Proximal Ileum Research Articles

Performance of Double Balloon Enteroscopy in the Overweight and Obese Patients

Introduction: There is an assumption that obesity may adversely affect the performance of DBE, when compared to patients with BMI <30. We sought to assess the differences in performance and complication rates of DBE in non-obese patients (BMI <30) compared to obese (BMI >30) and morbidly obese (BMI >35) patients. Methods: A retrospective cohort study was conducted using a registry of consecutive cases of double balloon enteroscopy at the Cleveland Clinic over 8 years from January 1, 2008- December 31,2016. Latest BMI within a 30-day period from the date of procedure was taken as the BMI for the patient. Performance of procedure was assessed on the basis of scope time (in minutes), extent reached and need for repeat procedures within 30 days. Numerical values were assigned based on the depth of scope insertion to assess extent reached: 1 = unable to reach small bowel, 2 = proximal jejunum for ante-grade and distal ileum for retro-grade, 3 = mid jejunum for ante-grade and mid ileum for retro-grade, and 4 = distal jejunum for ante-grade and proximal ileum for retro-grade studies. Patients were divided into 3 groups based on BMI(kg/m2) for comparison i.e. 1) BMI <30 or non-obese (group A), BMI 30-34 or obese (group B) and BMI >35 or morbidly obese (group C) Results: Of 1464 patients [median age 67.2±15.8; 50% female] who underwent DBE at our center during the study period, data on BMI was available in 1408 patients. A total of 862 (62%), 330 (23%) and 216 (15%) belonged to group A,B and C respectively. There were no differences seen between the 3 groups in the amount of scope time, depth of extent reached or rate of repeat 30-day endoscopy. Similarly, no differences were seen between the three groups regarding rates of perforation, aspiration, immediate post-operative gastrointestinal bleeding or changes in level of care. (Table 1) Conclusion: There is no difference in performance outcomes or complication rates in obese and even morbidly obese patients when compared to those with BMI <30. This study supports the fact that endoscopists can perform DBE in obese/morbidly obese patients without concern for increased risk of adverse outcomes.1039 Figure 1 No Caption available.

Antegrade versus Retrograde Single Balloon Enteroscopy - Which Is Better?

Introduction: There are 2 major approaches of single balloon enteroscopy- through mouth or ante-grade approach (AG), or through anus or retrograde (RG)approach. Aim of this study was to assess the differences in performance and complications of both these approaches. Methods: A retrospective cohort study was conducted using a registry of consecutive cases of single balloon enteroscopy at the Cleveland Clinic over 8 years from January 1, 2008- December 31,2016. Electronic medical records were utilized to collect variables including patient demographic, status of antiplatelet agents (at time of procedure), and coexisting comorbid diseases (cardiovascular, renal, and hepatic). Data on endoscopic findings, intervention (if received) was also obtained. Performance of procedures was assessed on the basis of scope time (in minutes), extent reached and need for repeat procedures within 30 days. Numerical values were assigned based on the depth of scope insertion to assess extent reached: 1 = unable to reach small bowel, 2 = proximal jejunum for ante-grade and distal ileum for retro-grade, 3 = mid jejunum for ante-grade and mid ileum for retro-grade, and 4 = distal jejunum for ante-grade and proximal ileum for retro-grade studies. Results: Of 510 patients who underwent SBE, 124 386 (75.7%) patients underwent AG procedures. At baseline patients in both groups were similar, except for older age (68.5 for RG vs 71 for AG, p=0.043) and higher antiplatelet use (34.7% for RG vs 42.5% for AG, p=0.042) in AG group. Deeper scope insertion depth (depth level 3 for AG vs 1 for RG, p < 0.001) and lesser scope time (37.4 mins in AG vs 48.9 mins in RG, p<0.001) was observed with AG procedures. On multivariate analysis AG procedures were found to have 118 higher odds (95% CI 60.5-229.9, p <0.001) of having a deeper scope insertion than RG, and RG procedures had 11.9 higher odds (95% CI 6.7-17, p <0.001) of longer scope time compared to AG. No difference in the rates of adverse outcomes including, bleeding, perforation, aspiration and change in level of care were noted between the two modalities. (Table 1&2)2793_A Figure 1 No Caption available.Conclusion: AG approach is less time consuming and more likely to have a deeper extent of insertion compared to RG approach, with similar rates of complications. Unless the lesion of interest is in close proximity to the ileo-cecal valve, it may be more prudent to proceed with AG approach rather than RG approach.2793_B Figure 2 No Caption available.

Itʼs Not Recurrence?

Case presentation A 53-year-old man was evaluated for nausea, fatigue and progressive weakness. He had a history of a 20cm (figure A) stage IIIb gastric high-grade, predominantly epithelioid, GIST (figure B, note the epithelioid appearing GIST within the black arrows, the oxyntic mucosa within the blue arrows and the muscularis separating the two areas) extirpated by partial gastrectomy and Billroth II ˜18 months prior. A 3cm LUQ mass was found on surveillance imaging 12 months later while being treated with adjuvant tyrosine-kinase inhibitors. Repeat imaging demonstrated an enlarging 6.7x7.0cm mass within the abdominal mesentery anterior to the left kidney. He was referred for laparoscopic partial small bowel resection and excision of a 10 cm mesenteric mass at the level of the efferent jejunal limb, a 3cm nodule at the level of the proximal ileum and 6 smaller nodules within the small bowel mesentery. Histopathology of the resected masses demonstrated a vimentin positive, uniform, spindled cell lesion with minimal inflammation and a rare mitotic figure. The lack of inflammation, storiform spindled pattern, mucin and obliterative vasculitis, helped exclude inflammatory myofibroblastic tumor and IgG4 disease. CD117 (c-kit) and CD34 were negative, excluding residual or recurrent GIST. However, the spindled cell did demonstrate nuclear and cytoplasmic positivity for beta-catenin, supporting the diagnosis of intra-abdominal mesenteric fibromatosis (figure C). Discussion Mesenteric fibromatosis or desmoid tumor is group of rare benign tumors that can be locally aggressive but do not metastasize. They develop in ˜20% of patients with FAP but can appear spontaneously, with tissue trauma and radiation exposure as reported risk factors. To date, there are about 30 reported cases of mesenteric fibromatosis following GIST resection. Co-existence of mesenteric fibromatosis with GIST has been reported as well. Distinguishing mesenteric fibromatosis from recurrent GIST may be difficult given common similarities in radiologic appearance and c-kit expression. Accurate diagnosis can only be made after surgical removal and histopathologic examination. Unfortunately, surgery for mesenteric fibromatosis is not always curative and high rates of recurrence are common. Watchful waiting should be considered after resection, especially in patients with minimal symptoms.2701_A Figure 1. CT of the abdomen2701_B Figure 2. Epithelioid GIST, 10X2701_C Figure 3. Jejunal mesenteric mass, desmin stain, 20x

Starch digestibility and apparent metabolizable energy of western Canadian wheat market classes in broiler chickens.

Wheat is the primary grain fed to poultry in western Canada, but its nutritional quality, including the nature of its starch digestibility, may be affected by wheat market class. The objectives of this study were to determine the rate and extent of starch digestibility of wheat market classes in broiler chickens, and to determine the relationship between starch digestibility and wheat apparent metabolizable energy (AME). In vitro starch digestion was assessed using gastric and small intestinal phases mimicking the chicken digestive tract, while in vivo evaluation used 468 male broiler chickens randomly assigned to dietary treatments from 0 to 21 d of age. The study evaluated 2 wheat cultivars from each of 6 western Canadian wheat classes: Canadian Prairie Spring (CPS), Canadian Western Amber Durum (CWAD), CW General Purpose (CWGP), CW Hard White Spring (CWHWS), CW Red Spring (CWRS), and CW Soft White Spring (CWSWS). All samples were analyzed for relevant grain characteristics. Data were analyzed as a randomized complete block design and cultivars were nested within market class. Pearson correlation was used to determine relationships between measured characteristics. Significance level was P ≤ 0.05. The starch digestibility range and wheat class rankings were: proximal jejunum - 23.7 to 50.6% (CWHWSc, CPSbc, CWSWSbc, CWRSab, CWGPa, CWADa); distal jejunum - 63.5 to 76.4% (CWHWSc, CPSbc, CWSWSbc, CWRSab, CWGPa, CWADa); proximal ileum - 88.7 to 96.9% (CWSWSc, CPSbc, CWHWSbc, CWRSb, CWGPb, CWADa); distal ileum - 94.4 to 98.5% (CWSWSb, CWHWSb, CPSb, CWRSab, CWGPab, CWADa); excreta - 98.4 to 99.3% (CPSb, CWRSb, CWHWSb, CWSWSab, CWGPab, CWADa). Wheat class affected wheat AMEn with levels ranging from 3,203 to 3,411 kcal/kg at 90% DM (CWRSc, CWSWSc, CPSb, CWGPb, CWADa, CWHWSa). Significant and moderately strong positive correlations were observed between in vitro and in vivo starch digestibility, but no correlations were found between AME and starch digestibility. In conclusion, rate and extent of starch digestibility and AME were affected by western Canadian wheat class, but starch digestibility did not predict AME.

Ginger (Zingiber officinale Roscoe) for the treatment and prevention of necrotizing enterocolitis

Ethnopharmacological relevanceNecrotizing enterocolitis (NEC) is the most important gastrointestinal emergency affecting especially preterm infants and causes severe morbidities and mortality. However, there is no cure. Oxidant stress, inflammation, apoptosis, as well as prematurity are believed to responsible in the pathogenesis of the disease. Ginger and its compounds have anti-inflammatory, antimicrobial, anti-oxidant properties and immunomodulatory, cytoprotective/regenerative actions. Aim of the studyThis study aimed to evaluate the beneficial effects of ginger on the intestinal damage in an experimental rat model of NEC. Materials and methodsThirty newborn Wistar rats were divided into three groups: NEC, NEC + ginger and control in this experimental study. NEC was induced by injection of intraperitoneal lipopolysaccharide, feeding with enteral formula, hypoxia-hyperoxia and cold stress exposure. The pups in the NEC + ginger group were orally administered ginger at a dose of 1000 mg/kg/day. Proximal colon and ileum were excised. Histopathological, immunohistochemical (TUNEL for apoptosis, caspase 3 and 8) and biochemical assays including xanthine oxidase (XO), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), malonaldehyde (MDA) and myeloperoxidase (MPO), tumor necrosis factor-α (TNF-α), interleukin1β (IL-1β), and interleukin 6 (IL-6) activity were evaluated. ResultsCompared with the NEC group, the rat pups in the NEC + ginger group had better clinical disease scores and weight gain (p < 0.05). Macroscopic evaluation, Histopathologic and apoptosis assessment (TUNEL, caspase 3 and 8) releaved that severity of intestinal damage were significantly lower in the NEC + ginger group (p < 0.05). The levels of TNF-α, IL-1β and IL-6 in the ginger treated group were significantly decreased (P < 0.05). The GSH-Px and SOD levels of the ginger treated group were significantly preserved in the NEC + ginger group (p < 0.05). The tissue XO, MDA and MPO levels of the NEC + ginger group were significantly lower than those in the NEC group (P < 0.05). ConclusionGinger therapy efficiently ameliorated the severity of intestinal damage in NEC and may be a promising treatment option.

Ghrelin stimulates intestinal adaptation following massive small bowel resection in parenterally fed rats

BackgroundSince short bowel syndrome (SBS) patients face life-threatening conditions, the development of therapeutic strategies to induce intestinal adaptation has been investigated. Ghrelin, a ligand of growth hormone (GH) secretagogue-receptor that stimulates the release of GH and insulin like growth factor-1 (IGF-1), has several pleiotropic effects. We investigated whether ghrelin induces intestinal adaptation in parenterally fed rats with SBS. MethodsSprague-Dawley rats underwent venous catheterization and were divided into 3 groups: those receiving 90% small bowel resection while leaving the proximal jejunum and distal ileum (90% SBR) with TPN (SBS/TPN group), those receiving 90% SBR with TPN + ghrelin (SBS/TPN/ghrelin group), and those receiving sham operation and fed chow (sham group). Ghrelin was administered intravenously at 10 μg/kg/day. On Day 13, the rats were euthanized and the small intestine harvested, and the histology and crypt cell proliferation rates (CCPR), apoptosis, and nutrient transporter protein levels were analyzed and the plasma hormones were measured. ResultsThe villus height and crypt depth of the ileum in the SBS/TPN/ghrelin group were significantly higher than in the SBS/TPN group. The CCPR of the jejunum and the ileum significantly increased by the administration of ghrelin; however, the apoptosis rates did not significantly differ between the SBS/TPN and SBS/TPN/ghrelin groups. Significant differences did not exist in the plasma IGF-1 and nutrient transporter protein levels among three groups. ConclusionsThe intravenous administration of ghrelin stimulated the morphological intestinal adaptation of the ileum to a greater degree than the jejunum due to the direct effect of ghrelin.

Life Threatening Obscure Lower Gastrointestinal Bleeding, Secondary to Isolated Proximal Ileal AV Malformation Management with Intraoperative Enteroscopy and Resection

Obscure gastrointestinal (GI) bleeding refers to intermittent or continuous loss of blood where the source is not identified after upper endoscopy and colonoscopy. It may be occult or overt. Obscure GI bleeding accounts for 10% of total GI bleeding cases. The small intestine is the least common site of GI bleeding (5%).Vascular etiologies like arteriovenous malformations (AVM) are a common cause of obscure bleeding, commonly found in jejunum or right colon (80–90%) and rarely in ileum (8%). AVMs are usually seen in patients over 60 years of age and present as recurrent spontaneous bleeding or anaemia or remain asymptomatic; very rarely, they present as life threatening bleeding. Diagnosis of AVMs is challenging as they are often missed on endoscopies as well as during laparotomies. This makes massive, life-threatening obscure bleeding secondary to AVM a therapeutic challenge, as AVMs tend to rebleed spontaneously, if left untreated. We present a case of middle aged man with no previous comorbidities or GI bleeding, presenting acutely with massive, life-threatening obscure lower GI bleeding. Due to rapidly developing shock and acidosis, surgical management was undertaken. On emergency exploration, with on-table enteroscopy, a single AVM was detected in proximal ileum. It was successfully managed with localised resection.

Efeito da suplementação de colostro enriquecido sobre as características morfológicas da mucosa intestinal de bezerros neonatos

Colostrum intake in neonatal calves is essential to obtain passive immunity and to influence metabolism, endocrine systems and the nutritional state. This study compares morphologic features of small intestine of calves fed a colostrum second meal at 12 hours of life with concentrations of immunoglobulin G (IgG) higher than 100mg mL -1 (fresh colostrum or artificially prepared with addition of lyophilized colostrum) or smaller than 30mg mL -1 . Twenty-four Holstein calves were randomly grouped according to concentration of IgG intake at 12 hours of life: low (less than 30mg mL -1 ); high (more than 100mg mL -1 ); plus lyophilized colostrum (more than 120mg mL -1 ). Intestinal tissue samples were collected at 0, 10, 24 and 72 hours after birth to evaluate morphology in segments: duodenum; proximal, middle and distal jejunum and ileum by examined with a scanning electron microscope. Villi of all segments showed more organized and uniform morphology characteristics with age. Only the animals fed colostrum with more than 100mg mL -1 of IgG at 24 hours after birth still showed the distal jejunum villi disoriented and more united in comparison to the other ages and groups. Intake of lyophilized colostrum affected ileum morphology along experiment period. Higher concentration of immunologic and bioactive elements supplied for longer period of time could be responsible for promoting effects on the enterocytes. Use of colostrum with high IgG concentrations, with or without addition of lyophilized colostrum, influenced the precocity of the intestinal mucosa development in newborn calves, suggesting earlier maturation of the mucosa.

Dietary starch influences growth performance, nutrient utilisation and digestive dynamics of protein and amino acids in broiler chickens offered low-protein diets

A total of 288 day-old, male Ross 308 chicks were offered six dietary treatments from 7 to 28 days post-hatch. A standard maize-soy diet was compared with five low protein diets containing high inclusions of maize starch and various combinations of supplemental amino acids. The assessed parameters included growth performance, nutrient utilisation, digestibility coefficients and disappearance rates of starch, protein and amino acids in four small intestinal segments. Also, the effects of three dietary treatments on free plasma amino acid concentrations in the anterior mesenteric vein or portal circulation were determined. The transition from standard to low protein diets elevated feed intakes and compromised FCR. Overall, tangible differences in responses were not observed in birds offered the five low protein diets which effectively precluded meaningful comparisons between the various combinations of crystalline amino acids. Maize starch inclusions in low protein diets enhanced starch digestibility coefficients and disappearance rates and parameters of nutrient utilisation. However, maize starch also depressed protein digestibility coefficients and disappearance rates. Moreover, amino acid digestibility coefficients were depressed in the three posterior segments of the small intestine. Instructively, proximal ileal starch digestibility coefficients were negatively correlated with digestibility coefficients of twelve amino acids in the proximal ileum to significant extents. Significant differences in concentrations of free amino acids in plasma from the anterior mesenteric vein were observed for histidine, lysine, methionine, threonine and valine in birds offered the standard and two low protein diets. The possibility that glucose and amino acids were effectively competing for intestinal uptakes, especially from the ileum, is discussed. Also, it appears that the metabolic fates of amino acids in enterocytes of the gut mucosa can be manipulated by dietary strategies and that crystalline amino acids may be less prone to undergo catabolism in the gut mucosa.

The Role of Surgery in a Patient with Carcinoid Syndrome, Complicated by Carcinoid Heart Disease

A 55-year-old female patient was admitted for flushing and abdominal pain in the right upper quadrant. Her past medical history revealed high blood pressure and a recent echocardiography showed thickened appearance of tricuspid valve with coaptation defect and grade II tricuspid regurgitation. Contrast enhanced abdominal CT scan and MRI were subsequently performed and revealed a large macronodular liver mass, as well as other micronodular lesions disseminated in the liver parenchyma. CT guided biopsy from the main liver mass revealed neuroendocrine tumor of unknown origin (probably GI) with Ki-67 of 8%. Surgical exploration was decided. During laparotomy, the primary tumor was found in the proximal ileum and the patient underwent segmental enterectomy. Non-anatomical hepatectomy was also performed to remove the bulk of the tumor burden (more than 90%). Postoperative course was uneventful and the carcinoid syndrome relieved. At present, 15 months postoperatively, the patient is under treatment with somatostatin analogue for its antiproliferative effect, with good clinical, biochemical and tumoral control and stable heart disease. In patients with neuroendocrine liver metastases from unknown primary, surgical exploration could allow detection (and resection) of the primary tumor and surgical debulking of liver metastases to control carcinoid syndrome and carcinoid heart disease.

Small Bowel Injury after Penetrating Abdominal Trauma despite normal Pre-operative Computerised Tomography. A Case Report of a Successful Laparoscopic Repair

Background: The surgical management of a patient with a penetrating injury can be challenging. We present a case of a patient with a small bowel injury after penetrating abdominal trauma and its successful management despite normal Computerised Tomography (CT).Case and methods: A 39-year-old female, suffering from an anterior abdominal stab wound (AASW), was transferred to Accident and Emergency Department (A&E) after attempting to suicide with a knife. During transfer and on arrival at A&E patient was haemodynamically stable. Primary survey (ABCDE) revealed no concerning findings and abdominal examination revealed a 3cm horizontal wound 4cm above umbilicus. Abdomen was soft, mildly tender. Resuscitation and basic investigations were performed according to ATLS principles. Decision was to proceed with CT scan of the abdomen and pelvis (CTAP). After CTAP, patient became hypotensive and was resuscitated with 1 unit of RBCs and tranexamic acid. CTAP showed no intraperitoneal injury with no free intraperitoneal gas or fluid. Patient was reviewed by surgeons and decision was to proceed with Diagnostic Laparoscopy.Results: Laparoscopy revealed peritoneal penetration, abdominal muscle haematoma with haemorrhagic fluid in pelvis and sero-muscular tear of the proximal ileum. Sero-muscular tear was repaired laparoscopically with an uneventful post-operative period.Conclusion: Detailed clinical examination and experienced surgeon with advanced laparoscopic skills can result to a successful management of stable patients with anterior abdominal stab wounds, faster recovery and avoidance of unnecessary CT scans and laparotomies.

Emergency laparotomy with synchronous Caesarean section for life-threatening strangulated Petersen's hernia

Introduction Bariatric surgery is the most effective treatment for morbid obesity and its co-morbidities. Women are advised against becoming pregnant in the first 12-18 months after surgery due to the potential nutritional compromise induced by weight loss. An increasingly recognised complication following bariatric surgery are Petersen-type internal hernias. We present a case of life-threatening Petersen’s hernia at 31 weeks of pregnancy in a patient who had previously undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity. Case description A 31-week pregnant 28-year-old (G2P1) presented as an emergency with abdominal pain, vomiting and absolute constipation. Two years previously she had undergone a laparoscopic Roux-en-Y gastric bypass and had lost 31kg. She was tachycardic, tachypnoeic and pyrexial. Blood tests performed showed a raised white cell count 14.4x109/L, haemoglobin 114g/L, C-reactive protein 36mg/L, urea 4.1mmol/L, creatinine 64μmol/L and lactate 1.94mmol/L. An abdominal ultrasound scan showed free fluid in the abdomen and confirmed a viable intra-uterine foetus. A targeted abdominal computer tomographic (CT) scan showed a closed loop obstruction of the jejunum and proximal ileum around the Roux-en-Y reconstruction, most likely an internal hernia of Petersen. The herniated small bowel was non-enhancing, distended and fluid-filled, therefore thought to be non-viable radiologically. Results and Conclusions The patient underwent emergency Caesarean section followed by laparotomy, small bowel resection and formation of laparotomy. She was returned to theatre 24 hours later for a second-look laparotomy. The intra-operative findings demonstrated healthy common channel measuring 270cm, bilio-pancreatic limb measuring 80cm and a long narrow gastric pouch and a small alimentary limb remnant. The gastric bypass was reversed by excising the remnant alimentary limb and fashioning gastro-gastrostomy and anastomosing the bilio-pancreatic limb to the common channel. The patient made an uneventful recovery. Clinicians involved in the management of patients with previous gastric bypass should be aware of the potential complications. We suggest that obstetric care of post-operative bariatric patients requires early liaison with the bariatric surgical team. Take home message Obstetric care of post-operative bariatric patients requires early liaison with the bariatric team. Clinical presentations of Petersen’s hernia are non-specific and clinicians should have a high index of suspicion of this diagnosis when assessing patients with previous surgery involving Roux-en-Y reconstruction.

Over-The-Scope-Clip pre-mounted onto a double balloon enteroscope for fast and successful closure of post-EMR jejunal perforation: case report

BackgroundFamilial adenomatous polyposis (FAP) is a rare, autosomal dominant disease clinically characterized by the early onset of many adenomatous polyps throughout the colon, which turn into colon cancer, if left untreated. In FAP patients, polyps can also occur in the upper gastrointestinal (GI) tract, especially in the duodenum. Adenomas beyond duodenum are rare and mostly located in the proximal jejunum and distal ileum. The management of such polyps can be either surgical or endoscopic, depending on the features of the polyp, Spigelman stage and patient’s clinical conditions. Endoscopic mucosal resection (EMR) of jejunal polyps can be challenging, because of the thinner wall of jejunum, compared to the rest of the GI tract, and of the difficulty of maintaining control and stability of the scope. For these reasons, jejunal perforation is a likely occurrence.Case presentationA 65-year-old woman with a stage IV FAP, who had previously undergone abdominal surgery because of her disease, came to our attention because of numerous adenomatous-looking duodenal polyps and a 25 mm lesion in proximal jejunum. According to Spigelman staging system, patient was candidate for surgical resection, in light of the risk of developing small bowel cancer. Despite the benefits of surgery were clearly explained to her, she refused to undergo small bowel resection. Therefore, EMR of the largest duodenal polyp and of the jejunal lesion was planned. After the removal of the jejunal polyp, a small perforation was noted. We were able to rapidly close such perforation by using the Over-The-Scope-Clip system (OTSC, 12/6 t; Ovesco, Tübingen, Germany) pre-mounted onto a double balloon (DB) enteroscope.ConclusionsThe endoscopic management of jejunal perforation can be tricky and the placement of traditional through-the-scope clips in a narrow space like jejunum may be difficult and time consuming.This case describes the use of the OTSC system pre-mounted onto a DB enteroscope for the closure of post-EMR jejunal perforation.

Gastrointestinal distribution of chicken gastrin-cholecystokinin family transcript expression and response to short-term nutritive state

The related peptide hormones cholecystokinin (CCK) and gastrin are conserved throughout vertebrate clades and implicated in energy homeostasis. CCK is generally accepted as a satiety hormone in poultry, but the role of gastrin remains poorly studied. Functional dissection of these ligands is required to characterise the molecular control of growth & satiety in the domestic chicken, for which there is an increasingly pressing mandate. There are limited descriptions of physiological distributions for the two genes in birds, and these are mostly reliant on immunohistochemistry which can prove problematic due to the shared structure of the targets. Therefore, we have defined the tissue distributions of CCK and gastrin in the chicken, focussing on the gastrointestinal tract, by using transcript-dependent techniques to improve reliability by increasing specificity. Though considerably more highly expressed in the brain, gastrointestinal CCK transcripts were dispersed throughout the small intestine and particularly around the proximal ileum. Gastrin expression was strictly limited to the gastric antrum region of the intestinal tract, albeit very highly expressed. We demonstrate that CCK mRNA expression does not respond as expected for a short-term satiety hormone, and that the short-term response of gastrin expression is paradoxical compared to its role in mammals. These results partially corroborate previous peptide distribution studies and initiate exploration of the nutrient-responsive roles of these hormones in avian energy balance.

Isolated Visceral Angioedema: An Uncommon Complication of ACEI Therapy

Angiotensin Converting Enzyme Inhibitors (ACEIs) are commonly prescribed medicines with well-known side effects. We report a lesser known side effect with a stereotypical presentation, “Isolated Visceral Angioedema” (IVAE). This can occur within hours to years after initiation of ACEIs with a strong female predominance clinically presenting with variable levels of abdominal pain, emesis, and diarrhea. Abdominal CT shows diffuse small bowel thickening and ascites. Recognition of this presentation will prevent unnecessary maneuvers including endoscopic procedures and surgical intervention. A 45-year-old white female with hypertension and hypothyroidism was taking Lisinopril (for 18 months), Levothyroxine and oral contraceptives. She experienced her first episode of abdominal pain with nausea and vomiting six months prior to presentation which spontaneously resolved. She described six additional episodes over the next six months leading to her presentation with severe abdominal pain which brought her into the hospital. At presentation she was in moderate to severe abdominal pain, vital signs were stable and abdominal exam demonstrated diffuse abdominal tenderness without rebound. CBC showed only a WBC of 17.7, chemistries were normal. CT abdomen and pelvis revealed thickening of her distal jejunum and proximal ileum spanning 30 cm in length and ascites. Negative stool culture, ova and parasites, and C. Difficile. C1 esterase inhibitor, C3 and C4 complement levels were normal. Treatment consisted of discontinuing her Lisinopril. Repeat abdominal and pelvic CT two weeks later, showed complete resolution of small bowel thickening and ascites. To date, 36 months later, the patient has had no recurrence of symptoms. Diagnosis of IVAE is based on the triad of typical symptoms (abdominal pain, nausea, vomiting and diarrhea); typical CT findings of thickened small bowel and ascites; and history of ACEI use. This occurs in the absence of peripheral manifestations of angioedema (lip or tongue swelling, urticaria, and respiratory symptoms). The differential of small bowel thickening and ascites includes: infections, ischemia, inflammation (Crohn's) and neoplastic causes. IVAE commonly resolves after recognition via history and imaging studies with immediate cessation of ACEIs followed by NPO and IVF hydration, and possible fresh frozen plasma used as second line agent in complicated refractory cases.Figure: Abdominal oral and IV contrast CT showing peri-hepatic ascites and thickening of the stomach walls.Figure: Abdominal oral and IV contrast CT showing peri-hepatic ascites with thickened stomach walls.Figure: Abdominal oral and IV contrast CT showing visible thickening of the intestinal wall.

Eosinophilic Enteritis: A Delayed Diagnosis

Eosinophilic Gastrointestinal Disorders (EGID) are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic esophagitis (EoE) is limited to the esophagus while eosinophilic gastroenteritis (EGE) can involve any portion of the GI tract. Patients often present with a wide range of signs and symptoms including abdominal pain, nausea, vomiting, dysphagia, diarrhea, and even more serious manifestations such as intestinal obstruction or perforation as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal1,4,10. As a part of the work-up, patients frequently undergo CT scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59 year-old male patient presenting with 2 months of nausea, abdominal pain and weight loss. He underwent EGDs, colonoscopies, a video capsule study and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic findings can be variable and often include mucosal erythema, edema, strictures, polypoid lesions and ulcerations8. Radiographic findings are also unpredictable and may include mural thickening, nodularity, luminal narrowing, and perienteric inflammation suggestive of an acute inflammatory condition2,3,8. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting with a flat pink appearance were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/hfu confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders including asthma, eczema, seasonal allergies and food allergies suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history4. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course8.Figure: Endoscopy showing erythematous gastric nodules in the antrum of the stomach.Figure: Endoscopy showing erythema, scalloping, and villous blunting throughout portions of gastrointestinal tract.

Eosinophilic Enteritis: A Delayed Diagnosis.

Eosinophilic gastrointestinal disorders are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Patients often present with a wide range of signs and symptoms as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal. As a part of the workup, patients frequently undergo computed tomography scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59-year-old male patient presenting with 2 months of nausea, abdominal pain, and weight loss. He underwent esophagogastroduodenoscopies, colonoscopies, video capsule study, and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic and radiographic findings can be variable and are usually unpredictable. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high-power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/high-power field confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course.

Macroscopic anatomical study of the distribution of the cranial mesenteric artery to the intestine in the rabbit.

Intestinal surgery is commonly performed to cure bowel obstruction in rabbits, but detailed descriptions of the arterial supply to the intestine are incomplete. We investigated anatomical variations of the distribution of the cranial mesenteric artery to the intestine in 33 New Zealand White rabbits by injecting colored latex into the arteries. The cranial mesenteric artery arose independently from the abdominal aorta at about 2.0cm caudal to the celiac artery and branched off the pancreaticoduodenal, middle colic, ileocecocolic, jejunal and ileal arteries. One or occasionally two caudal pancreaticoduodenal arteries supplied the distal duodenum, and one to three middle colic arteries supplied the transverse colon and the initial portion of the descending colon. The ileocecocolic artery arose distal to the middle colic arteries and provided the right colic, ileocecal and appendicular arteries, and branches to the proximal colon, with various branching patterns, which were grouped into four major types. These arteries and branches supplied the ileum, cecum, appendix and proximal colon. The cranial mesenteric artery also provided the jejunal arteries (predominantly 17; range 11-21) and one ileal artery supplying the jejunum and proximal ileum, respectively. The results show that the distribution patterns of the cranial mesenteric artery to the intestine in the rabbit are highly specialized to this species. Such specialization should always be considered when performing intestinal surgery in rabbits.

Marked stem/progenitor cell expansion occurs early after murine ileostomy: a new model

BackgroundImproving treatment for short bowel syndrome requires a better understanding of how intestinal adaptation is affected by factors like mechanoluminal stimulation. We hypothesized that in mice, luminal diversion via an ileostomy would drive adaptive changes similar to those seen in human intestine after diversion while offering the opportunity to study the immediate events after resection that precede intestinal adaptation. Materials and methodsWith Institutional Animal Care and Use Committee approval, a distal ileostomy with a long distal Hartman's was created in 9- to 14-week-old C57/B6 mice (n = 8). Control mice only had a midline laparotomy without stoma formation (n = 5). A rim of tissue from the proximal stoma was resected as a historical control for the proximal segment. Postoperatively, mice received a high-protein liquid diet and water ad libitum. On day 3, tissue from both the proximal and distal limbs were collected for histologic and RNA analysis. Morphometric measures, immunofluorescent antigen detection, and RNA expression were compared with Student paired t-tests with a P value < 0.05 considered significant. ResultsAt 3 d, survival for mice with an ileostomy was 87% and average weight loss was 12.5% of initial weight compared to 6.05% for control mice. Compared to the distal limb, the proximal limb in mice with an ileostomy demonstrated significantly taller villi with deeper and wider crypts. The proximal limb also had decreased expression of intestinal stem cell markers lgr5, bmi1, sox9, and ascl2. Fewer goblet and enteroendocrine cells per hemivillus were also noted in the proximal limb. In control mice, none of these measures were significant between proximal and distal ileum except for villus height. ConclusionsThis new murine ileostomy model allows study of intestinal adaptation without intestinal anastomosis, which can be technically challenging and morbid.

NOD2 Deficiency Impairs the Intestinal Tight Junction Barrier in a Murine Short Bowel Model.

Introduction: Short bowel syndrome with chronic intestinal failure occurs after extensive small bowel resection. Despite intestinal adaptation, protein, energy, fluid and micronutrient balance cannot be maintained by a conventional diet. NOD2 mutations are a risk factor for chronic intestinal failure independent of the underlying disease. The mechanisms are not well understood. In a murine short bowel model the epithelial barrier function in the adapted jejunum was studied in the presence and absence of NOD2. Methods: Male C57BL6/J NOD2 knockout (−/−) and wild type (+/+) mice underwent 40% ileocecal resection (ICR). Sham control mice received transsection of the ileum. Mice were followed up for 14 days. At baseline (d0) 1cm of the most proximal resected ileum was studied in a vertical Ussing chamber and histologically. After 14d 1cm of the most distal remaining small intestine was studied and compared to baseline. In order to study the paracellular leak pathway, flux of 4kDa FITC-dextran was measured. The pore pathway was characterized by transepithelial resistance (TER) and NaCl diultion potentials. Results: Both +/+ and −/− animals showed similar morphologic adaptation 7 days after ICR such as significantly increased villus height (+/+ 229% P=0.028 vs. d0 and −/− 191% P=0.028 vs. d0, n=6-7 each) and crypt depth (+/+ 153% P=0.028 vs. d0 and −/− 129% P=0.028 vs. d0, n=6-7 each). The barrier to uncharged macromolecules (4 kDa FITC-dextran flux) was largely unaffected by NOD2 status. TER was not different in jejunal segments of +/+ and −/− mice at baseline levels (d0) and increased in the adapted jejunum. TER increase at d14 was significantly higher in −/− mice (74.5±6.0 Ω*cm2 +/+ ICR vs. 105.0±10.6 Ω*cm2 −/− ICR, n=5). In line with this, relative permeability to sodium was more severely impaired in the adapted tissue of −/− mice (+/+ ICR d0 7.7±0.4 vs. 14d 6.9±0.3 P=0.35, −/− ICR d0 6.3±0.1 vs. 14d 5.7±0.1 P=0.0157, n=5 each). Conclusion: Profound morphologic adaptation occurs after extensive ileocecal resection. The paracellular leak flux across the adapted epithelium is unaffected by NOD2 status. In contrast, TER is increased after adaptation and more so in absence of NOD2. This may in part be explained by an altered internal electric field in the structurally altered mucosa. However, adaptation of the tight junction barrier occurs as well. Our studies indicate that NOD2 function specifically contributes to the regulation of tight junction mediated charge selective ion flux in the adapted jejunum.