Proximal Jejunum Research Articles

Robotic Pancreaticoduodenectomy Using "Rubber Band Traction Technique" for Complete Mesopancreas Dissection

Rubber band traction technique is our small technical innovation while performing uncinate dissection and complete mesopancreas dissection during Minimally invasive Pancreaticoduodenectomy. The proximal jejunum is divided in the supracolic compartment for easier identification and ligation of the first jejunal vessels. After transecting the pancreas, 2 rubber bands are taken inside the abdomen, and are stitched to the terminal part of duodenum and proximal jejunum and retracted to the right lateral aspect of abdominal wall.

Gastrointestinal stromal tumor of jejunum presenting as a pelvic mass: A rare case report and review of literature

Gastrointestinal stromal tumors (GISTs) are mesenchymal in origin and quite rare in the gastrointestinal system. Jejunal GISTs are extremely rare, approximately 0.1%–3% of all gastrointestinal (GI) tumors. The stomach is the most common site while small intestine (usually duodenum) is the second most common site in the GI tract. The clinical manifestations of GISTs range from asymptomatic to mild abdominal pain, mass, mechanical obstruction, and intestinal hemorrhage as well as perforation. Final diagnosis is made by combined histopathological examination (HPE) and immunohistochemistry (IHC) examination of resected specimen. Here, we present the rare case of jejunal GIST as pelvis mass in 48-year-old gentleman. The patient presented with pain abdomen and heaviness in lower abdomen. On contrast-enhanced computed tomography abdomen, diagnosis of pelvic mass was made. Exploratory laparotomy was done. A solid mass measuring 6 cm × 8 cm arising from antimesenteric border of proximal jejunum found into pelvic cavity. Jejunal segment with tumor resected and anastomosis done. HPE and IHC confirmed intermediate grade GIST of the jejunum. Imatinib mesylate was initiated due to probability of disease recurrence (24%). Carefully complete surgical excision and adjuvant therapy with imatinib is the cornerstone of intermediate to high degree GISTs.

Effects of Selective Breeding, Voluntary Exercise, and Sex on Endocannabinoid Levels in the Mouse Small-Intestinal Epithelium

The endocannabinoid (eCB) system in the gut communicates with the body and brain as part of the homeostatic mechanisms that affect energy balance. Although perhaps best known for its effects on energy intake, the eCB system also regulates voluntary locomotor behavior. Here, we examined gut eCB concentrations in relation to voluntary exercise, specifically in mice selectively bred for high voluntary wheel running behavior. We measured gut eCBs in four replicate non-selected Control (C) lines and four replicate lines of High Runner (HR) mice that had been selectively bred for 74 generations based on the average number of wheel revolutions on days 5 and 6 of a 6-day period of wheel access when young adults. On average, mice from HR lines run voluntarily on wheels ∼3-fold more than C mice on a daily basis. A recent study showed that circulating levels of primary endocannabinoids 2-arachidonoyl-sn-glycerol (2-AG) and anandamide (AEA) are altered by six days of wheel access, by acute wheel running, and differ between HR and C mice in sex-specific ways [1]. We hypothesized that eCBs in the upper small-intestinal epithelium (i.e., proximal jejunum), a region firmly implicated in eCB signaling, would differ between HR and C mice (linetype), between the sexes, between mice housed with vs. without wheels for six days, and would covary with amounts of acute running and/or home-cage activity (during the previous 30 minutes). We used the same 192 mice as in [1] , half males and half females, half HR and half C (all 8 lines), and half either given or not given access to wheels for six days. We assessed the eCBs, 2-AG and AEA, and their analogs docosahexaenoylglycerol (DHG), docosahexaenoylethanolamide (DHEA), and oleoylethanolamide (OEA). Both 2-AG and DHG showed a significant 3-way interaction of linetype, wheel access, and sex. In addition, HR mice had lower concentrations of 2-AG in the small-intestinal epithelium when compared to C mice, which may be functionally related to differences in locomotor activity or to differences in body composition and/or food consumption. Moreover, the amount of home-cage activity during the prior 30 min was a negative predictor of 2-AG and AEA concentrations in jejunum mucosa, particularly in the mice with no wheel access. Lastly, 2-AG, but not AEA, was significantly correlated with 2-AG in plasma in the same mice.

Surgical management of complex duodenal trauma using laterolateral duodenum enteroanastomosis: A case report.

Introduction and importanceDuodenal trauma is rare, however, it has high morbidity and mortality rates. Surgical treatment modalities are employed depending on severity, ranging from simple sutures to complex pancreaticoduodenectomy cases.Case presentationA male patient had a circular saw accident, leading to evisceration in an extensive wound from the thoracoabdominal transition to the inguinal region, with 75% laceration of the second duodenal portion circumference, laceration in hepatic segments, section from right mesocolon to transverse colon, and multiple perforations in small bowel loops between 70 and 90 cm from the angle of Treitz. Laterolateral duodenum enteroanastomosis was performed with proximal jejunum and gastroenteroanastomosis with the distal loop of the small intestine at 90 cm from the Treitz angle, and a termino lateral enteroanastomosis between food and the biliary loop at 20 cm from the gastroenteroanastomosis.Clinical discussionThis report presents a new surgical technique for patients with penetrating duodenal trauma associated with liver and intestinal injuries, to avoid the need for more complex procedures. In addition, it demonstrates postoperative management of complications, including confection of the enteroatmospheric fistula for feeding.ConclusionThe technique described in this article proved to be a good option for treating these lesions, as evidenced by optimal postoperative results.

Distribution of α-synuclein in normal human jejunum and its relations with the chemosensory and neuroendocrine system.

Alpha-synuclein (α-syn) is a presynaptic neuronal protein and its structural alterations play an important role in the pathogenesis of neurodegenerative diseases, such as Parkinson’s disease (PD). It has been originally described in the brain and aggregated α-syn has also been found in the peripheral nerves including the enteric nervous system (ENS) of PD patients. ENS is a network of neurons and glia found in the gut wall which controls gastrointestinal function independently from the central nervous system. Moreover, two types of epithelial cells are crucial in the creation of an interface between the lumen and the ENS: they are the tuft cells and the enteroendocrine cells (EECs). In addition, the abundant enteric glial cells (EGCs) in the intestinal mucosa play a key role in controlling the intestinal epithelial barrier. Our aim was to localize and characterize the presence of α-syn in the normal human jejunal wall. Surgical specimens of proximal jejunum were collected from patients submitted to pancreaticoduodenectomy and intestinal sections underwent immunohistochemical procedure. Alpha-syn has been found both at the level of the ENS and the epithelial cells. To characterize α-syn immunoreactive epithelial cells, we used markers such as choline acetyltransferase (ChAT), useful for the identification of tuft cells. Then we evaluated the co-presence of α-syn with serotonin (5-HT), expressed in EECs. Finally, we used the low-affinity nerve growth factor receptor (p75NTR), to detect peripheral EGCs. The presence of α-syn has been demonstrated in EECs, but not in the tuft cells. Additionally, p75NTR has been highlighted in EECs of the mucosal layer and co-localized with α-syn in EECs but not with ChAT-positive cells. These findings suggest that α-syn could play a possible role in synaptic transmission of the ENS and may contribute to maintain the integrity of the epithelial barrier of the small intestine through EECs.

Cystocolostomy as an unusual approach to recurrent pancreatic pseudocyst in a Ugandan male with dense hepatogastroduodenal adhesions: A case report.

Introduction and importancePancreatic pseudocyst is one of the most frequent late complications of acute pancreatitis with increasing prevalence in chronic pancreatitis. Other causes include abdominal trauma, biliary tract disease, and other idiopathic causes. 85% resolve spontaneously within 4–6 weeks. Interventions are required for persistently symptomatic, large and complicated pancreatic pseudocysts. Cystocolostomy is a rarely reported pancreatic pseudocyst drainage option.Case presentation20-year-old male with large recurrent pancreatic pseudocyst following trauma underwent 2 exploratory laparotomies from a peripheral hospital, before referral to Lubaga hospital. Ultrasound-guided cyst drainage was performed. He was readmitted two weeks later with features of cyst recurrence. Re-laparotomy was done and the stomach, duodenum and proximal jejunum were inaccessible due to extensive dense non-obstructive adhesions. Therefore, we performed a transverse cystocolostomy. Patient improved and was discharged on 5th post-operative day. Review was unremarkable at 6 weeks and 3 months post-surgery.Clinical discussionCurrent management of pancreatic pseudocyst is percutaneous, endoscopic or laparoscopic drainage. However in cases of large recurrent cysts despite the above interventions, open surgery still has a role. Cystogastrostomy, cystoduodenostomy or cystojejunostomy are the commonly performed drainage options. These 3 options were not possible in this patient due to dense adhesions, hence we performed a transverse cystocolostomy with no post-operative complications. Possible complications from the procedure might include recurrent pancreatitis, pancreatic abscess and stool leak into the pancreatic duct.ConclusionIn cases of inaccessibility to the stomach, duodenum and jejunum due to non-obstructing dense adhesions, a pancreatic cystocolostomy can be performed with equally good outcomes.

Large trichobezoar associated with misdiagnosis, a rare case report with a brief literature review.

IntroductionTrichobezoar is a rare disorder that almost exclusively affects young females. Up to 90% between 13 and 20 years of age. The current study aims to report and discuss a rare case of Misdiagnosis of Trichobezoar.Case presentationA 14-year-old girl student patient admitted to the Baxshin hospital, with a large trichobezoar filling the entire stomach with a long tail of hair extending within the pylorus into the proximal jejunum at a length of 70 cm; associated with abdominal pain, constipation, and vomiting. Laboratory data showed mild iron deficiency anemia, with a normal liver, and renal function test, patients' electrolytes showed a normal profile. Confirmation of the presence of the mass was done through abdominal Computed Tomography (CT) with contrast. The physician initially diagnosed as alopecia and suspected the abdominal pain was related to the postprandial emesis because the patient didn't provide a history of trichotillomania and used treatment for alopecia for a long time.DiscussionThe presence of a mass in the abdomen of a child is considered one of the most severe findings. Physical examination of the patient plus a full history taken, and the age of the patients provide a clear clue to the origin of the mass. Further investigation, including laboratory data and imaging findings, provides better understanding and a firm diagnosis. Trichobezoar should be considered by the physicians in this case.ConclusionIn the early diagnosis of the trichobezoar, the physicians should investigate for any medical history of clinical trichophagia, trichotillomania, or a psychological problem.

Diagnostika a endoskopická intervence u raritního MALT lymfomu proximálního jejuna

Summary: Extranodal lymphoma from the marginal zone mucosa-associated lymphoid tissue (MALT lymphoma) is one of the primary extranodal non-Hodgkin‘s lymphomas with low degrees of malignancy but with the risk of spreading to distant locations in the body. B-lymphomas are sometimes associated with other diseases (eg. Helicobacter pylori and Campylobacter jejuni infections or inflammatory bowel disease). B-lymphomas may manifest with a variety of clinical signs, from dyspeptic syndrome with malabsorption and weight loss to ileus or massive gastrointestinal bleeding. Dia­gnosis is based on the clinical condition and the results of laboratory tests and imaging techniques, while endoscopy is the essential procedure for visualizing the tumor mass and collecting a bio­psy sample to determine the definitive histopathological dia­gnosis. MALT lymphoma treatment is managed by oncologists and includes chemotherapy and/or radiotherapy, with resection indicated in rare cases. In this case report we present an elderly female patient who was referred to our IBD centre for non-specific abdominal pain with a positive fecal occult blood test. Computed tomography (CT) examination was used before endoscopy and showed an infiltration of the splenic flexure by an unspecified mass, a subsequent colonoscopy showed intact mucosa of the colon, including the terminal ileum. In the second reading of the CT scan the location of the infiltrate was identified more specifically as the area of the proximal jejunum and jejunal mesentery. Subsequent upper endoscopy revealed a stenosing exulcerated tumor in the proximal jejunum, with the stenosis impassable even for a pediatric colonoscope. The dia­gnosis of MALT lymphoma was confirmed by a histological examination of the bio­psied tissue. A follow-up upper endoscopy was performed after the patient had completed her oncological treatment (chemotherapy in combination with radiotherapy), showing the presence of stenosis at the proximal jejunum, still impassable for the endoscope. In clinical terms, the patient experienced weight loss, which was to some extent caused by intermittent pseudo-obstruction when on a solid diet, therefore we decided to enrich her oral intake with high-calorie sip feed. The next follow-up CT scan of the abdomen showed a regression of the infiltrate, but the stenosis of the proximal jejunum, about 7 centimeters long, persisted. To respect the patient‘s wishes, no surgical resection of the stenotic section of the intestine was performed, but we proceeded with endoscopic dilatation of the stenotic section of the jejunum with a balloon. After the first two endoscopic dilatations of the stenotic area the patient experienced a temporary improvement in solid food tolerance. Because of restenosis, a third endoscopic dilatation was performed, with the development of complications that included short-term circulatory instability with abdominal pain and eventually required an urgent surgical solution. Key words: marginal zone B-cell lymphoma – stenosis – dilatation – intestinal perforation – jejunum – MALT

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.

Rapunzel syndrome: an uncommon tale of a long hairy tail - case report and review of literature

Trichobezoar is a rare clinical entity in which a ball of hair accumulates within the alimentary tract. When the tail of the trichobezoar extends into the small intestine, this condition is called Rapunzel syndrome (RS). A 14-year-old female presented with pain abdomen and vomiting for 2 weeks, and a history of trichotillomania and trichophagia, and an epigastric lump. A contrast enhanced computerized tomography (CECT) of the abdomen showed a grossly distended stomach with a heterogeneous mass containing trapped air with underlying normal mucosa suggestive of trichobezoar, with its tail extending into the proximal jejunum suggestive of RS. During laparotomy, a giant trichobezoar was seen in the stomach with its tail extending beyond the duodenum into the proximal jejunum. The entire specimen was delivered out intact. On follow up, she has no surgical complications, and was on behaviour therapy. Trichobezoars form when ingested hair strands become retained in the folds of the gastric mucosa and becomes entangled, forming a ball too large to exit the stomach. Trichotillomania and trichophagia are seen in many of these patients. Patients present with abdominal pain, vomiting, gastric outlet obstruction, and an epigastric mass. In the case of RS, complete removal without breakage and distal migration is important. RS should be considered as a differential diagnosis in a young girl with abdominal pain, vomiting, anaemia and upper abdominal lump. Early diagnosis prevents complications. Surgical removal is treatment of choice. Trichobezoar often coexists with psychiatric illness. Psychiatric evaluation, counselling and treatment are helpful in preventing recurrence.

S2216 A Knot in My Stomach: A Rare Cause of a Malfunctioning PEG-J Tube

Introduction: Gastrostomy and jejunostomy tubes are placed to provide long term nutrition. Tube malfunctioning is not uncommon and usually due to coiling, occlusion, and malpositioning. We report a rare case of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) tube malfunction due to a knot formation. Case Description/Methods: A 45 year old female with history of traumatic brain injury with resultant tracheostomy and PEG-J tube, presented from a nursing home for PEG-J tube malfunction. The PEG-J tube was noted to be torn externally with an inability to administer feeds or medications. An abdominal CT scan revealed a percutaneous G-J tube with the balloon inflated within the gastric body, a portion of the tube coiled within the duodenum, but the distal end in the proximal jejunum. Bedside removal of the tube was unsuccessful due to significant resistance. She then underwent upper endoscopy which revealed an intact gastrostomy with the internal balloon properly inflated in the gastric body. The jejunal extension was found to have a knot in the tube in the gastric portion with the remainder of the tube extending into the duodenum. The distal end of the PEG-J was grasped with a snare, cut externally, and the knotted portion was withdrawn with the scope. A replacement PEG was then placed via the gastrostomy. The patient was subsequently discharged without further complication. Discussion: Enteral feeding tubes provide nutrition in patients who are unable to tolerate oral diet. This can be achieved with feeds administered into the stomach, or into the small bowel via gastrostomy with a longer tube, or via direct access into the small bowel. Jejunal feeding is preferred in patients with gastric bypass, gastroparesis, gastric outlet obstruction or refractory peptic ulcer disease. Complications of PEG-J tubes include coiling, kinking, malpositioning, and occlusion. There are six previously reported cases of knotted PEG-J tubes causing tube malfunction. A proposed mechanism is that the longer tube inserted distally into the GI tract is prone to coiling during peristalsis, which can lead to knot formation. Knotting of a PEG-J tube is a rare complication that may not be apparent on imaging as in this patient. It is important to consider this complication when deciding on the method of enteral feeding. It should also be considered in the differential diagnosis in a case of a malfunctioning PEG-J tube, especially if the tube cannot be removed bedside due to increased resistance to removal.Figure 1.: Knotted PEG-J.

CASE REPORT OF GASTRO-INTESTINAL STROMAL TUMOR (GIST)

GISTs are the most common sarcomatous tumors of GI tract, usually found in stomach and duodenum. Mostly GISTs arise as a de novo. Frequently present with hematemesis, melena and abdominal pain but sometimes diagnosed incidentally. CECT abdomen with pelvis is important to see the origin and extension of the tumor and to assess for metastasis. A 52 year old male admitted for left sided abdominal pain for 7 to 8 year and on examination lump is palpable in epigastrium, umbilical and left hypochondriac region. CT abdomen suggestive of mass arising from proximal jejunum. The patient underwent a surgical resection with free margins and had an uneventful recovery.

S2302 From an Unproved Venous Thromboembolism to a Jejunal Cancer: An Unmasking Prompted by Overt Small Bowel Bleeding

Introduction: Of all patients diagnosed with a venous thromboembolism, 2 to 25% will subsequently be diagnosed with malignancy. When considering possible malignancies, a primary small bowel neoplasm is not likely at the top of the list. Small bowel neoplasms may present with nonspecific signs or symptoms such as gastrointestinal bleeding. But even when bleeding does occur diagnosis can be challenging, as the initial work-up for with upper and lower endoscopy may not necessarily visualize the affected region. Small bowel bleeding can be categorized as occult or overt, with the former defined as a positive FIT result with no evidence of visible blood, and the latter implying a clear presentation with melena, hematochezia, or hematemesis. In this case we describe how treating an unprovoked DVT helped in the diagnosis a jejunal adenocarcinoma. Case Description/Methods: This is the case of a 69 year old male who presented to ER with a chief complaint of dark stools 2 weeks prior. Upon further questioning, patient mentioned a history of a fall from standing secondary to associated dizziness. He also noted he had been taking warfarin chronically for a prior diagnosis of a DVT. On initial evaluation patient was found severely anemic and orthostatic, thus admitted for further management. Throughout hospitalization, upper and a lower endoscopy were performed without evidence to explain known anemia. Small bowel bleeding was then suspected, and a pill endoscopy was performed, demonstrating multiple friable and ulcerated lesions distal to the duodenum. Given these findings, a push enteroscopy was subsequently performed and a biopsy was taken from a jejunal lesion with a resultant pathology of a poorly differentiated adenocarcinoma. Discussion: The diagnosis of an uncomplicated unprovoked VTE warrants age-appropriate cancer screening, which in this patient would have included a colonoscopy. If this patient had undergone a screening or surveillance colonoscopy under normal circumstances, this patient’s diagnosis could have gone unnoticed. We believe the use of warfarin for treating the venous thromboembolism was the likely detonator of gastrointestinal bleeding, which ultimately prompted further clinical investigation. The above case presentation not only denotes the classic step-by-step process required to identify a relatively rare small bowel malignancy, but also demonstrates how treating patients sometimes help us “unmask” other diagnoses.Figure 1.: Large, ulcerated, friable, circumferential lesion at proximal jejunum.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

S3050 Obstructive Histoplasmosis Resulting in Recurrent Nausea and Vomiting

Introduction: Histoplasmosis is a relatively uncommon invasive fungal infection that occurs via inhalation of microconidia in susceptible hosts. It most commonly affects individuals with HIV/AIDS and other immunocompromised states. Although uncommon, gastrointestinal histoplasmosis can present with bowel obstruction. Here we present a case of histoplasmosis of the proximal jejunum resulting in bowel obstruction in an HIV patient. Case Description/Methods: 37-year-old transgender woman presented to the emergency room for evaluation shortness of breath and weakness over the past few days. Review of systems was positive for intractable nausea and vomiting over the past few months. Her medical history was significant for AIDS and recurrent small bowel obstructions with last known CD4 count of < 50. She also had known histoplasmosis and was receiving treatment on fluconazole. Exam revealed normal vitals with diffuse abdominal pain and severe bilateral cervical adenopathy. A CT scan of the abdomen/pelvis showed dilation of the 1st, 2nd and 4th portions of the duodenum and stomach with a transition point near the ligament of Treitz. An NG tube was placed for decompression and GI was consulted for evaluation. An upper endoscopy with push enteroscopy of the duodenum revealed diffuse erythematous mucosa and a large friable mass in the 4th portion of the duodenum expanding into the jejunum. Pathology report revealed fungal elements consistent with histoplasmosis. She completed 14 days of amphotericin induction therapy followed by Itraconazole. A robotic gastrojejunal bypass was performed to alleviate the obstruction. Discussion: Clinically diagnosed histoplasmosis affecting the GI tract occurs in about 3-12% of disseminated cases. Disseminated cases commonly involve immunosuppressed patients, in whom the lymphoid tissue of the GI tracts is susceptible. Majority of cases that involve the GI tract will involve the terminal ileum or colon and usually manifests as abdominal pain associated with diarrhea. The obstructive symptoms as well location in the distal duodenum/jejunum are uncommon findings. Although there have been reported cases of obstructive histoplasma masses in the GI tract, most involve the colon and very rarely will affect the small bowel. Our case highlights that gastrointestinal histoplasmosis can present as an obstruction and may present at unusual locations. It is important to make the diagnosis early to prevent further complications, such as bowel perforation.Figure 1.: Obstructive Mass in the Fourth Portion of the Duodenum.

Bifidobacterium longum subsp. longum 51A Attenuates Signs of Inflammation in a Murine Model of Food Allergy.

Food allergy is a pathological condition that can lead to hives, swelling, gastrointestinal distress, cardiovascular and respiratory compromise, and even anaphylaxis. The lack of treatment resources emphasizes the necessity for new therapeutic strategies, and in this way, probiotics has been pointed out as an alternative, especially because of its immunomodulatory properties. The goal of this study was to evaluate the probiotic effect of Bifidobacterium longum subsp. longum 51A (BL51A) in a murine model of ovalbumin (OVA) food allergy, as well as to investigate the effect of the dose and viability of the bacteria on the proposed model. For this purpose, the probiotic effect was assessed by clinical, immunological, and histological parameters in mice treated or not with the BL51A and sensitized or not with OVA. Oral administration of BL51A prevented weight loss and reduced serum levels of IgE anti-OVA and of sIgA in the intestinal fluid. Also, it reduced the intestinal permeability, proximal jejunum damage, recruitment of eosinophils and neutrophils, and levels of eotaxin-1, CXCL1/KC, IL4, IL5, IL6, IL13, and TNF. Furthermore, the treatment was able to increase the levels of IL10. Investigating different doses administered, the level of 108CFU showed the best results in terms of protective effect. In addition, the administration of the inactivated bacteria did not present any beneficial effect. Results demonstrate that BL51A promotes a systemic immunomodulatory protective effect in a murine model of food allergy that depends on the dose and viability of the bacteria, suggesting its use as probiotic in such disease.

Direct Acting Oral Anticoagulants Following Gastrointestinal Tract Surgery.

Direct-acting oral anticoagulants (DOACs) vary in bioavailability and sites of absorption in the gastrointestinal tract (GIT). Data on DOAC use after major GIT surgery are limited. The aim of this case series was to report the impact of surgical resection or bypass of the GIT on rivaroxaban and apixaban peak plasma concentrations. This was a case series of patients who received rivaroxaban or apixaban after GIT surgery, during the period of July 1, 2019, to December 31, 2020. Peak plasma concentrations of rivaroxaban and apixaban were assessed for the expected concentrations. Of the 27 assessed patients, 18 (66.7%) received rivaroxaban, and 9 (33.3%) received apixaban. After rivaroxaban therapy, 4 of 5 patients (80%) who underwent gastrectomy, and 3 of 3 patients (100%) who underwent duodenum and proximal jejunum exclusion had peak plasma concentrations of rivaroxaban lower than the effective range, whereas 11 of 11 patients (100%) who underwent distal bowel or ileostomy had peak rivaroxaban plasma within the effective range. After apixaban therapy, 5 of 6 patients (83.3%) who underwent total or partial gastrectomy achieved effective peak concentrations. All the patients who underwent proximal and distal bowel resection or bypass had peak concentrations of apixaban within the effective range. In conclusion, surgical resection or bypass of the upper GIT could affect DOAC absorption and subsequently peak plasma concentrations. This effect was more observed among rivaroxaban recipients. An injectable anticoagulant or vitamin K antagonist may be preferred if DOAC concentrations cannot be measured after GIT surgery.

A Rare Case of Chronic Suppurative Appendicitis in Neonatal Presenting as Intestinal Malrotation

Neonatal appendicitis (NA) is an extremely rare acute abdomen condition, moreover, if it is a chronic suppurative one. The definite risk factor of NA is barely unknown. The signs and symptoms are often nonspecific and appear after perforation occurs. Most of the cases were found unexpectedly during surgery suspected as other diagnoses. A 7-day-old male neonate presenting lethargic and hypoglycemia since 1 st day of life. Patient drunk breast milk right after since he was born. Meconium was produced &lt;24 h. On the 3 rd day of hospitalization, he experienced bilious vomiting and abdominal distension, so nasogastric tube was installed. Physical examination revealed decreased bowel sound. Investigation showed leucocytosis, slightly increased procalcitonin and abdominal X-ray showed that gas distribution lasted until third part of duodenum followed by minimal gas distribution in the distal part of duodenum. The patient was suspected as distal duodenum stenosis or proximal jejunum. Intraoperatively, it was found that there was second part duodenum malrotation and open Ladd’s procedure was done. During Ladd’s procedure, a perforated appendix was also found. The histopathology result revealed that it was a chronic suppurative appendicitis. Patient was discharged in good condition 20 days after surgery. NA is a rare condition with nonspecific signs and symptoms which was usually found accidentally during surgery suspected as other diagnoses.

Low-calcium diets increase duodenal mRNA expression of calcium and phosphorus transporters and claudins but compromise growth performance irrespective of microbial phytase inclusion in broilers

The hypothesis that dietary inclusion of microbial phytase improves apparent calcium (Ca) digestibility thereby allowing a lower dietary Ca inclusion without compromising growth performance was tested. One-day-old male Ross 308 broilers (25 birds/pen, 9 pens/treatment) were assigned to 8 experimental diets containing one of 4 dietary Ca to retainable P (rP) ratios (1.3, 1.8, 2.3, and 2.8) with (1,000 FTU/kg) or without microbial phytase. On d 21 to 23, digesta from different intestinal segments of 8 birds per pen were collected to determine apparent Ca and P digestibility. Mid duodenal mucosa was collected for expression of Ca (CaBP-D28k, PMCA1) and P (NaPi-IIb, PiT-1, PiT-2, and XPR1) transporters by RT-qPCR. Dietary phytase inclusion in low Ca/rP diets increased Ca digestibility in the distal ileum (Pinteraction = 0.023) but not the proximal or distal jejunum. Broilers receiving the lowest Ca/rP displayed the lowest body weight gain, highest feed conversion ratio (P < 0.001), and lowest tibia strength, irrespective of dietary phytase inclusion. Incremental dietary Ca/rP linearly reduced P digestibility to a greater extent in the absence of phytase in the distal jejunum and ileum (Pinteraction = 0.021 and 0.001, respectively). Incremental dietary Ca/rP linearly reduced serum P more in phytase-free diets (Pinteraction < 0.001), and lowered duodenal expression of P transporters NaPi-IIb, PiT-2, and XPR1 (P = 0.052, 0.071 and 0.028, respectively). Incremental dietary Ca/rP linearly increased (P < 0.001) serum Ca irrespective of phytase inclusion, accompanied by a lower (P < 0.001) duodenal expression of Ca transporters CaSR, CaBP-D28k and PMCA1 and Ca-pore forming claudins CLDN-2 and CLDN-12. Dietary phytase increased (P = 0.026) NaPi-IIb but reduced (P = 0.029) CLDN-2 expression. Incremental Ca/rP reduced Ca and P digestibility, increased serum Ca, lowered serum P and inhibited mRNA levels of Ca and P-related transporters, indicating that these transporters and CLDN contribute to the observed effect of dietary Ca and phytase on Ca and P absorption. Despite the improvement in Ca digestibility, dietary phytase did not restore the compromised growth performance and tibia strength of broilers fed a Ca-deficient diet, leading to rejection of the hypothesis.

Expression of proposed methionine transporters along the gastrointestinal tract of pigs and their regulation by dietary methionine sources

BackgroundGiven the key role of methionine (Met) in biological processes like protein translation, methylation, and antioxidant defense, inadequate Met supply can limit performance. This study investigated the effect of different dietary Met sources on the expression profile of various Met transporters along the gastrointestinal tract (GIT) of pigs.MethodsA total of 27 pigs received a diet supplemented with 0.21% DL-Met, 0.21% L-Met, or 0.31% DL-2-hydroxy-4-(methylthio)butanoic acid (DL-HMTBA). Changes in mRNA expression of B0AT1, ATB0,+, rBAT, ASCT2, IMINO, LAT4, y+LAT1, LAT2, and SNAT2 were evaluated in the oral mucosa, cardia, fundus, pylorus, duodenum, proximal jejunum, middle jejunum, ileum, cecum, proximal colon, and distal colon, complemented by protein expression analysis of B0AT1, ASCT2, LAT2, and LAT4.ResultsExpression of all investigated transcripts differed significantly along the GIT. B0AT1, rBAT, y+LAT1, LAT2, and LAT4 showed strongest mRNA expression in small intestinal segments. ASCT2, IMINO, and SNAT2 were similarly expressed along the small and large intestines but expression differed in the oral mucosa and stomach. ATB0,+ showed highest mRNA expression in large intestinal tissues, cardia, and pylorus. In pigs fed DL-Met, mRNA expression of ASCT2 was higher than in pigs fed DL-HMTBA in small intestinal tissues and mRNA expression of IMINO was lower than in pigs fed L-Met in large intestinal tissues. Dietary DL-HMTBA induced a stronger mRNA expression of basolateral uptake systems either in the small (LAT2) or large (y+LAT1) intestine. Protein expression of B0AT1 was higher in the middle jejunum and ileum in pigs fed DL-Met when compared with the other Met supplements. LAT4 expression was higher in pigs fed DL-HMTBA when compared with DL-Met (small intestine) and L-Met (small intestine, oral mucosa, and stomach).ConclusionA high expression of several Met transporters in small intestinal segments underlines the primary role of these segments in amino acid absorption; however, some Met transporters show high transcript and protein levels also in large intestine, oral mucosa, and stomach. A diet containing DL-Met has potential to increase apical Met transport in the small intestine, whereas a diet containing DL-HMTBA has potential to increase basolateral Met transport in the small intestine and, partly, other gastrointestinal tissues.