Proximal Jejunum Research Articles

Changes in iron transporter divalent metal transporter 1 in proximal jejunum after gastric bypass.

To describe the variation that divalent metal transporter 1 (DMT1) shows in patients after Roux-en-Y gastric bypass (RYGB) surgery. Prospective and analytical study of DMT1 level at the brush border of proximal jejunum in patients having undergone RYGB surgery. The mucosa of proximal jejunum forming the gastrojejunal anastomosis was biopsied during surgery and after 6 mo later with an endoscopic biopsy. All the patients received precise instructions regarding feeding and nutritional supplementation. Both samples were processed at the same time by immunohistochemistry and western blot. Samples were analysed by a pathologist. For statistical analysis, the χ(2) and Wilcoxon tests were used. Sixteen patients were recruited, 13 of whom completed the study. Twelve were women. Average age and body mass index (BMI) were 44.1 and 40.4, respectively. Both body weight and BMI decreased significantly during the study period, with an average percent excess weight loss (%EWL) of 60% ± 13.3% and an average percent excess BMI loss (%EBMIL) of 79.6% ± 21.6%. Only two patients presented with mild anaemia 6 mo after surgery, but their ferritin levels stayed within normal ranges. Staining for DMT1 showed a significant increase in the cytoplasm of enterocytes located at the tips of the villi (χ(2) = 6.03; P = 0.049). Nevertheless, the total quantity of DMT1 decreased significantly (Z = 2.04; P = 0.04). Associated with these results, we observed a significant increase in goblet cells in the villi 6 mo postoperatively (Z = -2.47; P = 0.013). Six months after RYGB surgery, patients exhibit an increase in DMT1 expression in the enterocytes of the tips of the villi at the proximal jejunum.

A Short Bowel (Small Intestine = 40 cm), No Ileocecal Valve, and Colonic Inertia Patient Works Well with Oral Intake Alone without Parenteral Nutrition.

We present a 50-year-old male who suffered from ischemic bowel disease, having undergone massive resection of small intestine and ileocecal valve. He had to cope with 40 cm proximal jejunum and 70 cm distal colon remaining. In the postoperative period parenteral nutrition (PN) was used immediately for nutrition support and electrolyte imbalance correction. We gave him home PN as regular recommendation for the short bowel status after discharge from hospital. This patient has tolerated regular oral intake 2 months later and did not develop significant short bowel syndrome. There were several episodes of venous access infection which troubled this patient and admitted him for treatment during home PN. Therefore, we changed home PN to cyclic tapering pattern. The patient could maintain his nutrition and hydration with oral intake alone after tapering home PN 15 months later. He has survived more than one year without PN support and still maintained 80% ideal body weight with average albumin of 3.5 ± 0.2 mg/dL. Although patient was hospitalized every two months to supplement nutrients, however, this has greatly improved the quality of life.

Changes in Bacterial Population of Gastrointestinal Tract of Weaned Pigs Fed with Different Additives

This study aimed to provide novel insights into the gastrointestinal microbial diversity from different gastrointestinal locations in weaning piglets using PCR-restriction fragment length polymorphism (PCR-RFLP). Additionally, the effect of different feed additives was analyzed. Thirty-two piglets were fed with four different diets: a control group and three enriched diets, with avilamycin, sodium butyrate, and a plant extract mixture. Digesta samples were collected from eight different gastrointestinal segments of each animal and the bacterial population was analysed by a PCR-RFLP technique that uses 16S rDNA gene sequences. Bacterial diversity was assessed by calculating the number of bands and the Shannon-Weaver index. Dendrograms were constructed to estimate the similarity of bacterial populations. A higher bacterial diversity was detected in large intestine compared to small intestine. Among diets, the most relevant microbial diversity differences were found between sodium butyrate and plant extract mixture. Proximal jejunum, ileum, and proximal colon were identified as those segments that could be representative of microbial diversity in pig gut. Results indicate that PCR-RFLP technique allowed detecting modifications on the gastrointestinal microbial ecology in pigs fed with different additives, such as increased biodiversity by sodium butyrate in feed.

SPECT/CT Helps in Localization and Guiding Management of Small Bowel Gastrointestinal Hemorrhage

A 59-year-old female patient was hospitalized with anemia from recurrent gastrointestinal bleeding. Planar (99m)Tc-tagged red blood cell bleeding scan suggested an active site of low-rate hemorrhage in the left upper quadrant, but after 60 minutes it could not conclusively define the bleeding as originating in small versus large bowel. SPECT/CT unequivocally localized the hemorrhage to the small bowel and deemed it reachable by extended version ("push"’) endoscope. Subsequent push enteroscopy confirmed the bleeding in proximal jejunum and allowed effective treatment with electrocautery.

A case of carcinoid likely causing jejunal intussusception.

A 34-year-old female was admitted to Emergency Department with an abrupt onset of diffuse abdominal pain. A CT scan done prior to her transfer revealed significant dilated loops of bowel as well as multiple target signs with likely torsed bowel. The patient consented to an exploratory laparotomy. During surgery, the proximal jejunum was found to be intussuscepted, a rare finding in an adult. There was evidence of mesenteric foreshortening throughout the small bowel and multiple whitish lesions within the mesentery, both consistent with the desmoplastic response that is characteristic of carcinoid. The interest for this case report comes from the patient's surgical findings of jejunal intussusception as well as her extensive history, which includes a bowel resection with an ileocolic anastomosis for presumed ischemia and a carcinoid tumor in the stomach which had been removed endoscopically.

噴門側胃切除・空腸嚢間置再建術から13年を経て発生した空腸嚢癌の1例

噴門側胃切除・空腸嚢間置再建術から13年を経て発生した空腸嚢癌の1例を経験したので報告する．症例は81歳，女性．13年前に噴門部癌に対し，噴門側胃切除・空腸嚢間置再建術の既往歴がある．貧血を主訴に，近医にて上部消化管内視鏡検査を施行したところ，空腸嚢内に腫瘍性病変を認めた．生検にて高分化管状腺癌と診断され，手術を目的に当院紹介となった．空腸嚢癌の診断にて残胃空腸嚢全摘，Roux-en Y再建術を施行した．摘出された空腸嚢には5.0×4.5cm大の隆起性腫瘍（大腸癌肉眼型分類5型）を認めた．組織学的検索では粘膜固有層から漿膜下層にかけて，乳頭腺癌・中分化管状腺癌・高分化管状腺癌・粘液癌が混在して増生しており，乳頭腺癌が優位であった．噴門側胃切除・空腸嚢間置再建術後に発生した空腸嚢癌という非常に稀な症例を経験したので，若干の文献的考察を加えて報告する．

Immunohistochemical Study of the Effect of Chamomile Extract on 5-Fluorouracil Induced Intestinal Mucositis in Albino Rats

Background and objectives: 5-Fluorouracil (5-FU) is a commonly used drug for the treatment of malignant cancers. Approximately 80% of patients undergoing 5-FU treatment suffer from gastrointestinal mucositis. The aim of this study was to investigate the effect of chamomile extract on the pathogenesis of 5-FU induced intestinal mucositis in Albino rat.Materials and methods: In current study forty females Albino rats, weighing 220-280 g were used in the study. For the induction of mucositis, 60 mg/kg of 5-FU was administered intraperitoneally to each animal in the study group on day 0, and 40 mg/kg was administered on day 2. The control animals were intraperitoneally injected by normal saline in the same manner and dose like 5-FU on day 0 and 2. Then the rats in each group were randomly divided into two groups: Distilled water treated group and chamomile extract treated group (10 animals each).A volume of distilled water equal to chamomile extract was given by intragastric gavage tube, while the other group was gavaged with chamomile extract at a dose of (100 mg/ kg) two times daily. The treatment with distilled water or the chamomile extract was initiated on day 5 and the experiment continues for twelve days. The body weight for each rat was measured and then the animals were sacrificed on day 8 and 12 (five animals each). In each experiment, one centimeter of proximal jejunum was removed for histopathological, intestinal morphometry, and immunohistochemical analysis using Ki-67 and Bcl-2 immunolabeling.Results: Chamomile can protect the jejunum from fluorouracil-induced cytotoxicity and attenuate or decrease the associated injury. The chamomile in 5-FU/chamomile group causes significant increase in villi length, crypt depth, number of goblet cells, and Ki-67 and Bcl-2 immunexpression in comparison with 5-FU/water group at day 8. But longer duration of taking chamomile can cause cytotoxic and damaging effect to the jejunum. Conclusion: Chamomile can protect the jejunum from fluorouracil-induced mucositis, it attenuate the associated injury if it taken for short duration, but the reverse was occurred if it taken for longer period.

Late Postoperative Anterograde Jejunojejunal Intussusception after Total Gastrectomy with Loop Esophagojejunostomy

Anterograde jejunojejunal intussusception after total gastrectomy is a very rare postoperative complication. We report a 54-year-old man with a history of total gastrectomy, uncut Roux-en-Y gastric bypass, and Braun’s jejunojejunal anastomosis. An upper gastrointestinal endoscopy revealed a bulky, reddish mass in the efferent loop with congestion, edema, and mucosal bleeding. An emergency computed tomography showed a target-like multilayered wall thickening in the afferent loop and a lamellar structure arranged in a concentric circle. Surgical exploration revealed an anterograde intussusception of the afferent proximal jejunum adjacent to the jejunojejunostomy site. This is a very uncommon occurrence because most intussusceptions after total gastrectomy are of the retrograde type. Moreover, anterograde jejunojejunal intussusception tends to occur in the early postoperative period. We report a case of late postoperative anterograde jejunojejunal intussusception after total gastrectomy with Braun’s jejunojejunal anastomosis in a 54-year-old Korean man and review the related literature. (Korean J Helicobacter Up Gastrointest Res 2014;14:283-287)

REPAIRING OF TRANSVERSELY CUTTING ACHILLES TENDONWITH AUTOGENOUSSMALL INTESTINAL SUBMUCOSAL LAYER IN DOGS

The current trail designed toevaluate the effectivenessofusing small intestinalsubmucosa ( SIS ) to accelerate healing of Achilles tendon in thestray local breeddog .Ten healthy dogs of both sexeswere usedin thepresent studywhich randomly divided into two equal groups. Thefirstgroup;Achilles tendon acutetransversely transectedand sutured via cross mattress technique with silk suture materialwith supporting ofgypsona.The second groupacute transected tendon sutured andtreated with thesmall intestinal submucosal patch .All operative dogs inspected clinically,grossly as well ashistopathologically during different periods. Results obtained in the first group showed no contamination, no complicationsand there was no anatomical distortions were detectedat operative site except there is adhesion between tendon and neighboring tissues in the first group healing was uncompleted, suture material still presence up to 90 day.At treatment groupclinically animals lame and sign of mild stiffness appeared for three days, no serious complications, grossly was no adhesion detected, the submucosa subsided completely and complete healing occurs at 90 days postoperatively.Histologicallyatcontrol group 30 days post operativelyuncompleted healing, moderate fibroblast proliferation and inflammatory cells were presence, but at 90 dayspresence of dense connective at the site of operation. In treatmentgroup healing progress, autograft is mostly atrophied and organized with granulation at 90 days,hence healing completed perfectly at this period. In conclusion The repairing of acute transverse cutting of Achilles tendon was significantly accelerated with small intestinal submucosal layer which was absorbed andimproves the tissue quality render the native one . Bas.j.vet.Res. Vol.12,No.2,2013 922 INTRODUCTION The main objective of surgery for tendon injuries in the dog is to restore an adequate tensile strength to support body weight(1).As with other tissues its required to cell infiltrationfrom the blood system to provide the necessary reparative factors for tissue healing.(2(.Itis usually difficult and uncertain because the prognosis varies widely depending on the amount of trauma, vascularization, create adhesions and tension, active loads (3).Occurrence of massive adhesions post-operativelybetween tendon and surrounding soft tissuemay delay normal healing.(4), therefordifferent materials have been used for prevent adhesion such as small intestinal submucosa (SIS) has been used as a biological scaffold for the repair different tissue including those of the musculoskeletal systems and for repairing of defective urinary bladder in dog subcutaneous fascia in dogs (5-7).On other side ovine submucosa was used to repair superficial digital flexor tendon in goat(8). It has been also used experimentally in veterinary medicineas vascular grafts ,for reconstruction esophagus) and for accelerateligaments andtendons healing(8-11).the aim of present study to evaluate the efficiency of SIS to improve tendon healing. MATERIALS AND METHODS Tenadultsstray dogs of both sexeswere used in this study to perform current study . The experimentswere carried out withlicense ofveterinary medicine college in university of Mosul at animals house.Operative animals randomlydivided in two equal groups 5 for each.A protocol of anesthesia includedxylazine \ketamine mixture5mg \15 mg intramuscularly premedicated with atropine sulfate at dose of 0.04 mg \B.wt. In both groupssite of operation in left leg at Achilles tendon wasprepared aseptically, skin incised longitudinally about 5 cm over the tendon that exteriorizedfrom sheet Bas.j.vet.Res. Vol.12,No.2,2013 922 andresected transverselywith surgical blade.Group 1 ( control):tendon wassutured with cross mattress then sub cutaneous tissue closed with simple continuous suture technique then theskin incision was closed, gypsona applied to provide proper fixation. Group 2: The animals were prepared to perform laparotomy, loopfrom proximal jejunum exteriorized and 5 cm resected to preparethe submucosal layer.The tunica mucosa was mechanically removed by using a longitudinal wiping motion with ascalpel handle and moistened gauze. The segment was returned to original orientation and the tunica serosa and tunica muscularis were removed from the intestine by similar method. The remaining thin, whitish, translucent tube consisted of the tunica submucosa with attached stratum compactum and muscularis mucosa of the tunica mucosa (12). The SIS was then disinfected anddecellularized in a 0.1% peracetic acid for 2hand sterilized with ethylenealcohol 70 % for 18h and stored in distilled water at 4°C (hydrated form)and terminally re-hydrated in phosphate buffered saline for 20 min prior to use. In treatment group the Achills tendon was transected then sutured as group 1 the treated intestinalsubmucosa wasfixed firmly with non-absorbable suture material(Figure 1) then operation was completed as in group 1.The animals wereinspected clinically then gypsona removed after 30 days postoperatively, gross and histopathological examination were taken at 30 and 90 days post operatively. Bas.j.vet.Res. Vol.12,No.2,2013 929 Figure 1: Intestinalsubmucosa wasfixed firmly with non-absorbable suture material

Effect of method of delivery of sodium butyrate on maturation of the small intestine in newborn calves

The effect of sodium butyrate (SB) supplementation in milk replacer (MR), starter mixture (SM), or both on small intestine maturation in newborn calves was investigated. Twenty-eight male calves with a mean age of 5 (±1) d were randomly allocated into 1 of 4 groups (7 animals per group) and fed (1) MR and SM, without SB (MR− and SM−, respectively; MR−/SM−); (2) MR− and SM supplemented with SB encapsulated within triglyceride matrix (SM+, 0.6% as fed; MR−/SM+); (3) MR supplemented with crystalline SB (MR+, 0.3% as fed) and SM− (MR+/SM−); or (4) MR+ and SM+ (MR+/SM+). The MR was offered in amounts equal to 10% of initial body weight of the calf. The SM was blended with whole corn grain (50/50; wt/wt) and offered ad libitum as a starter diet. Calves were slaughtered at 26d (±1) of age and small intestine development was investigated. Treatment with MR+ decreased villus height in the proximal jejunum and decreased villus height, crypt depth, and tunica mucosa thickness in the middle jejunum, whereas treatment with SM+ tended to increase small intestine weight and crypt depth in the proximal jejunum, and increased villus height in the distal jejunum. In the duodenum, crypt depth and tunica mucosa thickness were greater for the MR−/SM+ group compared with MR−/SM−, MR+/SM−, and MR+/SM+ groups. In the ileum, crypt depth was less for MR−/SM+ compared with MR−/SM−. Supplementation with SB in both MR and SM enhanced cell proliferation and decreased apoptosis in the middle jejunum mucosa. Regarding brush border enzyme activities, addition of SB to MR increased lactase activity in the middle jejunum and maltase activity in the distal jejunum, and tended to increase lactase activity in the distal jejunum, aminopeptidase A activity in the middle jejunum and ileum, and aminopeptidase N activity in the ileum. In contrast, SM+ increased dipeptidylpeptidase IV activity in the distal jejunum and tended to increase aminopeptidase N in the distal jejunum. In conclusion, both MR+ and SM+ affected small intestine development in newborn calves. This effect depended on the method of SB delivery but MR+ generally had a more pronounced effect. No synergistic effect of SB supplementation into MR and SM was found.

Internal Incarceration of Left Paraduodenal Hernia with Necrosis of Proximal Jejunum and Atypical Reconstruction of the Passage: A Case Report

Summary Internal hernias are rare and most of them are diagnosed intraoperatively. We present a case of a 53-year-old man with proximal intestinal obstruction, caused by incarcerated internal hernia. During the operation, a proximal portion of 40 cm of the jejunum was found herniated and strangulated in the lesser sac through an opening of the transverse mesocolon. The jejunum was necrotic and local purulent peritonitis was present. After resection of the proximal 40 cm of the jejunum, the passage was restored using an unconventional approach. The distal duodenum was closed and, to protect the stump, the duodenum was ligated between its second and third parts. A latero-lateral anastomosis was made between the first part of duodenum and the jejunum. Anatomical, clinical and radiological findings, diagnosis and treatment of paraduodenal hernias are discussed in brief.

Incidence, Treatment, and Outcomes of Iron Deficiency after Laparoscopic Roux-en-Y Gastric Bypass: A 10-Year Analysis

Laparoscopic Roux-en-Y gastric bypass (LRYGB) can lead to iron malabsorption through exclusion of the duodenum and proximal jejunum, decreased gastric acidity, and modified diet. Intravenous (IV) iron is a treatment for severe iron deficiency, but the incidence of iron deficiency and the frequency of treatment with IV iron after LRYGB are largely unknown. Our objective was to determine the incidence of iron deficiency and the frequency of IV iron administration after LRYGB. After obtaining IRB approval, the medical records of patients who underwent LRYGB from September 2001 to December 2011 were retrospectively reviewed. Inclusion criteria consisted of determination of at least 1 ferritin value after surgery. Patients were grouped by level of iron deficiency. Patients with at least 1 ferritin <50 ng/mL were considered iron deficient. Statistical analysis included ANOVA. There were 959 patients included; 84.9% were female. Mean age was 43.8 years, and preoperative body mass index was 47.4 kg/m(2). Four hundred ninety-two (51.3%) patients were iron deficient. Of these, 40.9% were severely iron deficient, with a ferritin <30 ng/mL. Intravenous iron was required by 6.7%. After IV iron therapy, 53% had improvement in hemoglobin and ferritin values, and 39% had improvement in ferritin values only. Given the incidence of iron deficiency after LRYGB observed in our series, patients should have iron status monitored carefully by all providers and be appropriately referred for treatment. Female patients should be counseled that there is a 50% chance they will become iron deficient after LRYGB.

Ileal transposition surgery produces ileal length-dependent changes in food intake, body weight, gut hormones and glucose metabolism in rats

Enhanced stimulation of the lower gut is hypothesized to play a key role in the weight loss and resolution of diabetes following bariatric surgeries. Ileal transposition (IT) permits study of the effects of direct lower gut stimulation on body weight, glucose homeostasis and other metabolic adaptations without the confounds of gastric restriction or foregut exclusion. However, the underlying mechanisms and the length of the ileum sufficient to produce metabolic benefits following IT surgery remain largely unknown. To determine the effects of transposing varying lengths of the ileum to upper jejunum on food intake, body weight, glucose tolerance and lower gut hormones, and the expression of key markers of glucose and lipid metabolism in skeletal muscle and adipose tissue in rats. Adult male Sprague-Dawley rats (n=9/group) were subjected to IT surgery with translocation of 5, 10 or 20 cm of the ileal segment to proximal jejunum or sham manipulations. Daily food intake and body weight were recorded, and an intraperitoneal glucose tolerance test was performed. Blood samples were assayed for hormones and tissue samples for mRNA (RT-qPCR) and/or protein abundance (immunoblotting) of regulatory metabolic markers. We demonstrate that IT surgery exerts ileal length-dependent effects on multiple parameters including: (1) decreased food intake and weight gain, (2) improved glucose tolerance, (3) increased tissue expression and plasma concentrations of glucagon-like peptide-1 (GLP-1) and peptide YY (PYY), and decreased leptin concentrations and (4) upregulation of key markers of glucose metabolism (glucose transporter-4 (GLUT-4), insulin receptor substrate 1 (IRS-1), adenosine monophosphate-activated protein kinase (AMPK), hexokinase (HK) and phosphofructokinase (PFK)) together with a downregulation of lipogenic markers (fatty acid synthase (FAS)) in muscle and adipose tissue. Together, our data demonstrate that the reduction in food intake and weight gain, increase in lower gut hormones, glycemic improvements and associated changes in tissue metabolic markers following IT surgery are dependent on the length of the transposed ileum.

Effect of exploratory laparotomy on canine gastrointestinal motility and plasma ghrelin level and the prokinetic effect of erythromycin after operation

Objective To study the effect of exploratory laparotomy on canine gastrointestinal motility and plasma ghrelin level,and to observe the prokinetic effect of erythromycin after operation.Methods Chronic experiment was carried out in 38 conscious Beagles.Strain gauges were implanted on antrum,duodenum,proximal jejunum,and distal colon to record gastrointestinal motility.Dogs were prepared with chronic gastric fistula in addition to a jugular vein cannulation.There were 4 groups:(1) Control group,no laparotomy,no erythromycin ; (2) Exploratory laparotomy group ; (3) Exploratory laparotomy + erythromycin ; (4) Exploratory laparotomy + saline.Results (1) Control group showed typical interdigestive migrating motor complex (MMC).(2) In the exploratomy laparotomy group,on the day of surgery,during recovery period from anesthetia,no MMC was recorded.The sum of contracting waves increased in antrum,duodenum,and jejunum but decreased in colon.The amplitude index significantly decreased (70.76 ± 9.36) ％ to (92.51 ± 13.17) ％ (all P ＜0.01).On postoperative day 1 to 5,there was no MMC in conscious dogs.The sum of contracting waves increased in antrum and colon,but decreased in duodenum and jejunum.The amplitude index significantly decreased (33.83 ± 5.16) ％ to(70.71 ± 8.5) ％ (all P＜0.01).In both sedative and conscious status,by postoperative day 6 to 7,gastrointestinal motility recovered to baseline.On the postoperative day 0 to 5 the mean plasma ghrelin levels decreased markedly compared with the control group(P＜ 0.01).By postoperative day 7,the ghrelin recovered to baseline.(3) In exploratory laparatory +erythromycin group,intravenous injection of erythromycin 2 mg/kg significantly increased the postoperative gastrointestinal motility and stimulated ghrelin release.Conclusions Gastrointestinal motility was significantly disturbed after exploratory laparatomy.The motility and plasma ghrelin concentration both decreased markedly.Erythromycin showed a positive prokinetic effect through release of endogenous ghrelin in the dog. Key words: Explorotory laparotomy; Gastrointestinal motility ; Ghrelin ; Erythromycin

Newly designed coil tube for bowel decompression in patients with small bowel obstructions

The purpose of this study was to clinically evaluate a coil tube that we recently designed for bowel decompression in patients with a small bowel obstruction. The coil tube was composed of a stainless steel coil, a polyolefin tube, and a rubber adaptor. The tube was inserted under fluoroscopic guidance in 14 consecutive patients with small bowel obstructions. Technical success was defined as insertion of the distal end of the tube into at least the proximal jejunum, and clinical success was defined as intestinal decompression and relief of obstructive symptoms. The technical success rate was 100%. Clinical success was achieved in 12 patients (86%). The clinical failures were a patient with peritoneal carcinomatosis and an ileocolic fistula, and a patient with bezoars following intestinal hemorrhage. No coil-related complications occurred. Our newly designed coil tube was safe and effective in patients with bowel decompression associated with a small bowel obstruction. In addition, our tube has several advantages over other currently used tube types.

A Rare Case of Massive GI Bleeding due to Jejunal Diverticulosis: A Diagnostic Dilemma and the Importance of Endoscopic Timing and a Multidisciplinary Treatment Approach

Purpose: A 77-year-old man with no significant past medical history presented to an outside institution with worsening shortness of breath and melena. Hemoglobin 7.6 g/dL on admit. Transfused 3 units pRBC. Incremented to 9.2 g/dL but then fell to 7.2 g/dL the following day. EGD was normal. Colonoscopy with TI intubation showed pan-colonic diverticulosis without active bleeding. He continued to pass melena and require pRBC transfusions. Second EGD and small bowel (SB) enteroscopy performed showing diverticulum in proximal and mid-jejunum without bleeding. Abdominal CT angiography showed no active hemorrhage. He was transferred to our institution. Capsule endoscopy showed large jejunal diverticula with old blood. Balloon-assisted enteroscopy showed multiple large-sized diverticula in distal duodenum, proximal/mid-jejunum. Diverticula contained old blood/clots, but no actively bleeding lesion or recent stigmata seen. Surgical consultation obtained andopined since diverticula involved proximal duodenum and no active bleeding seen, any surgical intervention involving resection of this area would be technically difficult. Mesenteric angiogram showed no active bleeding. Patient required daily pRBC transfusion (total of 12 units since admission). Then began to pass maroon colored stools. Urgent SB enteroscopy with cap-fitted pediatric colonoscope performed. Fresh blood found in proximal jejunum. Large diverticulum with fresh clot/oozing blood identified (Fig 1) but no definitive target seen for endoscopic therapy. Tattoo marking applied. Patient taken for urgent surgery. Laparotomy showed jejunal tattoo with multiple surrounding large diverticuli. 40 cm segment containing tattooed jejunum resected (Fig 1) and fresh blood found inside. Pathology confirmed tattooed region of the diverticuli to be source of bleeding. No further episodes of rebleeding post-surgery or at 60 days. This case illustrates the importance of endoscopic timing in reaching the appropriate diagnosis and the multidisciplinary approach used in successful management. Evaluation of the SB during an episode of active bleeding, particularly in cases when EGD/Colonoscopy are non-diagnostic, can be the key to finding the correct diagnosis. In cases where the etiology of intestinal bleeding is unclear or other diagnostic testing is inconclusive, more urgent endoscopy at the time of active bleeding may have a role in establishing the diagnosis and providing treatment.Figure 1

Novel Use of Endoscopic Clips as Fiducials for Radiotherapy in Small Bowel Lymphoma

Purpose: A 31-year-old woman, raised in Chernobyl during the nuclear disaster, presented with non-bloody diarrhea, pyrosis, and abdominal pain. EGD showed multiple sub-centimeter white nodules in the second portion of the duodenum, with biopsies revealing grade 1 follicular lymphoma. Staging workup limited the disease to the small bowel. The patient underwent radiotherapy; however, on surveillance push enteroscopy, the lymphoma was again identified in the fourth part of duodenum and proximal jejunum. Endoscopic clips were used as fiducials to better localize the tumor during subsequent radiotherapy (1). After repeat radiation simulation, it was noted that a portion of the demarcated lymphomatous mucosa lay outside the previously irradiated field. Again, the patient received radiotherapy (2). The patient achieved complete remission and currently has no evidence of disease on surveillance. Endoscopic clips were developed for hemostasis of GI bleeding. They are being increasingly used for other purposes. Several published articles have described endoscopic clips as tools for localization in preoperative and pre-radiotherapy planning in luminal tumors. However, only one prior report exists describing duodenal follicular lymphoma tumor localization using endoscopic clips. In our case, endoscopic clipping was necessary to properly localize the tumor after treatment failure. Endoscopic clips are increasingly being used as tumor localization tools due to their ease of use and favorable risk/benefit ratio. Larger studies should be done to demonstrate their superiority in tumor localization and decrease in treatment and diseaserelated morbidity.Figure 1: Endoscopic images: one clip placed proximal to duodenal lesion, and 2. clips placed distally to jejunal lesions.Figure 2: CT Simulation: The red volume is the gross tumor volume while the magenta represents the Planning Target Volume which accounts for error due to motion and technique. Note the location of the clips acting as fiducials for future radiation.

PEG-J Administration of Therapeutic Agents for Neurological Disorders: Levodopa-Carbidopa Intestinal Gel for Advanced Parkinsonʼs Disease

Purpose: To determine whether PEG-J administration of levodopa-carbidopa intestinal gel (LCIG) is an effective method for the treatment of advanced Parkinson's disease (PD). Methods: Levodopa is the most effective treatment for PD. With advanced disease, irregular gastric emptying impedes standard oral levodopa effectiveness leading to “On”/”Off” motor fluctuations and dyskinesias. Two phase 3 clinical studies enrolled advanced PD patients with persistent motor fluctuations despite optimized oral therapy. For this novel treatment, involving the collaboration of neurologists and gastroenterologists, all patients underwent a PEG-J procedure for infusion of LCIG (or placebo gel) directly to the proximal jejunum. A 12-week, randomized, double-blind, double-dummy trial compared the effectiveness of LCIG with standard oral levodopa (LC-oral) at reducing motor fluctuations and improving quality of life. A 54-week open-label international trial examined the long-term safety and efficacy of LCIG. “Off” time (when medication is no longer effective and motor symptoms return), the Unified Parkinson's Disease Rating Scale (UPDRS) and the 39-item Parkinson's Disease Questionnaire (PDQ-39) were examined. Adverse events (AEs) were recorded. Results: 71 patients were enrolled in the double-blind, double-dummy trial (n=37 LCIG, 34 LC-Oral), with a mean PD duration of 10.9 years. The reduction in “off” time (P<0.01), improvement in UPDRS Part II (activities of daily living) score (P<0.01) and improvement in PDQ-39 Summary Index (P<0.05) was greater in the LCIG group than in the LC-oral group. Three hundred fifty four patients were enrolled in the long-term, open-label study. As with the double-blind trial, “off” time, UPDRS Part II score and PDQ-39 Summary Index versus baseline were improved at all visits (through Week 54; P<0.01). Most patients (97% in double-blind, 91% in open-label) experienced at least 1 AE; serious AEs occurred in 17% (double-blind) and 31% (open-label). AEs led to discontinuation in 4.2% (double-blind) and 7.6% (open-label). Most AEs were known AEs associated with either levodopa, underlying PD or the procedure and the device. Conclusion: Intrajejunal infusion of LCIG via PEG-J is a novel approach for the long-term delivery of medication in gel form, which improved motor fluctuations and the quality of life in advanced PD patients with limited treatment options. The range of PEG-J complications was within standard ranges reported in the literature and was not increased in this ambulatory patient cohort. Disclosure - Michael Epstein: Dr. Epstein served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Dr. Epstein also serves as a lecturer for AbbVie. David Johnson: Dr. Johnson served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Robert Hawes: Dr. Hawes served on the data adjudication panel for this study and has received compensation from AbbVie for serving as a consultant. Nathan Schmulewitz: Dr. Schmulewitz serves as a medical advisor and speaker for AbbVie. Arvydas Vanagunas: Dr. Vanagunas has received compensation from AbbVie and CVS Caremark's Pharmacy & Therapeutics Committee for serving as a consultant and has been a scientific advisory board member for AbbVie. Cindy Zadikoff: CZ was a study investigator and has received compensation from AbbVie for serving as a consultant and participating in scientific advisory boards. Rod Gossen: served as executive secretary for this study and is employed by a consulting agency under contract with AbbVie. Susan Eaton, Krai Chatamra, Weining Robieson, Jordan Dubow and Janet Benesh are employees of AbbVie and hold AbbVie stock and/or stock options. AbbVie participated in the study design, research, data collection, analysis and interpretation of data, writing, reviewing, and approving the publication. Michelle M. Koutsantonis, of AbbVie, provided medical writing assistance in the development of this publication. This research was supported by an industry grant from AbbVie.

An Unusual Case of Concomitant Multifocal Ileal Carcinoid and B Cell Lymphoma: A Call for Total Double Balloon Enteroscopy

Purpose: K.S. is a 56-year-old Caucasian woman who presented with abdominal pain. A CT abdomen/pelvis identified numerous liver metastases and extensive abdominal lymphadenopathy along ileocolic vessels and the ileal mesentery. A colonoscopy revealed a submucosal mass lesion at the terminal ileum consistent with carcinoid. The decision was made for K.S. to undergo an extended right hemicolectomy. However, because of the probability of multifocal ileal carcinoid she underwent a pre-operative retrograde double balloon enteroscopy. The carcinoid lesion at the terminal ileum was identified; however, at 100 cm proximal to the terminal ileum there were up to 27 more submucosal masses clustered at the mid to proximal ileum, validated by biopsy to be carcinoid, ki-67 <1%. Because of the extent of small bowel disease she then underwent an oral double balloon enteroscopy, making for a total enteroscopy. Per oral double balloon enteroscopy, at the level of the proximal jejunum there were multiple pearly white nodules spanning 5-10cm in length consistent with follicular type, grade 1, B cell lymphoma. She then underwent a distal small bowel to transverse colostomy, 15cm segment of small bowel resection, ileal-right hemicolectomy, pT3N1Mx. The decision was made to not treat the lymphoma at this time since it is considered to be an indolent non-Hodgkin lymphoma. This case illustrates the important role of double balloon enteroscopy in not only identifying multifocal ileal carcinoid as it can change surgical planning, but also the possibility of finding concomitant primary malignancies. Although Messer et al in GIE 2012 found no diagnostic or therapeutic difference between spiral enteroscopy and double balloon enteroscopy despite higher total enteroscopy success with the double balloon enteroscope, we would argue for an attempt at total enteroscopy in the setting of a known malignancy, as the diagnostic yield can be greater.Figure: Low-grade follicular B cell lymphoma, jejunum.

Preliminary assessment of including a reducing agent (sodium metabisulphite) in ‘all-sorghum’ diets for broiler chickens

The preliminary assessment was designed to determine appropriate inclusion levels of the reducing agent, sodium metabisulphite (SMBS), in ‘all-sorghum’ broiler diets. Dietary SMBS inclusion levels of 0, 1.25, 2.5, 5.0, 7.5, 10.0, 12.5 and 15.0gkg−1 were investigated with corresponding reductions (923–908gkg−1) in dietary sorghum concentrations. In vitro evaluations included the determination of concentrations of free sulphydryl groups and disulphide bonds in all-sorghum diets. In vivo parameters included growth performance (14–21 days post-hatch), nutrient utilisation and apparent nitrogen (N) digestibility coefficients in four small intestinal sites in broilers at 21 days post-hatch. In addition, the effect of 5.0gkg−1 SMBS on starch digestibility coefficients and sites of starch disappearance along the small intestine were determined. The reducing agent significantly increased free sulphydryl group and decreased disulphide bond concentrations. SMBS significantly depressed feed intakes at 5.0gkg−1 and at higher inclusion levels and there was a linear reduction in feed intakes (r=−0.783; P<0.001). SMBS had cubic effects on weight gain (r=0.588; P<0.001) and feed conversion ratios (r=0.500; P<0.01). It may be deduced from the relevant regression equations that the optimum SMBS inclusions are 2.47gkg−1 for weight gains and 2.14gkg−1 for feed conversion ratios. SMBS significantly increased apparent metabolisable energy (AME) at inclusions of 1.25, 5.0, 10.0 and 12.5gkg−1. At the lowest inclusion of 1.25gkg−1 SMBS increased AME by 0.39MJ (14.80 versus 14.41MJkg−1; P<0.001) and the most profound response of 0.56MJ (14.97 versus 14.41MJkg−1; P<0.001) was observed at 10.0gkg−1. SMBS linearly increased N retention (r=0.592; P<0.001). In the distal jejunum, SMBS significantly depressed N digestibility coefficients at inclusions of 1.25, 2.5, 10.0, and 15.0gkg−1 and in the distal ileum with SMBS inclusions of 1.25, 10.0 and 15.0gkg−1. SMBS did not influence N digestibility in the proximal jejunum (P>0.60) and proximal ileum (P>0.55). At 5.0gkg−1, SMBS increased starch digestibility coefficients by 3.76% in the proximal ileum (0.966 versus 0.931; P<0.01) and 3.27% in the distal ileum (0.980 versus 0.949; P<0.001). Also, SMBS significantly decreased the quantity of starch disappearance in the proximal jejunum, or abruptly digestible starch, by 16.3% (245.6 versus 293.4gbird−1; P<0.01). It is concluded that birds are able to tolerate dietary inclusions of SMBS approaching 5.0gkg−1 and that SMBS has the capacity to enhance energy utilisation of sorghum-based diets by broiler chickens. Consideration is given to the mechanisms whereby SMBS might enhance energy utilisation.