Proximal Duodenum Research Articles

Influence of Feeding Enzymatically Hydrolyzed Yeast Cell Wall on Growth Performance and Digestive Function of Feedlot Cattle during Periods of Elevated Ambient Temperature.

In experiment 1, eighty crossbred steers (239±15 kg) were used in a 229-d experiment to evaluate the effects of increasing levels of enzymatically hydrolyzed yeast (EHY) cell wall in diets on growth performance feedlot cattle during periods of elevated ambient temperature. Treatments consisted of steam-flaked corn-based diets supplemented to provide 0, 1, 2, or 3 g EHY/hd/d. There were no effects on growth performance during the initial 139-d period. However, from d 139 to harvest, when 24-h temperature humidity index averaged 80, EHY increased dry matter intake (DMI) (linear effect, p<0.01) and average daily gain (ADG) (linear effect, p = 0.01). There were no treatment effects (p>0.10) on carcass characteristics. In experiment 2, four Holstein steers (292±5 kg) with cannulas in the rumen and proximal duodenum were used in a 4×4 Latin Square design experiment to evaluate treatments effects on characteristics of ruminal and total tract digestion in steers. There were no treatment effects (p>0.10) on ruminal pH, total volatile fatty acid, molar proportions of acetate, butyrate, or estimated methane production. Supplemental EHY decreased ruminal molar proportion of acetate (p = 0.08), increased molar proportion of propionate (p = 0.09), and decreased acetate:propionate molar ratio (p = 0.07) and estimated ruminal methane production (p = 0.09). It is concluded that supplemental EHY may enhance DMI and ADG of feedlot steers during periods of high ambient temperature. Supplemental EHY may also enhance ruminal fiber digestion and decrease ruminal acetate:propionate molar ratios in feedlot steers fed steam-flaked corn-based finishing diets.

Gastric Adenocarcinoma in patients with Roux-en-Y Gastric bypass: A case series

/10.10 15 A mmo ence: . gedr@ The incidence of gastric cancer is approximately 24,000 cases per year with a mortality of 14,000 cases per year. There has been an increasing incidence of proximal gastric cancer and gastroesophageal junction cancer in the United States over the past 5–10 years [1]. Gastric cancer in patients who had previously undergone gastric restrictive surgery and gastric bypass has been reported but is rare. Seventeen case reports and series have been performed describing patients with gastric cancer after undergoing gastric bypass surgery [2]. In the majority of patients who had undergone previous Roux-en-Y gastric bypass surgery, gastric cancer developed in the excluded stomach, leading to delayed diagnosis. Unfortunately, management for these patients is difficult, given their often late diagnoses, which results in the advanced nature of their cancers when symptoms eventually develop [2]. Two cases of gastric adenocarcinoma in patients after Roux-en-Y gastric bypass will be described.

Postruminal synthesis modifies the odd- and branched-chain fatty acid profile from the duodenum to milk

Milk odd- and branched-chain fatty acids (OBCFA) have been suggested as potential biomarkers for rumen function. The potential of milk OBCFA as a biomarker depends on whether their profile reflects the profile observed in the duodenum. The objective of this study was to evaluate whether the OBCFA profile in duodenum samples is reflected in plasma and milk. For this, 2 dairy cattle experiments were used. In experiment 1, 4 Holstein cows fitted with rumen and proximal duodenum cannulas were used in a 4×4 Latin square design. The treatments consisted of 2 nitrogen levels (143 vs. 110g of crude protein/kg of dry matter for high and low N, respectively) combined with either 1 of the 2 energy sources (i.e., starch from barley, corn, and wheat or fiber from soybean hulls and dehydrated beet pulp). In experiment 2, 4 Holstein cows fitted with rumen and proximal duodenum cannulas were used in a 3×3 Latin square design, with the treatments consisting of 3 diets: (1) RNB−, a diet with a crude protein content of 122g/kg of dry matter, predicted to provide protein digested in the small intestine according to the requirement of the animals, but with a shortage of rumen degradable protein; (2) RNB− to which 6g/d of niacin was added through inclusion in the mineral and vitamin premix, and (3) RNB− to which urea was added to balance rumen degradable N supply resulting in a CP content of 156g/kg of dry matter. In both experiments, samples of duodenal digesta, plasma, and milk were collected and analyzed for fatty acids. Additionally, lipids in plasma samples were separated in lipid classes and analyzed for fatty acids. The OBCFA profile in milk was enriched in 15:0, iso-17:0, anteiso-17:0, and cis-9–17:1 as compared with duodenal samples, and milk secretions even exceeded duodenal flows, which suggests occurrence of postruminal synthesis, such as de novo synthesis, desaturation, and elongation. The postruminal modification of the OBCFA profile might hamper the application of OBCFA as diagnostic tools of rumen function.

Comparative effect of intraduodenal and intrajejunal glucose infusion on the gut-incretin axis response in healthy males.

The region of enteral nutrient exposure may be an important determinant of postprandial incretin hormone secretion and blood glucose homoeostasis. We compared responses of plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin and glucagon, and blood glucose to a standardised glucose infusion into the proximal jejunum and duodenum in healthy humans. Ten healthy males were evaluated during a standardised glucose infusion (2 kcal min−1 over 120 min) into the proximal jejunum (50 cm post pylorus) and were compared with another 10 healthy males matched for ethnicity, age and body mass index who received an identical glucose infusion into the duodenum (12 cm post pylorus). Blood was sampled frequently for measurements of blood glucose and plasma hormones. Plasma GLP-1, GIP and insulin responses, as well as the insulin:glucose ratio and the insulinogenic index 1 (IGI1) were greater (P<0.05 for each) after intrajejunal (i.j.) than intraduodenal glucose infusion, without a significant difference in blood glucose or plasma glucagon. Pooled analyses revealed direct relationships between IGI1 and the responses of GLP-1 and GIP (r=0.48 and 0.56, respectively, P<0.05 each), and between glucagon and GLP-1 (r=0.70, P<0.001). In conclusion, i.j. glucose elicits greater incretin hormone and insulin secretion than intraduodenal glucose in healthy humans, suggesting regional specificity of the gut–incretin axis.

Study of gastric outlet obstruction in Al-gamhuria Teaching Hospital-Aden (January 2004-December 2013)

Gastric outlet obstruction implies a complete or incomplete obstruction of the distal stomach, pylorus or proximal duodenum. This retrospective study was carried out in Al-gamhuria Modern General Hospital, Aden, between January 2004 and December 2013, to highlight the etiological spectrum, diagnostic tools, management and outcome. Males are more often affected, with a male to female ratio 4.1:1. The mean age was 42.38 ± 13.71, years while in children the mean age was 2.11 ± 2.83 months. The most common clinical presentation was non-bilious vomiting-56 (100%). The etiology was benign in majority [52 (92.9%)] and gastric cancer was the only malignant etiology [4 (7.1%)]. Hypertrophic pyloric stenosis [35 (62.5%)] was the commonest etiology in children, while peptic ulcer disease was 7 (12.5%) in adult. Abdominal ultrasound [42 (75%)] and upper gastrointestinal endoscopy [11 (19.6%)] was the common diagnostic procedures. The common surgical procedures performed were pyloromyotomy 35 (67.3%) , gastrojejunostomy and pyloroplasty each of them had the same frequency 6 (11.5%). The mortality rate was 3 (5.3%). In conclusion, gastric outlet obstruction is still remaining a surgical problem in our situation, since determining the underlying pathology needs early appropriate imagining studies and timely surgical intervention to avoid mortality.

Aspirin (ASA) Absorption In Rats is much Greater in Stomach vs Duodenum

It is generally believed that ASA absorption is greater in the duodenum than stomach, similar to related salicylates (Rainsford, 1984). The objective of this experiment was to evaluate the GI location and kinetics of ASA uptake in rats. ASA or saline (control, n=6/group) was intragastrically administered to fasted rats at a dose of 100 mg ASA/kg and the gastric body, antrum, and proximal duodenum were collected, extracted in acetonitrile and ASA and salicylic acid (SA) concs were examined by HPLC. The ASA conc (µg ASA/g tissue) at 15, 30 and 60 min for: the gastric body was 278 ± 46, 78 ± 9 and 104 ± 34; antrum were 308 ± 54, 95 ± 12 and 0±0; and duodenum were 34.5 ± 10.8, 6.6 ± 1.9 and 7.9 ± 2.3 respectively. The SA concentration (µg SA/g tissue) at 15, 30 and 60 minutes for: gastric body were 524 ± 33, 434 ± 35 and 236 ± 48; antrum were 572 ± 31, 433 ± 37, and 240 ± 50; and duodenum were 1,052.0 ± 125, 630 ± 75.1 and 408 ± 103, respectively. Serum ASA conc peaked at 15 min at 3.4 ± 0.5 µg/ml falling to undetectable levels thereafter, whereas serum SA reached Cmax at 15 and 30 min at 178 ± 8 µg/ml and 152 ± 22, respectively. Conclusion Significantly greater amount of ASA (>8 times) is absorbed in the stomach of rats vs duodenum at 15 and 30 min (p<0.05). In contrast, SA absorption was not significantly different in the stomach and proximal duodenum at 15 or 30 minutes. Serum ASA peaked at 15 min falling thereafter, whereas SA remained elevated at values 40-50-fold higher for at least 30 min. Thus contrary to belief that aspirin is predominately absorbed in the duodenum due to its large surface area, this data provides evidence that aspirin is predominately absorbed in the stomach, where ASA-induced GI injury predominantly occurs. Supported by NIDDK T35DK007676-21A1.

Neuropeptide S Reduces Gut Motility in Rats and Humans

The actions of NPS on intestinal motility and duodenal mucosal barrier function in anaesthetized rat in vivo and human circular muscle strips in vitro were elucidated in this study.A segment of the proximal duodenum or descending colon with an intact blood supply of male Sprague‐Dawley rat was perfused in situ. The effects of intravenous (i.v.) administration of neuropeptide S (NPS) and NG‐nitro‐L‐arginine methyl ester (L‐NAME) were investigated on intestinal motility and duodenal mucosal paracellular permeability. The influence of NPS on ethanol‐induced changes of duodenal mucosal bicarbonate secretion (DBS) was studied. Normal human circular colonic muscle strips were studied in organ bath. Tension changes were measured after NPS administration, NPS challenge with L‐NAME, tetrodotoxin (TTX) or stimulated with EFS. Values are mean ± SEM, compared by 1‐ or 2‐way ANOVA or paired t test when appropriate.NPS decreases both small intestinal and colonic motility but increases duodenal paracellular permeability. Pre‐treating animals with the non‐selective NOS inhibitor L‐NAME abolished the effect of NPS on duodenal motility but not on permeability. NPS reduces ethanol‐induced increases in DBS. In the human colonic smooth muscle strip, NPS dampened contractility with or without electrical field stimulation, which abolished by administration of L‐NAME and TTX.NPS inhibits gastrointestinal motility in animal and man, most likely via a neural nitric oxide (NO) release. To this end, NPS increases paracellular permeability may represent an early step of inflammatory response.

An Unusual Giant Duodenal Mass Lesion

Question: A 76-year-old Japanese woman presented to our hospital with epigastric fullness. Physical examination and laboratory results were unremarkable. Esophagogastroduodenoscopy showed a protruding lesion with smooth mucosal surface extending from the first to second portion of the duodenum, for which mucosal biopsies were nondiagnostic (Figure A). Abdominal CT revealed a round mass with internal multifocal low densities in the proximal duodenum (Figure B, arrow). An upper gastrointestinal barium study showed a filling defect in the duodenal bulb, resulting in narrowing of the duodenal lumen (Figure C, arrow).

What Is the Whipple Procedure and What Is the Appropriate Nutrition Therapy for It?

What Is the Whipple Procedure and What Is the Appropriate Nutrition Therapy for It?

The improvement of treatment efficacy of gastropathy associated with the use of nonsteroidal anti-inflammatory drugs in Helicobacter pylori-negative patients with osteoarthritis

Abstract Among the more common side effects of osteoarthritis treatment are NSAID-gastropathy and NSAID-enteropathy. NSAIDs can cause direct injury to colon tissue and also impair synthesis of prostaglandins, reduce mucosal integrity, increase permeability and promote an influx of bacteria and toxins. Alterations in gastrointestinal permeability are considered as an initial step in the development of lesions of the gastric mucosa such as erosions and ulcers. The mechanisms underlying the ability of NSAIDs to cause ulceration in the stomach and proximal duodenum are well understood and this injury can be largely be prevented through suppression of gastric acid secretion. However, our work showed that 28-day administration of the anti-secretory preparation pantoprazole (20 mg 2 times per day) resulted in a statistically significant increase of dysbiosis. Monitoring of patients with osteoarthritis who used NSAIDs for more than three months showed that, in comparison to the situation before the beginning of treatment, changes in colonic microbiota were present. Multiprobiotic “Symbiter® acidophilic concentrated” introduced simultaneously with pantoprazole during 20 days prevented formation of dysbiotic changes and led to the quicker healing of gastric mucous healing, in comparison with patients who used only pantoprazole alone. Moreover, it brought about total healing of the gastric mucosa within 4 weeks from the beginning of treatment.

Feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs.

Differentiating hepatocellular disease versus biliary obstruction can be challenging in dogs presented for icterus. The purpose of this prospective study was to determine the feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs. Ten normal dogs weighing 7.6-13.0 kg (median 9.8 kg) were recruited. All dogs were considered normal based on complete blood count, serum chemistry profile, ultrasound examination, and percutaneous radiographic cholecystography. Percutaneous contrast ultrasound-guided cholecystography was performed using 0.5 ml of commercially available contrast agent and two conventional ultrasound machines for simultaneous scanning at two different locations. Two observers independently evaluated the time to initial detection of contrast in the proximal duodenum and duration of contrast enhancement via visual monitoring. Dynamic contrast enhancement was calculated using time-intensity curves. Mean (± SD) and median (range) of time to initial detection were 8.60 s (± 3.35) and 8.0 s (2.0-11.0), respectively, and mean and median duration were 50.45 s (± 23.24) and 53.0 s (20.0 - 70.0), respectively. Mean, median, and range of peak intensity were 114.1 mean pixel value (MPV) (SD ± 30.7), 109.2 MPV, and 79.7-166.7, respectively, and mean, median, and range of time to peak intensity were 26.1 s (SD ± 7.1 s), 24.0 s, and 19.0-41.0 s, respectively. Findings indicated that percutaneous contrast ultrasound-guided cholecystography is a feasible technique for detecting and quantifying patency of the bile duct in normal dogs. Future studies are needed to assess the diagnostic utility of this technique for dogs with biliary obstruction.

Delayed Diagnosis of Gastric Outlet Obstruction from Bouveret Syndrome in a Young Woman

Bouveret syndrome is a rare presentation of gastric outlet obstruction caused by a gallstone in the proximal duodenum via a bilioenteric fistula. This is an infrequent although clinically significant cause of abdominal pain, almost exclusively in the elderly. The clinical presentation is similar to that of a small bowel obstruction with abdominal pain, nausea and vomiting. Surgery or endoscopy is often required for definitive diagnosis and therapy. We describe the case of a young woman with this condition who had a delayed diagnosis in part because of her age and the rarity of the condition.

Extra-ampullary duodenal adenocarcinoma.

Extra-ampullary duodenal adenocarcinomas are rare, and when studied, frequently have been grouped with jejunoileal adenocarcinomas. Nevertheless, anecdotal experiences suggest that these neoplasms may present 2 or more distinct phenotypes. To better characterize these neoplasms, we performed a retrospective review of 38 cases with a special focus on the morphologic and immunophenotypic characteristics and their clinicopathologic significance. Our cohort of extra-ampullary duodenal adenocarcinomas was classified on the basis of the morphologic features into gastric type (n=19, 50%), intestinal type (n=14, 37%), pancreaticobiliary type (n=2, 5%), and others (n=3, 8%). Most gastric-type adenocarcinomas (n=18, 95%) developed in the proximal duodenum, whereas the other types were located equally in the proximal and distal duodenum. Intestinal-type dysplasia was present at the periphery of 8 (57%) intestinal-type adenocarcinomas, and 8 (42%) gastric-type adenocarcinoma were associated with gastric-type dysplasia. Gastric foveolar metaplasia (n=12) and Brunner gland hyperplasia (n=10) were exclusively recognized adjacent to gastric-type adenocarcinomas. Notably, intestinal-type histology and the absence of lymph node metastasis were significantly associated with favorable disease-free survival in univariate and multivariate analyses. In summary, this study demonstrated that 2 major subsets of extra-ampullary duodenal adenocarcinoma, intestinal type and gastric type, are associated with distinct histopathologic features and clinical behavior.

A Case of Feline Gastrointestinal Eosinophilic Sclerosing Fibroplasia Associated with Phycomycetes

Feline gastrointestinal eosinophilic sclerosing fibroplasia (FGESF) is a recently described inflammatory condition of domestic cats with unknown aetiology. A proportion of cases of FGESF are associated with bacteria, but antibiotic treatment is ineffective. It has been hypothesized that genetically predisposed cats may develop FGESF in response to the introduction of bacteria or other antigens into the intestinal wall. A 9- month-old male Persian cat presented with a history of marked acute haematemesis. A mass (10 cm diameter) was detected within the pylorus and proximal duodenum and this was not surgically accessible. On necropsy examination the duodenal wall was seen to be markedly thickened with extensive mucosal ulceration. Microscopically, there were haphazardly oriented trabecular bands of dense eosinophilic collagen, separated by wide, clear areas containing variable numbers of fibroblasts, eosinophils, mast cells, neutrophils, macrophages, lymphocytes and plasma cells. Numerous pleomorphic, non-parallel walled, sparsely septate hyphae, characteristic of phycomycetes, were present within the collagen matrix. Colonies of gram-positive and gram-negative rods were also present within the lesion. This is the first description of FGESF with intralesional fungi.

Gastroduodenal Signet-Ring Cell Carcinoma Presenting as IgG4-Related Sclerosing Cholangitis: Not Everything That Glitters Is Gold

Introduction: IgG4-related sclerosing cholangitis (IgG4-SC) is a new entity of cholangiopathy and IgG4-related disease, described as dense infiltration of IgG4-positive plasma cells and extensive fibrosis in the bile duct wall. We presented a case of signet-ring cell carcinoma of the duodenum with initial presentation of IgG4-SC. A 75-year-old male presented with gradual-onset painless jaundice and right upper quadrant pain for 3 weeks. He was afebrile, with mild right upper quadrant tenderness, without Murphy’s sign. Labs were pertinent for AST of 142 U/L, ALT of 142 U/L, alkaline phosphatase of 461 U/L, and direct/total bilirubin of 3.5/9.3 mg/dL. MRCP showed intrahepatic biliary dilatation with right hepatic duct strictures and non-visualization of the proximal common hepatic and central common bile ducts, replaced with vague enhancement. Further investigations were significant for negative CA 19-9, CA-125 of 125 U/mL (0-30), and normal gamma immunoglobulin subclasses. EUS showed marked thickening of the extrahepatic bile duct up to the hilum without definite mass lesion. He underwent ERCP for biliary sphincterotomy and biliary stenting. Biopsies of the ampulla and the bile duct showed frequent IgG4-positive plasma cells (30 cells/highpower field). Steroid was initiated for possible IgG4-SC. At 10 days after the index ERCP, he had worsening nausea and vomiting without worsening labs. ERCP for biliary stent exchange showed narrowing of the duodenal bulb and the proximal second portion of the duodenum. Biopsies of the duodenum and the bile duct showed nonspecific inflammatory changes without evidence of malignancy. Over a 4-week follow-up after the index ERCP, he developed worsening clinical gastric outlet obstruction. Repeat ERCP/EUS revealed thickening of the pre-pyloric antrum and proximal duodenum without obvious mass, and diffuse sclerosis of the bile duct, especially the right hepatic duct, and markedly dilated left duct. Duodenal biopsies eventually revealed poorly differentiated signet-ring cell carcinoma. At 2 months, he developed new-onset symptomatic pleural effusion and ascites. Cytology analysis of the fluids showed adenocarcinoma. He died under hospice care at 2 months after initial presentation. IgG4-SC is a new challenging disease that clinicians should consider in the differential diagnosis of cholangiopathy (e.g., cholangiocarcinoma and primary sclerosing cholangitis). This case represents an example of signet-ring cell carcinoma of the stomach and duodenum that presented as IgG4-SC. These could represent separate concurrent disease processes; the latter could result from immune dysregulation secondary to occult malignancy, or represent a nonspecific change.

Successful Endoscopic Management of Bouveret’s Syndrome: A Rare Cause of Duodenal Obstruction

Introduction: Bouveret’s syndrome is gastric outlet obstruction caused by a gallstone impacted in the proximal duodenum or pylorus. Endoscopic management is the preferred approach in these patients. We report one such case, which was successfully managed endoscopically. Case Report: An 82-year-old male with history of dementia, heart failure, and atrial fibrillation presented with 3 days of nausea, vomiting, and inability to tolerate per oral intake. He was tachycardic, dehydrated, and had a slightly distended but non-tender abdomen with hypoactive bowel sounds. Abdominal x-ray revealed nonobstructive bowel gas pattern with linear branching lucencies overlying the left hepatic lobe consistent with pneumobilia. CT scan revealed gastric outlet obstruction due to a large gallstone. Given the patient’s multiple comorbidities and age, he was deemed to be a poor surgical candidate and was referred for endoscopic evaluation and management. At endoscopy, a large gallstone occupying the entire lumen of the duodenal bulb was seen. The stone was fragmented using electrohydraulic lithotripsy. A rat tooth forceps and a stone retrieval basket were used to remove the larger pieces of the stone from the stomach. Upon complete removal of the stone, no evidence of a gross biliary-enteric fistula was found. Patient did well post procedure and was discharged home. Discussion: A rare complication of gallstones is formation of a cholecystoduodenal fistula, which can lead to passage of stones into the small bowel causing what is known as gallstone ileus. In 1-3% of these cases, the gallstone can be lodged in the duodenum causing gastric outlet obstruction, which is known as Bouveret’s syndrome. It is most commonly seen in elderly women. Clinical presentation can be nonspecific. Imaging with CT/MRI can reveal the Rigler’s triad of pneumobilia, bowel obstruction and ectopic gallstone. Early diagnosis is key since mortality can be high in this condition, reportedly between 12% and 33%. Endoscopic management has been well described in the literature and is the preferred therapeutic option. Fragmentation of the stone can be performed endoscopically with mechanical, electrohydraulic, or laser lithotripsy. Surgery is often not pursued, as these patients are usually poor surgical candidates such as in our case. Surgery, however, may still be needed for patients with impaction of the gallstone more distally in the small bowel. Conclusion: Endoscopic management of Bouveret’s syndrome should be considered a first line option, especially in an elderly patient with multiple medical comorbidities. Electrohydraulic lithotripsy is a safe and highly effective modality for managing this challenging endoscopic entity.

Cholecystoduodenal Fistula Masquerading as a Duodenal Mass

Introduction: We report a case of a complicated gallstone disease with cholecystoduodenal fistula (CCDF) masquerading as a duodenal mass. Case Report: A 78-year-old man with multiple medical comorbidities presented with hematemesis shortly after starting warfarin for atrial fibrillation. Initial EGD reported a mass with large clot in the proximal duodenum. CT and MRI imaging showed an apparent 8.6-cm mass arising from the duodenum or gallbladder with extension into the inferior right liver. Thrombosis was present in the portal vein. A 1.7-cm portocaval lymph node was also noted. The CBD was mildly dilated at 1.0 cm with low-grade elevation of liver tests. Diagnostic laparoscopy with biopsy of the mass was inconclusive. He was subsequently transferred to our facility for evaluation of suspected neoplastic disease. Repeat EGD revealed a 4-5 cm diverticular-like cavity in the posterior duodenal bulb with inflammatory change, scar, and apparent fistulous tracts within. EUS revealed a 1.7-cm poorly defined mixed echogenic process in the periduodenal space communicating with the diverticulum. Biopsies and FNA showed inflammatory change. EUS revealed an incidental <1 cm distal CBD stone. ERCP confirmed stone with no stricture. The cystic duct was seen to partially fill with contrast and air was seen in the gallbladder. Percutaneous biopsy of the questionable right hepatic process was also negative. Based on the above it was determined that findings were consistent with complications from CCDF and not a malignant process. The patient was managed conservatively. Follow-up CT at 4 months showed improving pericholecystic soft tissue inflammatory change with no detectable enteric fistula. Discussion: Complications from gallstone disease can present in a variety of ways and may rarely masquerade as a malignant process. Fistulas complicate 2-3% of all cases of gallstone associated cholecystitis. CCDF is the most common type occurring in nearly two-thirds of cases. The mechanism of formation is thought to be a result of pericholecystic inflammation that leads to the development of adhesions between the biliary and enteric tract. Pressure necrosis by the gallstone results in fistula formation. Many patients are asymptomatic; however abdominal pain, gastric outlet obstruction (Bouveret syndrome), intestinal obstruction (gallstone ileus), biliary obstruction (Mirizzi syndrome), bleeding, or infection may occur. Fistulas may be challenging to detect on imaging and may be unsuspectedly found during endoscopy or intra-operatively. Although surgery may be needed, expectant management may be appropriate in the large subset of high-risk patients without progressive clinical sequelae.

Congenital Diaphragmatic Hernia: A Rare Cause of Acute Abdomen

Introduction: Congenital diaphragmatic hernias (CDH) in adults are usually asymptomatic. However, they can present with symptoms ranging from mild abdominal discomfort to symptoms of acute abdomen. Overall mortality rate is estimated to be 50%. Clinicians and surgeons need to be aware of this entity and should be cautious before dismissing them as insignificant. Case Report: An 87-year-old man presented to the emergency department with intractable nausea, vomiting, and intermittent upper abdominal pain for the past 2 days. Past medical history was significant for Parkinson’s disease and chronic kidney disease. At admission, the patient’s cardiac and respiratory examination were normal, the abdomen was soft, mildly distended with tenderness to deep palpation in the right upper quadrant. A rectal exam was guaiac-negative. Complete blood count, pancreatic enzymes, and a comprehensive metabolic panel were normal, other than a high serum creatinine consistent with a history of chronic kidney disease. A plain radiograph of the chest and abdomen revealed an elevated right hemidiaphragm with a gas distended structure in the upper abdomen. CT abdomen scout film revealed herniation of abdominal contents up into the lower chest through a possible defect in the diaphragm. The scan revealed swirling of mesentery with a proximal dilatation of the stomach. The hepatic flexure of the colon, distal stomach, and proximal duodenum were located in the right lower chest. The patient failed to respond to conservative management and the white cell count started rising along with a serum lactate. The patient was taken to the OR emergently and a Morgagni hernia with incarcerated transverse colon was discovered at laparotomy. The bowel contents were reduced and the hernia sac excised. Discussion: CDH was first described by Lazarus Riverius in 1679. Giovanni Battista Morgagni described the classical anterior diaphragmatic hernia. Three types of CDH are described in literature are Morgagni’s hernia, Bochdalek or the posterolateral hernia, and eventration of the diaphragm. CDH has an overall mortality of 50%. Treatment depends on the symptoms. It is important to be aware of strangulated Morgagni hernia as a rare cause of acute abdomen. Prompt diagnosis ensures a higher chance of successful repair. While these are considered to be benign, it is logical to expect that they will enlarge with time, and physicians should be cautious before dismissing Morgagni hernias in adults as clinically insignificant.

Correction: Characterisation of Mixing in the Proximal Duodenum of the Rat during Longitudinal Contractions and Comparison with a Fluid Mechanical Model Based on Spatiotemporal Motility Data

Correction: Characterisation of Mixing in the Proximal Duodenum of the Rat during Longitudinal Contractions and Comparison with a Fluid Mechanical Model Based on Spatiotemporal Motility Data

The ethanol-induced stimulation of rat duodenal mucosal bicarbonate secretion in vivo is critically dependent on luminal Cl-.

Alcohol may induce metabolic and functional changes in gastrointestinal epithelial cells, contributing to impaired mucosal barrier function. Duodenal mucosal bicarbonate secretion (DBS) is a primary epithelial defense against gastric acid and also has an important function in maintaining the homeostasis of the juxtamucosal microenvironment. The aim in this study was to investigate the effects of the luminal perfusion of moderate concentrations of ethanol in vivo on epithelial DBS, fluid secretion and paracellular permeability. Under thiobarbiturate anesthesia, a ∼30-mm segment of the proximal duodenum with an intact blood supply was perfused in situ in rats. The effects on DBS, duodenal transepithelial net fluid flux and the blood-to-lumen clearance of 51Cr-EDTA were investigated. Perfusing the duodenum with isotonic solutions of 10% or 15% ethanol-by-volume for 30 min increased DBS in a concentration-dependent manner, while the net fluid flux did not change. Pre-treatment with the CFTR inhibitor CFTRinh172 (i.p. or i.v.) did not change the secretory response to ethanol, while removing Cl− from the luminal perfusate abolished the ethanol-induced increase in DBS. The administration of hexamethonium (i.v.) but not capsazepine significantly reduced the basal net fluid flux and the ethanol-induced increase in DBS. Perfusing the duodenum with a combination of 1.0 mM HCl and 15% ethanol induced significantly greater increases in DBS than 15% ethanol or 1.0 mM HCl alone but did not influence fluid flux. Our data demonstrate that ethanol induces increases in DBS through a mechanism that is critically dependent on luminal Cl− and partly dependent on enteric neural pathways involving nicotinic receptors. Ethanol and HCl appears to stimulate DBS via the activation of different bicarbonate transporting mechanisms.