Proximal Duodenum Research Articles

To study the Helicobacter pylori infection in peptic ulcer

Helicobacter pylori is a gram negative bacterium which causes chronic gastritis and plays important roles in peptic ulcer disease, gastric carcinoma, and gastric lymphoma. Its major in the human pathogen that produces inflammation of the stomach and etiologically related to the duodenal ulcer, gastric ulcer, gastric cancer and mucosa-lymphoid tissue. It is weakens the protective mucous coating of the stomach and duodenum, thus allowing acid to get through to the sensitive lining beneath. Both the acid and the bacteria irritate the lining and cause a sore, or ulcer. Helicobacter treated with a combination of antibiotics plus a proton pump inhibitor. Peptic ulcer is characterized by discontinuation in the inner lining of the gastrointestinal tract because of the gastric acid secretion or pepsin. It extends into muscularis propria layer of the gastric epithelium. It usually occurs in the stomach and proximal duodenum. Peptic means that cause of the problem is due to the acid. It is most common causes in the peptic ulcers are infection with the bacterium and causes the long-term use of the non-steroidal anti-inflammatory drugs. Gastric ulcer occurs in the stomach. Duodenal ulcer occurs in the first part of the small intestine. The interplay of gastritis phenotype related to the bacterium colonization and resulting acid secretion.

A Case of Peptic Ulcer in Recent Op/C/O Total Thyroidectomy: A Rare Case Report

Gastric acid secretion induces the inner lining of the gastrointestinal tract to rupture, which is the hallmark of peptic ulcer disease. It mainly affects the stomach and proximal duodenum, but it can also affect the lower esophagus, distal duodenum, or jejunum. The two main factors interfering with the mucosal resistance to damage are H. pylori and NSAIDs. Goitre is a disorder characterized by an enlarged thyroid gland that may or may not be linked to hyper or hypothyroidism. It can be manifested with normal thyroid hormone levels (euthyroid). Both the entities are different. Here, we describe a case of peptic ulcer discovered in a patient who had undergone a total thyroidectomy recently for a massive diffuse nodular goitre.

Percutaneous Removal of Migrated Gastrointestinal Stents Using Gastrostomy Access

This report describes the experience of removing migrated gastrointestinal (GI) stents using a gastrostomy (G) access. Four male patients aged 23–62 years (mean, 42 years) had 6 migrated stents removed using an existing (n = 3) or new (n = 1) G access. Removed stents included 5 covered esophageal stents that migrated into the stomach and 1 distal noncovered duodenal stent that migrated into the proximal duodenum. One patient had 2 stents removed during the same session. All stents were removed successfully without complications. Techniques used included the folding technique using a wire in 3 stents and forceps in 2 stents. Eversion technique was used in the duodenal stent. The G or gastrojejunostomy tubes were replaced after stent removal and used for enteral feedings. In conclusion, removing migrated GI stents using an existing or new G access is technically successful and safe.

EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum

Abstract Background Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications. Methods This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management. Results To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well. Conclusions Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.

Endoscopic and surgical treatment of non-neoplastic proximal duodenal ulceration in dogs, and anatomical study of proximal duodenal vascularisation.

Proximal duodenal ulceration is often characterised by continuous bleeding, and treatment is challenging. The aims of this study were to investigate the role of vascularisation in proximal duodenal ulceration and describe clinical aspects, endoscopic features and treatment in dogs. Polyurethane foam casts of gastroduodenal vessels were obtained from five dogs which had died from disorders unrelated to the digestive system. In addition, 12 dogs having proximal duodenal ulcers diagnosed by endoscopic examination were enrolled in a treatment trial. After the endoscopic diagnosis of a duodenal ulcer, all the dogs were treated medically and, in the absence of resolution, were subsequently treated by endoscopic electrocauterisation or by surgery. A submucosal vascular network was evident in all the casts, with a prominent venous plexus seen exclusively in the first half inch of the duodenum. In clinical cases, on endoscopic examination, the duodenal ulcer was located at the proximal part of the duodenum, involving the mesenteric portion of the wall. The dogs not responding to medical treatment (6/12) were treated with endoscopic electrocauterisation, surgical coagulation or resection of the proximal duodenal portion. All the dogs survived until discharge, and the median survival time following discharge was 107.5 days. Based on the anatomical details highlighted in this study, the continuous bleeding observed in our patients may have been due to the prominent venous plexus evidenced at the level of the proximal duodenum. Surgical and endoscopic treatments in six patients resolved the ulcer bleeding with no recurrences noted during follow-up.

Risk Factors for Postoperative Morbidity, Suture Insufficiency, Re-Surgery and Mortality in Patients with Gastroduodenal Perforation.

(1) Background: The aim of the present study was to identify risk factors associated with postoperative morbidity, suture/anastomotic insufficiency, re-surgery, and mortality in patients undergoing surgery for gastroduodenal perforation. (2) Methods: A retrospective analysis of 273 adult patients who received surgical treatment for gastroduodenal perforation from January 2006 to June 2021 at the University Hospital Erlangen was performed. The patient demographics and preoperative, intraoperative, and postoperative parameters were collected and compared among the different outcome groups (in-hospital morbidity, suture/anastomotic insufficiency, re-surgery, and 90-day mortality). (3) Results: In-hospital morbidity, suture/anastomotic insufficiency, need for re-surgery, and 90-day mortality occurred in 71%, 10%, 26%, and 25% of patients, respectively. The independent risk factors for morbidity were a significantly reduced general condition, a lower preoperative hemoglobin level, and a higher preoperative creatinine level. The independent risk factors for suture/anastomotic insufficiency could be identified as an intake of preoperative steroids and a perforation localization in the proximal stomach or duodenum. The four parameters were independent risk factors for the need for re-surgery: a significantly reduced general condition, a perforation localization in the proximal stomach, a higher preoperative creatinine level, and a higher preoperative CRP level. An age over 66 years and a higher preoperative CRP level were independent risk factors for 90-day mortality. (4) Conclusions: Our study could identify relevant risk factors for the postoperative outcome of patients undergoing surgical treatment for gastroduodenal perforation. Patients exhibiting the identified risk factors should receive heightened attention in the postoperative period and may potentially benefit from personalized and tailored therapy.

Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection

Video 1Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman with a several-week history of intermittent postprandial nausea and vomiting presented to the emergency room after experiencing syncope, following several hours of persistent abdominal pain, nausea, and vomiting. A contrast-enhanced CT scan of the abdomen and pelvis was arranged. Axial images show gastrogastric intussusception with the intussusceptum, indicated by the dashed lines, telescoping into the intussuscipiens indicated by the arrowheads. There is a lobulated mass indicated by the asterisk, serving as the lead point for the intussusception, and there is also a small volume of fluid indicated by the arrow, which delineates the mass from the duodenum. In the coronal images, we can again see a long-segment intussusception indicated by the dashed line with a lobulated mass indicated by the asterisk serving as the lead point and extending into the proximal duodenum. Then the lobulated mass occupying and expanding the duodenal lumen can be seen, indicated by the asterisk. Upon entry into the stomach through endoscopy, the gastrogastric intussusception can be seen. The lobulated mass serving as the lead point can be seen being pulled distally. With air insufflation, the intussusception spontaneously resolved. With continued insufflation, within a few minutes, the native confirmation of the polyp was established. It was located in the proximal body along the greater curve with a lobulated appearance with a Paris 1sp morphology. In addition, there was panatrophy in the background mucosa, which was consistent with autoimmune atrophic gastritis that was subsequently confirmed on histopathology and positive anti-parietal cell antibiotics. An EUS was performed and did not show any evidence of T2 disease. Doppler showed large central feeding vessel. A plan was made for endoscopic submucosal dissection (ESD). The strategy for the ESD was an initial circumferential incision and trimming with subsequent application of multipoint traction. After a circumferential incision, a rich vascular supply is seen. After completion of the incision and trimming, the snare was advanced over the scope and the clip advanced through the instrument channel. Multiple clips were then used to secure the snare to the distal end of the lesion. With traction applied, access to the submucosa became much easier and the ESD proceeded easily. For the final remnant of submucosa, it was more easily dissected in a forward view. Chess is one of the merits of multipoint traction in that traction can be applied both proximally and distally to the lesion. The lesion was resected en bloc. The specimen was retrieved using the attached snare, but unfortunately, some of the friable head was fragmented because of its large size, yet the base remained intact. Final pathology demonstrated PGD+HGD with clear margins vertically and laterally along the base. This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.

448 Case Study of a Giant Duodenal Perforation: Where Is the Ampulla?

Abstract Concurrent duodenal and gallbladder perforation is a rare finding. Whilst cholecystoduodenal fistulas have been observed in literature, massive duodenal perforation with gallbladder erosion has not been recorded. We present the case of a 77-year-old female who was found to have a giant duodenal perforation (measuring 10cmx5cm) with an associated gallbladder perforation as well. On patient’s first presentation, a Computed Tomography of the abdomen was performed due to abdominal pain and constipation. Images showed pneumoperitoneum and intra-abdominal free fluid. Upon performing an explorative laparotomy, findings of duodenal and gallbladder perforations were observed. Distal gastrectomy, cholecystectomy and gastrojejunostomy were performed. Due to uncertainty of the location of the ampulla to the ulcer edges, a cholangiogram catheter was advanced into the Ampulla of Vater via the Cystic Duct to definitively identify it prior to D1/D2 stapling. Gastrograffin study was conducted on Day-5, showing good contrast flow. No major events occurred during her post operative recovery. The main concern is inadvertent stapling of D1/D2 together with the ampulla. The passage of a catheter down the Cystic Duct, into the Common Bile Duct and through the ampulla is a definitive way to locate its position. In addition, Common Bile Duct patency with cholangiography can be ensured. Intra-operative improvisation such as advancing a cholangiogram catheter into the ampulla would assist surgeons in safely resecting proximal duodenum especially when it encroaches on the D1/2 junction.

Expression Profiling along the Murine Intestine: Different Mucosal Protection Systems and Alterations in Tff1-Deficient Animals.

Tff1 is a typical gastric peptide secreted together with the mucin, Muc5ac. Tff1-deficient (Tff1KO) mice are well known for their prominent gastric phenotype and represent a recognized model for antral tumorigenesis. Notably, intestinal abnormalities have also been reported in the past in these animals. Here, we have compared the expression of selected genes in Tff1KO mice and their corresponding wild-type littermates (RT-PCR analyses), focusing on different mucosal protection systems along the murine intestine. As hallmarks, genes were identified with maximum expression in the proximal colon and/or the duodenum: Agr2, Muc6/A4gnt/Tff2, Tff1, Fut2, Gkn2, Gkn3, Duox2/Lpo, Nox1. This is indicative of different protection systems such as Tff2/Muc6, Tff1-Fcgbp, gastrokines, fucosylation, and reactive oxygen species (ROS) in the proximal colon and/or duodenum. Few significant transcriptional changes were observed in the intestine of Tff1KO mice when compared with wild-type littermates, Clca1 (Gob5), Gkn1, Gkn2, Nox1, Tff2. We also analyzed the expression of Tff1, Tff2, and Tff3 in the pancreas, liver, and lung of Tff1KO and wild-type animals, indicating a cross-regulation of Tff gene expression. Furthermore, on the protein level, heteromeric Tff1-Fcgbp and various monomeric Tff1 forms were identified in the duodenum and a high-molecular-mass Tff2/Muc6 complex was identified in the proximal colon (FPLC, proteomics).

A duodenal diverticulum in a deerhound

AbstractA 23‐month‐old, spayed, female deerhound experienced an acute onset of anorexia and regurgitation. The initial regurgitant contained leaves and grass, but over the next 24 hours, it changed to dark brown granular material consistent with digested blood. Radiography revealed a dilated segment of bowel caudal to the liver, suggesting mechanical or functional intestinal obstruction. Exploratory laparotomy revealed a roughly spherical, 6‐cm diameter diverticulum in the proximal duodenum, which was removed by resection and anastomosis. The dog made an uneventful recovery. To date, duodenal diverticula have been reported predominantly in young Boxers. This is the first report of a duodenal diverticulum in a deerhound.

Long-Term Exposure to Cadmium Causes Hepatic Iron Deficiency through the Suppression of Iron-Transport-Related Gene Expression in the Proximal Duodenum.

Cadmium (Cd) is an environmental pollutant that damages various tissues. Cd may cause a depletion of iron stores and subsequently an iron deficiency state in the liver. However, the molecular mechanism of decreased iron accumulation in the liver induced by long-term exposure to Cd is unknown. In this study, we investigated the hepatic accumulation of iron and the proximal duodenal expression of the genes involved in iron transport using mice chronically exposed to Cd. Five-week-old female C57BL/6J mice were fed a diet containing 300 ppm Cd for 12, 15, 19 and 21 months. The iron concentration in the liver was markedly decreased by Cd. Among iron-transport-related genes in the proximal duodenum, the gene expression of HCP1 and Cybrd1 was significantly decreased by Cd. HCP1 is an influx transporter of heme iron. Cybrd1 is a reductase that allows non-heme iron to enter cells. The expression of iron-transport-related genes on the duodenal basolateral membrane side was hardly altered by Cd. These results suggest that long-term exposure to Cd suppresses the expression of HCP1 and Cybrd1 in the proximal duodenum, resulting in reduced iron absorption and iron accumulation in the liver.

Impact of positive resection margins on recurrence and survival following resection and adjuvant chemotherapy in pancreatic cancer: Results of the PRODIGE 24-CCTG PA-6 trial.

4160 Background: Pancreatic adenocarcinoma (PDAC) has a poor prognosis. Only 10-15% of patients present with resectable tumors upfront, and most patients develop recurrence and die prematurely. The data are incongruous when considering R1 status, direct invasion is not consistently a significant prognostic factor. It is recommended that 7 margins be identified for surgery: the bile duct, pancreatic neck, proximal and distal duodenum, superior mesenteric vein (SMV), superior mesenteric artery (SMA), and posterior pancreas. By analyzing data from the PRODIGE 24-CCTG PA-6 trial that validated the mFOLFIRINOX regimen in adjuvant setting, our main objective was to analyze the prognostic value of margin involvement on disease-free survival (DFS). Methods: The protocol recommended that the surgeon inked the resection margins. R1 was defined as direct tumor margin infiltration within 1 mm of one or more resection margins. All patient data were re-evaluated centrally by an external review committee including pathologists, surgeons, and medical oncologists to verify key prognostic factors, including inking and filling of resection margins. Results: Among the 400 patients included in the study, the median number of documented margins was 6, IQR (5-7). In 214 patients (53.5%), fewer than 7 margins were reported. The most common margin involvement was on the SMV groove (28.3%), posterior margin (21%), SMA (14.5%), and pancreatic neck transection (5.3%). Margin inking was performed in 64.9% of cases. Misclassification of the R1 status concerned 24.1% of the files after centralized review. When positive, only 3 margins (SMV groove, median and posterior) were significant prognostic factors in unifactorial analysis (all p < 0.01). When combined, one R1 margin among these three had independent prognostic value in multivariable analysis. In multivariate analysis, DFS was significantly different by quality of resection margins in the gemcitabine arm (HR 95% CI 1.97 [1.23;3.16]; p = .005) but not in the mFOLFIRINOX arm (HR 95% CI 1.46 [0.91;2.35]; p = .114). Conclusions: Few studies have examined the prognostic implications of each margin. We consider that every effort should be made to evaluate the 3 best prognostic margins. One finding of this work is the likely effect of mFOLFIRINOX on local invasion in operated patients. It seems that this chemotherapy regimen (unlike gemcitabine) corrects the alteration related to margin involvement, probably explaining all or part of the improved survival. Therefore, the value of additional therapies, such as cloture radiotherapy, should be evaluated in patients with unknown marginal status or in those who did not benefit from mFOLFIRINOX chemotherapy. A patient who received mFOLFIRINOX as adjuvant therapy is more likely to recur with distant metastasis (80%) and with a better survival of 28 months. Clinical trial information: NCT01526135 .

Review of Toxic Chemical Factors Influence in Gastric and Duodenal Ulcers

ABSTRACT Peptic ulcer is a lesion most often located in the stomach or the proximal duodenum. The incidence, the hospitalization rate and the associated mortality in the last decades is decreasing due to modern therapy and hygiene measures. Approximately half of the population is colonized by H. Pylori, which is one of the main causes of ulcers. Other contributing factors are diet and stress. Non-steroidal anti-inflammatories cause damage to the gastro-duodenal mucosa by inhibiting cyclooxygenase-1. Concomitant consumption of proton pump inhibitors can be a solution. Natural evolution can lead to healing or complications. Ulcer perforation is one of the loudest and most serious complications of ulcers. Alcohol consumption has been shown to be a strong risk factor. Various studies have shown that smokers have a double risk of developing gastro-duodenal ulcers.

Enteral protease inhibition reduces systemic enzymatic activity and proteolysis after experimental trauma-hemorrhagic shock

Trauma-hemorrhagic shock (T-HS) is a major cause of multiorgan failure and mortality world-wide. Our previous work demonstrates that uncontrolled proteolysis in T-HS is associated with poor outcomes and that enteral inhibition of proteolytic activity may be beneficial. However, the enzymes involved, their degradation products, and the systemic consequences of protease activity in T-HS are not well understood. Our aim was to identify plasma enzymatic activity and the resulting peptidome in experimental T-HS, and determine the changes in this activity following enteral protease inhibition. Anesthetized male Wistar rats (~400g) were subjected to T-HS via laparotomy followed by blood removal to achieve a mean blood pressure of ~35-40mmHg for 90 min. An orogastric catheter was passed through the mouth into the proximal duodenum and Golytely (Shock-control, n=8) or Golytely+gabexate mesilate, 10mg/kg (GM-treated, n=8) was enterally infused starting 30 minutes into the shock period. Animals were resuscitated with Lactated Ringers solution (LR) and monitored for 120 min after reperfusion. The gabexate mesilate treatment improved mean arterial pressure after reperfusion (57.6±4.3 mmHg) compared to Shock-control group (43.7±4.5mmHg, p<0.0001) requiring significantly less resuscitation fluid (14±3ml vs 25.7±2.3 ml, respectively, p<0.0001). Systemic proteolysis, as measured by the plasma peptidome, increased by 630±212% in the Shock-control group compared to baseline, and was mitigated by treatment with gabexate mesilate to 203±70% (p=0.02). Using tagged fluorescent substrates, trypsin-like activity in plasma increased with T-HS to 937±90% of baseline (p<0.0001) and was reduced by enteral protease inhibition to 321±72% of baseline (p=0.0321 vs. baseline, p=0.0078 vs. Shock-control). The most common proteins to be degraded were structural (myosin, actin, and collagen), coagulation-related (inter-alpha trypsin inhibitor, kininogen, complement C4, and fibrinogen) and metabolic in function (apolipoprotein E, fructose-bisphosphate aldolase, and carbonyl reductase). These proteins were cleaved after T-HS 1.5-4 times more in the Shock-control compared to the GM-treated group. In conclusion, we were able to identify trypsin-like activity in plasma from animals subjected to T-HS. Enteral inhibition of serine proteases was able to significantly decrease this activity and improve outcomes, suggesting that the gut is a driver of uncontrolled proteolysis and resulting morbidity in T-HS. Enteral serine protease inhibition may be an effective clinical strategy for decreasing inappropriate systemic proteolysis and improving outcomes in T-HS. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs and the Defense Health Agency J9, Research and Development Directorate under Award No. W81XWH-17-2-0047. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Duodenal Biopsies: Individual or Multiple Samples?

We read with great interest the recent American College of Gastroenterology Guidelines Update on Diagnosis and Management of Celiac Disease, coauthored by Rubio-Tapia et al (1) with detailed answers to relevant questions surrounding this evolving topic. When addressing the subject of duodenal biopsies for the diagnosis of celiac disease, they state “It has been recommended by expert opinion that only a single biopsy specimen should be obtained with each pass of the biopsy forceps (2), based on the notion that specimen orientation may be improved (3).” We recently published a study comparing adequacy of tissue obtained for assessment of duodenal pathology using individual and multiple samples and found there was no difference in the quality of the specimen as assessed by the pathologist (4). The ease of taking multiple samples with a single pass of the forceps increases the likelihood of practitioners obtaining sufficient tissue for diagnosis, as well as taking samples from the distal and proximal duodenum, as has been previously recommended. We believe our work, if validated by others, should serve as evidence to support these recommendations, which at the present time can only be stated as expert opinion. CONFLICTS OF INTEREST Guarantor of the article: Carlos Rettally, MD. Specific author contributions: The entire correspondence was prepared by C.R. Financial support: None to report. Potential competing interests: None to report.

The Forms of the Lectin Tff2 Differ in the Murine Stomach and Pancreas: Indications for Different Molecular Functions.

The lectin TFF2 belongs to the trefoil factor family (TFF). This polypeptide is typically co-secreted with the mucin MUC6 from gastric mucous neck cells, antral gland cells, and duodenal Brunner glands. Here, TFF2 fulfills a protective function by forming a high-molecular-mass complex with the MUC6, physically stabilizing the mucus barrier. In pigs and mice, and slightly in humans, TFF2 is also synthesized in the pancreas. Here, we investigated the murine stomach, pancreas, and duodenum by fast protein liquid chromatography (FPLC) and proteomics and identified different forms of Tff2. In both the stomach and duodenum, the predominant form is a high-molecular-mass complex with Muc6, whereas, in the pancreas, only low-molecular-mass monomeric Tff2 was detectable. We also investigated the expression of Tff2 and other selected genes in the stomach, pancreas, and the proximal, medial, and distal duodenum (RT-PCR analysis). The absence of the Tff2/Muc6 complex in the pancreas is due to a lack of Muc6. Based on its known motogenic, anti-apoptotic, and anti-inflammatory effects, we propose a protective receptor-mediated function of monomeric Tff2 for the pancreatic ductal epithelium. This view is supported by a report that a loss of Tff2 promotes the formation of pancreatic intraductal mucinous neoplasms.

A255 CHOLECYSTO-COLONIC FISTULA AND GASTRIC OUTLET OBSTRUCTION DUE TO EXTRINSIC COMPRESSION: A RARE BOUVERET-LIKE SYNDROME

Abstract Background Bouveret syndrome is a rare form of gastric outlet obstruction due to gallstone ileus. It is caused by passage of a large stone from the gallbladder into the duodenum via a bilio-duodenal fistula causing gastric outlet obstruction. It was first described by Leon Bouveret in 1896 and occurs most commonly in elderly patients with a higher incidence in women. In classic Bouveret syndrome, the stone itself becomes impacted in the intestinal lumen. A case series of 128 cases found only 2 cases where the endoscopic finding was of extrinsic compression. Purpose To present a rare case of Cholecysto-colonic fistula and gastric outlet obstruction due to extrinsic compression as a rare Bouveret-like syndrome. Method Chart review was conducted including clinical notes, laboratory, radiographic, and endoscopy reports. A relevant literature review was conducted. Result(s) A 76-year-old female with recent hospitalization for weight loss, anemia and cognitive decline presented to hospital with sudden onset vomiting without abdominal pain. She was admitted to general surgery. CT scan of the abdomen and pelvis were done and described a subhepatic inflammatory mass with inflammation of the proximal duodenum causing a partial gastric outlet obstruction as well as a fistula between with hepatobiliary system and a loop of ascending colon with associated pneumobilia. The etiology of the fistula was unclear but thought to be due to infection vs malignancy vs stone disease and the patient was put on antibiotic therapy. Due to inability to tolerate oral intake, she was put on parenteral nutrition. The Gastroenterology (GI) service was then consulted for consideration of gastroscopy and possible stent placement for obstruction. The GI service requested an MRI for further characterization. This revealed a 20mm impacted gallstone in the fistula tract with 3 other similarly sized stones passed into the colon, as well as evidence of a partial outlet obstruction due to the inflammatory mass in the porta hepatis. Gastroscopy was pursued to identify any intraluminal compression, which revealed duodenal edema in the first segment of the duodenum without any intraluminal pathology. Given that the compression was not intraluminal, a stent was not offered. Surgical options would be extensive surgery including cholecystectomy, duodenal wedge resection and partial colonic resection. Given her comorbidities, plan was made for conservative management instead. After 2 weeks of admission and conservative management, her outlet obstruction resolved and she was able to tolerate oral intake again. Image Conclusion(s) Impacted gallstones causing chronic cholecystitis can result in fistula formation with the colon and due to the size of the stones in the tract and resultant inflammation, extrinsic compression of the duodenum may occur presenting as clinical gastric outlet obstruction. In this event, conservative management can be an effective strategy of management as a safe alternative to extensive surgical resection and bypass. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The effects of NutraGen supplement on cattle growth performance, energetic efficiency, carcass characteristics, and characteristics of digestion in calf-fed Holstein steers.

Evaluation of the effects of feeding NutraGen supplement (NutraGen, NTG; Phibro Animal Health, Teaneck, NJ, USA) on growth performance, energetic efficiency, carcass characteristcs, and characteristics of digestion in calf-fed Holstein steers fed a conventional growing-finishing diet. Trial 1 evaluated growth performance, dietary energetics and carcass characteristics. Two hundred Holstein steer calves (134 ± 5 kg) were blocked by initial body weight (BW) and randomly assigned to 40 pens (5 steers/pen). Dietary treatments consisted of a steam-flaked corn-based growing-finishing diet supplemented with 0, 0.2, 0.4, or 0.6% NTG (DM basis). In trial 2, four Holstein steers (170 ±6 kg) with cannulas in the rumen and proximal duodenum were used in a 4 × 4 Latin square experiment to evaluate digestibility and ruminal characteristics using the treatments from trial 1. Compared to non-supplemented cattle, NTG increased BW (2.0%, P = 0.02) and tended to increase ADG (3.6%, P = 0.07) during the initial 56 d period. However, there were no treatment effects on overall growth performance and efficiency of dietary energy utilization after the first 56 days (P > 0.10). Supplementation of NTG increased (linear effect; P ≤ 0.03) longissimus muscle area and kidney, pelvic, and heart fat. There was no effect (P ≥ 0.05) of NTG supplementation on other carcass characteristics, liver abscess incidence, or liver abscess scars. Supplementation decreased the molar proportion of ruminal propionate (P = 0.05) and tended to increase acetate:propionate molar ratio (P = 0.09). However, there was no effect of NTG supplementation on ruminal and total tract diet digestion. NTG increased performance of Holstein steers during the first 56 d on feed in the feedlot. In addition, the steers had an increase in KPH fat and LM area, indicating that the additive induced change in metabolism of the steers.

A Study into the Identity, Patterns of Infection and Potential Pathological Effects of Rumen Fluke and the Frequency of Co-Infections with Liver Fluke in Cattle and Sheep

Rumen fluke (RF) are trematode parasites that have increased in prevalence within European ruminant livestock since the 1990s. Morbidity and mortality can result from the development of juvenile flukes in the duodenum, however, evidence for significant impacts of adult fluke in the rumen of the final host is equivocal. The presence of rumen fluke in Scotland had not previously been quantified, so the purpose of this study was to use historical coprological data collected between 2008 and 2018 at the School of Veterinary Medicine in Glasgow to evaluate the frequency of rumen fluke infection and to compare this with the presence of liver fluke. This analysis showed evidence of adult rumen fluke in 6.6% of samples submitted, with a substantial and significant increase in positive diagnoses from 2016, following which positive rumen fluke diagnoses equaled or slightly outnumbered those of liver fluke. A prospective post-mortem examination study was also carried out to determine the presence of rumen and liver fluke in cattle and sheep, to quantify adult rumen fluke burdens and to assess any pathological changes in the reticulorumen and proximal duodenum associated with infection. The presence of rumen fluke in post-mortem cases was 26.9% (n = 18/67), the majority (66.7%, n = 12/18) with burdens of less than 100 adult rumen flukes. There was no significant difference in mean ruminal papillar density and length in animals with and without adult rumen fluke and no significant gross pathology was observed in the rumen or reticulum. Examination of animals with adult rumen fluke provided no evidence of any consistent associations with acute or chronic inflammatory changes in the duodenum. All rumen fluke collected at necropsy were identified by PCR and sequencing as Calicophoron daubneyi.

[Contrast-Enhanced Ultrasound of Fibrolamellar Hepatocellular Carcinoma].

We present the case of a 24-year-old male patient, who was admitted for endoscopy due to sustained pain in the upper abdomen with nausea and postprandial fullness without vomiting for more than 5 months. In the physical examination, an epigastric induration was found. Endoscopy revealed an external impression of the proximal duodenum. Beyond that, normal findings could be ascertained in gastroscopy and ileo-colonoscopy. Abdominal ultrasound identified a large hypoechoic lesion in the left liver lobe with a sharp delineation. Along the upper mesenteric vessels, enlarged lymphnodes were visible with contact to the proximal duodenum. Contrast-enhanced ultrasound (CE-US) was conducted and revealed the typical perfusion pattern of hepatocellular carcinoma. For further assessment, an ultrasound-guided core-biopsy of the lesion was performed. The histopathological evaluations resulted in the diagnosis of a hepatocellular carcinoma of fibrolamellar subtype.With the present case, we want to illustrate the perfusion pattern of a fibrolamellar hepatocellular carcinoma in contrast-enhanced ultrasound. Even though the tumor tissue is surrounded by lamellar bands of fibrosis with collagen-rich fibers, the perfusion pattern is consistent with the previously known appearance of HCC in CE-US.