Small Bowel Injury Research Articles

Prevention and management of non-steroidal anti-inflammatory drugs-induced small intestinal injury

Non-steroidal anti-inflammatory drug (NSAID)-induced small bowel injury is a topic that deserves attention since the advent of capsule endoscopy and balloon enteroscopy. NSAID enteropathy is common and is mostly asymptomatic. However, massive bleeding, stricture, or perforation may occur. The pathogenesis of small intestine injury by NSAIDs is complex and different from that of the upper gastrointestinal tract. No drug has yet been developed that can completely prevent or treat NSAID enteropathy. Therefore, a long-term randomized study in chronic NSAID users is needed.

Combination of low-dose aspirin and thienopyridine exacerbates small bowel injury

Objective. Antithrombotics is increasingly being used for cardiovascular prevention. In more recent studies, small bowel injury and enteropathy associated with low-dose aspirin are increasingly being recognized. Aim of this study was to evaluate small bowel injury using video capsule endoscopy (VCE) in obscure gastrointestinal bleeding (OGIB) patients taking low-dose aspirin including other antithrombotics. Material and methods. This is a retrospective review of chronic users of antithrombotics who underwent VCE for suspected small bowel bleeding. Small bowel mucosal injury was evaluated using VCE findings. Results. Fifty-four OGIB patients (36 men and 18 women, mean age 72.4 years) underwent VCE from January 2007 to May 2009. Twenty-two patients were taking 100 mg of enteric-coated aspirin (aspirin group), 8 taking thienopyridine, (ticlopidine or clopidogrel, thienopyridine group), 13 taking aspirin combined with thienopyridine (combined group), and 11 taking warfarin (warfarin group). The mucosal injury, especially ulcers were most frequently detected in the combined group (46.2%, p = 0.01) among the four groups. The median number of redness lesions in the combined group was the highest among the four groups and was significantly higher than that in the warfarin group. The lesions of redness or small erosions in the aspirin and the combined groups tended to exist in the proximal part of small bowel. Conclusions. Combination of low-dose aspirin therapy and thienopyridine may exacerbate small bowel injury, and the preventive strategies should be established.

Undisclosed Use of Nonsteroidal Anti-Inflammatory Drugs May Underlie Small-Bowel Injury Observed by Capsule Endoscopy

Findings from capsule endoscopies (CEs) of patients with enteropathy from nonsteroidal anti-inflammatory drugs (NSAIDs) may be indistinguishable from those with Crohn's disease, making medication history crucial to image interpretation. Undeclared NSAID use has been proposed to cause unexplained peptic ulcers; we investigated whether it is also an issue among patients referred for small-bowel CE. We collected demographic data, indications for CE, and medication history prospectively. A salicylate spot test and gas chromatography-mass spectrometry were performed for NSAID metabolites in urine samples of patients undergoing routine CE. Videos were analyzed by a gastroenterologist who was blinded to the urinalysis results. Seventy-six patients (52 women; mean age, 50 y) underwent CE for suspected small-bowel pathology. Urinalysis was positive in 13.6% of patients (salicylates, n = 3; ibuprofen, n = 6; and ibuprofen and diclofenac, n = 1) although only 1 of these patients declared use of an NSAID (aspirin). Although 2 patients had normal CE results, 80% had positive results, including the presence of erosions (n = 5), ulceration (n = 2), and ulcers with early stricturing (n = 1, diagnosed with Crohn's disease). A patient with small-bowel ulceration underwent surgery and was found to have NSAID-associated enteropathy, based on histologic analysis. Of patients who undergo CE, 13.6% took NSAIDs or aspirin, but most did not declare using these medications. Small-bowel inflammation was common in this cohort and could be mistaken for Crohn's disease. Patients should be questioned about use of over-the-counter medications, and routine urinalysis for NSAID metabolites may be helpful before interpretation of CE findings.

Blunt Traumatic Abdominal Aortic Dissection and Concomitant Traumatic Abdominal Wall Hernia and Small Bowel Injury: A Surgical Conundrum

Blunt Traumatic Abdominal Aortic Dissection and Concomitant Traumatic Abdominal Wall Hernia and Small Bowel Injury: A Surgical Conundrum

Induction of intestinal ischemia reperfusion injury by portal vein outflow occlusion in rats

Intestinal ischemia can occur from mesenteric artery (MA) occlusion and portal vein (PV) occlusion. The degree and mechanisms of ischemia/reperfusion (I/R) injury in these conditions may differ. Metabolic changes are seen early in I/R. This study compares tissue histology, inflammation, and metabolic response during small bowel I/R due to superior MA or PV occlusion. Anesthetized male Wistar rats (250-300g) underwent laparotomy followed by MA or PV occlusion for 40min. After 120min of reperfusion, small bowel tissue was collected. The expression of heat shock protein (HSP)-32 and HSP70 was evaluated to compare physiological stress responses between groups. Metabolic profiles were obtained using (1)H-nuclear magnetic resonance spectroscopy (NMR)-based quantitative metabolomics. Histological injury of small bowel was graded from 0 (normal) to 4 (extensive ischemic damage). Protein expression of HSP32 and HSP70 increased when compared to sham but was not different in the MA I/R and PV I/R groups. Metabolic profiles demonstrated decreased glucose levels and highly elevated tissue lactate and amino acids and fatty acids following I/R, with more pronounced changes with PV occlusion. Lipid peroxidation was equally increased in both groups, while depletion of reduced glutathione (GSH) was more severe with MA occlusion. The epithelial necrosis score was higher with MA (3.5±0.6) than with PV occlusion (2.3±0.8). Histological injury of the intestine is less pronounced following PV occlusion, most likely due to higher oxygen and substrate availability during I/R by PV occlusion. This conclusion is supported by a more pronounced metabolic synthetic response (increased glycolysis and fatty acid and amino acid accumulation) with PV occlusion, while oxidative stress was higher with MA occlusion. The inflammatory response showed little difference between the groups.

Selective Nonoperative Management of Torso Gunshot Wounds: When Is It Safe to Discharge?

For patients sustaining torso gunshot wounds (GSWs) who undergo a trial of nonoperative management (NOM), the optimal observation time required to exclude a hollow viscus injury before discharge is unknown. The purpose of this study was to analyze a continuous series of patients undergoing NOM after sustaining a GSW to the torso to determine the safe period of observation before discharge. This is a retrospective analysis of a continuous series of patients assessed at a Level I Trauma Center undergoing NOM of their torso GSWs from 2005 to 2007. After Institutional Review Board approval, injury demographics, operative procedures, time to operation, computed tomographic imaging results, and outcomes were abstracted. During the 3-year study period, a total of 863 patients sustained a GSW to the torso. Of these, 61 patients (7.1%) died in the emergency department and 15 (1.7%) did not have admission data. After excluding these patients, a total of 787 patients were available for analysis. Mean age was 26.2 +/- 9.7 years (range, 16 - 87 years), 93.6% were male, and mean Injury Severity Score was 10.7 +/- 10.6. Overall, 151 patients (19.2%) underwent immediate exploratory laparotomy, based on clinical criteria, and 636 patients (80.8%) underwent a trial of NOM. Of these, patients, 29 (4.6%) failed and were subsequently taken to the operating room. Two patients had a negative laparotomy; the remaining had colon or rectal (58.6%), small bowel (24.1%), stomach (17.2%), and bladder (6.9%) injuries requiring repair. All patients developed clinical or laboratory evidence of a missed injury by 24 hours of observation. For patients undergoing NOM of their torso GSWs, all patients who failed and required a laparotomy did so within 24 hours of admission. Patients undergoing selective NOM required a minimum of 24 hours of close observation before discharge.

Outcome of Lymphatic- and Artery-Sparing Surgery for Pediatric Varicocoele

In recent years, laparoscopic equipment, and experience with its use, has improved. We are now able to appreciate microanatomy, and dissection of individual lymphatic channels is possible. Previously, the results of laparoscopic lymphatic-sparing procedures has been reported. In this study, we report our experience of the preservation of both the lymphatic channels and the testicular artery during laparoscopic varicocelectomy and its outcomes. All boys undergoing laparoscopic varicocelectomy between June 2004 and February 2009 were included in the study. The demographic details, operative findings, complications, and length of stay were recorded on a Microsoft Excel spreadsheet and complications at follow-up noted. The operation was performed via a transperitoneal approach, and the retroperitoneum was entered proximal to the internal ring by peritoneal division over the vessels. The spermatic vein or veins were isolated and stripped of the surrounding lymphatics and artery and secured with ligaclips. Any other tortuous veins around the internal ring were also ligated at the time of operation. Nineteen boys underwent laparoscopic varicolectomy. Complications were 1 intraoperative small bowel injury, 1 hydrocele (5%), and 4 persistent varices (21%), one of which was symptomatic, requiring a low ligation of spermatic veins through a groin approach. This study shows good results with regard to postoperative hydrocoele rates. The preservation of the lymphatic supply ensures adequate lymphatic drainage, therefore, minimizing the risk of developing a hydrocele postoperatively. The risk of persistent varices, compared to the traditional en-masse technique, is a source of concern and requires further study.

M1248 Small Bowel Injury With Chronic Antithrombotic Therapy

M1248 Small Bowel Injury With Chronic Antithrombotic Therapy

PTH-095 Surreptitious use of non-steroidal anti-inflammatory drugs and aspirin may be responsible for small bowel injury seen by capsule endoscopy

Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause small bowel injury and present with anaemia, bleeding or symptoms suggestive of Crohn9s disease, the most common indications for capsule endoscopy (CE). Previous studies have suggested that the surreptitious use of these drugs may be a common cause of unexplained peptic ulcer disease.1 We hypothesised that surreptitious NSAID or aspirin use occurred in patients undergoing CE and that this might be responsible for symptoms or abnormalities being investigated. Methods Demographic data, indications for CE and medications were recorded prospectively. A salicylate spot test and gas chromatography mass spectrometry for NSAID metabolites were performed on urine samples of consecutive patients undergoing routine CE. Videos were analysed by an experienced gastroenterologist who was blinded to the urinalysis results. Results Seventy-six patients (52 female; mean age 50 years) underwent CE for suspected small bowel pathology. Urinalysis was positive in 13.6% of patients (n=10/76), although only one of these patients declared the relevant drug (aspirin) in their drug history. The indication for CE in the 10 patients included iron deficiency anaemia (n=2), investigation of suspected active Crohn9s disease (n=7) and possible coeliac complications (n=1). The presence of salicylates was detected in 3.9% of patients (n=3) while NSAID metabolites were detected in 9.2% (n=7: 6 patients ibuprofen alone and both ibuprofen and diclofenac in 1 patient). While CE was normal in 2 patients, positive findings were seen in 80% of patients (n=8) which included the presence of erosions± red patches in 5 patients, small bowel ulceration in 2 patients and ulceration with early stricturing in one patient. Follow-up data revealed that the patient with small bowel stricturing was subsequently diagnosed as Crohn9s disease while a patient with small bowel ulceration underwent small bowel resection at a further presentation which confirmed NSAID enteropathy histologically. Conclusion 13.6% of patients undergoing capsule endoscopy were taking NSAIDs or aspirin, of which the majority were not declared in the clinical history. In 11.8% of patients, NSAIDs or aspirin could have been contributing to the symptoms or anaemia being investigated. Patients should be carefully questioned about their use of these drugs and over the counter medications which might contain them, prior to CE.

What are the features of abusive abdominal injury? a systematic review

Aims Abusive abdominal injuries carry significant morbidity and mortality, yet are rarely recognised. The authors aim to determine the prevalence and characteristics both clinically and biochemically. Methods The authors performed a literature search of databases, websites and references from 1950 to 2009. Of 2352 abstracts, 180 studies underwent two independent reviews using standardised criteria, with a third review if there was disagreement. Inclusion criteria: primary studies of children Results Overall, 58 studies (854 children; 103 with abusive abdominal injuries) were included. Of these, 1. Conclusion Abdominal injury should be considered in any physically abused child, as symptoms may be non-specific. The absence of local bruising does not preclude significant injury. Small bowel injuries in young children have a strong association with abuse, but liver injury is also common. Measurement of AST and ALT may assist in assessing for occult abdominal injury and may be useful prognostically.

Delayed presentation of small bowel injury during suprapubic catheterisation.

We present a case of small intestine injury resulting from suprapubic catheter insertion. This case is of particular interest for three reasons. Firstly, the presentation of the injury was delayed by three months, until the time of the first catheter exchange. Secondly, the injury was managed conservatively, without surgical exploration. Finally, the injury occurred using a newer, Seldinger-type suprapubic catheter insertion kit.

Assessment and outcome of 496 penetrating gastrointestinal warfare injuries

AimThe abdominal viscera are among the most vulnerable organs of the body to penetrating trauma. Proper management of such trauma in war victims at the first-line hospital where these victims...

Improving Local Control in Rectal Cancer: Radiation Sensitizers or Radiation Dose?

Improving Local Control in Rectal Cancer: Radiation Sensitizers or Radiation Dose?

Video capsule endoscopy of the small bowel

It is now over 8 years since small bowel capsule endoscopy (SBCE) was first introduced to the gastrointestinal community. The original capsule (Given Imaging, YoKneam, Israel) - a disposable 26 x 11 mm video capsule containing its own optical dome, light source, batteries, transmitter and antenna - is swallowed with water after a 12 h fast. The capsule is propelled via peristalsis through the gastrointestinal tract and is excreted naturally. We will review all recent work concerning SBCE. At present there are three other SBCEs in the market. SBCE has become a first-line tool to detect abnormalities in the small bowel, as all other imaging technologies are rather ineffective, or very tedious.Indications for SBCE include obscure gastrointestinal bleeding, suspected small bowel tumor, suspected Crohn's disease, surveillance of inherited polyposis syndromes, drug-induced small bowel injury or any abnormal small bowel imaging and new ones are emerging like small bowel motility. Since most of the articles in the literature relate to the PillCam small bowel capsule the data presented will refer mainly to this capsule endoscopy. SBCE has shed new light into our knowledge of the small bowel, paving the way for new modalities to come.

Small Bowel Injury as a Complication of Lumbar Microdiscectomy : Case Report and Literature Review

Small bowel injury resulting from unforeseen penetration of the anterior annulus fibrosus and longitudinal ligament is a rare complication of lumbar microdiscectomy. The patient complained of abdominal tenderness and distention immediately after microdiscectomy for L4-5 and L5-S1 disc herniation. Using abdominal computed tomography, we found several foci of air overlying the anterior aspect of the vertebral body at the L5-S1 level. Segmental resection of the small bowel including small tears and primary anastomosis of the jejunum were performed. Here, we present a case of intestinal perforation after lumbar microdiscectomy and discuss technical methods to prevent this complication with a review of literature.

The trend view of nonsteroidal anti-inflammatory drug-induced small bowel injury

The trend view of nonsteroidal anti-inflammatory drug-induced small bowel injury

A Novel Composite Endpoint to Evaluate the Gastrointestinal Effects of NSAID Through the Entire GI Tract: Introducing CSULGIE

The notion that nonsteroidal antiinflammatory drugs (NSAID) cause gastric and duodenal ulcers, which can bleed or perforate, has certainly had its fair share of attention over the past 40 years. Yet, in rodent models, the burden of injury is in the terminal ileum, not the stomach or duodenum1. A small but growing constituency has argued that small bowel injury may be as important in humans. This proposition, which is commercially attractive to manufacturers of selective cyclooxygenase (COX)-2 inhibitors, which may lack this property, is increasingly discussed. In this issue of The Journal Francis Chan and his colleagues introduce the notion of Clinically Significant Upper and Lower GastroIntestinal Events2 (the acronym CSULGIE proudly maintaining the dysphonia originally established with the acronym NSAID!). They suggest that upper and lower GI events should be aggregated in assessing patients with drug-induced GI damage. In assessing this proposition, it is worthwhile reviewing lessons from the upper GI (UGI) tract. The first evidence that aspirin was gastrotoxic was conveyed by watercolor paintings of acute lesions detected by rigid endoscopy3, but the first systematic investigation used microbleeding as a surrogate for injury4 before volunteer endoscopy took over. Such studies also showed that non-aspirin NSAID caused injury, and numerous epidemiological studies associated aspirin and non-aspirin NSAID with GI bleeding5,6. While endoscopy and a couple of secondary prevention studies were regarded as adequate to establish the validity of Helicobacter pylori eradication, different standards were applied to NSAID and COX-2 inhibitors with the advent of the outcomes study7. As with H. pylori , endoscopy studies are broadly predictive of outcomes. Where there are differences, this may well be because of imprecisions in outcome studies. Nevertheless, the vogue for outcomes shows no signs of abating and accidentally generates interesting … Address correspondence to Prof. Hawkey; E-mail: cj.hawkey{at}nottingham.ac.uk

Wireless Capsule Endoscopy in Enteropathy Induced by Nonsteroidal Anti-inflammatory Drugs in Pigs

The aim of this study is to evaluate the diagnostic yield of capsule endoscopy in nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy in pigs. Indomethacin (400 mg/day) was administrated orally for 10 days to eight female pigs weighing 36.3+/-2.4 kg. Afterwards, capsule endoscopy was performed, using the EndoCapsule system (Olympus Optical Co., Tokyo, Japan). The following morning, pharmacological euthanasia and immediate autopsy were performed. Small bowel injury compatible with NSAID-induced enteropathy was observed in 7/8 animals. The most common lesions were red spots and erosions. Ulcers and small intestinal bleeding were identified sporadically. Sensitivity and specificity of capsule endoscopy were 83.3% and 95.8%, respectively. Our results indicate that wireless capsule endoscopy is a highly accurate noninvasive method for evaluation of experimental NSAID-induced enteropathy.

Randomized, double-blind, pilot study of geranylgeranylacetone versus placebo in patients taking low-dose enteric-coated aspirin. Low-dose aspirin-induced small bowel damage

Objective. Low-dose enteric-coated aspirin is increasingly being used for prevention of cardiovascular disease. The aim of this study was to evaluate whether geranylgeranylacetone (GGA) could prevent aspirin-induced small bowel injury. Material and methods. This was a prospective, randomized, double-blind, pilot study of GGA versus placebo in subjects taking low-dose enteric-coated aspirin. Young healthy volunteers were enrolled and each received 100 mg of enteric-coated aspirin per day plus either GGA (150 mg/day) or matching placebo for 7 days. Video capsule endoscopy of the small bowel and the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire were performed before and after the administration of aspirin. Results. Twenty volunteers were evaluated. There was no significant difference in the number of lesions in any category between those receiving or not receiving GGA. Large erosions or ulcers were observed in 12 (60%; 95% confidence interval 36%– 80%) aspirin users. Mucosal breaks were most frequently found in the latter half of the proximal small bowel. Conclusions. Short-term administration of low-dose enteric-coated aspirin was associated with visible small bowel damage in the majority of users. We could not prove that aspirin-induced small bowel mucosal injury was prevented by GGA.

An audit of failed non-operative management of abdominal stab wounds

Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures. Methods The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12 h) there is little additional morbidity. Recognition of the need for surgical intervention after 12 h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time. Results A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12 h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3). Conclusion Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12 h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.