final laparoscopy and necropsy. In the treatment group, adhesions did not form again after separation. During final laparoscopy and necropsy, a focal adhesion between the omentum and site of the initial laparoscope portal was observed in 5 of 8 foals. The serosal abrasion model is useful for studying abdominal adhesions in foals. Laparoscopic adhesiolysis was an effective technique to break down experimentally induced adhesions in the early maturation stage of formation in pony foals. Studies are required to investigate prevention of de novo adhesions at the laparoscope portal sites.

Pancreatic secretory response to intraileal amino acids: studies in dogs with an in situ neurally isolated ileum.

Intraileal carbohydrates and lipids affect the pancreatic exocrine secretion, but the effect of intraileal amino acids and the role of the extrinsic nerves of the ileum as mediators of the pancreatic bicarbonate and enzyme output are unknown. Four dogs underwent total extrinsic denervation of the entire ileum. Thomas-like cannulas were placed into the stomach, duodenum (to collect pure pancreatic juice), and at the jejuno-ileal junction. Eight neurally intact control dogs received only the three fistulas. After recovery, in both sets of dogs, dose-response studies of the pancreatic secretory response to intraileal infusion with graded loads of tryptophan (0.12-10.0 mmol/h) were performed, given against an intravenous (iv) background of secretin (20.5 pmol/kg/h) and cerulein (29.6 pmol/kg/h). On separate days, control experiments with intraileal infusion of 0.15 M NaCl were performed. In both sets of dogs, iv secretin plus cerulein significantly (p < 0.05) increased pancreatic bicarbonate and protein output above basal. Intraileal tryptophan caused a dose-dependent decrease in the pancreatic bicarbonate and protein response to secretin plus cerulein. In the dogs with denervated ileum, this inhibition was significantly stronger than in the intact animals. In both sets of dogs, the 225-min integrated bicarbonate (IBR) and protein response (IPR) to all loads of tryptophan were significantly lower than in control experiments. Both IBR and IPR were significantly lower in the denervated as compared with the intact animals. 1) Extrinsic denervation of the entire ileum is a valuable preparation to study the role of nerves in the control of pancreatic exocrine secretion; 2) both in the intact and denervated animals the amino acid tryptophan induces an "ileal brake" of the hormonally stimulated pancreatic bicarbonate and protein output; 3) the extrinsic nerves of the ileum are probably not the dominant mediators of the inhibitory action of intraileal tryptophan but rather counteract this effect.

The regional differences in the mucosal-cell lysosomal proteases within the rat small intestine

The specific aim of this study is to understand the distribution of lysosomal enzymes along the intestine. The rat was used as the animal model. Intestinal homogenates were prepared from the jejunum, jejunoileal junction, ileum, and caecum. Activities of lysosomal carboxypeptidase A, dipeptidyl peptidase II, prolyl carboxypeptidase, and cathepsin B in homogenates were studied at pH 4.5 using specific substrates. Prolyl carboxypeptidase, cathepsin B, and dipeptidyl peptidase II had the highest activities in the caecum; carboxypeptidase A had the highest activity in the jejunum. The ileum had the lowest activities of these four lysosomal proteases. In summary, except carboxypeptidase A, the distribution profiles of prolyl carboxypeptidase, cathepsin B, and dipeptidyl peptidase II are somewhat close. Carboxypeptidase A, prolyl carboxypeptidase, and dipeptidyl peptidase II are all serine proteases but do not share similar intestinal distribution profiles.

Distribution of brush-border membrane peptidases along the rat intestine.

The longitudinal distribution of brush-border endopeptidase-24.11, endopeptidase-2, aminopeptidase W, angiotensin-converting enzyme (ACE), dipeptidyl peptidase IV (DPP IV), carboxypeptidase P, and aminopeptidase P in the rat intestine was determined. The jejunum has the highest activities of endopeptidase-24.11 and ACE while the ileum has the highest activities of aminopeptidase W and carboxypeptidase P, and the jejunoileal junction has the highest activity of aminopeptidase P. The jejunum and ileum have similar activities of DPP IV. The profiles of differential hydrolysis of neurotensin and acetylneurotensin (8-13) along the intestine agree with distribution of endopeptidase-24.11 and ACE, suggesting that amino acid sequences of peptides and the substrate specificity of enzymes will determine site-dependent hydrolysis. There is substantial similarity in the intestinal distribution of peptidases in the human, rat, and rabbit.

Influences of regional differences in activities of brush-border membrane peptidases within the rat intestine on site-dependent stability of peptide drugs

Proteolytic hydrolysis rates of neurotensin and acetyl-neurotensin-(8–13) by brush-border membranes from various rat intestinal segments were as follows: jejunum > duodenum ∼ jejunoileal junction > ileum > caecum. The rank order of endopeptidase-24.11 activity along the intestine was jejunum > duodenum ∼ jejunoileal junction > ileum > caecum. Angiotensin converting enzyme (ACE) had a similar distribution profile as endopeptidase-24.11. Activities of these two enzymes were lower in the distal intestine. Distribution of endopeptidase-2 activity along the intestine was different: ileum > duodenum ∼ jejunum ∼ jejunoileal junction > caecum. The profiles of differential hydrolysis of neurotensin and acetylneurotensin-(8–13) within the gut corresponded to the distribution of endopeptidase-24.11 and ACE. Moreover, effects of enzyme inhibitors confirm that these two enzymes initiated proteolysis of neurotensin and acetylneurotensin-(8–13). These results suggest that the regional differences in the activities of key brush-border membrane peptidases will affect site-dependent stability of peptide drugs.

Relative Merits of Techniques for Gastrostomy Tube Removal

<h3>To the Editor.</h3> —Our experience with percutaneous endoscopic gastrostomy (PEG) tube removal differs from that of Korula and Harma.¹We have seen instances in which the internal components of the PEG tube remained in the stomach and in which the internal bumper would not pass through a colostomy stoma. Wilson et al²have recently reported a perforation at the jejunoileal junction in a patient whose PEG tube was removed in this manner. If one were to follow the suggestion of using serial radiographs to check for elimination of the severed PEG tube, the cost, including that of transporting the patient for the study, could be considerable. If a PEG tube is in place and cannot be removed by traction, immediate endoscopic removal of the severed bumper should be performed. At the present time, there are at least three manufacturers that produce a gastrostomy tube that can be removed

Relative Merits of Techniques for Gastrostomy Tube Removal

To the Editor. —Our experience with percutaneous endoscopic gastrostomy (PEG) tube removal differs from that of Korula and Harma. 1 We have seen instances in which the internal components of the PEG tube remained in the stomach and in which the internal bumper would not pass through a colostomy stoma. Wilson et al 2 have recently reported a perforation at the jejunoileal junction in a patient whose PEG tube was removed in this manner. If one were to follow the suggestion of using serial radiographs to check for elimination of the severed PEG tube, the cost, including that of transporting the patient for the study, could be considerable. If a PEG tube is in place and cannot be removed by traction, immediate endoscopic removal of the severed bumper should be performed. At the present time, there are at least three manufacturers that produce a gastrostomy tube that can be removed

Experimental Intestinal Obstruction in Rats.Studies on Structure and Disaccharidase Activities*

An experimental model of congenital intestinal obstruction (CIO) was created in rats by means of fetal intrauterine surgery between the 16th and 20th days of gestation. By the use of a microsurgical technique areas at the mid-jejunum or the jejuno-ileal junction were infarcted by coagulation of mesenteric vessels. Gestation was terminated by Cesarean section within 24 hours before expected term to avoid cannibalism. The structure of the intestinal mucosal cells proximal and distal to the CIO at the light microscopy as well as the ultrastructure level was not changed indicating that the surgical method was successful. The activities of the brush border enzymes, maltase and lactase were significantly reduced distal to the obstruction as compared to controls. Proximal to the obstruction lactase was the only enzyme showing reduced activity in comparison to controls. These findings were not dependent on the localization of the obstruction or when it was performed and suggest that CIO causes selective changes of the biochemical properties of the cell membrane. The results are in agreement with the findings of disaccharidase activities in biopsies taken from human infants with CIO and point to the importance of a normal intestinal passage for the development of brush border enzymes.

Composition of the intestinal fluid and the functional jejunoileal junction in secretory diarrhea of cholera in children.

The study critically evaluates the changes in the chemical composition of the luminal fluid along the whole length of the small intestine in four children with acute cholera and in one with acute noncholeraic diarrhea. In the children with cholera the total CO2 content rose abruptly from a mean of 7.1 mEq/l to 19.6 mEq/l at about two thirds the tube distance from the ligament of Trietz to the end of the ileum and increased further distally. At around the same point the pH also rose and the chloride fell. It is proposed that this level of the small intestine where a sharp transition in total CO2 content occurs be regarded as the functional jejunoileal junction. Sodium and potassium levels were similar in the jejunum and the ileum and the measured osmolality could be accounted for by them. The child with noncholera diarrhea had a very different small intestinal composition i.e. the total CO2 and pH as well as the sodium level remained low while the measured osmolality was high, indicating a high osmotic gap. The presence of a large amount of organic acid anions of bacterial origin and carbohydrate breakdown products may fully explain the findings in this child. More studies, however, are needed on children with noncholera diarrhea to confirm these findings.