Proximal Duodenum Research Articles

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.

Feeding Corn Silage or Grass Hay as Sole Dietary Forage Sources: Overall Mechanism of Forages Regulating Health-Promoting Fatty Acid Status in Milk of Dairy Cows.

Different dietary forage sources regulate health-promoting fatty acids (HPFAs), such as conjugated linoleic acids (CLAs) and omega-3 polyunsaturated fatty acids (n-3 PUFAs), in the milk of lactating cows. However, the overall mechanism of forages regulating lipid metabolism from the gastrointestinal tract to the mammary glands (MGs) is not clear. Three isocaloric diets that contained (1) 46% corn silage (CS), (2) a mixture of 23% corn silage and 14% grass hays (MIX), and (3) 28% grass hays (GH) as the forage sources and six cannulated (rumen, proximal duodenum, and terminal ileum) lactating cows were assigned to a double 3 × 3 Latin square design. Our results show that a higher proportion of grass hay in the diets increased the relative contents of short-chain fatty acids (SCFAs), CLAs, and n-3 PUFAs. The lower relative content of SCFA in the milk of CS was predominantly due to the reduction in acetate production in the rumen and arteriovenous differences in the MG, indicating that the de novo synthesis pathways were inhibited. The elevated relative contents of total CLA and n-3 PUFA in the milk of GH were attributed to the increases in apparent intestinal digestion and arteriovenous differences in total CLA and n-3 PUFA, together with the higher Δ9-desaturase activity in the MG. In conclusion, this study provides an overall mechanism of dietary forages regulating HPFA status in the milk of dairy cows.

Vagal preganglionic axons arborize in the myenteric plexus into two types: nitrergic and non-nitrergic postganglionic motor pools?

Vagal preganglionic neurons innervate myenteric ganglia. These autonomic efferents are distributed so densely within the ganglia that it has been impractical to track individual vagal axons through the myenteric plexus with tracer labeling. To evaluate whether vagal efferent axons evidence selectivity, particularly for nitrergic or non-nitrergic myenteric neurons within the plexus, we limited the numbers and volumes of brainstem dextran biotin tracer injections per animal. Reduced labeling and the use of immunohistochemistry generated cases in which some individual axons could be distinguished and traced in three dimensions (Neurolucida) within and among successive (up to 46) myenteric ganglia. In the myenteric plexus of all stomach regions, the majority (∼86%) of vagal efferents were organized into two distinct subtypes. One subtype (∼24% of dextran-labeled efferents, designated "primarily nitrergic") selectively contacted and linked-both within and between ganglia-nitric oxide synthase positive (nNOS+) neurons into presumptive motor modules. A second subtype (∼62% of efferents, designated "primarily non-nitrergic") appeared to selectively contact and link-both within and between ganglia-non-nitrergic enteric neurons into a second type of effector ensemble. A third candidate type (∼14% of labeled preganglionics), appeared to lack "nitrergic selectivity" and to contact both nNOS+ and nNOS- enteric neurons. In addition to the quantitative assessment of the efferent axons in stomach, qualitative observations of the proximal duodenum indicated similar selective vagal efferent projections, in proportions comparable with those evaluated in the stomach. Limited injections of tracer, three-dimensional (3-D) tracing of individual axons, and histochemistry of myenteric neurons might distinguish additional efferent phenotypes.NEW & NOTEWORTHY The present study highlights the following: 1) one type of vagal efferent axon selectively innervates nitrergic upper gastrointestinal myenteric neurons; 2) a second type of vagal efferent selectively innervates non-nitrergic gastrointestinal myenteric neurons; and 3) the two types of vagal efferents might modulate peristalsis reciprocally and cooperatively.

Practical parameters for assessing starch digestion and feeding value of steam-flaked corn in finishing diets for feedlot cattle

ABSTRACT Six Holstein steers (153 kg ± 11) with cannulas in the rumen and proximal duodenum were used in a 6 × 6 Latin square design experiment to compare flake density (FD, kg/L), flake thickness (FT, mm), amyloglucosidase reactivity (AGR, % DM) and faecal starch (FS, % DM) as predictors of ruminal (RSD, %) and total tract (TSD, %) starch digestion. Dietary treatments consisted of a finishing diet containing 77% corn. The six corn processing treatments consisted of dry-rolled corn (DRC) with a density of 0.54 kg/L, and steam-flaked corn (SFC) processed to obtain densities of 0.46, 0.41, 0.36, 0.31 and 0.26 kg/L. Compared with DRC, steam flaking enhanced postruminal (34.2%, P < 0.01) and TSD (7.8%, P < 0.01). Measures of FS were the best single predictor of both ruminal (r 2 = 0.97) and TSD (r 2 = 0.98). Whereas AGR was a good predictor of RSD (r 2 = 0.94), it was less effective than FS for estimation of TSD (r 2 = 0.91). We conclude that compared with dry rolling, stream flaking markedly enhances the feeding value of corn. To evaluate the consistency of the flaking process, we recommend in addition to the determinations of FD, measurements of FT, starch enzymatic reactivity and FS are useful indicators.

Hemodynamics in the right gastroepiploic artery and its practical application

To study functional anatomy of the right gastroepiploic artery (RGEA), its gastric and omental branches and practical significance of these anatomical features. We analyzed 20 cadaveric organ complexes (11 men and 9 women, aged 49-85 years) between 2018 and 2019. The organ complexes consisted of the stomach, proximal duodenum and large omentum. RGEA catheterization at the level of pylorus was followed by selective real time angiography. We assessed the following parameters of RGEA: total length, diameter at the level of pylorus, number and diameter of gastric and omental branches. To objectify the study, we visually divided RGEA into 5 equal segments between pylorus and the last branch arising from this artery. The RGEA looks like a gradually and evenly narrowing tube. Mean diameter of the artery at the level of pylorus was 2.2±0.68 mm, mean length - 23.6±3.7 cm. Mean number of gastric and omental branches was 16.2±4.8 and 8.6±2.6, respectively. The number of gastric branches in the distal part of the RGEA increased, while the diameters of the gastric branches did not significantly differ. The number of gastric branches in distal RGEA increased, while diameters of gastric branches were similar. The greatest number of omental branches with the largest diameter was observed in the 2nd and 3rd segments of the artery. Considering these data, we formulated the equation for RGEA hemodynamics and developed the technique for optimal blood supply to proximal part of the gastric transplant during esophagogastroplasty. Anatomical features of the right gastroepiploic artery can be used in reconstructive surgery of abdominal cavity and chest.

Influence of level of dried distillers grains plus solubles substitution for steam-flaked corn on characteristics of growth performance, and dietary energetics of calf-fed Holstein steers during the initial 16-week growing phase: metabolizable protein versus metabolizable amino acids.

This study evaluates the partial replacement of steam-flaked corn (SFC) with increasing dried distillers grains plus solubles (DDGS) levels in growing-finishing diets for calf-fed Holstein steers. Two experiments were conducted. In trial 1, 100 Holstein calves (136 ± 7 kg) were used to evaluate the effect of DDGS as a metabolizable protein source on cattle growth performance, and dietary energetics of calf-fed Holstein steers during the initial 111 d growing phase. Four dietary levels of DDGS were evaluated (10, 15, 20, and 25%, dry matter basis), replacing SFC (flake density, 0.31 kg/L). In trial 2, four Holstein steers (368 ± 20 kg) with cannulas in the rumen and proximal duodenum were used to evaluate treatment effects on characteristics of ruminal and total tract digestion of organic matter (OM), neutral detergent fiber, nitrogen (N), and indispensable amino acid supply to the small intestine. The increasing level of DDGS did not affect (P ≥ 0.13) average daily gain, gain efficiency, and estimated dietary net energy values. Replacement of SFC with increasing levels of DDGS decreased (linear; P = 0.01) ruminal OM digestion. There was no treatment effect on the flow of microbial nitrogen to the small intestine (P = 0.34) and ruminal microbial efficiency (P = 0.79). However, increasing levels of DDGS in the diet increased (linear; P ≤ 0.04) flow of methionine, histidine, phenylalanine, threonine, leucine, isoleucine, and valine but did not affect (P = 0.74) intestinal supply of lysine. Increasing DDGS in the diet increased (linear, P < 0.01) flow of N to the small intestine but decreased (linear; P < 0.01) ruminal N efficiency. Replacing SFC with DDGS increased intake and amino acid leaving the abomasum. Still, this effect was not sufficient to increase the growth performance of calf-fed Holstein during the first 111 d on feed.

1265: EFFECTS OF ENTERAL PROTEASE INHIBITION ON COAGULATION PROTEOLYSIS AFTER TRAUMA-HEMORRHAGIC SHOCK

Introduction: Coagulopathy and uncontrolled proteolysis are frequent sequelae of circulatory shock, and are associated with poor outcomes. We have previously demonstrated that enteral protease inhibition improves hemodynamics and survival in experimental shock. However, the mechanisms of inappropriate systemic protease activity in shock are not well understood. Our aim was to identify the effects of enteral protease inhibition on plasma proteolysis by examination of the plasma peptidome in experimental trauma-hemorrhagic shock (T-HS). Methods: Anesthetized Wistar rats were subjected to experimental T-HS with laparotomy. An oral catheter was inserted into the proximal duodenum and either gabexate mesilate+Golytely (GM) (10mg/kg) (n=8) or Golytely as a vehicle (n=8) was enterally infused starting 30min into the hypotension period. Blood was removed to achieve a mean blood pressure (MAP) of 35-40mmHg for 90min before reperfusion with lactated Ringer’s to obtain a target MAP of ≥65mmHg. Blood was taken for mass spectrometry peptidomics analysis at baseline and 120min after reperfusion. Results: Plasma proteolysis was increased 8.8±0.9 fold in the Shock-control group, and was reduced to 2.0±0.2 times baseline values in GM-treated animals (p< 0.0001). Despite representing only 0.3% of all proteins found in the peptidome, fibrinogen fragments comprised 11.3% of all peptides recovered after T-HS in our model, and were often non-canonically cleaved. Enteral GM decreased proteolysis of other proteins involved in coagulation, including: C4 (increased 1092±131% from baseline in Shock-control vs 154±22% in GM-treated animals, p< 0.0001); Kininogen-1 (relative intensity 90.5±20.4 in Shock-control vs. 19.8±1.4 in GM-treated group, p< 0.0001); Protein C (118% in Shock-control vs. GM-treated animals, p=0.0012). In addition, fragments from inter-alpha-trypsin inhibitor were exclusively found in the Shock-control group, suggesting breakdown of anti-proteases in the blood after shock. Conclusions: Enteral protease inhibition with gabexate mesilate significantly reduced plasma proteolysis after experimental T/HS as measured by peptidomics, especially of proteins involved with coagulation. This approach opens new insights for the understanding and treatment of Trauma-hemorrhagic shock, particularly related to coagulopathies.

Surgical Management of Benign Neoplasms of the Small Intestine

Small intestinal benign tumours are uncommon clinical conditions that frequently go asymptomatic for the entirety of a patient's life. The small bowel contains only a tiny number of primary neoplasms, while making up most of the surface area and most of the length of the gastrointestinal (GI) tract. There are the following subtypes: Hyperplastic polyps, hamartomas, adenoma, stromal tumours, lipomas, hemangiomas, and patients who have Peutz-Jeghers syndrome. Clinically, speaking, benign small-bowel lesions are distinguished by the absence of distinguishing symptoms. Up to the proximal duodenum lesions can be diagnosed with enteroscopy. Push or double-balloon enteroscopy methods can be used to reach the GI tract beyond the ligament of Treitz. The sole method of treatment for those who have small bowel adenocarcinoma is surgery. The majority of research state that between 40 and 65 percent of patients lend themselves to curative resection. The utilisation of laparoscopic surgery (LS) for small intestine gastrointestinal stromal tumours (GISTs) has expanded with the introduction of LS. There is currently no evidence to suggest a statistically significant difference between LS and open surgery in terms of prognosis. This review aims to summarize evaluation and management of benign neoplasms of the small intestine.

Which style of duodenojejunostomy is better after resection of distal duodenum

BackgroundDistal duodenal resections are sometimes necessary for radical surgery, but how to restore duodenal continuity is still unclear. This study aimed at determining which style of anastomosis was more suitable for the duodenojejunostomy after resection of distal duodenum.Patients and methodsWe retrospectively identified 34 patients who underwent distal duodenum resection at our center between January 2014 and December 2021. According to whether the end or the side of the proximal duodenum was involved in reconstruction, duodenojejunostomy were classified as End style (E-style) and Side style (S-style). Demographic data, clinicopathological details, and postoperative complications were analyzed between two groups.ResultsThirteen patients (38.2%) received E-style duodenojejunostomy, and 21 patients (62.8%) received S-style duodenojejunostomy. Comparative analysis showed that in group of E-style, patients had a lower rate of multivisceral resection(5/13 vs 18/21; P = 0.008), delayed gastric emptying (DGE) (1/13 vs 11/21; P = 0.011) and intraperitoneal infection (2/13 vs 12/21; P = 0.03). In this study, the incidence of major complications was up to 35.3% (12/34) and no patient died of complication in perioperative period. In two group, there was no difference in the incidence of major complications (E-style vs S-style: 3/13 vs 9/21; P = 0.292).ConclusionsThe E-style duodenojejunostomy for the reconstruction of distal duodenum resection is safe and feasible. The E-style anastomosis may have potential value in decreasing the occurrence of complications such as DGE and intraperitoneal infection, and the definitive advantages still need to be verified.

The Review on Peptic Ulcer Disease

Peptic ulcer is a chronic disease affecting up to 10% of the world’s population. The formation of peptic ulcers depends on the presence of gastric juice pH and the decrease in mucosal defenses. Non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (H. pylori) infection are the two major factors disrupting the mucosal resistance to injury. Conventional treatments of peptic ulcers, such as proton pump inhibitors (PPIs) and histamine-2 (H2) receptor antagonists, have demonstrated adverse effects, relapses, and various drug interactions. Peptic ulcer disease is characterized by discontinuation in the inner lining of the gastrointestinal (GI) tract because of gastric acid secretion or pepsin. It extends into the muscularis propria layer of the gastric epithelium. It usually occurs in the stomach and proximal duodenum. It may involve the lower esophagus, distal duodenum, or jejunum. Hence, this review presents common medicinal plants that may be used for the treatment or prevention of peptic ulcers. Peptic ulcer disease results from an imbalance between factors that protect the mucosa of the stomach and duodenum, and factors that cause damage to itPeptic ulcer disease presents with gastrointestinal symptoms similar to dyspepsia and can be difficult to distinguish clinically. It can have potentially serious complications such as bleeding or perforation, with a high risk of mortality.

Diagnosis and Treatment of Upper Gastrointestinal Bleeding for the Primary Care Physician

Upper gastrointestinal bleeding (UGIB) is a highly prevalent medical-surgical emergency that must be treated early due to its high morbidity and mortality. It presents as bleeding from the esophagus, stomach or proximal duodenum, and is divided into non-variceal and variceal etiology. Among non-variceal ulcers, peptic ulcer stands out as the most frequent, being this produced by an imbalance between protective and aggressive factors. On the other hand, in variceal-type hemorrhages, gastroduodenal varices stand out, which are a consequence of increased portal pressure. The incidence of UGIB worldwide varies considerably between literature and mortality between 5 and 14% according to different studies. Unfortunately, there are no reliable national figures for incidence and prevalence. The physician must have a good understanding of the clinical presentation and pathophysiology in order to be assertive in the suspicion, diagnosis and management of this pathology. Regarding treatment, the confrontation is divided into emergency management and then endoscopic management, since early intensive resuscitation can reduce morbidity and mortality in patients with upper gastrointestinal bleeding.

Diagnosis, treatment and outcome of metallic foreign body ingestion in two new world camelids

AbstractA 14‐year‐old alpaca and a 3‐year‐old llama presented independently with vague symptoms of abdominal discomfort. Bloodwork was unremarkable in the alpaca, but showed signs of sepsis in the llama, and abdominal ultrasonography was normal in both animals. Abdominal radiography revealed a metallic gastrointestinal foreign body in both cases. Ventral midline laparotomy was performed, and the foreign bodies were retrieved from the C3 compartment in the alpaca and from the proximal duodenum in the llama. Both camelids received broad‐spectrum antimicrobial drugs, non‐steroidal anti‐inflammatory drugs and supportive care. The alpaca and llama were discharged from the hospital 16 and 8 days after surgery, respectively. The alpaca was euthansed due to recumbency of unknown aetiology 2 months later, while the llama was doing well 4 months after discharge. This report shows the usefulness of abdominal radiographs in camelids presenting with unspecific clinical signs and demonstrates that hardware disease should be considered as a differential diagnosis.

ODP553 Hypoglycemia after sleeve gastrectomy: a rare case of an insulinoma

Abstract Background The obesity pandemic has become a great topic of interest due its implications for quality of life, comorbidities, increasing mortality and the economic impact on health services worldwide(1). Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective and durable treatment for severe obesity and glucose metabolism disorders, achieving weight loss due to its restrictive and humoral effects (2). Its prevalence has increased from 5 to 37% since 2008 (3). One common complication after bariatric surgery (BS) is the postprandial hyperinsulinemic hypoglycemic state (4). While rare, insulinomas can cause it, where symptoms are more common during the fasting state; thus, evaluation of insulin secretion is needed to exclude dumping syndrome or nesidioblastosis. Until now, this is the first report of insulinoma after LSG. Clinical Case We here present 43-year-old women who was referred to the Obesity Clinic two years after LSG was performed. She had symptoms of hypoglycemia predominantly in the fasting state with a documented glycemic level of less than 30 mg/dl, compatible with Whipple's Triad. Initially, we suspected dumping syndrome but after documentation of a second low fasting plasma glucose, we decided to perform a 72-hour fasting test, which tested positive. Computed tomography and endoscopic ultrasound were performed, identifying the presence of a homogeneous hypoechoic semioval tumoral lesion in the pancreas. The diagnosis was compatible with insulinoma. A laparoscopic enucleation of insulinoma was performed, and after that, the hypoglycemic symptoms and blood sugar levels improved, remaining asymptomatic until now. The histopathological report described a well-differentiated grade 2 neuroendocrine tumor with positive chromogranin and synaptophysin and Ki67 immunopositivity in 4% of the neoplastic cells. Conclusion This is the first case of insulinoma after sleeve gastrectomy, the suggested physiopathology is due to a combination of increased plasma concentrations of incretins, mainly glucagon-like peptide 1 (GLP-1), and an accelerated release of nutrients in the proximal duodenum (5). Although this is a very rare case condition, clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state.

Granulated Cane Sugar as a Partial Replacement for Steam-Flaked Corn in Diets for Feedlot Cattle: Ruminal Fermentation and Microbial Protein Synthesis

The aim of this study was to evaluate the influence of supplemental granulated cane sugar (GCS) levels (0, 13.3, 26.6, and 39.9% on a dry matter basis) in a steam-flaked corn-based finishing diet on measures of ruminal fermentation and the site and extent of nutrient digestion. Four Holstein steers (251 ± 3.6 kg live weight) with “T” type cannulas in the rumen and proximal duodenum were used in a 4 × 4 Latin square experiment to evaluate the treatments. The experiment lasted 84 d. Replacing steam-flaked corn (SFC) with GCS linearly decreased the flow of ammonia-N (NH3-N) to the small intestine, increasing the flow of microbial nitrogen (MN; quadratic effect, p = 0.02), ruminal N efficiency (linear effect, p = 0.03) and MN efficiency (quadratic effect, p = 0.04). The ruminal digestion of starch and neutral detergent fiber (NDF) decreased (linear effect, p ≤ 0.02) as the level of GCS increased. The postruminal digestion of organic matter (OM), neutral detergent fiber (NDF), and starch were not affected by the GCS inclusion. However, postruminal N digestion decreased (linear effect, p = 0.02) as the level of GCS increased. There were no treatment effects on total tract OM digestion. However, total tract NDF and N digestion decreased (linear effect, p ≤ 0.02) as the level of GCS increased. The ruminal pH decreased (linear effect, p &lt; 0.01) as the GCS increased in the diet. The ruminal acetate molar proportion decreased (linear effect, p = 0.02) and the ruminal valerate molar proportion tended to increase (linear effect, p = 0.08) as the level of GCS increased. It is concluded that replacing as much as 13% of SFC with GCS in a finishing diet will enhance the efficiency of N utilization (g non-ammonia-N entering the small intestine/g N intake) without detrimental effects on total tract OM digestion. The inclusion of GCS decreased the ruminal proportion of acetate linearly without an effect on the acetate-to-propionate ratio or estimated methane production. Some of the effects on N utilization at a high level of GCS inclusion (27 and 40%) can be magnified by the differences in the CP content between diets. A higher level of GCS supplementation in the diet decreased the ruminal pH below 5.5, increasing the risk of ruminal acidosis.