Prepyloric Area Research Articles

990 A Rare Case of Adenomyoma in Gastric Pylorus of a Young Adult Female: A Case Report

Abstract Introduction Gastric adenomyoma is a rare benign tumour which occurs 85% in antrum and 15% in pylorus. Although adenomyomas are benign, diagnosis is difficult as they are commonly found alongside with adenocarcinomas. Case report A 20-year-old previously healthy female presented with epigastric pain, gastric outflow obstruction features and weight loss for 3 months. Initial USS was followed by a CECT which, showed intramural mass lesion with necrotic centre arising from the inferior wall of the pre pyloric area of the stomach with acute inflammatory changes of the adjacent omental fat, giving differential diagnosis of GIST or gastrinoma at pyloric region. Subsequent upper GI endoscopy revealed a protruding pyloric mass without mucosal lesions. Unfortunately, the unavailability of EUS and biopsy posed a diagnostic hurdle. Intraoperatively, a mass intricately adhered to the transverse colon and omentum was discovered, leading to a surgical intervention involving distal gastrectomy, gastrojejunostomy, and jejunojejunostomy. Unexpectedly, histological analysis unveiled adenomyoma at the prepyloric area, characterized by Brunner’s glands, dilated glands, and heterotrophic small intestinal tissue. Discussion This rare manifestation of adenomyoma in the gastric pylorus, particularly in a young adult, highlights the challenges in accurate preoperative diagnosis. The favourable postoperative outcome prompts reflection on the potential role of advanced diagnostic tools, emphasizing the significance of EUS and biopsy in steering clear of extensive surgeries. Conclusions This case report underscores the crucial role of personalized diagnostic methods, especially in cases like ours where a rare adenomyoma mimicking other tumours.

Pentadecapeptide BPC 157 Anti‐Ulcer Effect After Stomach Perforation also Opposed the Intracranial Hypertension (Superior Sagittal Sinus), Portal and Caval Hypertension and Aortal Hypotension

We report that rat stomach perforation (surgery with 5‐mm diameter metal needle on the ventral side in the prepyloric area) induced a defect that would not heal. Also, stomach perforation rapidly induced the intracranial hypertension (superior sagittal sinus), portal and caval hypertension and aortal hypotension. Stable gastric pentadecapeptide BPC 157 largely attenuated or eliminated these pressure disturbances. Finally, BPC 157 completely healed stomach defect. Previously, BPC 157 largely attenuated or even eliminated the consequences of Budd‐Chiari syndrome in rats, in particular, portal and caval hypertension and aortal hypotension, and then, huge thrombosis in both veins and arteries, and multiple organ dysfunction syndrome, heart, lung, liver, kidney and gastrointestinal lesions. These beneficial effects may relieve a Virchow's triad situation that may be commonly presented as well as counteracted (i.e.,duodenal venous congestion lesions (World J Gastroenterol 2018), perforated cecum (World J Gastroenterol 2018), bile duct ligation induced liver cirrhosis and portal hypertension (Eur J Pharmacol 2109), Pringle maneuver, ischemia, reperfusion (World J Hepatol 2020), and suprahepatic occlusion of the inferior caval vein (Budd‐Chiari‐syndrome) (World J Gastrointest Pathophysiol 2020)). Likewise, given in reperfusion, after clamping of the common carotid arteries, BPC 157 counteracted stroke (i.e., both early and delayed neural hippocampal damage, achieving also full functional recovery) (Brain Behav 2020).MethodsTherapy (BPC 157 (10 µg or 10 ng/kg) or saline (5 ml/kg)) was given intragatrically, at 1 min after stomach perforation. At 5 min after stomach perforation, as described before (World J Hepatol 2020), recordings were made in deeply anesthetized rats. Briefly, a cannula (BD Neoflon™ Cannula) was connected to a pressure transducer (78534C MONITOR/ TERMINAL; Hewlett Packard, USA) inserted into the superior sagittal sinus, and portal vein, and inferior vena cava, and abdominal aorta at the level of the bifurcation. We used five minutes recording. For superior sagittal sinus pressure recording, we made a single burr hole in the rostral part of the sagittal suture, above the superior sagittal sinus, and cannulated superior sagittal sinus anterior part by Braun intravenous cannulas, and then, in laparatomized rats, we recorded portal vein, inferior vena cava and abdominal aorta pressure.ResultsWithout therapy, the severely increased intracranial hypertension (10±2 mmHg in superior sagittal sinus), portal (33±4 mmHg) and caval (28±3 mmHg) hypertension and aortal hypotension (59±3 mmHg) occurred rapidly. Both BPC 157 regimens markedly counteracted intracranial hypertension (‐6±2 mmHg in superior sagittal sinus), portal (6±2 mmHg) and caval (5±2 mmHg) hypertension and aortal hypotension (81±3 mmHg) (i.e., 10 ng).ConclusionBPC 157 anti‐ulcer effect also opposed the intracranial hypertension (superior sagittal sinus), portal and caval hypertension and aortal hypotension.

S3713 Pre-Pyloric Gastric Ulcer Leading to Stenosed Pylorus, Obstruction of Gastric Outlet and Pseudo-Gastroparesis

Introduction: Gastric outlet obstruction (GOO) is a syndrome manifested with combination of early satiety, abdominal pain, postprandial vomiting and weight loss. The usual etiology is either mechanical (benign or malignant) or motility related. Most common cause of benign obstruction is peptic ulcer disease. Here we discuss a case of pre-pyloric ulcer with significant stenosis that mimics gastroparesis causing acquired GOO. Case Description/Methods: 58 year old female with history of migraines, anxiety and chronic pain presented with generalized weakness and epigastric pain. She had been taking 2 pills of aspirin and Advil each every 3 hours for past 2 weeks for her toothache. She also reported melanotic stools. In the ER, she was vitally stable but had hemoglobin of 5.5. CTA of abdomen pelvis noted abnormal duodenum with diffuse mural thickening and mildly prominent lymph nodes. She was transfused 2 units of PRBC. EGD done revealed linear antral ulcer occupying two-thirds of pre-pyloric area measuring 4 cm extending into the pylorus with minimal oozing on contact. Pylorus was severely narrowed and ulcerated; it could not be traversed with adult scope. XP scope was then used which passed with ease through the pylorus into the duodenal bulb which appeared to be severely ulcerated. Rest of the duodenum was normal. Patient subsequently had Gastrografin follow through study to evaluate for gastric outlet obstruction which showed suspected mild stenosis &/or edema in pylorus secondary to ulcerative dislocation; however no bowel obstruction was noted since the contrast passed through the duodenum. Biopsy ruled out malignancy & H. pylori infection and was consistent with chemical gastropathy. Gastrin level was also noted to be normal. Patient was on placed on clear liquid diet initially and later transitioned to full liquids since she was unable to tolerate solid foods. She had a repeat EGD 4 weeks later while on Pantoprazole 2 times daily and eventually showed partial resolution of ulcerated lesions. Discussion: Pre-pyloric ulcers are the most common form of peptic ulcer disease leading to GOO. Most common site is the pyloric channel or duodenal bulb which was the case in our patient. Acute ulcers usually cause inflammation and edema that leads to tissue deformation and obstruction especially with solid food particles getting lodged into the ulcer. Despite these, obstruction usually occurs in 2% of the cases of peptic ulcer disease and is the least common complication contributing to gastroparesis like symptoms.Figure 1.: Figure 1). Pre-pyloric stomach ulcer 2). Pre-pyloric stomach ulcer 3). Pylorus with food residue/Bezoar stuck in the stenosed pylorus 4). Pre-pyloric stomach ulcer after 4 weeks of Protonix therapy 5). Ulcer at 11-1 o clock 6). Ulcer at 12 o clock.

Image case: Gastric tuberculosis

35 years old male presented by recurrent hematemesis attacks and recurrent blood transfusion, no history of cough, with history of anti-tuberculosis therapy for pulmonary TB 2 years ago. General examination revealed pallor, emaciated, no lymphadenopathy, local examination showed epigastric tenderness and no organomegaly, and examination of other systems was unremarkable. Haemglobolin was 8 gm% (normocytic normochromic), chest X ray and abdominal ultrasound were free. Upper gastrointestinal endoscopy revealed ulcerated fundal mass. Endoscopic biopsies revealed caseating granulomas by histopathology examination. Discussion Gastrointestinal tuberculosis is a rare disease, presented mainly in the ileoceceal region. Mycobacterium tuberculosis infection in the stomach is similar to gastric carcinoma manifestations. Gastric TB is mainly secondary to pulmonary TB. Antrum and prepyloric area is the most common sites affected. Gastric tuberculosis is mainly existed as ulcerative followed by hypertrophic lesions. GTB diagnosis can be established by detection of acid fast bacilli and/or caseating granuloma in gastric mucosa or submucosa. Chemotherapy is mainly give good results, while surgery may be needed in gastric outlet obstruction cases.

Validation of quantitative assessment of indocyanine green fluorescent imaging in a one-vessel model.

Evaluation of intestinal perfusion remains subjective and depends on the surgeon´s individual experience. Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) fluorescence using a near-infrared camera system has been described in different ways and for different indications. The aim of the present study was to evaluate fluorescent imaging (FI) in the quantitative assessment of intestinal perfusion in a gastric tube model in pigs and to compare the results to results obtained with florescent microspheres (FM), the gold standard for tissue perfusion. Seven pigs (56.0±3.0 kg), both males and females, underwent gastric tube formation after transection and ligation of the gastric arteries, except the right gastroepiploic artery, to avoid collateral blood flow. After baseline assessment (T0), hypotension (T1) was induced by propofol (Karampinis et al 2017) (< 60 mmHg). Then, propofol was paused to obtain normotension (T2, Mean arterial pressure (MAP) 60-90 mmHg). Finally, hypertension (T3, MAP>90 mmHg) was induced by norepinephrine. Measurements were performed in three regions of interest (ROIs) under standardized conditions: the fundus (D1), corpus (D2), and prepyloric area (D3). Hemodynamic parameters and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. FI, FM and the partial pressure of tissue oxygen (TpO2) were quantified in each ROI. The study protocol could successfully be performed during stable hemodynamics. Flow in the gastroepiploic artery measured by transit time flow measurement (TTFM) was related to hemodynamic changes between the measurements, indicating improved blood flow with increasing MAP. The distal part of the gastric tube (D1) showed significantly (p<0.05) impaired perfusion compared to the proximal parts D3 and D2 using FM. ICG-FI also showed the highest values in D3 and the lowest values in D1 at all hemodynamic levels (T1-T3; p<0,05). Visual and quantitative assessment of gastric tube perfusion is feasible in an experimental setting using ICG-FI. This might be a promising tool for intraoperative assessment during visceral surgery in the future.

2776 Not for Human Consumption: Caustic Ingestion Causing Delayed Gastric Outlet Obstruction

INTRODUCTION: Corrosive injuries from acid ingestion can cause scarring and fibrosis of the pyloric antrum. Scar formation of the gastric outlet may be evident as early as three weeks, occurring within eight weeks in 80% of cases. We present a rare case of caustic ingestion causing a delayed onset of gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 55-year-old male with a past medical history of hypertension and caustic ingestion of toilet cleaner as a suicide attempt in 1986 presented with intermittent dysphagia. Endoscopy in 2012 showed antral narrowing with a normal pyloric channel. Vitals were significant for blood pressure of 158/94 mmHg otherwise within normal limits. Complete blood count and complete metabolic panel were within reference ranges. Repeat endoscopy found a pyloric stricture and biopsies were negative for neoplastic changes. Patient was managed conservatively with lifestyle modifications. DISCUSSION: Gastric outlet obstruction is a late sequelae of caustic injury and is more common with acid ingestion. Concentrated acids, such as hydrochloric acid, are generally the active ingredient of toilet cleaners. Acids clear rapidly from the esophagus into the stomach and pool in the pre-pyloric area due to corrosive-induced pyloric spasms, leading to damage of the pyloric antrum through scarring and surrounding adhesions. Endoscopic evaluation of the upper gastrointestinal tract establishes the diagnosis and determines the extent and severity of injury. Intralesional triamcinolone injections have been proposed for preventing stricture formation, but its efficacy remains unknown. The treatment of choice for gastric outlet obstruction is endoscopic dilatation. Surgery is an option for endoscopic failure or for patients with complications from endoscopic dilatation.

An innovative laparoscopic and endoscopic technique in an animal model: combined gastric full-thickness tumor resection.

Background and study aims The combination of endoscopy with laparoscopy for full-thickness gastric resection has received much attention. The advantage in using it is removak of the target lesion without resection of excessive normal tissue. The technique could prevent deformed scars, particularly at the cardia and in the prepyloric area. The aim of this protocol was to evaluate a new combined operation for full-thickness resection of the gastric wall. Materials and methods Gastric subepithelial lesions in multiple topographic locations of the stomach were simulated in seven live pigs. Full-thickness gastric resection was undertaken and after assessment of the outcome, the animals were euthanized. The primary endpoint was accomplishment of the procedure following all steps in the new technique, in various gastric locations. The secondary endpoints were duration of the procedure, quality of specimen margins, and complications. Results Resections were successful, complete, and complication-free, ensuring a safe surgical margin of healthy tissue. The procedure was completed in 50 minutes. No mucosal perforation or gas escape occurred. Conclusions The combined technique was safe, effective and minimally invasive. No expensive materials were used. Lesion exposure, gastric content leakage, incomplete resection, and excessive normal tissue elimination were avoided. Human trials of this technique may be warranted.

Neurochemical characteristics of calbindin-like immunoreactive coeliac-cranial mesenteric ganglion complex (CCMG) neurons supplying the pre-pyloric region of the porcine stomach.

The present study was designed to determine the distribution, morphology and co-localization of calbindin-D28k (CB) with other neuroactive substances in the coeliac-cranial mesenteric ganglion complex (CCMG) neurons supplying the prepyloric region of the porcine stomach. In all animals, a median laparotomy was performed and the fluorescent retrograde neuronal tracer Fast Blue was injected into the wall of the stomach prepyloric area. On the 28th day, all animals were euthanized and the CCMG complexes were then collected and processed for double-labelling immunofluorescence for CB and tyrosine hydroxylase (TH), galanin (GAL), somatostatin (SOM), leu 5-enkephalin (LENK), vasoactive intestinal peptide (VIP), substance P (SP) and cocaine- and amphetamine-regulated transcript peptide (CART), Immunohistochemistry revealed that 8.27±0.51% of FB-positive neurons expressed CB-like immunoreactivity. Furthermore, CB co-localized with TH, GAL and SOM in retrogradely labelled cell bodies, whereas CART, LENK, VIP and SP were detected only in nerve terminals surrounding FB+/CB+ neurons. The presence of CB in the stomach-projecting neurons may indicate the contribution of CB in the sympathetic regulation of the stomach function. Furthermore, CB-LI neurons had a catecholaminergic character and co-localized with TH, GAL and SOM, which suggests multiple functions of this neuroactive substance in the CCMG neurons supplying the porcine prepyloric area.

Changes in expression of somatostatin in the CSMG neurons supplying prepyloric area of the porcine stomach during gastritis induced by intragastric infusion of hydrochloric acid

Changes in expression of somatostatin in the CSMG neurons supplying prepyloric area of the porcine stomach during gastritis induced by intragastric infusion of hydrochloric acid

Changes in Somatostatin-Like Immunoreactivity in the Sympathetic Neurons Projecting to the Prepyloric Area of the Porcine Stomach Induced by Selected Pathological Conditions.

The aim of the present study was to define changes in the expression of somatostatin (SOM) in the sympathetic perikarya innervating the porcine stomach prepyloric area during acetylsalicylic-acid-induced gastritis (ASA) and experimentally induced hyperacidity (HCL) and following partial stomach resection (RES). On day 1, the stomachs were injected with neuronal retrograde tracer Fast Blue (FB). Animals in the ASA group were given acetylsalicylic acid orally for 21 days. On the 22nd day after FB injection, partial stomach resection was performed in RES animals. On day 23, HCL animals were intragastrically given 5 ml/kg of body weight of a 0.25 M aqueous solution of hydrochloric acid. On day 28, all pigs were euthanized. Then, 14-μm thick cryostat sections of the coeliac-superior mesenteric ganglion (CSMG) complexes were processed for routine double-labelling immunofluorescence. All pathological conditions studied resulted in upregulation of SOM-like (SOM-LI) immunoreactivity (from 14.97 ± 1.57% in control group to 33.72 ± 4.39% in the ASA group, to 39.02 ± 3.65% in the RES group, and to 29.63 ± 0.85% in the HCL group). The present studies showed that altered expression of SOM occurs in sympathetic neurons supplying the prepyloric area of the porcine stomach during adaptation to various pathological insults.

Simultaneous combined laparoscopic-endoscopic removal of a large gastric trichobezoar and gastric polypectomy

Introduction. Trichobezoars and gastric polyps are very rare conditions in children and may pose a diagnostic and therapeutic challenge. The purpose of this work is to present our successful experience using combined laparoscopic-endoscopic procedure for simultaneous treatment of a trichobezoar and gastric polyp in the same patient. Case outline. We present an unusual case of a 15-year-old girl whose symptoms included abdominal pain, non-bilious vomiting after feeding, including undigested food and sometimes hair. Positive history of trichophagia indicated that a trichobezoar could be the reason for her problems. Endoscopy and ultrasound examination revealed a trichobezoar occupying almost the entire capacity of the stomach, as well as one oval polyp in the prepyloric area of the antrum. Simultaneous combined laparoscopicendoscopic rendezvous procedure was performed. The trichobezoar (14 ? 6 cm) and the gastric polyp (2.2 ? 1.7 cm) were completely removed laparoscopically through anterior gastrotomy, with great support of an adequate endobag and mechanical fragmentation of trichobezoar. The postoperative course was uneventful. Conclusion. This case shows that diagnostic endoscopy is valuable and that the combined laparoscopicendoscopic technique is feasible, safe and recommended treatment for simultaneous removal of a gastric trichobezoar and gastric polypectomy.

Smoking History Is More Highly Associated with Perforated Peptic Ulcer Than the Rate of Helocobacter pylori Infection

Introduction: Perforated peptic ulcer disease is a relatively common surgical emergency. We conducted a retrospective review of patients with perforated peptic ulcer disease in one institution to evaluate factors associated with ulcer perforation. Methods: A retrospective review of patients from April 2012 to March 2016 with perforated peptic ulcers was performed. Data collected from the medical records includes age, gender, BMI, operation, perforation site, Helicobacter pylori infection status, smoking history, steroid use, NSAID use, morbidity and mortality. Results: A total of 76 patients (62 men and 14 women) were included in this study. Perforation sites include the duodenal bulb (n=56), second portion of the duodenum (n=1), prepyloric area (n=4), gastric body (n=12), and gastric fundus (n=2). Of these, 69 underwent operation and seven were treated non-operatively. The prevalence of Helicobacter pylori infection was 70% in patients with duodenal perforation and 63% in patients with gastric perforation. The prevalence of smoking was 82% in duodenal perforations and 87% in gastric perforations. Steroid use was 2% in duodenal and 11% in gastric perforations. NSAID use was 9% in duodenal and 17% in gastric perforations. In patients with either duodenal or gastric perforation, the prevalence of a smoking history was higher than the rate of Helicobacter pylori infection. Conclusion: Perforated peptic ulcer disease is a common surgical emergency. Etiologic factors associated with perforation have been reported, including Helicobacter pylori infection and NSAID use. In the present study, smoking history is the predominant risk factor in patients with perforated peptic ulcer disease, among risk factors including Helicobacter pylori infection, NSAID use, and steroid use. This result is significant because Japan is known have a higher rate of Helicobacter pylori than in high income countries. Well-known risk factors including NSAID and steroid use were less associated with perforation in this study. Smoking history is the risk factor most highly associated with perforation.

Neuropeptide profile changes in sensory neurones after partial prepyloric resection in pigs

This report details the first identification of the sources of sensory innervation of the porcine stomach prepyloric region. The Fast Blue (FB) retrograde tracing technique detected the sensory prepyloric neurons in the bilateral nodose ganglia (NGs) as well as thoracic dorsal root ganglia (DRGs). Double-labelling immunofluorescence demonstrated expression of substance P (SP), calcitonin gene-related peptide (CGRP), neuronal isoform of nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP) and galanin (GAL) in both NGs and DRGs. Additionally, we found that partial resection of the stomach prepyloric area increased expression of the SP, CGRP, NOS, VIP and GAL in the prepyloric sensory neurons.In the control left NGs, both a higher total number of FB-positive perikarya as well as a higher percentage of the peptides expressing prepyloric neurons were visualized than in the right NGs.However, compared to the control group, prepyloric resection evoked greater increases in peptide expression in the right-side NGs sensory neurons. In the ganglia of this side, the proportion of the SP-IR perikarya increased by approximately 15%, while CGRP-IR increased by 28%, NOS-IR 14%, VIP-IR 43% and GAL-IR 13%. On the opposite left side, the ganglia proportion of the CGRP-IR perikarya increased by approximately 10%, while NOS-IR increased by 3%, VIP-IR 36% and GAL-IR by 2%. The only decrease (by 5%) was observed in the case of SP expression. We also found that 92% of the sensory neurons originated from NGs and 8% from DRGs.Our results indicate that, in the pig, SP, CGRP, NOS, VIP and GAL participate in the vagal sensory transduction from the stomach prepyloric area. Moreover, increased expression of the peptides and neuronal isoform of nitric oxide synthase in the sensory neurons following transection of their peripheral dendrites suggests their possible participation in the neuronal recovery and/or reinnervation process.

Acetylsalicylic acid-induced changes in the chemical coding of extrinsic sensory neurons supplying the prepyloric area of the porcine stomach

Acetylsalicylic acid is a popular drug that is commonly used to treat fever and inflammation, but which can also negativity affect the mucosal layer of the stomach, although knowledge concerning its influence on gastric innervation is very scarce. Thus, the aim of the present study was to study the influence of prolonged acetylsalicylic acid supplementation on the extrinsic primary sensory neurons supplying the porcine stomach prepyloric region. Fast Blue (FB) was injected into the above-mentioned region of the stomach. Acetylsalicylic acid was then given orally to the experimental gilts from the seventh day after FB injection to the 27th day of the experiment. After euthanasia, the nodose ganglia (NG) and dorsal root ganglia (DRG) were collected. Sections of these ganglia were processed for routine double-labelling immunofluorescence technique for substance P (SP), calcitonine gene related peptide (CGRP), galanin (GAL), neuronal isoform of nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP). Under physiological conditions within the nodose ganglia, the percentage of the FB-labeled neurons immunoreactive to particular substances ranged between 17.9±2.7% (VIP-like immunoreactive (LI) neurons in the right NG) and 60.4±1.7% (SP-LI cells within the left NG). Acetylsalicylic acid supplementation caused a considerable increase in the expression of all active substances studied within both left and right NG and the percentage of neurons positive to particular substances fluctuated from 47.2±3.6% (GAL-LI neurons in the right NG) to 67.2±2.0% (cells immunoreactive to SP in the left NG). All studied substances were also observed in DRG neurons supplying the prepyloric region of the stomach, but the number of immunoreactive neurons was too small to conduct a statistical analysis. The obtained results show that ASA may influence chemical coding of the sensory neurons supplying the porcine stomach, but the exact mechanisms of this action still remain unknown.

Neurochemical Plasticity of the Coeliac-Superior Mesenteric Ganglion Complex Neurons Projecting to the Prepyloric Area of the Porcine Stomach following Hyperacidity

This study was designed to determine neurochemical properties of the coeliac-superior mesenteric ganglion (CSMG) neurons supplying the prepyloric area of the porcine stomach in physiological state and following experimentally induced hyperacidity. To localize sympathetic neurons innervating the studied area of stomach, the neuronal retrograde tracer Fast Blue (FB) was applied to control animals and hydrochloric acid infusion (HCl) groups. After 23 days, animals of the HCl group were reintroduced into a state of general anesthesia and intragastrically given 5 mL/kg of body weight of 0.25 M aqueous solution of hydrochloric acid. On the 28th day, all animals were sacrificed. The CSMG complexes were then collected and processed for double-labeling immunofluorescence. In the control animals, FB-positive perikarya displayed immunoreactivity to tyrosine hydroxylase (TH), dopamine β-hydroxylase (DβH), neuropeptide Y (NPY), and galanin (GAL). Experimentally induced gastric hyperacidity changed the neurochemical phenotype of the studied neurons. An upregulated expression of GAL and NPY and the de novo synthesis of neuronal nitric oxide synthase (nNOS) and leu5-enkephalin (LENK) as well as downregulated expression of TH and DβH in the stomach-projecting neurons were observed. These findings enrich existing knowledge about the participation of these active substances in adaptive mechanism(s) of the sympathetic neurons during pathological processes within the gastrointestinal tract.

Alterations of neurochemical expression of the coeliac-superior mesenteric ganglion complex (CSMG) neurons supplying the prepyloric region of the porcine stomach following partial stomach resection.

The purpose of the present study was to determine the response of the porcine coeliac-superior mesenteric ganglion complex (CSMG) neurons projecting to the prepyloric area of the porcine stomach to peripheral neuronal damage following partial stomach resection. To identify the sympathetic neurons innervating the studied area of stomach, the neuronal retrograde tracer Fast Blue (FB) was applied to control and partial stomach resection (RES) groups. On the 22nd day after FB injection, following laparotomy, the partial resection of the previously FB-injected stomach prepyloric area was performed in animals of RES group. On the 28th day, all animals were re-anaesthetized and euthanized. The CSMG complex was then collected and processed for double-labeling immunofluorescence. In control animals, retrograde-labelled perikarya were immunoreactive to tyrosine hydroxylase (TH), dopamine β-hydroxylase (DβH), neuropeptide Y (NPY) and galanin (GAL). Partial stomach resection decreased the numbers of FB-positive neurons immunopositive for TH and DβH. However, the strong increase of NPY and GAL expression, as well as de novo-synthesis of neuronal nitric oxide synthase (nNOS) and leu5-Enkephalin (LENK) was noted in studied neurons. Furthermore, FB-positive neurons in all pigs were surrounded by a network of cocaine- and amphetamine-regulated transcript peptide (CART)-, calcitonin gene-related peptide (CGRP)-, and substance P (SP)-, vasoactive intestinal peptide (VIP)-, LENK- and nNOS- immunoreactive nerve fibers. This may suggest neuroprotective contribution of these neurotransmitters in traumatic responses of sympathetic neurons to peripheral axonal damage.

The Influence of Prolonged Acetylsalicylic Acid Supplementation-Induced Gastritis on the Neurochemistry of the Sympathetic Neurons Supplying Prepyloric Region of the Porcine Stomach.

This experiment was designed to establish the localization and neurochemical phenotyping of sympathetic neurons supplying prepyloric area of the porcine stomach in a physiological state and during acetylsalicylic acid (ASA) induced gastritis. In order to localize the sympathetic perikarya the stomachs of both control and acetylsalicylic acid treated (ASA group) animals were injected with neuronal retrograde tracer Fast Blue (FB). Seven days post FB injection, animals were divided into a control and ASA supplementation group. The ASA group was given 100 mg/kg of b.w. ASA orally for 21 days. On the 28th day all pigs were euthanized with gradual overdose of anesthetic. Then fourteen-micrometer-thick cryostat sections were processed for routine double-labeling immunofluorescence, using primary antisera directed towards tyrosine hydroxylase (TH), dopamine β-hydroxylase (DβH), neuropeptide Y (NPY), galanin (GAL), neuronal nitric oxide synthase (nNOS), leu 5-enkephalin (LENK), cocaine- and amphetamine- regulated transcript peptide (CART), calcitonin gene-related peptide (CGRP), substance P (SP) and vasoactive intestinal peptide (VIP). The data obtained in this study indicate that postganglionic sympathetic nerve fibers supplying prepyloric area of the porcine stomach originate from the coeliac-cranial mesenteric ganglion complex (CCMG). In control animals, the FB-labelled neurons expressed TH (94.85 ± 1.01%), DβH (97.10 ± 0.97%), NPY (46.88 ± 2.53%) and GAL (8.40 ± 0.53%). In ASA group, TH- and DβH- positive nerve cells were reduced (85.78 ± 2.65% and 88.82 ± 1.63% respectively). Moreover, ASA- induced gastritis resulted in increased expression of NPY (76.59 ± 3.02%) and GAL (26.45 ± 2.75%) as well as the novo-synthesis of nNOS (6.13 ± 1.11%) and LENK (4.77 ± 0.42%) in traced CCMG neurons. Additionally, a network of CART-, CGRP-, SP-, VIP-, LENK-, nNOS- immunoreactive (IR) nerve fibers encircling the FB-positive perikarya were observed in both intact and ASA-treated animals. The results of this study indicate involvement of these neuropeptides in the development or presumably counteraction of gastric inflammation.

Bread Bag Clip: A Rare Cause of Gastrointestinal (GI) Bleeding

Introduction: Ingestion of plastic bread bag clip has been reported in 25 cases. Our patient is the third reported case of GI bleeding secondary to bread bag clip ingestion (1). Case Presentation: An 83 year old man presented with a two day history of fatigue, dizziness and melena. Hematocrit was 30. NG lavage showed coffee-ground aspirate. EGD revealed small erosions in the prepyloric area. In the duodenal bulb, a bread bag clip was visualized. The edge of the clip was located at the initial portion of the duodenal sweep. The clip was grasped with a rat-toothed forceps and was pulled into the overtube and removed. A linear bleeding ulcer was noted in the most proximal portion of the sweep, due to injury from the pincer-like grasp of bread bag clip. Endoscopic control of bleeding failed. Angiographic embolization and Vasopressin administration were attempted but he continued to bleed. He required over 20 units of blood. Finally, exploratory laparotomy and oversew of duodenal ulcer with pyloroplasty was done. His hematocrit remained stable after the procedure. Discussion: Ingested bread bag clips are associated with a high risk of complications like perforation, obstruction and bleeding. Small bowel is the most common site of impaction. Majority of ingestion occur in children, people with visual deficits and adults who have dentures (1). It is thought that decreased palate sensation due to dentures increases susceptibility to swallowing these clips (1). Our patient had full dentures. When a bread bag clip is knowingly ingested, prompt endoscopic removal should be attempted, as the risk of serious complications is high. Despite having been eliminated from several countries, bread bag clips still remain a cause of significant morbidity and mortality (1).Figure: Bread bag clip in the duodenal sweep.

Localization and Chemical Coding of the Dorsal Motor Vagal Nucleus (DMX) Neurons Projecting to the Porcine Stomach Prepyloric Area in the Physiological State and After Stomach Partial Resection

The aim of our study was to localize and define immunocytochemical characteristic of the dorsal motor nucleus of the vagus (DMX) neurons projecting to the porcine stomach prepyloric region in the physiological state and after gastric partial resection. To identify the stomach-projecting perikarya, the neuronal retrograde tracer--Fast Blue (FB) was injected into the studied region of control and resection group (RES). In the RES group, on 22nd day after FB injection, the partial resection of the stomach region previously injected with FB was performed. Sections were immunostained with ChAT, pituitary adenylate cyclase-activating peptide (PACAP), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), galanin (GAL), substance P (SP), leu-enkephalin (LENK), and cocaine- and amphetamine-regulated transcript (CART). In the DMX of control and RES group, the stomach-projecting perikarya were found in the entire extent of the nucleus bilaterally. Within control animals, 30.08 ± 1.97 % of the gastric DMX perikarya expressed PACAP, while other substances were found only in the neuronal fibers. In the RES group DMX, PACAP was found in 45.58 ± 2.2 %, VIP in 28.83 ± 3.63 %, NOS in 21.22 ± 3.32 %, and GAL in 5.67 ± 1.49 % of the FB-labeled gastric perikarya. Our data implicate PACAP, VIP, NOS, and GAL as neuronal survival promoting substances and the CART-, LENK-, SP- NOS-, and GAL-immunoreactive processes in control of the gastric vagal neurons in the pig.

Endoscopic Findings in a Mass Screening Program for Gastric Cancer in a High Risk Region - Guilan Province of Iran

Gastric cancer is a leading cause of cancer-related deaths in both sexes in Iran. This study was designed to assess upper GI endoscopic findings among people>50 years targeted in a mass screening program in a hot-point region. Based on the pilot results in Guilan Cancer Registry study(GCRS), one of the high point regions for GC - Lashtenesha - was selected. The target population was called mainly using two methods: in rural regions, by house-house direct referral and in urban areas using public media. Upper GI endoscopy was performed by trained endoscopists. All participants underwent biopsies for rapid urea test (RUT) from the antrum and also further biopsies from five defined points of stomach for detection of precancerous lesions. In cases of visible gross lesions, more diagnostic biopsies were taken and submitted for histopathologic evaluation. Of 1,394 initial participants, finally 1,382 persons (702 women, 680 men) with a mean age of 61.7 ± 9.0 years (range:50-87 years) underwent upper GI endoscopy. H.pylori infection based on the RUT was positive in 66.6%. Gastric adenocarcinoma and squamous cell carcinoma of esophagus were detected in seven (0.5%) and one(0.07%) persons, respectively. A remarkable proportion of studied participants were found to have esophageal hiatal hernia(38.4%). Asymptomatic gastric masses found in 1.1% (15) of cases which were mostly located in antrum (33.3%), cardia (20.0%) and prepyloric area (20.0%). Gastric and duodenal ulcers were found in 5.9% (82) and 6.9% (96) of the screened population. Upper endoscopy screening is an effective technique for early detection of GC especially in high risk populations. Further studies are required to evaluate cost effectiveness, cost benefit and mortality and morbidity of this method among high and moderate risk population before recommending this method for GC surveillance program at the national level.