Segment Of Small Bowel Research Articles

Features of the diagnostics and treatment of a rare source of small bowel bleeding — venous malformations of the small bowel with Blue rubber bleb nevus syndrome (Bean’s syndrome)

The aim of the study is to demonstrate the possibilities of enteroscopy in diagnostics of rare source of small bowel bleeding in patient with blue rubber blue nevus syndrome.A 31-years old patient with severe anemia from the early age applied to our Hospital to diagnose the source of gastrointestinal bleeding. Previously performed EGD and colonoscopy didn’t reveal any sources of bleeding. Scintigraphy detected the signs of ongoing intestinal bleeding. Endoscopic methods (videocapsule and balloon-assisted enteroscopy) revealed multiple venous malformations of small bowel, as the source of gastrointestinal bleeding of «unknown source». The patient was performed surgery — resection of segments of small bowel with malformations. The diagnosis was verified morphologically. Postoperative period was without complications. For the first time in several years the patient had a fully restored level of hemoglobin.

Modelo simple y novedoso para la formación del recambio de catéter suprapúbico (CSP)

ObjectivesTo develop a suprapubic catheter (SPC) training model as no specific realistic training model exists to replicate SPC exchange where a catheter tract is present. Materials and methodsWe describe a novel, anatomically realistic, animal simulator model for use in SPC training, which was trialed at a national urology simulation boot camp by new urology trainees and validated by expert urologists. A scale reproduction of an abdominal wall was created using a porcine abdominal wall. A segment of small bowel was stitched around a size 16F Foley catheter to form a tract. Abdominal wall tissue was excised cylindrically to create an opening, and the small bowel tract was passed through the abdominal wall and sutured anteriorly, producing a realistic SPC tract: inferiorly, the tract was anastomosed to a porcine urinary bladder. This model was evaluated by 10 expert urologists for content validity with an 8-item 5-point rating scale used to evaluate domains relevant to the simulator. ResultsThe domains were scored between 1 and 5 by 10 expert urologists, 1 being «strongly disagree» and 5 being «strongly agree». The average expert ratings of the domains were then calculated and tabulated following the training course. There was an average global rating of 4.2/5 for the model, with an average usefulness for training score of 4.6/5. ConclusionThe feedback from experts and trainees (informal) was overwhelmingly positive. On average, our experts reported high satisfaction with their experience using this simulator as a training tool.

Delayed occult gastrointestinal bleeding secondary to ulcer at site of neonatal ileoileostomy

Abstract Meconium peritonitis occurs in neonates after an in-utero bowel perforation. It can sometimes be treated initially with peritoneal drainage, and usually will also require a laparotomy, possibly with enterostomy, in order to evacuate remaining intraluminal meconium to relieve the resulting bowel obstruction. In most neonates with enterostomies, the stoma can be closed and intestinal continuity restored when the patient has reached a sufficient weight and is healthy. Stricture of the anastomosis in such cases is a well-known complication. However, gastrointestinal bleeding from the anastomotic site is less common. Here, we present the case of a young lady who had a neonatal ileostomy followed by ileostomy closure, who developed chronic anemia from occult GI bleeding that did not present for more than a decade. An extensive workup revealed bleeding from the ileoileostomy site, diagnosed during a combined exploratory laparotomy and push enteroscopy procedure. It was treated by segmental small bowel resection with primary anastomosis.

Laparoscopic diverticulectomy or laparoscopic-assisted resection of symptomatic Meckel diverticulum in children? A systematic review.

Recent reports have recommended laparoscopic diverticulectomy for symptomatic Meckel diverticulum (MD) rather than laparoscopic-assisted extracorporeal resection. This technique may risk leaving residual ectopic mucosa leading to complications. This systematic review attempts to quantify the relative risks of both approaches. A systematic review was conducted according to PRISMA guidelines. Articles were eligible for inclusion if they reported data on the laparoscopic management of symptomatic MD in children. Eleven reports were identified, all of which were institutional retrospective studies. Pooled outcome data on 248 children showed no statistically significant difference in complications between laparoscopic diverticulectomy (n = 133) and laparoscopic-assisted segmental resection (n = 115) (3% vs. 6.1%, p = 0.39). One patient from the diverticulectomy group re-presented with recurrent bleeding necessitating segmental small bowel resection. Conclusions are limited by the number of patients and variable follow up. Short, wide MD with a height:base ratio of < 2; diverticula with thickening or ischemia at the base and those complicated by volvulus or small bowel obstruction are probably best treated by laparoscopic-assisted extracorporeal resection. For other symptomatic diverticula laparoscopic diverticulectomy is a reasonable approachwith a less than 1% risk of leaving residual ectopic gastric mucosa.

Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas.

Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25–75%, 2–10) after admission and continued for 64 d (45–95), including 81 patients at home for 47 d (28–74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0–7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84–40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.

Normothermic extracorporeal membrane oxygenation support: Improving the function of intestinal grafts obtained from cardiac death donors.

Extracorporeal membrane oxygenation (ECMO) could ameliorate the energy status and viability of bowel grafts from cardiac death donors. However, the function of these grafts after transplantation is not clear. The purpose of the study was to evaluate the early function of intestinal grafts after transplantation from expected cardiac death donors supported with normothermic extracorporeal support using a porcine allogeneic orthotopic segmental small bowel transplantation model. Eighteen domestic crossbred donor pigs were assigned to living donation (LD), donation after cardiac death (DCD), and ECMO groups. In the LD group, small bowels were harvested and preserved immediately in cold storage. In the other two groups, the donor pigs received conventional rapid recovery treatment or 1-hour normothermic extracorporeal support after 10-minutes expected cardiac arrest. Subsequently, the small bowels were removed and preserved in cold storage. After 5-6hours of preservation, small bowel grafts were transplanted into the recipient pigs that underwent enterectomy. The pathology and electron microscopy results, cell apoptosis rate, tight junction protein expression level in the intestinal mucosa, and plasma endotoxin level were evaluated after transplantation. All grafts functioned on the basis of the maltose absorption test results at day 7 after transplantation. There were no significant differences in the morphological changes in the intestinal mucosa among the three groups at day 7 after transplantation. The cell apoptosis rate and plasma endotoxin level in the ECMO group did not differ significantly than those in the LD group, but were evidently lower than those in the DCD group (P<.001). The intestinal absorptive function improved significantly in the ECMO group in contrast with that in the DCD group (P<.001). Short-term ECMO intervention can alleviate ischemia-reperfusion injuries in intestinal grafts and improve intestinal absorptive function in the early stage after transplantation. Reducing caspase-3 protein expression and cell apoptosis in the intestinal mucosa may be one of the protective mechanisms of ECMO intervention.

Trans-Serosal Multimodal Optical Coherence Tomography for Visualization of Microstructure and Blood Circulation of the Small Intestine Wall.

The aim of the study was to evaluate the performance of trans-serosal multimodal OCT (MM OCT) in in vivo detecting of changes in microstructure and blood circulation of the small intestine wall caused by arteriovenous ischemia resulted from intestine strangulation.Materials and MethodsIn experiments on Wistar rats (n=22), we examined the small intestine wall in vivo using MM OCT; the access to the intestine was reached through laparotomy. The microvasculature and microstructure of the wall were studied before and after acute arteriovenous ischemia created by ligation of a small bowel segment. The results were then added with data obtained from histological and intravital microscopic examination.ResultsTrans-serous MM OCT allowed us to visualize the bowel wall to its entire thickness, distinguish between the serous-muscular and mucous-submucosal layers, and detect the villi and functioning blood vessels. The structures were best seen after a fat emulsion had been administered into the bowel lumen. In OCT images made in the optical coherent angiography (OCA) mode, large paired vessels (arteries and veins) and micro-vessels with a diameter of >15 μm could be seen. Most of the blood vessels were imaged in the depth range of 80–300 μm from the surface. Capillaries with a diameter of 7–10 μm were not seen, but they produced an overall bright background. In the OCA images reconstructed from a volume of 2.4×2.4×1.8 mm, the total length of the vascular bed before ischemia was 18.3 [16.6; 19.8] mm.Strangulation of the intestinal loop was associated with changes in the CP OCT picture: the villi-associated vertical pattern and shadows of blood vessels disappeared and the depth of tissue visualization in the cross-channel decreased. The optical equivalents of the serous-muscular layer were preserved; after 180±12 min of ischemia, their proportion in the intestinal wall thickness increased from 25 [18; 32] to 42 [31; 55]% (p=0.031). At that time-point, OCA images of the strangulated bowel loop looked all similar: a uniform dark background with isolated fragmentary large vessels and no signs of blood flow in the microvascular network.ConclusionTrans-serous MM OCT provides for in vivo visualization of microstructures critical for surgical gastroenterology: the intestinal wall layers including villi and blood vessels of each layer, as confirmed by histological analysis. Destructive processes in the intestinal wall resulting from bowel ligation bring about optical changes, which can be detected using real-time MM OCT.

Severe gastrointestinal haemorrhage from an eroding jejuno-jejunal fistula

Abstract Children with complex needs often have limited communication which makes clinical assessment extremely difficult. They also require complex feeding regimes and are prone to chronic bowel dysfunction and dysmotility requiring frequent admissions to hospital. We present the case of an 11-year old boy with mosaic trisomy 13 and an end ileostomy (for gut dysmotility) who presented with a catastrophic gastrointestinal haemorrhage during a prolonged Paediatric Intensive Care (PICU) stay recovering from an episode of presumed sepsis. A normal upper GI endoscopy was followed by a laparoscopy which revealed a small bowel adhesion to the anterior abdominal wall which had facilitated the creation of a jejuno-jejunal fistula that had eroded through a mesenteric artery. The child recovered well after a limited laparotomy and segmental small bowel resection. This case highlights an extremely unusual cause of gastrointestinal bleeding in a child and emphasises the role of Laparoscopy in the comprehensive assessment of this presentation.

A Rare Case of Sigmoid Colon Carcinoma in Incarcerated Inguinal Hernia

Incarcerated inguinal hernia is a common diagnosis in patients presenting a painful and nonreducible groin mass. Although the diagnosis is usually made by physical examination, the content of the hernia sac and the extent of the surgical operation may vary and can require multimodal imaging integration (e.g., ultrasonography, computed tomography); the usual finding is a segment of small bowel and, less commonly, large bowel. We present an extremely rare case of a sigmoid cancer incarcerated in a left inguinal hernia and infiltrating the spermatic cord. The patient underwent whole-body computed tomography (CT) with contrast agent injection for staging, followed by a left hemicolectomy paralleled by a unilateral orchiectomy.

P105 PREDICTIVE FACTORS FOR DEVELOPING SMALL BOWEL OBSTRUCTIONS AFTER ILEAL RESECTION IN PATIENTS WITH CROHN’S DISEASE

Abstract Background and Aims Patients with Crohn’s disease (CD) may require small bowel resections. Unfortunately, some of these patients may develop post-operative small bowel obstructions (SBO). Many clinicians perceive ileal resections dramatically increase the risk of developing SBO in the future, but the incidence and risk factors to developing SBO are poorly described. The primary aim of this study is to document the incidence and factors associated with the development of SBO not related to recurrence of disease in CD patients that undergo ileal resection. We also sought to assess long-term outcomes of this complication. Methods We performed a retrospective cohort study including patients aged 18 years or older with CD, who have had ileocecal resection with ileocolonic anastomosis or segmental small bowel resection. Data abstracted included demographics, phenotype and therapies of CD, disease recurrence post-ileal resection and multiple surgical variables. The primary outcome was the development of SBO within 5 years post-surgery not including obstructions secondary to recurrence of CD. Results 92 total patients were included in the analysis. All had a colonoscopy within a year of the surgery. The mean Rutgeerts score was 0 (interquartile range [IQR] 0 to 2) and the mean short endoscopic score was 0 (IQR 0 to 4). The remainder of baseline characteristics are shown in Table 1. At 6 months, 1 year, and 5 years, the rate of SBO was 4/92 (4%), 6/92 (6.5%), and 15/92 (16%), respectively. Throughout follow-up, only 5 patients had an SBO attributed to intra-abdominal adhesions and only 2 patients required surgical lysis of adhesions. Patients that were found to have histologic inflammation in the margins of the resected bowel specimen had a significantly higher chance of developing an SBO within 5 years of the initial surgery (OR: 4.5 [95%CI: 1.3–15.3], p=0.02 - Table 2). Conversely, patients with either active endoscopic and/or radiologic inflammation on post surgical surveillance colonoscopy did not have a higher risk of developing an SBO within 5 years of the initial surgery (p=0.37). Finally the length of bowel resected at the index surgery was not associated with the development of an SBO (AUC: 0.62, p=0.18). Conclusions The incidence of SBO after ileal resection in CD is low and resolves with medical management on most cases. Inflammation in the margins of the resected bowel and previous bowel resections were associated with new SBO within 5 years. These results must take into account the study population were monitored and cannot be extrapolated to those patients that lost follow-up.

P481 Repeated surgery for recurrent ileocolonic Crohn’s disease: does the outcome keep worsening operation after operation? A comparative study of 1224 consecutive procedures

Abstract Background Despite relevant improvement in the medical treatment of ileocolic Crohn’s disease (CD), still surgery is needed in 80% of patients and clinical recurrence occurs in more than 50% of cases after surgery. Aim of the study is to assess the outcome for patients undergoing repeated surgery for recurrent CD. Methods All patients undergoing surgery for ileal or colonic CD between 1993 and 2018 in our tertiary care centre were retrospectively reviewed. We considered all small bowel resections, colonic resections, conventional (SP) and not conventional strictureplasties (NCSP). Results In the study period, 1224 CD patients underwent a surgical operation. We performed 713 (58.2%) primary operations (1R), 325 (26.5%) re-operations (2R group) and 186 (15.3%) three or more interventions (≥3R group). A CD diagnosis and the time of first surgery at early age were a negative prognostic factor, favouring repeated surgery in the time (R1 vs. R2p &amp;lt; 0.004 and R1 vs. ≥3R p &amp;lt; 0.0001 comparing age at diagnosis; R1 vs. R2p &amp;lt; 0.0001 and R1vs. ≥3R&amp;lt; 0.0001 regarding the time to firstt surgery). The indication for surgery (stenosis, fistula/abscess and refractoriness to medical therapy) does no’t change significantly with the number of surgeries regarding the analysis of variance of the three groups (p = 0.3). In the repeated surgery (R2 and ≥3R group) the incidence of recurrence appears to be more frequent at the anastomotic site for the 2R group (197/325, 61% vs. 103/186, 55% p &amp;lt; 0.05) and at SP site for the ≥3R group (19/325, 5% vs. 23/186, 12% p &amp;lt; 0.01). The ≥3R group underwent to a higher number of strictureplasties in comparison to the 1R group (100/186, 53% vs. 305/713, 43% p &amp;lt; 0.0001) and the 2R group (100/186, 53 vs. 127/325, 43% p &amp;lt; 0.0004). The duration of the surgical procedure tends to be higher for the ≥3R group but without reaching a statistical significance (p = 0.2). Postoperative morbidity (Clavien Dindo I-V) was increased in the 2R and in the ≥3R group but not in a significant way: (1R group n = 187 (26%); 2R group n = 102 (31%); ≥3R group n = 64 (34%); 1R vs. 2R p = 0.1, 2R vs. ≥3R group p = 0.5). In particular there was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥3): 1R group n = 69 (9.6%); 2R group n = 37 (11%); ≥3R group n = 24 (12%); 1R vs. 2R p = 0.4, 2R vs. ≥3R group p = 0.7. Conclusion In this series, we treated more than 40% of the small bowel segments with SP and NCSP at first surgery. This percentage gradually increases to 49% in 2R group and to 53% in ≥3R group. Even if the overall morbidity rate was higher, repeated surgery for recurrent CD doesn’t appear to be related to an increased risk of severe postoperative morbidity in our experience.

P158 Semi-automated detection of qualitative features of Crohn’s disease activity found on CT-enterography using machine learning

Abstract Background Imaging is essential in the assessment of Crohn’s disease (CD) severity, phenotype, and therapeutic response. However, qualitative findings can be limited by interobserver variation and ambiguous feature definitions. Our aim was to evaluate computational approaches for identifying qualitative disease features using CT-enterography (CTE). Methods CD subjects with ileal CD and CTE imaging between 2009 and 2017 were retrospective identified at a single tertiary care centre. CTE scans were reviewed by two fellowship-trained abdominal radiologists who labelled diseased and normal bowel transitions agreeing on definitions of qualitative findings prior to labelling. Computed intestinal features were used by machine learning methods (k-nearest neighbour, support vector machines, random forest) to model regions of diseased bowel and predict qualitative findings with 5-fold cross validation. Cohen’s kappa with quadratic weighting was used to assess agreement between radiologists and model predictions. Results In 206 unique patients, 548 small bowel segments underwent paired radiologist review for qualitative imaging findings. Automated localisation of diseased vs. normal bowel segments had excellent performance, with an AUC, PPV, and NPV of 0.922, 0.924, and 0.918, respectively (Figure 1). Radiologist-to-Radiologist and Radiologist-to-automated prediction agreement on qualitative findings are shown in Table 1. Agreement on the degree of mural enhancement between radiologists was very good (k = 0.75,95% CI 0.68–0.82), with nearly identical agreement (k = 0.75, 95% CI 0.72–0.79) between radiologists and automated grading models. Conclusion Computer vision methods have excellent performance for automatically distinguishing diseased from normal ileum and show potential for qualitative disease assessments of Crohn’s disease on CTEs.

Potentiated serotonin signaling in serotonin re-uptake transporter knockout mice increases enterocyte mass and small intestinal absorptive function.

Genetic knockout of the serotonin reuptake transporter (SERT) potentiates serotonin signaling and increases crypt‐cell proliferation, neuroplasticity, and mucosal surface area. However, it remains unknown whether these changes occur throughout the small intestine and whether they increase nutrient absorption. We hypothesized that serotonin‐mediated mucosal growth would occur throughout the intestine and would increase enterocyte mass and absorptive function. Following institutional approval, intestinal segments spanning the bowel were harvested from 10 to 12 week‐old SERT knockout (SERTKO) and wild‐type (WT) C57Bl/6 mice. Histologic sections were used to measure villus height (VH), crypt depth (CD), and crypt proliferation index (CPI). Plasma citrulline was measured colorimetrically. Glucose and peptide absorption in isolated segments of small bowel were calculated using a previously described method for quantification after luminal instillation of substrate. At baseline, morphometric (VH/CD) and proliferative (CPI) parameters varied from jejunum to ileum. Enhanced 5‐HT signaling significantly increased plasma citrulline levels and morphometric/proliferative parameters in all regions analyzed. Glucose absorption in WT mice varied throughout the small intestine, and SERTKO mice demonstrated significant increases in the middle and distal bowel. WT peptide absorption was similar throughout the small bowel, and SERTKO mice had significant increases in the proximal and distal bowel. Enhanced serotonin signaling results in increased morphometric and proliferative parameters throughout the small intestine, and results in increased enterocyte mass and intestinal absorptive function. These data further advance the concept that the serotonin system is an attractive therapeutic target for increasing functional intestinal mucosa.

Ectopic pancreas in the ileum: An unusual condition and our experience.

Background:Ectopic pancreas in the ileum, including lesions within Meckel diverticulum, can cause severe manifestations and complications; yet, it was seldom reported in English literature.Aim:This study aimed to raise awareness and provide information for better clinical management of this rare yet serious condition.Methods:A total of 1713 cases of small bowel resection were performed in our hospital between 2009 and 2018, among which 10 cases of ileac ectopic pancreas were identified. A comprehensive retrospective review of the 10 cases was taken.Results:Five lesions were located in the ileum wall and 5 were within Meckel diverticulum. Two lesions within Meckel diverticulum were incidental; the remaining 8 lesions were all associated with abdominal pain, gastrointestinal bleeding, and anemia. Of the 5 patients with lesions in the ileum wall, computed tomography uniformly revealed ileoileal intussusceptions with masses as lead points. Capsule endoscopies were performed in 6 cases, of which 3 showed positive findings. Double-balloon enteroscopy was conducted in one case and revealed an ileal diverticulum. Therapeutically, the offending bowel segments were removed, and intussusceptions were restored except for one case in which diverticulectomy was applied. No relapse or sequela was observed in the follow-up.Conclusions:Ileac ectopic pancreas can be seen in the ileum wall or Meckel diverticulum. The majority of the lesions found in clinical practice present with abdominal pain, gastrointestinal bleeding, and anemia. Lesions in the ileum wall often cause ileoileal intussusception. Computed tomography, capsule endoscopy, and double-balloon enteroscopy are helpful preoperative examinations. Segmental small bowel resection is the treatment of choice.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn\u2019s disease with a higher ileostomy and complication rate

BackgroundRepeated intestinal resections may have disabling consequences in patients with Crohn’s disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn’s disease.MethodsA prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn’s disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn’s disease undergoing elective surgery; (2) patients with ileocaecal Crohn’s disease undergoing emergency surgery; (3) patients with recurrent Crohn’s disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes.ResultsOne hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn’s disease.ConclusionsPatients undergoing emergency surgery for Crohn’s disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

Trans-ileostomy management to Dieulafoy's lesion.

A 64‐year‐old male patient was admitted to our level 1 trauma centre following a high‐speed motorbike crash with thoracic spine, abdominal, bilateral upper and lower extremities injuries. On admission, the trauma series computed tomography (CT) scan did not suggest any acute bowel pathology; however, 24 hours later whilst in theatre for re‐washout of the lower extremity wound and increasing ionotropic requirement, we decided to do a laparotomy. Intraoperative findings were suggestive of ischaemic necrosis of the colon and majority of small bowel. He underwent a subtotal colectomy, along with small bowel resection – the proximal jejunum (100 cm from duodeno‐jejunal junction) and most of the ileum, sparing 20 cm of distal ileum. After 24 hours, as physiology improved, re‐look laparotomy with hand‐sewn jejuno‐ileal anastomosis and end ileostomy was carried out. Histology suggested gangrenous infarction and wall necrosis, and no evidence of embolus or thrombus. Post‐operatively, on day 21, he developed selective trans‐stomal bleeding requiring blood products to maintain haemodynamic stability. Further resection of small bowel was not an option as the patient and the next of kin declined surgery due to reluctance of being on lifelong total parenteral nutrition. Upper gastrointestinal (GI) endoscopy was negative and CT with angiography and delayed venous phase suggested extravasation of contrast (Fig. 1). Interventional radiology managed this with selective coils to the bleeding vessel to avoid ischaemia of the small bowel segment. Unfortunately, 48 h later, he developed further bleeding. At this time, we proceeded to trans‐stomal enteroscopy where a Dieulafoy's lesion (DL) was found 50 cm from the stoma (Fig. 2). Two clips were successfully placed over the DL, no further bleeds were noted and his haemodynamics improved (Fig. 3).

2572 Metastatic Renal Cell Carcinoma to the Small Bowel: A Rare Cause of Gastrointestinal Hemorrhage

INTRODUCTION: We present a case of overt gastrointestinal blood loss which after thorough investigation, was found to be a manifestation of metastatic renal cell carcinoma (RCC). CASE DESCRIPTION/METHODS: A 55 year-old female with a history of clear cell RCC removed with nephrectomy and breast cancer on chemotherapy presented with melena and abdominal pain. The patient was assessed in the ED and was hemodynamically stable. On exam she had tenderness in her left lower quadrant. She was found to have a hemoglobin of 8.2 g/dL. CT revealed active diverticulitis, but no obvious masses were noted. Gastroenterology evaluated the patient and recommended admission and EGD for further evaluation. The EGD was obtained which did not reveal any source of bleeding, which prompted colonoscopy. The colonoscopy demonstrated sigmoid diverticulosis, patchy segmental inflammation of the sigmoid colon, but no active bleeding. Approximately one week later, the patient was readmitted for worsening fatigue and continued melena. A capsule endoscopy was done which revealed a bleeding mass in the proximal and distal small bowel. A push enteroscopy was advanced to the jejunum but no bleeding was found. MRE was completed, which revealed a 1.9 × 1.6 cm nodule in the left pelvic small bowel, diverticulitis as well as a 3.2 × 2.2 cm left lower pole renal mass. The patient later went for an exploratory laparotomy with resection of two segments of small bowel. Pathology showed a diagnosis of metastatic renal cell carcinoma. DISCUSSION: Renal cell carcinoma is a common urological malignancy that can have many systemic complications. RCC presents with metastasis in as many as 30% of cases, however some signs may not lead physicians to timely diagnosis. RCC metastasizes to the small bowel in less than 0.5% of cases. Of these cases, gastrointestinal bleeding occurs in 1% of cases with &lt;1% of cases coming from the small bowel. Small bowel involvement is rare and there are only a few case reports reporting this presentation. GI bleeding from metastatic RCC is an underdiagnosed disease and can cause increased morbidity and mortality. Being able to diagnose metastatic cancer and small bowel bleeding can be difficult. When it causes potentially life threatening symptoms, it becomes a priority to diagnose it. Prompt treatment requires knowledge of complications of RCC. Being able to identify these complications will not only allow us to improve outcomes in patients, but to better understand and anticipate future complications for our future patients.

3155 Macroscopic to Microscopic: A Case of Crohn's Disease Progressing to Collagenous Colitis

INTRODUCTION: Microscopic colitis (MC), sub-typed into lymphocytic and collagenous colitis is characterized by normal endoscopic/macroscopic/radiologic colonic mucosa but abnormal histological findings and presents as chronic, non-bloody diarrhea mostly in elderly females. Association of MC with inflammatory bowel disorders (IBD), Crohn's or Ulcerative colitis is unclear and has been rarely reported. Herein, we present a patient with Crohn's disease with eventual progression to MC. CASE DESCRIPTION/METHODS: 56-year-old female presented with 12-day non-bloody diarrhea with nocturnal symptoms, weight loss, and diffuse cramping abdominal pain. No fever, sick contacts, travel, food contamination, recent antibiotics or new medications. CT Abdomen/Pelvis was normal. Labs showed leukocytosis, elevated CRP and fecal-calprotectin. Colonoscopy showed inflammation characterized by congestion, granularity, cobblestoning of mucosa from the rectum to the transverse colon. The IC valve was stenotic and difficult to intubate. Biopsy showed mild-chronic active colitis without granulomas or dysplasia. CT Enterography showed narrowing of TI and two other small bowel segments. The patient was started on steroids for possible Crohn's disease and bridged to Adalimumab. Despite being compliant, the patient was re-admitted with 10-day non-bloody diarrhea after 2-3 months. Colonoscopy showed improved endoscopic inflammation but biopsies revealed collagenous microscopic colitis. Trials of budesonide, cholestyramine, bismuth and loperamide along with Adalimumab were unsuccessful. The patient was on SSRI, which was discontinued. The patient continued to be symptomatic. Repeat colonoscopy showed endoscopically benign mucosa and continued presence of collagenous colitis on biopsy. Given the refractoriness of the patient's symptoms, she was referred to IBD specialist at a tertiary center. DISCUSSION: Concomitant presence of MC with IBD or progression of one condition to other is rare and the pathogenesis is unclear. It is hypothesized that IBD and MC may share common pathophysiologic pathway, but there is no clear data. A study proposed increased Th1/Tc1, TNFα-producing cells, and a subset of Th2/Tc2 cells, to be involved in MC-to-IBD transformation. The clinical relevance of our case is to emphasize the consideration of MC in a patient with UC or CD, who develops chronic, non-bloody diarrhea. Mucosal biopsies should be obtained to rule out MC. Once confirmed, the management should be adjusted accordingly.

2599 Retained Video Capsule Due to Stricturing Crohn's Disease Safely Diagnosed With Use of Magnetic Resonance Imaging (MRI) in a Pregnant Patient

INTRODUCTION: Videocapsule endoscopy (VCE) is a noninvasive technology that provides diagnostic imaging of the small intestine. We present a case where MRI was safely utilized to diagnose a retained VCE in a pregnant patient. There is a lack of literature on the use of VCE in pregnancy as well as the use of MRI to diagnose retained VCE. Our case highlights the use of MRI to diagnose a retained VCE during pregnancy without any harmful effects to the patient or fetus. CASE DESCRIPTION/METHODS: A 16-year-old woman with a 4-year history of Crohn's disease presented at 24 weeks gestation with six months of achy, left upper quadrant (LUQ) abdominal pain associated with a 20-pound weight loss. On presentation, the patient was depressed, withdrawn and provided limited history. Exam demonstrated a thin young female with gravid uterus and LUQ tenderness. Labs were notable for ESR &gt;100 mm/h and CRP 4.1 mg/L. An MRI was performed to aid diagnosis and minimize risk of radiation to the fetus. This revealed artifact at the anterolateral aspect of the left mid-abdomen (Figure 1). CT enterography confirmed foreign body in the left mid small bowel, likely jejunum, compatible with retained videocapsule (Figure 2). There was an adjacent segment of small bowel with suspected stricture (Figure 3). Additional history was then revealed by the patient's mother. She had undergone VCE six months prior. Shortly after, pregnancy testing was positive and imaging to confirm passage of the VCE was deferred. Subsequently, her pain worsened. Antegrade double balloon enteroscopy was attempted but could not reach the videocapsule. She underwent exploratory laparotomy revealing an intra-abdominal phlegmon and a loop ileostomy was performed. Patient delivered a healthy infant at 34 weeks. Resection of phlegmon and retrieval of foreign body were performed post-partum. DISCUSSION: Capsule retention is a potential complication of VCE, with a rate of 2.6% in patients with known or suspected Crohn's disease compared to an overall retention rate of 1.4%. Pregnancy is a relative contraindication to VCE due to a lack of safety data on whether the electromagnetic field of the capsule-recorder-system could harm the fetus. There is also feared theoretical complication of performing MRI while a capsule is within the gastrointestinal tract due to migration of the capsule and the potential for bowel injury or perforation. Our case reinforces the theory that 1.5 Tesla MRI can be safely performed in pregnancy with retained VCE without harm to patient or fetus.

1916 Gastrointestinal Stromal Tumor: Cause of Massive Lower Gastrointestinal Bleed in Young Patient

INTRODUCTION: Gastrointestinal stromal tumor (GIST) is one of the rare causes of gastrointestinal malignancies. GIST most commonly occurs in stomach. It arises from one of the specialized cells of GI tract, called as Interstitial Cells of Cajal (ICC) and mutations in one of the KIT gene or PDGFRA are responsible for the development of this tumor. We are here presenting a case of massive GI bleed in a very young patient from GIST tumor in small intestine. CASE DESCRIPTION/METHODS: 26-year-old male presented to ED complaining of having 3–4 bloody bowel movements in the last 2 days. He stated having soft stool mixed with a large amount of bright red blood. Patient denied abdominal pain, nausea, vomiting, recent travel, sick contacts or weight loss. Patient had low systolic blood pressure in the range of 70–80 on admission. Blood pressure was stabilized with IV fluids. Patient dropped hemoglobin during hospitalization to 5.8 and was transfused 7 PRBC’s. CT abdomen w/contrast revealed a circumferential, lobulated proximal ileal small bowel mass measuring 2.3 × 2.2 × 2.9 cm. EGD and Colonoscopy were done initially which showed extensive amount of blood and clots throughout the colon with very limited views of underlying mucosa but terminal ileum was normal in appearance. No active bleeding was noted. General surgery was consulted and resection of the tumor, that appeared to be the source of the bleeding, was performed in the mid ileum. A 5 cm resection of segment of small bowel was done. Pathology report showed GIST tumor. Patient bleeding stopped subsequently after surgery. DISCUSSION: GIST most commonly arises in fifth and sixth decades of life. It may be familial or sporadic. Mutations of KIT (80 %) and PDGFRA (10 %) are associated with both familial and sporadic causes. GIST tumors majority of the time are incidental findings but when symptomatic presenting complaints may include abdominal pain and swelling, nausea, vomiting, loss of appetite, or weight loss. Patient may also present with bowel perforation, acute abdomen and peritonitis. Rarely, they present with GI blood loss resulting in symptomatic anemia and hemodynamic instability. Almost 30% of the GIST tumors are malignant with the histological findings including highly cellular spindle cells or epitheloid mesenchymal tumors. The diagnosis is confirmed by immunohistochemical techniques and expression of tyrosine kinase receptor. Treatment for resectable tumors is surgery while those of non-resectable tumors is Imatinib a tyrosine kinase inhibitor.