Massive Bowel Research Articles

Escherichia coli translocation in experimental short bowel syndrome: probiotic supplementation and detection by polymerase chain reaction

After massive bowel resection, bacterial overgrowth is frequent and favors the occurrence of Gram-negative intestinal bacterial translocation (BT). Probiotics have been recommended in several diseases and may also have beneficial effects on BT. Conversely, polymerase chain reaction (PCR) technique has shown better sensitivity than conventional methods in bacterial detection and has not been investigated in experimental models of short bowel syndrome and BT. To test the hypothesis that Bifidobacterium lactis (BL) administration decreases Escherichia coli bacterial translocation (ECBT) in experimental short bowel syndrome and to confirm the better sensitivity of PCR technique to detect ECBT. Forty-eight adult Wistar rats, orally fed with standard rat chow and tap water ad libitum, were maintained in individual metabolic cages for 10days and divided into three groups: Control group (n=15): non-manipulated animals. RES group (n=15): 80% gut resection. 1ml of sterile water was administered daily after orogastric intubation. RES-PRO group (n=18): same resection as RES group and daily administration of 7.8×10(9) BL (CFU). At the end of the study, portal blood, peripheral blood and mesenteric lymph node (MLN) samples were recovered and cultured. Also, genomic DNA from E. coli was detected by PCR technique. In conventional culture there was no ECBT in control animals whereas 73% of RES and 33% of RES-PRO animals showed it. PCR detected ECBT in 47, 87 and 33%, respectively, showing higher sensitivity.

Retroperitoneal Laparoscopic Live-Donor Nephrectomy: Introduction of Simple Hand-Assisted Technique (Without Hand Port)

Objective Compared with the transperitoneal approach, retroperitoneal laparoscopic live-donor nephrectomy offers a substantial advantage. However, retroperitoneal access is more difficult because of the limited working space. The objective of this study was to report our experience with hand-assisted retroperitoneal laparoscopic live-donor nephrectomy without a hand port. Materials and Methods Intraoperative and immediate postoperative surgical outcomes were reviewed for 23 modified retroperitoneal laparoscopic live-donor nephrectomies performed from May 2009 to January 2010. All kidneys were from living related donors. No prisoners or organs from prisoners were used in this study. Results Retroperitoneal laparoscopic live-donor nephrectomy was successfully completed in all patients, without conversion to open surgery. Mean (range) operative was 114 (98–130) minutes; warm ischemia time was 1.6 (1.3–2.1) minutes; estimated blood loss was 20 (10–50) mL; and postoperative hospital stay was 6.9 (5–10) days. No serious complications such as massive bleeding or bowel injury occurred. In 1 patient, a hematoma of renal fossa developed, which was successfully treated at repeat operation. All kidneys demonstrated good primary function except 1 that exhibited delayed graft function. Conclusions Retroperitoneal laparoscopic live-donor nephrectomy combines the benefits of both hand assistance and the retroperitoneal approach, to minimize the risk of short- and long-term complications associated with the transabdominal approach. The technique could be a cost-effective procedure suitable for use in developing countries.

Fulminant necrotizing enterocolitis in a multihospital healthcare system

A subset of necrotizing enterocolitis (NEC) cases is fulminant, characterized by rapid progression to death with massive bowel necrosis found at laparotomy or autopsy. We sought to identify and report all such cases in a multihospital healthcare system during the past 9 years and to characterize this entity using case-control methodologies. This was a multicentered, cross-sectional, historic cohort study conducted using Intermountain Healthcare hospital patient data. All neonates who died of NEC within 48 h of onset, during 2001 to 2009, were compared with two matched control groups: (1) demographically matched controls who developed non-fulminant NEC, (2) demographically matched controls that did not develop NEC. During this period, 2 71 327 live births occurred in the Intermountain Healthcare hospitals. Of these, 318 had a diagnosis of NEC (Bell stage ≥II). Also during this period, 205 other neonates were transferred into an Intermountain hospital for treatment of NEC. Of these 523 NEC cases, 35 (6.7%) had a fulminant course. Compared with the non-fulminant cases, the fulminant group were born at lower weight (1088±545 vs 1652±817 g, P=0.000) and earlier gestational age (27.5±3.3 vs 31.1±4.4 weeks, P=0.000), and were more likely to have: (1) radiographic evidence of portal venous air (P=0.000), (2) hematocrit <22% (P=0.000), (3) increase in feeding volume >20 ml/kg/day (P=0.003), (4) immature to total (I/T) neutrophil ratio >0.5 (P=0.005), (5) blood lymphocyte count <4000/μl (P=0.018), (6) an increase in concentration of human milk fortifier within 48 h before developing NEC (P=0.020). Portal venous air, anemia, rapid feeding escalation, a high I/T neutrophil ratio, a low lymphocyte count and recent increases in fortifier may all be associated with fulminant NEC.

Trends in peptic ulcer disease and the identification of Helicobacter Pylori as a causative organism: Population-based estimates from the US nationwide inpatient sample

Background:Peptic ulcer disease can lead to serious complications including massive hemorrhage or bowel perforation. The modern treatment of peptic ulcer disease has transitioned from the control of gastric acid secretion to include antibiotic therapy in light of the identification of Helicobacter pylori as a causative infectious organism. We sought to determine trends related to this discovery by using a national database.Materials and Methods:Patient discharges with peptic ulcer disease and associated sequelae were queried from the Nationwide Inpatient Sample, 1993 to 2007, under the auspices of a data user agreement. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. Standard error was calculated using SUDAAN software (Research Triangle International, NC, USA).Results:Decreases in the incidences of gastrointestinal perforation, gastrointestinal hemorrhage, and surgical procedures most specific to peptic ulcer disease were statistically significant over the study period [range of P value (two tailed) = 0.000 – 0.00353; significant at P < 0.001 to < 0.01]. The incidence of H. pylori rose dramatically, peaking at an estimated 97,823 cases in 1998 [SE = 3155; 95% CI = 6,184]. Since that time it has decreased and then stabilized.Conclusions:The identification of H. pylori as the causative agent in the majority of peptic ulcer disease has revolutionized the understanding and management of the disease. Medical conditions and surgical procedures associated with end-stage peptic ulcer disease have significantly decreased according to analysis of selected index categories. Resident physician education objectives may need to be modified in light of these trends.Review Criteria:We reviewed patients with peptic ulcer disease. The database used was the Nationwide Inpatient Sample, 1993 to 2007.Message for the Clinic:Medical therapy has resulted in decreased morbidity from H. pylori infection as it is the causative agent in the majority of peptic ulcer disease. Aggressive screening and treatment of this infection will lead to further reduction in morbidity.

Adult necrotizing enterocolitis and non occlusive mesenteric ischemia

Adult necrotizing enterocolitis and non occlusive mesenteric ischemia are rare causes of acute abdomen in adults. Accurate preoperative diagnosis is often difficult in these cases. Here, four cases of massive bowel necrosis with varying segments of small and large bowel involvement are described, all of whom underwent surgery. These cases give an opportunity to review the literature on such lethal diseases including non occlusive intestinal necrosis, neonatal necrotizing enterocolitis and adult necrotizing enterocolitis. The similarities and differences in etiology, pathophysiology, clinical and radiological findings are discussed.

Outcomes of surgical treatment of malrotation in children

Abnormalities of rotation and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with volvulus which has catastrophic consequences when diagnosis is delayed or not even considered. This study evaluates the outcomes of surgical management of intestinal malrotation (IM) in children. The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2000 and September 2009, were reviewed. Patients' characteristics, management, complications, and survival were evaluated. Nine patients (eight boys and a girl) underwent surgery for malrotation at a median age of 15 days. Eight presented with acute symptoms and one with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in two of them. Volvulus was found at the time of surgery in seven patients, five of whom were neonates. One patient also had associated mesentery cyst. Seven patients were treated by Ladd's operation. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was one perioperative death from anastomostic leak. Median length of stay was 9 days. Postoperative bowel obstruction was seen in two patients (one died), resulting in an overall mortality of 22.2%. Bowel gangrene from volvulus contributes to mortality, and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for IM. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention. There is a need for high index of suspicion in babies with bilious vomiting especially when recurrent to prevent devastating complications when present.

Mesenteric Cystic Masses: A Series of 21 Pediatric Cases and Review of the Literature

Mesenteric cysts, seen in all age groups, represent a rare cause of benign abdominal masses in children. We reviewed 21 patients with mesenteric/omental cysts. Gross and radiologic images, along with histologic sections, were reviewed to categorize the structures and determine the relationship to the mesentery and intestines. The cysts were composed of multi-loculated dilated channels at the serosal surface consistent with lymphangioma. Most treatment was simple excision, infrequently with intestinal resection. Nineteen patients did well after surgery. One patient developed short-gut syndrome after massive bowel resection, and one patient died immediately after birth due to massive fetal hydrops and heart failure.

Extensive Bowel Ischaemia after Nifedipine Overdose

A 57-year-old woman presented with abdominal distension and vomiting two days after overdosing an unknown amount of sustained-release nifedipine tablets. She had refractory shock requiring calcium chloride, glucagon, insulin-glucose and multiple high-dose inotropic agent infusions in the intensive care unit. Her abdominal computed tomography showed features of bowel ischaemia and exploratory laporotomy reviewed non-salvageable massive bowel ischaemia. She finally succumbed after 22 days of hospital treatment. This case illustrates the importance of awareness of this potentially fatal complication of calcium channel blocker overdose, requiring early recognition and intervention.

Mediastinal cryptococcosis masquerading as therapy-refractory lymphoma

Dear Editor, A 58-year-old woman presented with a 1-month history of abdominal pain and weight loss. Positron emission tomography computerized tomography (PET-CT) showed markedly thickened and hypermetabolic small bowel (standardized uptake value maximum, SUVmax: 8.7) associated with multiple abdominal and pelvic lymphadenopathy (Fig. 1a). Intestinal obstruction soon developed, necessitating small bowel resection. Histologic examination showed enteropathy-associated T-cell lymphoma. She was treated with three cycles of chemotherapy comprising steroid, methotrexate, ifosphamide, l-asparaginase, and etoposide [1]. Interim reassessment PET-CT showed complete resolution of the abdominal and pelvic lesions (Fig. 1b). However, new pretracheal, precarinal, subcarinal, and left hilar lymphadenopathy (SUVmax, 7.4; Fig. 1b, arrows) developed. The patient was afebrile with no respiratory symptoms. Owing to discrepant responses of lymphadenopathy to chemotherapy, further diagnostic evaluation was pursued. To avoid general anesthesia necessary for mediastinoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) was performed under local anesthesia with conscious sedation. Multiple mediastinal lymph nodes located in the upper, lower paratracheal, and subcarinal area were aspirated. Conventional fiberoptic bronchoscopy was also performed with no endobronchial abnormality detected. Both cytologic and histologic specimens obtained from all sampled lymph nodes demonstrated epithelioid-like cells and multinucleated giant cells, with no atypical lymphoid cells found. Roundish spore-like organisms were indentified (Fig. 2a, arrows). These organisms were positive for the fungal mucicarmine (Fig. 2b, arrows) and Grocott stains. The histopathologic features were consistent with cryptococcal lymphadenitis. Serum cryptococcal antigen was also positive at 1:16. The cerebrospinal fluid was normal. She was treated with oral fluconazole (400 mg daily). A PET-CT scan after 6 weeks of fluconazole showed that the mediastinal lymphadenopathy had largely resolved. Fig. 1 Positron emission tomography. a Before treatment, showing massive bowel and pelvic involvement (arrows). b After chemotherapy, showing resolution of all previous lesions, but matted mediastinal lymphadenopathy of similar metabolic activity as the original ... Fig. 2 Lymph node findings. a Histologic examination showed numerous spore-like organisms (arrows). b The organisms were positive for the fungal stain mucicarmine (arrows) Cryptococcal infection usually results from inhalation of fungal spores, and may be confined to the lungs or disseminate systemically. Radiologically, pulmonary cryptococcosis may present as a single well-defined consolidation or mass, diffusely scattered nodules or reticulonodules [2]. Cryptococcal lymphadenopathy, especially affecting the mediastinum, is infrequent and mainly reported in patients infected with the human immunodeficiency virus (HIV) [3, 4]. Radiologically, in HIV-negative patients, pulmonary cryptococcal infection usually presents as large nodular lesions or alveolar infiltrates. In HIV-infected patients, lymphadenopathy and interstitial infiltrates are instead the common findings [5]. In cryptococcal lymphadenitis, lymph nodes are generally <1.5 cm and accompanied by pulmonary parenchymal changes [6]. Hence, the extensive multifocal mediastinal lymphadenopathy without parenchymal lesions in our patient was more consistent radiologically with lymphoma progression. However, suitable investigations finally revealed the correct diagnosis. Conventional transbronchial needle aspiration with a histology needle in immunocompromised patients with intrathoracic lymphadenopathy has a poor diagnostic yield [7]. EBUS-TBNA with a designated 22-gauge needle has significant advantages. In addition to a high diagnostic yield for mediastinal lymphadenopathy, both histologic and cytologic specimens can be obtained. A histological specimen aids in the diagnosis of non-malignant mediastinal lymphadenopathy such as sarcoidosis, as well as eliminates the possibility of false-positive microbiologic results from contamination by airway colonization. Our case illustrated well the utility of EBUS-TBNA as a minimally invasive technique in clinching the diagnosis.

Endoscopy-based early enterostomy closure for superior mesenteric arterial occlusion

To evaluate the efficacy of endoscopic examination of blood flow and edema in the remnant bowel. We retrospectively studied 15 patients who underwent massive bowel resection with enterostomy for superior mesenteric arterial occlusion (SMAO); the patients were divided into a delayed closure group (D group) and an early closure group (E group). The mean duration from initial operation to enterostomy closure was significantly shorter in the E group (18.3 +/- 2.1 d) than in the D group (34.3 +/- 5.9 d) (P < 0.0001). The duration of hospitalization after surgery was significantly shorter in the E group (33 +/- 2.2 d) than in the D group (51 +/- 8.9 d) (P < 0.0002). Endoscopic examination of blood flow and edema in the remnant bowel is useful to assess the feasibility of early closure of enterostomy in SMAO cases.

Short‐term complications of wide‐lumen stapled anastomosis after ileocolic resection for Crohn’s disease: who is at risk?

There is growing evidence that stapled anastomoses are similarly effective compared to hand-sewn anastomoses in Crohn's patients. This study was designed to assess safety and limitations of wide-lumen stapled ileocolic anastomoses. All patients with ileocolic resections for Crohn's disease perfomed between 1998 and 2006 were studied. A stapled anastomosis was constructed whenever possible. Potential risk factors for postoperative complications were recorded, retrospectively. Univariate and multivariate analyses were performed. In 209 out of 220 cases (95%, 132 primary operations) stapled anastomoses were performed. Eleven patients underwent a hand-sewn anastomosis owing to massive bowel dilatation (n = 7) or increased wall thickness (n = 4). There were 10 major (4.5%; surgical: 8, medical: 2) complications including two anastomotic leaks and one anastomotic bleed (all from stapled anastomoses) and one death not related to the anastomosis. Minor complications occurred in 25 patients. In multivariate analysis, major surgical postoperative complications were significantly associated with a low level of albumin (P = 0.0113) and previous resections for Crohn's disease (P = 0.0144). Stapled ileocolic anastomosis was safe in the majority of Crohn's patients. The most important limitation was technical impracticability. A low level of albumin and a history of previous resection increased the risk of postoperative complications.

Radiological Findings and Endovascular Management of Three Cases with Segmental Arterial Mediolysis

Segmental arterial mediolysis (SAM) is an uncommon self-limited disorder that can cause abdominal catastrophes through massive bleeding or bowel infarction. The former arise from arterial aneurysms, and the latter from arterial stenosis or occlusions. Although this is an acute self-limiting disease, the catastrophic consequence, originating from intra-abdominal hemorrhage (arterial dilatation, aneurysms, dissecting hematomas) or bowel infarction (arterial stenosis, arterial occlusions), is not rare. The identification of these lesions is very important in the differential diagnosis of suspected patients with complaints of abdominal pain with hemorrhage. We report computerized tomography angiography and digital subtraction angiography findings of three cases with abdominal SAM, who were treated with endovascular management due to abdominal bleeding. Angiography showed arterial dilatations, aneurysms, and occlusions of visceral arteries in all three cases, The string-of-beads appearance was present in only one case. Bleeding stopped immediately after embolization of three cases and follow-up revealed no evidence of recurrences at 23, 18, and 15 months, respectively, Arterial coil embolization is an effective treatment modality for bleeding complications of SAM. Close follow-up is recommended, primarily to ascertain the fate of the nontreated arterial lesions.

Surprisingly delayed escalation of severe verapamil poisoning

We present a case report of intoxication by a potentially lethal dose of sustained-release verapamil with delayed escalation of complications. The patient was hospitalized 1.5 h after an attempted suicide with a very high dose of verapamil sustained-release (7.2 g). On admission the plasma concentrations were extremely high (3600 ng/l). Heart rate and blood pressure declined slowly with a surprising sudden escalation on the third day coupled with hemodynamic collapse and loss of consciousness. Complete recovery was achieved in spite of 2 h of extreme hypotension. We outline the clinical course, a need for massive bowel irrigation in case of sustained-release medication, the timing of a temporary pacing and the effect of centralization of circulation even on invasively measured blood pressure.

Massive Gastrointestinal Bleeding and Diffuse Bowel Wall Thickening

Purpose: Henoch-Schönlein purpura (HSP) is a systemic vasculitis characterized by immune complex deposition, usually in the skin and kidney, rarely in the gastrointestinal (GI) tract. It occurs mainly in young children. While the triad of purpura, arthritis, and abdominal pain is the classic presentation of HSP, the manifestation of GI involvement in adults is less defined. Methods: We report a rare case of massive GI bleeding and diffuse bowel wall thickening caused by mesenteric small vessel vasculitis due to HSP post-MRSA infection. Results: Patient is a 24 year old male with a medical history of multiple left arm MRSA-abscesses in the past. The patient now presents with severe left lower quadrant abdominal pain, hematemesis, and melena. Computed tomography of the abdomen and pelvis revealed diffuse small bowel wall thickening. Subsequent esophagogastroduodenoscopy (EGD) and push enteroscopy showed acute gastritis and “punched-out” ulcers in the proximal jejunum. The patient developed a diffuse palpable, pruritic, coalescing rash throughout his bilateral lower extremities 6 days after the initial symptoms. Skin biopsy of the rash showed vasculitis consistent with HSP. Plasmapheresis and immunosuppressive therapy with oral prednisone were begun. However, the patient developed recurrent hematemesis and melena. Repeat EGD showed an ulcerated esophageal mucosa with severe inflammation; biopsy demonstrated a neutrophilic vasculitis. Small bowel biopsy showed granulation tissue with a neutrophilic vasculitis with fibrinoid necrosis. The patient was kept on bowel rest with parenteral nutrition and given intravenous methylprednisolone. The hospital course was complicated by alveolar hemorrhage and acute renal failure likely from HSP vasculitis, requiring intubation and hemodialysis. Subsequent kidney biopsy showed vasculitis with acute post infectious glomerular nephritis. Eventually, the patient improved clinically with the resolution of the rash and improvement of pulmonary and renal function to baseline. The patient was tapered off steroids, tolerated oral feeds and was finally discharged home on hospital day 21. Conclusion: HSP vasculitis with diffuse GI involvement causing massive GI bleeding is rare, but carries a high mortality. This case presentation is that of adult onset HSP developed after MRSA infection in a patient that presented with massive GI bleeding prior to the appearance of typical palpable purpura In an era when MRSA is omnipresent, it should be considered as an important risk factor for developing HSP. Furthermore, early endoscopic intervention and biopsies are vital to diagnosing this rare entity in order to initiate early systemic steroid therapy, especially when the GI hemorrhage is the only initial presentation.

Evaluation of small bowel measurement in alive patients

Based on the importance of bowel length in massive bowel resection, the aim of this study is to evaluate the small bowel length in patients who had laparotomy. In this study, 100 consecutive adults (age >/= 20 years old) who underwent laparotomy were studied. Patients with peritonitis, intra-abdominal infection, bowel obstruction and ascitis were excluded. For comparison we used 30 cadavers as control group after case control matching. Under general anesthesia and after opening of abdomen, bowel length was measured by an umbilical tape from Treitz' ligament to ileocecal valve, antimesentrically. Data such as age, sex, height, weight and bowel length were measured and analyzed. Between May 2007 and December 2007, 100 patients (54 males and 46 females) aged 20-43 years were studied. The small bowel length was 459.6 +/- 78.47 cm in patients and 632.5 +/- 88.9 cm in cadavers (P < 0.01). Small bowel length was 452.2 +/- 79.36 cm in males and 468.2 +/- 80.44 cm in females (P = NS). Jejunum length was 140.2 +/- 45.4 cm in males and 138.6 +/- 40.2 cm in females (P = NS). Ileum length was 286.3 +/- 34.7 cm in males and 289.9 +/- 37.8 cm in females (P = NS). In this study, we report a measurement of the length of small bowel more accurate than the estimation given by the classical anatomic books. In our study, there was no correlation between bowel length and age, gender, height and weight.

27. Induction of Diurnal Expression of Intestinal Hexose Transporter SGLT1 in Rat Ileum After Massive Small Bowel Resection

Diurnal patterns in gene expression (mRNA protein) of the intestinal hexose transporters sodium glucose transporter 1 (SGLT1) and glucose transporters-2 and −5 (GLUT2 and GLUT5) are well-established in the rat duodenum and jejunum. In contrast, in ileum, mRNA but not protein expression varies diurnally. We hypothesized that diurnal expressions of intestinal hexose transporters are inducible in the ileum after massive proximal small bowel resection. Aim: To determine whether 70% jejunoileal resection can induce a diurnal rhythm in protein expression of hexose transporters. Methods: Diurnal expressions of mRNA (SGLT1, GLUT2, GLUT5) and protein (SGLT1) were studied in ileum of rats 1 and 8 wk after 70% mid-small bowel resection at four time points (3AM, 9AM, 3PM, and 9PM; n=6 rats at each time point; 24 rats were studied similarly at 1 wk after sham celiotomy with bowel manipulation only. Mucosal scrapings of rat ileum were obtained. RT-PCR was used to measure mRNA, and protein levels were determined by semi-quantitative Western blotting. Both RNA and protein levels are expressed as a ratio to the housekeeping gene GAPDH for standardization. Continuous data (weight) are x±SEM. Results: At 1 wk after 70% resection, rats lost 5±1% body weight but by 8 wk had gained 48±4% over preoperative weight. During the postoperative period, rats continued to eat primarily at night time (65% to 74% intake 6PM to 6AM). Our previous studies in normal rats showed that mRNA of SGLT1 peaked at 9PM (3.1 fold), but protein levels had no diurnal variation (Surgery, 2007). Similarly, this pattern persisted in sham-operated rats 1 wk postoperatively (p<0.03). In rats 1 wk after 70% jejunoileal resection, SGLT1 mRNA levels continued to demonstrate a diurnal rhythm with peak expression at 9PM in the remnant ileum (p<0.002); however, 70% resection was also associated with a diurnal rhythm of SGLT1 protein expression in the remnant ileum (peak expression at 9PM, p<0.03). The diurnal rhythms in RNA and protein expression disappeared in the remnant ileum 8 wk after resection (p≤0.08). mRNA for GLUT2 varied similarly to SGLT1, while mRNA for GLUT5 continued to cycle diurnally at both 1 and 8 wk postoperatively (p<0.003). Protein data for GLUT2 and GLUT5 are pending. Summary: Massive (70%) mid-small bowel resection induced a dirunal rhythm in SGLT1 protein expression in the remnant ileum that disappeared by 8 wk postoperatively. Conclusion: Ileum responds early on to the effects of extensive small bowel resection (? more intraluminal nutrients) by adopting a diurnal expression in SGLT1 protein via a post-translational process; chronic adaptation reverses this diurnal variation of SGLT1 gene and protein expression in the remnant ileum. Loss of diurnal variation after 8 wk suggests that other mechanisms, such as jejunal mucosal hyperplasia, are activated because of loss of absorptive surface to increase absorption proximally via intestinal adaptation.

Accurate diagnosis and successful treatment for massive obscure small intestinal bleeding by means of intra-operative enteroscopy: a case report

Obscure gastrointestinal bleeding from the jejunum and ileum is always difficult to diagnose. Unstable patients with massive bleeding are not good candidates either for radiological studies or traditional endoscopic techniques. They usually need urgent operations to stop the bleeding. To identify the lesions, intraoperative enteroscopy is crucial for a better curing rate and for preventing massive unnecessary bowel resection. We report a 53-year-old unstable patient with massive obscure small intestinal bleeding. Urgent laparotomy with intraoperative enteroscopy was done. Two bleeding ulcers in the distal ileum were accurately identified and the diseased ileum was resected. Intraoperative enteroscopy may be a choice of diagnostic and therapeutic modality for unstable patients with obscure small intestinal bleeding.

Small bowel obstruction caused by an anomalous congenital band in an infant

Intestinal obstruction is not uncommon in infants. The common causes of intestinal obstruction in the neonatal period are Hirschsprung disease, intestinal atresia, meconium ileus, and intussusception. However, small bowel obstruction caused by a congenital band is very rare. We report a 27-day-old baby who was admitted with abdominal distension and fever. The abdominal X-ray revealed massive bowel dilatation and the contrast gastrografin enema suggested a distal small bowel obstruction. The explolaparotomy showed small bowel entrapment due to an unusual anomalous congenital band.

Volvulus of a jejunal lymphatic vascular malformation presenting with bilious vomiting and the radiological appearances of malrotation

Bile-stained vomiting in infancy is abnormal. Malrotation with small bowel volvulus is probably the most worrying of possible causes because if untreated for too long, it can result in massive bowel necrosis. As a consequence, if examination or plain radiography does not suggest another cause, an upper gastrointestinal (GI) series is often performed to exclude malrotation. If the examination is normal however and symptoms settle, should investigation stop, or how far should it be pursued? Small bowel lymphatic vascular malformations in children are extremely rare but carry a risk of obstruction, volvulus, and loss of small bowel. We present a case of a 5-year-old boy referred to our unit with bilious vomiting and the radiological findings of malrotation on upper GI series. Interestingly, a previous upper GI series undertaken during the first year of life for intermittent bilious vomiting was normal. Operative findings were of a 16-cm cystic lymphatic vascular malformation of the jejunal wall causing a 360 degrees volvulus. The mesentery was derotated, and the cyst removed with the attached section of jejunum. This case highlights the need to reinvestigate patients with bilious vomiting despite a previous normal upper GI series. The case raises the issue of whether bilious vomiting, with a normal upper GI series, should be investigated further with an abdominal ultrasound scan to identify more unusual causes such as jejunal lymphatic vascular malformations.

Small bowel bacterial overgrowth in adults: A potential contributor to intestinal failure

Small bowel bacterial overgrowth (SBBO), in which colon-derived bacteria colonize the upper small bowel, is found in a wide variety of adult diseases associated with intestinal failure and dysfunction, including short bowel syndrome and other conditions following massive bowel resection, dysmotility disorders, and inflammatory bowel disease. SBBO also appears to be relatively common in the elderly, in whom it often goes unrecognized. SBBO is an important cause of malabsorption and thus may contribute to diarrhea and malnutrition. Elevated upper small intestinal aspirate colony counts remain the gold standard diagnostic test; a variety of noninvasive tests that detect elevated levels of breath hydrogen produced by bacterial fermentation of oral carbohydrate loads are also performed for diagnosis. Physicians commonly prescribe a variety of oral antibiotic regimens for documented or presumed SBBO. Additional research is needed to define the epidemiology, optimal diagnostic test(s), and therapeutic regimens for this condition.