Short Gut Research Articles

Closing Gastroschisis: eine Sonderform der Gastroschisis mit hoher Morbidität und Mortalität

We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome. We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009. Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage. We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis. Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

Pregnancy in an Intestinal Transplant Recipient

Intestinal transplantation is a relatively new form of therapy for short gut syndrome. Pregnancy after intestinal transplantation is rare. A 26-year-old small bowel transplant recipient presented for prenatal care. She previously had undergone bariatric surgery and later experienced small bowel necrosis and resection. The resulting short gut syndrome was treated with an isolated small bowel transplant. Medications during this pregnancy included prednisone, esomeprazole, diphenoxylate-atropine, ascorbic acid, tacrolimus, and magnesium supplementation. Throughout her pregnancy, her creatinine level was elevated. Labor was induced at 39 3/7 weeks and resulted in a spontaneous vaginal delivery of a healthy female neonate. Twelve weeks after delivery, the mother was admitted for a rejection reaction that was treated successfully. A successful pregnancy in an intestinal transplant recipient resulted in delivery of a healthy term newborn.

Reasons and Operative Outcomes After Reversal of Gastric Bypass and Jejunoileal Bypass

Limited information is available regarding reversal of gastric bypass. While reversal will lead to weight regain and return of comorbid conditions, procedure reversal is sometimes necessary due to complications. The decision to reverse versus revise is difficult; currently, there are no established guidelines. The objective was to review one center's experience with reversals of gastric bypass and jejunoileal bypass procedures and identify potential indications as well as technical feasibility and short-term outcomes. A retrospective review of a prospectively collected database from 1999 to 2010 was conducted; 12 patients who underwent reversal of non-banding bariatric procedures were included. There was no major perioperative morbidity in elective patients; one patient whose reversal was part of a second-look operation had massive intestinal necrosis. There was one (8.3%) non-procedure-related postoperative death. No leaks were identified in any of the reversals. Leak rates were compared with other revisional procedures such as reversals, revisions, and conversions, with no statistical significance regarding leak rates between all three groups; however, revisions and conversions were performed via open or laparoscopic approach, while reversals were performed exclusively via open approach. Reversals of bariatric (non-banding) procedures, either combined or purely malabsorptive, are technically challenging. Indications remain poorly defined. In our experience, short gut syndrome, renal failure, marginal ulceration, and malnutrition were the most common indications for reversal, differing from previously published data. Indications can depend on patient and surgeon preferences, but primarily on surgeon experience and type of complications. Based on this initial experience, these operations can be performed using the open approach with good outcomes.

The Relative Contribution of Specialists and Generalists to Mistletoe Dispersal: Insights from a Neotropical Rain Forest

AbstractMistletoes rely on birds for seed dispersal, but the presumed importance of mistletoe‐specialist frugivores has not been critically examined nor compared with generalist frugivores and opportunistic foragers. The contribution of these three groups was compared directly by quantifying bird visitation to fruiting mistletoe plants ( Oryctanthus occidentalis: Loranthaceae) at Barro Colorado Island, Panama, and by comparing these results with proportions calculated from other empirical studies of mistletoe visitation conducted elsewhere. After more than 100 h of timed watches, 23 bird species were recorded visiting eight heavily infected host trees ( Luehea seemannii: Tiliaceae). Eight of these species visited mistletoe, of which five (all tyrannids) consumed mistletoe fruit. Although two mistletoe specialist frugivores ( Tyrannulus elatus and Zimmerius vilissimus) removed most fruit (73%), more than a quarter was consumed by one generalist frugivore ( Mionectes oleagineus) and two opportunists ( Myiozetetes cayanensis and Myiozetetes similis). Post consumption behaviour varied: the specialists flew from mistletoe to mistletoe, the generalist rested in the subcanopy and understory, and the opportunists spent most time hawking insects and resting high in the canopy. Integrating these data with previous work, the dietary specialization, short gut passage rate and strict habitat preferences of mistletoe specialists suggests that their services relate primarily to intensification and contagious dispersal, while species with broader diets are more likely to visit uninfected trees and establish new infections. The presumed importance of mistletoe‐specialist frugivores was not supported and mistletoes are considered to be comparable to many other bird‐dispersed plants, relying on both specialist and generalist frugivores, while opportunists may be disproportionately important in long‐distance dispersal.

Severe Hypomagnesemia Associated With Reversible Subacute Ataxia and Cerebellar Hyperintensities on MRI

Hypomagnesemia has been associated with various neurological symptoms including ataxia. Reversible changes in cerebellar function have been described due to hypertensive changes, eclampsia, and immunosuppressive therapy in the context of posterior reversible encephalopathy syndrome. In this report we document isolated, reversible cerebellar findings with the corresponding neuroimaging correlates associated with critically low magnesium levels. A 72-year-old male with metastatic colorectal cancer and short gut syndrome presented with subacute ataxia and cerebellar T2 hyperintensities on magnetic resonance imaging. The patient showed rapid clinical and radiologic improvement in his cerebellar findings after receiving only magnesium supplementation. Our report suggests that low magnesium levels may mimic the vascular endothelial dysregulation that is seen in the context of rapid rises in blood pressure in both posterior reversible encephalopathy syndrome and eclampsia. This rare case suggests a potential role of magnesium in stabilizing the vascular endothelium and, when deficient, in contributing to cerebral edema of the posterior circulation territories.

Editorial introductions

Editorial introductions

PMO-073 Post-operative enteral nutrition and recirculation of jejunal effluent in the management of a paraduodenal hernia: a case report

IntroductionShort gut secondary to surgical resection often requires post-operative total parenteral nutrition. We present a case of ischaemic gut secondary to a paraduodenal hernia. Post-operative nutritional requirements were met using...

Gut Balance, a synbiotic supplement, increases fecal Lactobacillus paracasei but has little effect on immunity in healthy physically active individuals

Synbiotic supplements, which contain multiple functional ingredients, may enhance the immune system more than the use of individual ingredients alone. A double blind active controlled parallel trial over a 21 day exercise training period was conducted to evaluate the effect of Gut BalanceTM, which contains Lactobacillus paracasei subsp paracasei (L. casei 431®), Bifidobacterium animalis ssp lactis (BB-12®), Lactobacillus acidophilus (LA-5®), Lactobacillus rhamnosus (LGG®), two prebiotics (raftiline and raftilose) and bovine whey derived lactoferrin and immunoglobulins with acacia gum on fecal microbiota, short chain fatty acids (SCFA), gut permeability, salivary lactoferrin and serum cytokines. All subjects randomized were included in the analysis. There was a 9-fold (1.2-fold to 64-fold; 95% confidence intervals p = 0.03) greater increase in fecal L. paracasei numbers with Gut BalanceTM compared with acacia gum supplementation. Gut BalanceTM was associated with a 50% (-12% to 72%; p = 0.02) smaller increase in the concentration of serum IL-16 in comparison to acacia gum from pre- to post-study. No substantial effects of either supplement were evident in fecal SCFA concentrations, measures of mucosal immunity or GI permeability. Clinical studies are now required to determine whether Gut BalanceTM may exert beneficial GI health effects by increasing the recovery of fecal L. paracasei. Both supplements had little effect on immunity. Twenty-two healthy physically active male subjects (mean age = 33.9 ± 6.5 y) were randomly allocated to either daily prebiotic or synbiotic supplementation for 21 day. Saliva, blood, urine and fecal samples were collected pre-, mid- and post-intervention. Participants recorded patterns of physical activity on a self-reported questionnaire.

Hepatoadrenal syndrome in pediatric patients with end-stage liver disease*

Adrenal insufficiency in patients with liver failure, referred to as hepatoadrenal syndrome, is well characterized in adult patients but has not yet been described in children. We present 22 pediatric subjects with end-stage liver disease and adrenal insufficiency, diagnosed using the cosyntropin stimulation test. A retrospective chart review using inpatient records from a pediatric intensive care unit in an academic medical center with a busy pediatric transplant program. Most were infants with anatomical short gut and severe, total parenteral nutrition-induced liver failure awaiting liver transplantation. Many were critically ill; 68% required mechanical ventilation and 59% required vasopressors. None. All patients had low baseline cortisol levels and ten also had an abnormal cosyntropin stimulation test. Cortisol levels at baseline and increments of serum cortisol at 30 and 60 mins post cosyntropin were 9.3 ± 5 μg/dL, 9.3 ± 4 μg/dL, and 10.7 ± 6 μg/dL, respectively, compared to these values in five patients with liver failure and normal adrenal function (21.3 ± 3 μg/dL, 10.5 ± 5 μg/dL, and 12.7 ± 3 μg/dL, respectively). Baseline cortisol levels were higher in patients who required vasopressors (11.1 ± 5 μg/dL) compared to those who did not (6.6 ± 4.3 μg/dL, p = .04), and 60-min increment cortisol levels were lower in nonsurvivors compared to survivors (8.6 ± 4.8 μg/dL vs. 15.1 ± 5.1 μg/dL, p = .002). The severity of adrenal insufficiency did not correlate with the degree of hepatic decompensation. Clinical characteristics, including serum electrolytes and vasopressor requirements, were similar in patients with hepatoadrenal syndrome and patients with liver failure and normal adrenal function. Twelve (55%) of the patients died in the hospital, 11 without receiving a transplant. Hydrocortisone therapy permitted rapid weaning of vasopressor therapy but did not affect survival. Children with end-stage liver disease are at risk for hepatoadrenal syndrome and should have their cortisol levels monitored since clinical manifestations may not be diagnostic.

Intestinal Rehabilitation and Bowel Reconstructive Surgery

Short bowel syndrome poses a great challenge to pediatric teams. Several innovative techniques in the management of total parenteral nutrition (TPN) and bowel reconstructive surgery have improved the outcomes of these children. The authors present their experience during the last decade as a specialist unit using improved techniques and multidisciplinary approaches in the management of this condition. All of the children presenting with short bowel syndrome between 2000 and 2009 were identified. Diagnosis, length of residual gut, age at definitive surgery, length of gut prelengthening, length of gut postlengthening, TPN status, and survival were recorded. Median values were calculated. Twenty-seven children were identified (14 boys, 13 girls). Overall survival was 92%. Two children died. Nineteen children required bowel lengthening and 8 children had simple bowel reconstruction while on our protocol. Overall median age at definitive surgery was 12 months. Overall median residual gut length for these was 35.5 cm, whereas the median residual gut length for patients undergoing bowel lengthening was 25 cm. Postbowel lengthening, the median gut length was 90 cm. TPN data were unavailable for 2 patients. Overall, excluding the 2 patients who died and the 2 we have no TPN data on, of 23 patients, 21 (91%) are now off TPN. Our series shows improved results not only with survival but also in the number of patients that are off TPN. Multidisciplinary approach consisting of both medical and surgical expertise is necessary in the management of these patients. The authors advocate centralisation of short gut services to experienced centers with multidisciplinary expertise.

Short Bowel Syndrome: A Practical Pathway Leading to Successful Enteral Autonomy

Short bowel syndrome is a multisystemic disorder that results from the loss of a significant amount of small bowel. The goal of treatment in these patients is to achieve complete enteral autonomy while minimizing complications. Our unit has 30 years of experience in the management of short gut patients. During the past decade, our results have improved significantly, especially in children with severe short bowel syndrome. This brief communication looks at the algorithm presently used in our unit. In this communication, the principles in management of short bowel syndrome in our unit are discussed. In addition, our algorithm is published for the first time. A brief summary of our results is provided. Twenty-seven children were enrolled from 2000 to 2009. In this cohort, two patients died because of significant liver disease: one after having two liver and bowel transplants. Overall, survival stands at 92%. All had autologous gastrointestinal reconstruction, and 19 patients underwent bowel lengthening (longitudinal intestinal lengthening and tailoring). The median residual length of bowel of this subgroup at first operation was 25 cm in those who had their gut measured. Two patients were lost to follow-up. Two patients remain on supplemental total parenteral nutrition (TPN), with an overall 91% of surviving patients off TPN at a median of 6 months after reconstruction. We believe this improvement is related to the development-over many years-of a structured pathway for managing these patients.

In vitro tissue engineering of smooth muscle sheets with peristalsis using a murine induced pluripotent stem cell line

PurposeCurrently, therapeutic options for short gut syndrome are limited, ranging from total parenteral nutrition pending intestinal adaption to small bowel transplantation with its associated problems of rejection. The aim of this study was to differentiate murine induced pluripotent stem cells (iPSCs) into gut tissues, including contracting smooth muscle, as a precursor to using tissue engineering techniques to generate functioning intestinal tissue from the patient's own cells. MethodInduced pluripotent stem cells were cultured for 6 days in low adherent 96-well plates (500-5000 cells per well) in a differentiation medium comprising Knockout Dulbecco's modified Eagle medium (Invitrogen, Carlsbad, Calif) supplemented with 10% fetal bovine serum, l-glutamine, nonessential amino acids, 2-mercaptoethanol, penicillin, and streptomycin. After 6 days, the embryoid body that had formed in each well was transferred into a 12-well plate, each well containing 8 embryoid bodies. ResultsOutgrowth culture produced differentiated cell clusters, including cardiaclike cells, sheets of smooth muscle with peristalticlike activity, and mucosal cells. Cardiaclike cells exhibited spontaneous rhythmic regular contraction, but the sheets of smooth muscle contracted in a co-ordinated way, just as is seen in peristaltic bowel, as shown using video imaging. ConclusionTissue engineering techniques using iPSCs have the potential to ultimately replace the need for small bowel transplantation and allow patients to “grow” their own small bowel.

Indications et résultats de la transplantation intestinale chez l’adulte

Optimised home parenteral nutrition is still, after 35 years of progress, the "gold standard "for benign but chronic intestinal failure. better recognition of chronic intestinal failure, in its multiple facets, is needed to improve Home Parenteral Nutrition by adding associated treatments such as intestinal trophic factors, rehabilitative surgery (reestablishment of colonic continuity, reverse jejunal segment in severe short gut type II) and/or reconstructive surgery (intestinal transplantation for end-stage intestinal failure). Intestinal transplantation is now a mature therapy with formal indications, especially in case of failure of Home Parenteral Nutrition (mainly Home Parenteral Nutrition-associated severe liver disease), where combined Liver-intestine transplantation is indicated before end-stage liver failure occurs. For high-risk patients, 'preemptive' intestinal transplantation alone should be discussed before home parenteral nutrition-related complications occur. Even, if the results in terms of patient survival have improved over the past 20 years, the 5-year survival rate still does not exceed 50%. Thus, each case should be discussed in a dedicated tertiary center. The ESPEN Home Artificial Nutrition Working Group conducted a survey in 2004 to assess potential candidates for intestinal transplantation in France, among the adult population of patients with home parenteral nutrition. The prevalence of potential candidates for intestinal transplantation was estimated at about 20% (about 40 new adult cases per year). Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantation were developed in the 1960s, very few patients were transplanted before 1990, because of inadequate initial immunosuppressive regimens. most patients died within days or months after Intestine transplantation. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990, the development of tacrolimus-based immunosuppression, as well as improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and better patient selection helped to improve actuarial graft and patient survival rates for all types of intestine transplantation. In adult intestinal transplantation, three kinds of graft can be proposed: isolated small bowel, combined liver and small bowel, and multivisceral transplantation. In isolated small bowel transplantation, the length of the graft ranges between 1.5 and 2 meters, but depends on the size of the recipient (and the abdominal cavity volume, which is reduced). The graft is anastomosed with the recipient's duodenum or remnant proximal jejunum. the distal part of the small bowel graft is on a temporary stoma, in order to allow biopsies for early detection of rejection. Vascular anastomoses are usually performed directly on the aorta for the superior mesenteric artery and either the recipient's portal vein or vena cava for the donor superior mesenteric vein. In combined liver and intestinal transplantation, one venous anastomosis is avoided because the graft is in one piece. Finally, one specificity of this transplantation is the fact that it usually concerns patients with numerous previous abdominal operations and with total or subtotal enterectomy. Thus, the residual abdominal cavity is usually very small, and this can be a major problem for graft insertion. For this reason, abdominal closure is performed with a temporary prosthesis, because even cutaneous closure remains impossible if a compartment syndrome is to be avoided.

Short bowel syndrome, gut failure and nutrition

The normal small intestine length is 300 to 800 cm, dependent on the mode of measurement, either radiological, surgical or necropsy [1-3]. Short bowel syndrome is generally considered to occur when there is less than 200cm remaining. Short bowel may be consequent to congenital abnormalities, necrotizing enterocolitis, extensive agangliosis, and volvulus in children, and following surgery for ischemia, Crohn’s disease, tumors and trauma in adults. A “functional short bowel” may result from refractory celiac sprue, chronic intestinal pseudo-obstruction, and radiation enteritis. Short bowel syndrome may be defined as “reduction of functioning gut mass below the minimum amount necessary for adequate water and electrolyte absorption and adequate digestion and absorption of nutrients” [4,5].

Dietary resistant starch dose-dependently reduces adiposity in obesity-prone and obesity-resistant male rats.

BackgroundAnimal studies show that diets containing resistant starch (RS) at levels not achievable in the human diet result in lower body weight and/or adiposity in rodents. We aimed to determine whether RS dose-dependently reduces adiposity in obesity-prone (OP) and obesity-resistant (OR) rats.MethodsMale Sprague–Dawley rats (n=120) were fed a moderate-fat, high-energy diet for 4 wk. Rats that gained the most weight (40%) were classified as obesity-prone (OP) and obesity-resistant (OR) rats were the 40% that gained the least weight. OP and OR rats were randomly allocated to one of six groups (n=8 for each phenotype). One group was killed for baseline measurements, the other five groups were allocated to AIN-93 based diets that contained 0, 4, 8, 12 and 16% RS (as high amylose maize starch) for 4 wk. These diets were matched for total carbohydrate content. At 0, 4 and 7 wk from the start of the study insulin sensitivity was calculated by homeostasis model assessment of insulin resistance (HOMA-IR) and adiposity was determined by dual-energy X-ray absorptiometry (DXA). At 8 wk, rats were euthanized and fat pad weights, intestinal digesta short chain fatty acid (SCFA) pools and plasma gut hormone levels were determined.ResultsObesity prone rats gained less weight with 4, 12 and 16% RS compared to 0% RS, but the effect in OR animals was significant only at 16% RS. Irrespective of phenotype, diets containing ≥8% RS reduced adiposity compared to 0% RS. Energy intake decreased by 9.8 kJ/d for every 4% increase in RS. All diets containing RS increased total SCFA pools in the caecum and lowered plasma GIP concentrations compared to the 0% RS, whereas plasma GLP-1 and PYY were increased when the diet contained at least 8% RS. Insulin sensitivity was not affected by RS.ConclusionRS in amounts that could be potentially consumed by humans were effective in reducing adiposity and weight gain in OP and OR rats, due in part to a reduction in energy intake, and changes in gut hormones and large bowel carbohydrate fermentation.

Pediococcus acidilactici Endocarditis Successfully Treated with Daptomycin

This report describes the first case of persistent bacteremia with endocarditis caused by Pediococcus acidilactici in a 32-year-old male with a history of short gut syndrome following a small bowel transplant. The results showed the utility of sequencing the intergenic spacer region for species identification and successful treatment using daptomycin.

Successful switch-over administration of intravenous-to-oral tacrolimus after isolated living-donor liver transplantation in a child with ultra short gut syndrome

Successful switch-over administration of intravenous-to-oral tacrolimus after isolated living-donor liver transplantation in a child with ultra short gut syndrome

Early observations in the use of oral rotavirus vaccination in infants with functional short gut syndrome

Universal vaccination with an oral live-attenuated rotavirus vaccine at 2, 4 and 6 months of age was introduced in Australia in July 2007. There are no data on the short-term effects of vaccination for those infants most at risk of severe complications from rotavirus infection. The aim of this study was to describe the effects of rotavirus vaccination on weight gain and gastrointestinal losses in infants with functional short gut syndrome secondary to an ileostomy. A retrospective review of all infants with an ileostomy who received RotaTeq while hospitalised at the Royal Children's Hospital, Melbourne from July 2007 to July 2009 was performed. Daily data were collected from 1 week before to 2 weeks after vaccination. The data included type and volume of feeds, ileostomy losses, need for fluid replacement of ileostomy losses, weight, temperature, urine sodium, stool culture, suspected and confirmed sepsis. Nine infants (age at first RotaTeq 61-99 days) were identified. The median (range) gestational age was 26 (24, 38) completed weeks and birthweight was 737 (620, 2714) grams. Compared to the day of vaccination, the median (range) ileostomy losses 1 week before, 1 and 2 weeks after vaccination were -1.1 (-13.6, 4.9) mL/kg/day, 2 (-11.1, 25.0) mL/kg/day and 2.4 (-15.7, 27.2) mL/kg/day, respectively. One infant developed severe stomal losses after vaccination. Overall, rotavirus vaccination did not alter weight gain, temperature or urinary sodium. In this small series, oral live-attenuated rotavirus vaccination of infants with high-output ileostomy was tolerated in most cases.

Gastrocolic Fistula Secondary to Benign Ulcer Disease: An Unusual Case of Post-prandial Osmotic Diarrhea

Purpose: Gastrocolic fistulae are a rare entity, occurring most commonly in the context of neoplastic disease or less frequently as a complication of benign ulcers, Crohn's disease, iatrogenic injury, or tuberculosis. We report the case of a 55 year-old woman with a recent history of a gastric ulcer and a distant history of a perforated duodenal ulcer who was admitted with six weeks of watery diarrhea associated with intermittent nausea and vomiting, generalized abdominal discomfort, loss of appetite, and a 25-pound unintentional weight loss. Physical examination was notable for cachexia and a well-healed midline abdominal incision but was otherwise unremarkable. Initial laboratory testing revealed severe metabolic acidosis, severe hypokalemia, hypoalbuminemia, and negative stool tests for occult blood, fecal fat, and infectious causes of diarrhea. Further work-up was significant for a stool osmotic gap of greater than 300 mOsm/kg. A computed tomography scan of the abdomen and pelvis suggested a soft tissue mass within the left upper quadrant adjacent to the stomach and transverse colon. Upper endoscopy and colonoscopy revealed a giant, deeply-cratered gastric ulcer involving the lesser curvature and antrum with fistulization to the distal transverse colon. Total parenteral nutrition (TPN) was initiated to optimize nutritional status prior to surgery: takedown of gastrocolic fistula, repair of gastrotomy, partial colectomy, and Hartmann's procedure with end colostomy. The pathology specimen demonstrated chronic inflammatory changes including granulation tissue, fibrosis, and fibrin deposition without evidence of tumor. The patient was discharged once she was weaned off of TPN and was tolerating oral feeding. Conclusions: Though rare, fistulization within the intestinal tract and subsequent formation of a functional “short gut,” should be suspected in patients with unexplained post-prandial osmotic diarrhea.

PP73 FROM CHILDHOOD TO ADOLESCENCE: THE COELIAC DISEASE EXPERIENCE FROM THE POINT OF VIEW OF THOSE WHO ARE GROWING UP AND THOSE WHO ARE TAKING CARE OF THEM

Stool calprotectin is useful in monitoring rejection in small bowel transplantation. We report about our initial experience in Children’s Hospital “Bambino Gesu” in Rome on monitoring gut rejection by using stool calprotectin together with intestinal biopsies. Case 1: a 12 year-old boy underwent at the age of 8 SBTx for short gut syndrome; he experienced one ACR, recovered on steroid bolus and he did well for 6 months. Sirolimus was started for initial renal damage, but it had to be discontinued for severe thrombotic micro-angiopathy. A second severe ACR occurred 1 year after transplant and again medical therapy was effective in recovery. After 3 years of well being, with no previous evidence of rejection at histology, he was admitted in Rome for acute diarrhea following Rotavirus infection. Hystology revealed ACR, initially treated by steroid without any effects so repeated steroid bolus, infliximab and mesenchymal cell infusion were administered, but severe exfoliative rejection led to re-transplant, performed in Rome on TAC, steroid, MMF and basiliximab; at + 3 months, CMV enteritis occurred, successfully treated by ganciclovir. Before and after re-Tx, stool calprotectin levels were strict monitoring: normal levels ( 1000 mcg/g) if severe ACR, while in CMV infection levels were always below 800 mcg/g. Case 2: C.S. is now a 10 yr-old boy affected by CIPO who underwent SBTx at the age of 7 for recurrence of severe dehydration and hemorrhagic events; surgical procedure was uneventful, on basiliximab, TAC and steroid therapy. Six months after transplant he experienced ACR and severe CMV enteritis, with complete recovery. The follow-up was continued in Rome, where he underwent protocol biopsies without any evidence of rejection so far. Stool calprotectin levels were always within normal ranges (<250 mcg/g), according to histology. In our experience stool calprotectin levels appear to correlate to gut inflammation, and high levels seem to be more associated to rejection. This could be a useful tool to suspect graft dysfunction.