Proximal Ileum Research Articles

An unusual case of subacute small bowel obstruction - Gallstone ileus.

Introduction and importanceGallstone ileus is caused by an impaction of one or more gallstones within the gastrointestinal tract, leading to mechanical intestinal obstruction. It is a rare complication of cholelithiasis leading to the formation of a cholecystoenteric fistula and is associated with high mortality rates. We report a case of atypical subacute small bowel obstruction due to gallstone ileus.Presentation of caseAn 82-year-old man, with previously diagnosed cholelithiasis, presented with abdominal pain and vomiting for nine days. The contracted gallbladder with distended bowel loops was visualized on abdominal ultrasound. Computed tomography of the abdomen and pelvis revealed dilated loops of the small intestine with a gallstone in the proximal ileum, causing intestinal obstruction with pneumobilia, suggesting gallstone ileus with cholecystoduodenal fistula. The patient underwent an emergency laparotomy and enterolithotomy to remove the impacting gallstone. The cholecystoduodenal fistula was left undisturbed due to the significant risk of duodenal injury. The patient had an uneventful postoperative recovery.ConclusionGallstone ileus almost always requires surgical management. However, performing an interval biliary surgery is based on the clinical judgment of the surgeon. In our case, the patient's clinical status determined the treatment in which an enterotomy with stone extraction alone was largely sufficient, and has supported the literature. Gallstone ileus is an important differential diagnosis in elderly patients with gallstone disease, untreated or undiagnosed, presenting with features of small bowel obstruction.

Effectiveness of ultrasound in the differential diagnosis of ileitis detected by computed tomography.

CASE REPORT A 86-year-old man with a recent history of stent placement for infrarenal aortic aneurysm arrives to the emergency department with abdominal pain. Computed tomography (CT) is performed to rule out complications of the endovascular procedure. The CT showed a loop of ileum with decreased caliber, fat trabeculation and hypervascularity causing proximal dilatation. No signs of ischemia or complications related to the prosthesis were observed. He was admitted to our service due to findings of non-specific ileitis. An intestinal ultrasound was performed and revealed a short segment of proximal ileum with pathological wall thickening with an intraluminal birefringent filamentary hyperechoic material (foreign body), which crossed all the layers of the wall. In the following days serial ultrasounds were performed showing that the foreign body remained in the same location and it was decided to perform surgery. During surgery the foreign body turned out to be a blister which conditioned an ileitis. Finally, intestinal resection was performed and the patient presented good clinical evolution. DISCUSSION The most validated technique for the diagnosis of foreign bodies is CT (1). However, intestinal ultrasound could help in its identification, especially for the non-radiopaque ingested material. On the other hand, it is especially useful in the pediatric age, where exposure to ionizing radiation should be avoided (2,3). In our case, it allowed not only to establish the diagnosis immediately but also to evaluate the evolutionary behavior of the same in terms of its mobilization or detection of local complications.

Dietary carbohydrate modifies the density of L cells in the chicken ileum.

Glucagon-like peptides (GLPs) are secreted from intestinal L cells and stimulate various physiological functions in the gastrointestinal tract. The secretion of GLPs is influenced by macronutrient ingestion. This study aims to clarify the effects of dietary carbohydrate (CHO) on L cells in the chicken ileum. Six-week-old, male White Leghorn chickens were divided into three groups: control, low-CHO and CHO-free, with five chickens in each group. Paraffin sections were made from the proximal and distal ileum of each animal and subjected to immunohistochemistry for GLP-1 and GLP-2 peptides and in situ hybridization for proglucagon (PG) mRNA. A significant reduction of GLP-1- and GLP-2-immunoreactive cells was observed in the two experimental groups compared with that in the control. A reduction of cells expressing PG mRNA was observed in the proximal and distal ileum of the CHO-free group compared with that in the control. The ratio of GLP-1-immunoreactive cells showing Ki-67 immunoreactivity was significantly lower in the distal ileum of the CHO-free group than that in the control group. These data suggest that dietary CHO is an effective stimulator for modifying L cell density in the chicken ileum.

Dystrophin in the Neonatal and Adult Rat Intestine.

Background: Gastrointestinal (GI) complaints are frequently noted in aging dystrophinopathy patients, yet their underlying molecular mechanisms are largely unknown. As dystrophin protein isoform 71 (Dp71) is particularly implicated in the development of smooth muscle cells, we evaluated its distribution in the neonatal and adult rat intestine in this study. Methods: Dp71 expression levels were assessed in the proximal (duodenum, jejunum and ileum) and distal (caecum, colon and rectum) intestine by Western blotting and qPCR. In addition, the cellular distribution of total Dp was evaluated in the duodenum and colon by immunohistochemical colocalization studies with alpha-smooth muscle actin (aSMA), Hu RNA binding proteins C and D (HuC/HuD) for neurons and vimentin (VIM) for interstitial cells. Results: In neonatal and adult rats, the distal intestine expressed 2.5 times more Dp71 protein than the proximal part (p < 0.01). This regional difference was not observed in Dp71 mRNA. During both stages, Dp-immunoreactivity was predominant in the muscularis propria, where it co-localized with aSMA and HuC/HuD. Conclusions: In neonatal and adult rats, Dp71 was expressed highest in the distal intestine. Together with the observation that Dp may be expressed by myenteric neurons, this warrants a paradigm shift in the treatment of GI comorbidities.

EP.TH.717Triple tumour: A myriad of serial incidental findings in a patient presenting with Gallstone pancreatitis

Abstract Aim To present a rare incidental synchronous triple tumours - colonic adenocarcinoma, endometroid ovarian adenocarcinoma and benign Brenner tumour in a patient admitted with acute gallstone pancreatitis. Methods A 75-year-old female presented with epigastric pain. Blood-tests and USS abdomen confirmed gallstones and pancreatitis. She was treated conservatively. USS also showed incidental pelvic mass which was further characterised by CT and MR scans. These scans confirmed heterogeneous lobulated mass in the left adnexa. CT scan also picked-up incidental mass in transverse colon, which was confirmed as cancer by colonoscopy. She was offered therapeutic resection after discussion in Colorectal and Gynaecology MDT. Intra-operatively, transverse colonic tumour was invading into the proximal ileum. Laprascopic surgery concluded with extended right hemicolectomy, small bowel resection-anastomosis, omentectomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy. Results The patient had gradual recovery without any complications. Histopathology showed T4N2 poorly differentiated adenocarcinoma of colonic mass, FIGO grade 1 stage 1c endometrioid adenocarcinoma of left ovary and benign brenner tumour of right ovary. Post-operative MDT did not offer adjuvant-therapy due to slow recovery and fraility. So far, two-years of follow-up did not show any recurrence. Conclusion This report adds to the limited literature of triple synchronous tumours, including rare Brenner accounting for 5% of benign ovarian tumours and endometrioid ovarian tumour with an incidence of 4 -7%. Multi-disciplinary approach and combined surgery can achieve a desirable outcome in such complex cases. It is crucial to identify the primary status of the tumours as it will guide the adjuvant treatment.

S551 Efficacy and Safety of Double- versus Single-Balloon Retrograde Enteroscopy

Introduction: Previous studies have reported conflicting results on the outcomes of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE). We aimed to compare efficacy and safety of DBE to SBE via retrograde approach. Methods: We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large, tertiary referral center from 2008 to 2018. Data was collected on demographics, baseline comorbidities, antiplatelet and anti-coagulation use. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion and procedural duration. The analysis was done using SPSS software. Results: A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 in DBE and SBE group, respectively. There was no difference in gender, comorbidities, smoking history, clopidogrel, anti-coagulation use, platelet count, and laboratory parameters between both groups. Aspirin use was significantly higher in DBE group (40.8% vs. 29.9%, P = 0.03) (Table 1). The indication for enteroscopy was obscure gastrointestinal bleeding (OGIB) in 66.5% and 55.8% of DBE and SBE procedures, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95) and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) but higher maximal depth of insertion from ileo-cecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). In addition, proximal ileum was reached in 22.6% of DBE procedure as compared to 6% in SBE (P < 0.001). On subgroup analysis based on OGIB indication, DBE again had significantly higher depth of insertion (113.1 ± 87.07 cm vs. 79.9 ± 66.5 cm, P = 0.02) and rates of proximal ileum reach (23.7% vs. 7.1%, P = 0.006) as compared to SBE but there was no statistically significant difference in diagnostic yield (34.5% vs. 26.9%, P = 0.23) and therapeutics (20.3% vs. 14.9%, P = 0.31). Safety events were rare and similar in both groups (Table 2). Conclusion: Retrograde DBE is associated with significantly higher depth of insertion and shorter procedural duration but similar diagnostic yield and technical success as compared to.Figure:: Baseline and Demographics factors for both groupsTable 2.: Outcomes comparing DBE and SBE

Effect of sodium sources and exogenous phytase supplementation on growth performance, nutrient digestibility, and digesta pH of 21-day-old broilers

The effect of sodium chloride (NaCl) and NaCl+sodium hydrogen carbonate (NaHCO3) and supplemental phytase (0, 500, 1,000, and 2,000 FTU/kg) on performance, nutrient digestibility and utilization, and digesta pH of male broiler chickens were investigated in a 2 × 4+1 factorial arrangement of treatments in a completely randomized design with 6 replicate cages of 8 birds per replicate. Data were analyzed as a 2 × 4 factorial with contrast between the positive control and the diets containing 0 FTU phytase. Phytase supplementation linearly improved (P < 0.05) average body weigh gain (BWG) and feed intake (d 0–14 and 0–21). Apparent jejunal dry matter (DM) digestibility and digestible energy in birds fed diets containing only NaCl increased (linear and quadratic; P < 0.05) with phytase supplementation whereas quadratic (P < 0.05) effect was observed in birds fed diets containing a combination of NaCl and NaHCO3. Phytase supplementation improved (linear and quadratic; P < 0.05) apparent ileal nitrogen and P digestibility. Apparent utilization of DM, nitrogen, energy, and metabolizable energy increased (linear; P < 0.05) with increasing level of phytase supplementation. Apparent P utilization increased (linear and quadratic; P < 0.05) for both sodium sources but calcium utilization only increased (linear; P < 0.05) with the combination of NaCl and NaHCO3. Bone breaking strength (linear and quadratic) and bone ash (linear) increased (P < 0.05) with phytase supplementation. The combination of NaCl and NaHCO3 resulted in lower (P < 0.05) pH of digesta in the proximal ileum whereas the pH of the digesta in the distal ileum (linear) and the average pH of ileal contents (linear and quadratic) increased (P < 0.05) with phytase supplementation. Results from this study showed that birds’ performance and utilization of nutrients and energy by broilers in the presence of phytase was, in general, not influenced by the source of sodium in the diet. Data from this study showed that NaHCO3 can replace a portion of NaCl in the diet of broilers supplemented with phytase without any significant negative effect on performance and that the 2,000 FTU phytase level resulted in better BWG and feed intake as well nutrient and energy utilization.

The protective effect and mechanism of epidermal growth factor on necrotizing enterocolitis in a neonatal rat model.

BackgroundNecrotizing enterocolitis (NEC) is the most common acquired gastrointestinal emergency in premature infants. This study aimed to investigate the protective effect and mechanism of epidermal growth factor (EGF) on NEC in a neonatal rat model.MethodsWe randomly divided 50 newborn SD rats into a control group, NEC group, NEC + 50 ng/mL EGF group, NEC + 500 ng/mL EGF group, and NEC + 1,000 ng/mL EGF group, with 10 cases in each group. The appearance of intestinal tissue, physiological status score, inflammatory factor level, HE staining, and pathological score were used to evaluate the protective effect. A one cm tissue sample from the proximal ileum of the ileocecal area of five rats from the NEC group and the group that showed a significant protective effect were extracted for transcriptome sequencing.ResultsThe levels of IL-1β and IL-6 in the intestinal mucosa in the NEC + 500 ng/mL EGF group were significantly lower than those in the NEC + 1,000 ng/mL EGF group (P<0.05). Transcriptome sequencing suggested that EGF effects the intestinal barrier, apoptosis, and inflammation of the NEC intestine.ConclusionsWe conclude that the oral administration of 500 ng/mL EGF effectively inhibits intestinal inflammation in NEC neonatal rat models, thereby affecting the barrier function of the intestinal tract.

Canola meal or soybean meal as protein source and the effect of microencapsulated sodium butyrate supplementation in calf starter mixture. II. Development of the gastrointestinal tract

The aim of this study was to assess the effect of protein source, either soybean meal (SM) or canola meal (CM), and microencapsulated sodium butyrate (MSB) supplementation in a pelleted starter mixture on the development of the gastrointestinal tract (GIT) in dairy calves. Twenty-eight bull calves (8.7 ± 0.8 d of age and 43.0 ± 4.4 kg; mean ± SD) were assigned to 1 of 4 treatments in a 2 × 2 factorial arrangement: CM as a main source of protein without or with MSB or SM without or with MSB. Calves were fed starters ad libitum and exposed to a gradual weaning program, with weaning taking place on 51.7 ± 0.8 d of age. Calves were observed for an additional 3 wk after weaning and slaughtered on d 72.1 ± 0.9 of age, after which the GIT was dissected. Morphometric measurements were recorded, and samples for determination of ruminal fermentation, histology, gene expression, and brush border enzyme activities were collected. Canola meal use in the starter mixture increased abomasal tissue weight, jejunal tissue weight and length, and mRNA expression of SLC16A4 (formerly known as MCT4) and FFAR2 (GPR43) in the ruminal epithelium, and decreased ruminal ammonia and mRNA expression of SLC15A2 (PEPT2) and SLC6A14 (ATB0+) in the proximal small intestine and ileum, respectively. However, MSB inclusion in the starter mixture decreased ruminal papillae length, ruminal epithelial surface, and ruminal epithelium dry weight, while increasing mRNA expression of SLC16A1 (MCT1) in ruminal epithelia. Reduced ruminal surface area associated with MSB supplementation was the most apparent when MSB was combined with CM in the starter mixture. Additionally, MSB supplementation decreased the thickness of omasal epithelium, omasal epithelium living strata, and stratum corneum, and increased duodenal and ileal aminopeptidase A enzymatic activity and ileal aminopeptidase N enzymatic activity. Overall, CM might increase growth of the GIT of calves, particularly of the small intestine, but may negatively affect intestinal epithelium function and peptide and AA absorption. Supplementation of MSB has a negative effect on the ruminal and omasal epithelium development, particularly when combined in a starter mixture with CM.

Bowel Wall Visualization Using MR Enterography in Relationship to Bowel Lumen Contents and Patient Demographics.

MR enterography (MRE) is generally performed without bowel preparation, but the frequency and extent by which bowel contents affect bowel wall visualization are poorly described in the literature. To evaluate MRE bowel wall visualization quality relative to bowel lumen contents and patient demographics. Retrospective, single-center. One hundred and four consecutive patients (mean age 29 years, range 5-76 years) without prior bowel resection who had undergone MRE. 3 T (N=87) or 1.5 T (N=17)/T2-weighted single-shot spin echo (T2WI) and fat-saturated T1-weighted gradient echo (T1WI) without and with gadolinium. For the proximal and distal jejunum and ileum and colon, three readers independently categorized bowel lumen signal (water=bright T2 dark T1, T1-bright, or air=dark T2 and T1 signal) and scored distension (0=poor, 1=moderate, 2=well) and wall enhancement (0=unclear, 1=perceptible, 2=clear) based upon gadolinium enhanced T1WI for the 104 MRE exams). The bowel visualization score was the sum of the wall enhancement and distension scores and was considered adequate if ≥3. Wilcoxon signed-rank test. The bowel lumen content was water signal in 93% (97/104 scans), 92% (95/104), 98% (102/104), and 93% (92/104) of the proximal and distal jejunum and proximal and distal ileum, respectively, but only in 12.5% (13/104) of the colon. There was adequate bowel visualization of 53.8%, 77.8%, 84.6%, 90.4% of the proximal and distal jejunum and proximal and distal ileum, respectively, but only 19.2% of the colon. In children (age < 18 years), the visualization score of the ileum was lower when the adjacent colon contained air (2.4 ± 0.97) compared to water (3.75 ± 0.29, P < 0.05) or T1-bright material (3.21 ± 0.82, P < 0.05). Without bowel preparation, colon wall visualization was often unsatisfactory at MRE, and air-filled colon also degraded small bowel visualization, particularly in children. 4 TECHNICAL EFFICACY: Stage 1.

Resection rate curves by location along the small intestine provide perspectives on characteristics of Crohn's disease.

Crohn's disease (CD) can affect any part of the gastrointestinal tract; however, the frequency of CD lesions differs by location. This work aimed to examine resection rates by location to clarify locational characteristics of the small intestine in surgical CD cases. This was a single-centre retrospective case note review of patients who had undergone resection for CD affecting the small intestine between January 2014 and February 2020. Operative details, including length of the small intestine, location and extent of the resection, identified the pattern of disease. By normalizing these data the resection rate along the length of the intestine was calculated to create resection rate curves. One hundred and twenty six surgical cases were identified. The resection rate curves could be divided into two types: exponential and bimodal. For primary surgery, this depended on whether or not surgery was limited to an ileocolic resection. At subsequent surgery, a previous ileocaecal resection influenced the pattern of disease. The peaks of the bimodal curve were located at the proximal and distal ileum. CD patients requiring resection of the small intestine can be divided into terminal ileum type (exponential type) and proximal ileum type (bimodal type). In the future this analytical method may help predict the site of any recurrent disease but also provides a new perspective on the disease.

Intestinal bezoar aggravated by hypomotility of ischemic small intestine: A case report

AbstractThere is limited literature on the subject of intestinal bezoars in the setting of small bowel ischemia. Furthermore, no evidence‐based pathogenesis has been offered in current case reports. This report describes a unique case of small bowel ischemia with simultaneous bezoar aggravation in the small intestine. An 82‐year‐old woman with a history of diabetes mellitus and hyperlipidemia presented with intermittent severe postprandial abdominal pain over the last 2 days. An upper endoscopy 3 weeks prior revealed a gastric bezoar approximately 1.5 cm in diameter. However, during this visit, the gastric bezoar was not visible upon repeat upper endoscopy. A plain abdominal X‐ray was ordered and revealed patterns consistent with small bowel ileus. Upon further investigation, an abdominal computed tomography revealed mid‐ileum vessel delayed arterial enhancement and dilatation of the proximal ileum. This finding is consistent with intestinal ischemia‐induced congestion and bowel obstruction. Bowel perforation was also suspected. A subsequent laparoscopic surgery revealed a bezoar at the level of bowel ischemia. The bezoar was removed and the ischemic segment was resected. Coexistence of intestinal bezoar and small bowel ischemia is rare. Based on the patient's clinical evidence and published experimental evidence, we hypothesized that intestinal ischemia predisposes a patient to intestinal hypomotility, causing bezoar aggravation or formation in the small intestine. Early treatment of gastric bezoars and consideration of bowel ischemia risk due to atherosclerosis are crucial to minimizing bezoar complications.

Complete migration of a composite mesh into small bowel incidentally found during laparotomy for colectomy in an asymptomatic patient: a case report

BackgroundComposite meshes are used for incisional hernia repair because they enable intraperitoneal mesh placement due to their dorsal surface, which is made of inert material. We report, for the first time, to our knowledge, a case of composite mesh migration detected incidentally during a laparotomy for colon cancer in an asymptomatic patient.Case presentationOur patient was a 71-year-old South Asian man who underwent ventral mesh repair following a postoperative complication after right hemicolectomy for colon cancer. The patient was diagnosed with a metachronous sigmoid cancer 5 years later, for which he underwent laparotomy. During laparotomy, a migrated mesh was incidentally found and extracted from his proximal ileum without any evidence of abscess or fistula formation.ConclusionTo our knowledge, this is the first report of an incidentally found migrated composite mesh from a bowel lumen in an asymptomatic patient.

Short communication: Effect of delaying the first colostrum feeding on small intestinal histomorphology and serum insulin-like growth factor-1 concentrations in neonatal male Holstein calves

The primary objective of this study was to determine the effect of delaying the first colostrum feeding on small intestinal histomorphology and serum insulin-like growth factor-1 (IGF-1) concentrations, and the secondary objective was to characterize the ultrastructure of the small intestine of neonatal calves at 51 h of life. Twenty-seven male Holstein calves were fed pooled, pasteurized colostrum (7.5% of birth body weight; 62 g of IgG/L) at 45 min (0H, n = 9), 6 h (6H, n = 9), or 12 h (12H, n = 9) after birth. At 12 h after their respective colostrum feeding, calves were fed milk replacer at 2.5% of birth body weight per meal and every 6 h thereafter. Blood samples were collected every 6 h using a jugular catheter and analyzed for serum IGF-1 concentrations using an automated solid-phase chemiluminescent immunoassay. At 51 h of life, calves were euthanized to facilitate collection of the duodenum, proximal and distal jejunum, and ileum. All segments of the small intestine were assessed for histomorphology, whereas scanning electron and transmission electron microscopy analyses were conducted only for the proximal jejunum and ileum. The results revealed that there was no overall effect of colostrum feeding time on serum IGF-1 concentrations; however, serum IGF-1 concentrations were influenced by time. Specifically, concentrations of serum IGF-1 at 48 h were 29% greater than concentrations at 0 h of life (312.8 ± 14.85 vs. 241.9 ± 14.06 ng/mL). Although there was no overall effect of colostrum feeding time on all histomorphological measures assessed, treatment × segment interactions were observed. Villi height was 1.4 times greater in the distal jejunum of 0H calves than in 6H and 12H calves, and 0H calves tended to have 1.2 times greater ileal villus height than 12H calves. In addition, 0H calves had 1.2 and 1.3 times greater ileal crypt depth than 6H and 12H calves, respectively, and 1.3 times greater surface area index than 12H calves in the distal jejunum. Qualitative ultrastructural evaluation of small intestinal enterocytes conducted irrespective of colostrum treatment revealed the presence of large vacuoles of electron-dense material, apical mitochondria, and apical canalicular systems in the jejunum and ileum. These results indicate that the calf intestine at 51 h of life contains unique enterocyte characteristics similar to fetal enterocytes and that delaying colostrum feeding may negatively influence intestinal growth and development.

S2872 A Case of CMV Enteritis Resulting in Severe Obscure GI Bleeding

INTRODUCTION: Small bowel (SB) bleeding accounts for less than 5% of gastrointestinal (GI) bleeds, in non-IBD patients, with an even smaller portion originating from the jejunum [1]. Locating SB bleeds poses great challenges, frequently resulting in delay in diagnosis. Although SB arteriovenous malformations (AVMs) are most common, other rare etiologies such as infectious enteritis should be considered. CASE DESCRIPTION/METHODS: A 62 year old male was diagnosed with T-cell lymphoma with EBV positivity and placed on high-dose steroids for one month. Staging CT chest, abdomen, and pelvis incidentally revealed intraperitoneal free air with concerns for a gastric wall neoplasm. EGD revealed a 4cm, deep, non-bleeding, non-perforated ulcer in the gastric body (Image 1). Two weeks after, he had painless melanotic stools, requiring multiple transfusions. Emergent arteriography of the celiac and mesenteric arteries did not identify a source of bleeding. Repeat CT imaging was negative for worsening free air. His course continued to worsen, requiring high-dose vasopressors and continued transfusions. Emergent EGD and colonoscopy were performed. EGD revealed a known, non-bleeding gastric ulcer. Colonoscopy showed bright red blood to the cecum with scattered, non-bleeding, ischemic-appearing ulcers (Image 2). Repeat celiac angiogram was performed two more times, eventually revealing active bleeding from small jejunal artery branches which were embolized. Due to concern for ongoing bleeding, surgical resection of the distal jejunum and proximal ileum was performed. Gross pathology demonstrated extensive ulcerations, with biopsies negative for malignancy (Image 3). Serum testing for Cytomegalovirus (CMV) was positive for strongly elevated quantitative levels and the patient was started on Valganciclovir. DISCUSSION: Delays in diagnosing SB bleeds are not uncommon and can frequently be fatal. Our case presents a complex diagnostic scenario where bleeding was presumed to be from the known gastric lesion, but complicated by inability to perform EGD safely with pneumoperitoneum. Ultimately, the patient’s immunocompromised state and steroids predisposed him to opportunistic infections such as CMV, resulting in bleeding ulcers in the jejunum and ileum. Upon literature review, CMV enteritis is exceedingly rare and accounts for under 5% of all CMV infections in the GI tract [2]. Though rare, CMV enteritis has been reported to cause massive hemorrhage requiring emergent surgery and is often associated with high mortality.Figure 1.: 4cm non-bleeding ulcer in the gastric body seen on the initial EGD.Figure 2.: Scattered ischemic-appearing colonic ulcers.Figure 3.: Gross specimen of resected and ulcerated jejunum.

S2865 A Case of COVID-19-Related Small Bowel Disease in Patient With Melena

INTRODUCTION: N/a. CASE DESCRIPTION/METHODS: A 30-year-old male with no past medical history or family history of GI disease presented to an outside hospital with two weeks of cough and dyspnea. He was found to be positive for COVID-19, and shortly after admission developed respiratory failure requiring intubation. His hospitalization was complicated by septic shock and renal failure. He also developed intracerebral hemorrhage while on prophylactic heparin infusion. The patient was transferred to our facility for neurosurgical evaluation though no intervention was needed. One week after arrival he developed melena and anemia. He underwent upper endoscopy, which was only notable for a small GE junction ulcer treated with band ligation. Due to continued melena, he underwent colonoscopy, but no blood was noted in colon or terminal ileum. Capsule endoscopy subsequently revealed clean based and actively bleeding ulcers at the jejunum and proximal ileum concerning for COVID-19-related small bowel disease. He improved with supportive care with no further overt bleeding. He is planned for repeat capsule endoscopy. DISCUSSION: COVID-19 is commonly thought of as a pulmonary disorder. However, studies report frequent GI symptoms of diarrhea, nausea/vomiting and abdominal pain. Prevalence ranges widely from 2-40%, may occur in absence of other features, and often portends worse prognosis. SARS-CoV-2 has been recovered from feces and may persist even after clearance from the respiratory tract. SARS-CoV-2 is also thought to have direct pathologic effects on the GI tract from cytotoxicity and systemic inflammation. The virus has a tropism for the GI tract mediated by the ACE2 receptor, which it uses to internalize into human cells. ACE2 is expressed throughout the GI tract, particularly in the small bowel. Histology of infected small bowel has shown evidence of enterocyte desquamation, edema and lymphocytic infiltration. Despite this, there are few reports of COVID-related GI tract disease. In one case, a patient presented with bloody diarrhea after returning from travel to Egypt. Endoscopy revealed patchy erythema throughout the left colon, though with normal pathology, consistent with a diagnosis of COVID-related hemorrhagic colitis. In a similar case from Italy, a young woman with diarrhea was found to have ulcerative lesions on ileocecal valve with presence of viral particles on pathology. To the best of our knowledge, this is the first case of a patient with COVID-19 with isolated small bowel involvement.Figure 1.: EGD, colonoscopy. A. GE junction ulcer with overlying clot (arrow), B. GE junction ulcer after banding, C. Cecum, with normal appearing mucosa, D. Terminal ileum, with normal appearing mucosa.Fig: 2Capsule endoscopy. A. Ulcer in proximal jejunum, B.-C. Ulcerated jejunal mucosa, D. Ulcerated ileal mucosa with active oozing.

Initial assessment of protein and amino acid digestive dynamics in protein-rich feedstuffs for broiler chickens.

A study evaluating apparent digestibilities of protein and amino acids and their corresponding digestion rates in four small intestinal sites in broiler chickens was completed to further investigate dietary optimisation via synchronised nutrient digestion and absorption. A total of 288 male Ross 308 broiler chickens were offered semi-purified diets with eight protein-rich feedstuffs, including; blood meal (BM), plasma protein meal (PPM), cold pressed (CCM) and expeller-pressed (ECM) canola meal, high (SBM HCP) and low (SBM LCP) crude protein soybean meals, lupins and peas. Diets were iso-caloric, iso-nitrogenous and the test ingredient was the sole source of dietary nitrogen. Each diet was offered to 6 bioassay cages with 6 birds per cage from day 21 to 28 post hatch. On day 28, all birds were euthanized and digesta samples were collected from the proximal jejunum, distal jejunum, proximal ileum and distal ileum to determine apparent protein and amino acids digestibility coefficients, digestion rates and potential digestible protein and amino acids. Dietary protein source significantly influenced energy utilisation, nitrogen retention, apparent protein (N) digestibilities, digestion rates and potential digestible protein along the small intestine. Diets containing BM and SBM LCP exhibited the highest protein digestion rate and potential digestible protein, respectively. Digestibility coefficients and disappearance rates of the majority of amino acids in four sections of the small intestine were influenced by dietary protein source (P < 0.01) and blood meal had the fastest protein digestion rate. In general, jejunal amino acid and protein digestibilities were more variable in comparison to ileal digestibilities, and the differences in protein and amino acid disappearance rates were more pronounced between types of feedstuffs than sources of similar feedstuffs.

Omega-3 Phospholipids from Krill Oil Enhance Intestinal Fatty Acid Oxidation More Effectively than Omega-3 Triacylglycerols in High-Fat Diet-Fed Obese Mice.

Antisteatotic effects of omega-3 fatty acids (Omega-3) in obese rodents seem to vary depending on the lipid form of their administration. Whether these effects could reflect changes in intestinal metabolism is unknown. Here, we compare Omega-3-containing phospholipids (krill oil; ω3PL-H) and triacylglycerols (ω3TG) in terms of their effects on morphology, gene expression and fatty acid (FA) oxidation in the small intestine. Male C57BL/6N mice were fed for 8 weeks with a high-fat diet (HFD) alone or supplemented with 30 mg/g diet of ω3TG or ω3PL-H. Omega-3 index, reflecting the bioavailability of Omega-3, reached 12.5% and 7.5% in the ω3PL-H and ω3TG groups, respectively. Compared to HFD mice, ω3PL-H but not ω3TG animals had lower body weight gain (−40%), mesenteric adipose tissue (−43%), and hepatic lipid content (−64%). The highest number and expression level of regulated intestinal genes was observed in ω3PL-H mice. The expression of FA ω-oxidation genes was enhanced in both Omega-3-supplemented groups, but gene expression within the FA β-oxidation pathway and functional palmitate oxidation in the proximal ileum was significantly increased only in ω3PL-H mice. In conclusion, enhanced intestinal FA oxidation could contribute to the strong antisteatotic effects of Omega-3 when administered as phospholipids to dietary obese mice.

Protein digestive dynamics of meat and bone meals in broiler chickens

This study determined the variations in protein digestibilities and digestion rates in broiler chickens offered diets containing 7 different meat and bone meals (MBM). A total of 252 male Ross 308 broiler chickens were offered 7 atypical diets largely based on maize and MBM from 24 to 28 d post-hatch. Each experimental diet was offered to 6 replicates with 6 birds per replicate cage. Excreta were collected in their entirety from 25 to 27 d post-hatch and on 28 d post-hatch. Digesta samples were collected from the proximal jejunum, distal jejunum, proximal ileum and distal ileum. Apparent digestibilities of protein were determined in each segment and apparent digestibilities of amino acids were measured in the distal ileum. There were significant differences in apparent protein digestibility coefficients in the proximal jejunum (P = 0.006), where broiler chickens offered the high ash beef meal (diet 7) generated the lowest protein digestibility in the proximal jejunum (0.318). Similarly, there were significant differences in apparent digestibility coefficients in the distal jejunum (P < 0.001) and distal ileum (P < 0.001) but not in the proximal ileum. More pronounced differences were found in the disappearance rate of protein and there were significant differences in all 4 segments of the small intestine (P < 0.001). Broiler chickens offered the high ash beef meal had the lowest protein disappearance rate (P < 0.001). No difference was observed in the predicted protein digestion rate (P = 0.486) but chickens offered the high ash beef meal had the lowest potential digestible protein (0.662, P = 0.034) whereas the highest potential digestible protein (0.739) was detected in diet 5 (containing a beef meal). This study contributed to the establishment of a preliminary database to include digestion rates of starch and protein into practical diet formulation.

Coarse limestone does not alleviate the negative effect of a low Ca/P ratio diet on characteristics of tibia strength and growth performance in broilers

The hypothesis was tested that an increased digestion of coarse compared with fine limestone can alleviate the negative effects of a low dietary Ca/P ratio on the growth performance and characteristics of tibia strength (CTS) in broilers. A total of 1,152 Ross 308 broiler chickens received a standard commercial starter feed from day 0 to 13. From day 14 onward, birds received 1 of 12 diets containing 1 of 6 Ca/P ratios (0.50, 0.75, 1.00, 1.25, 1.50, and 1.75) and 1 of 2 limestone particle sizes (<500 [fine] and 500 to 2,000 [coarse] μm) in a study with a 6 × 2 factorial arrangement of treatments. Total P content was fixed at 5.5 g/kg for all treatment diets. Each treatment was replicated 6 times with 16 birds per replicate pen. On day 20 and 21, twelve birds per pen were randomly selected from 4 of the 6 replicate pens for tibia analysis and digesta collection from different gut segments. The apparent Ca digestibility was higher for fine than coarse limestone in the jejunum (P = 0.043). However, this difference in Ca digestibility disappeared for the low, whereas it remained for the high Ca/P ratios in the proximal (Pinteraction = 0.067) and distal (Pinteraction = 0.052) ileum. In addition, coarse limestone improved apparent P digestibility in the proximal and distal ileum (P < 0.001) but not in the jejunum (P = 0.305). Regardless of limestone particle size, reducing dietary Ca/P ratio linearly improved apparent Ca and P digestibility in the proximal and distal ileum (P < 0.001). Moreover, decreasing dietary Ca/P ratio linearly (P < 0.001) and quadratically (P < 0.046) reduced the CTS. Reducing dietary Ca/P ratio linearly (P < 0.003) and quadratically (P ≤ 0.006) decreased body weight gain and increased feed conversion ratio. For both fine and coarse limestone, the optimal Ca/P ratio was 1.00 to 1.25 to optimize apparent Ca and P digestibility while maintaining growth performance and CTS. Reducing Ca/P ratio from 1.75 to 1.00 improved distal ileal Ca and P apparent digestibility from 36.6 to 53.7% and 48.0 to 58.3%, respectively. In conclusion, coarse limestone is equally digestible with fine limestone at a low Ca/P ratio but is less digestible at a high Ca/P ratio, and the optimal Ca/P ratio in the diet is 1.00 to 1.25 for both fine and coarse limestone.