Vascular anatomy of the gastrointestinal tract

The blood supply of the gastrointestinal system has intramural and extramural components. The intramural vascular distribution is generally well developed with plexuses in the different layers of the bowel wall and with specializations in the liver, small intestine and gastroesophageal junction, adapted to the function of these organs. The extramural arterial supply for the oesophagus is derived from the thoracic aorta or its major branches. Blood supply to the abdominal organs is provided by three major unpaired vessels arising from the abdominal aorta, namely the coeliac trunk and the superior and inferior mesenteric arteries. The branches of these vessels form anastomotic systems that provide a rich blood supply to the adjoining organs. In many areas the systems overlap while in other regions linkages are limited. Interrelations and weak points are of significant clinical importance. As well as this, there is a great individual variability in the anatomy of the gastrointestinal vasculature.

Acute intestinal ischaemia

The subsets of acute mesenteric ischaemia include mesenteric arterial occlusion (by embolus or thrombosis), mesenteric venous thrombosis and non-occlusive mesenteric ischaemia. Despite advances in pathophysiology, laboratory diagnosis and imaging techniques, acute mesenteric ischaemia is still associated with mortality rates of more than 60% and continues to be a challenging diagnostic problem. The key to a better outcome (and the main problem in clinical practice) is early diagnosis. Clinical presentation may be unspecific, but is often characterized by an initial discrepancy between severe subjective pain and relatively unspectacular findings on physical examination. Up to now, there are no simple and non-invasive diagnostic tests of sufficient sensitivity and specificity; thus, angiography remains the cornerstone of diagnosis and should be performed early in all patients in which mesenteric ischaemia is a realistic differential diagnosis. Treatment for obstructive mesenteric arterial syndromes and most patients with mesenteric venous thrombosis is surgical, whereas non-occlusive mesenteric ischaemia may be managed by pharmacological vasodilation.

[Anatomic-topographic description of the stomach, small intestine, large intestine and their arteries of the greater mara (Dolichotis patagonum Desmarest 1820)]

The abdominal parts of the alimentary canal and the associated arteries from seven male and nine female maras are described. The mara possesses a stomach with a single cavity and a glandular mucosa lining. The large stomach is situated caudal of the liver at right-angles to the longitudinal body axis. The long jejunum is located on the left side of the body caudal of the stomach. The cecum has two teniae and numerous haustra which are proximal larger than distal. The smooth colon ascendens runs proximal parallel to the cecum and describes distal an U-shaped double-loop. The internal surface of the proximal part of the colon ascendens is characterized by two parallel mucosal ledges. Cecum and colon ascendens lie right caudal of the liver. The colon descendens is coiled and situated on the left body side. The A. gastrica sinistra and branches of the A. lienalis and the A. hepatica supply the stomach. The A. mesenterica cranialis which branches of separately from the A. coeliaca is a large and long vessel that supplies the major parts of the small intestine and the colon. The A. mesenterica caudalis supplies parts of the colon desendens and of the rectum.

Myoelectric assessment of large bowel viability: an experiment in dogs

OBJECTIVE

To design a device for myoelectric assessment of intestinal ischaemia and compare it with every day surgical experience and Doppler signals recorded on the bowel wall.

DESIGN

Experimental study.

SETTING

Thessaloniki university hospital, Greece.

MATERIAL

12 adult mongrel dogs.

INTERVENTIONS

On the first day the large intestine was devascularised for a length of 20 cm, 5 cm away from the ileocaecal valve, and the threshold of the electric stimulus (mA) required to produce a contraction of the normal large bowel was recorded. On the second day, measurements were made on the ischaemic segment of the large bowel at 0.5 cm intervals. Bowel resection and anastomoses were done at the stimulus level of 40 mA.

RESULTS

The mean (SD) stimulus threshold of the normal large intestine was 12.2 mA. The necrotic intestine demanded current stimulus of 100 mA or failed to contract. On the eighth postoperative day the animals were killed to assess anastomotic healing. Of the 12 anastomoses made at the 40 mA stimulus point, only one ruptured. The 40 mA limit of the stimulus level seems to be of value in assessments of bowel viability in vivo.

CONCLUSION

The use of a personal computer as a read out device makes myoelectric analysis easier and more reliable in the assessment of intestinal viability. This method may have a clinical application.

[Vascular complications in intestinal obstructions. The role of computed tomography]

INTRODUCTION

We investigated CT capabilities in showing vascular complications (ischemia, infarction) secondary to intestinal obstruction.

SUBJECTS AND METHODS

32 patients with small bowel obstruction, subdivided in two groups, were examined with CT. The first group consisted of 12 patients with small bowel obstruction complicated by ischemic injury. It was due to loop strangulation in 10 cases and loop distension secondary to colon carcinoma in 2 cases. At surgery the loop strangulation was caused by adhesions in 9 cases and by jejunal hernia in 1 case. Vascular complications were segmentary small bowel infarction in 7 cases, colonic infarction in 2 cases and ischemia, which was resolved after loop debridement, in 3 cases. The second group consisted of 20 patients with intestinal occlusion due to adhesions complicated by a closed loop in 4 cases. All patients were examined with(out) i.v. contrast agent administration. Filling of the intestinal loops by oral contrast agent was never performed.

RESULTS

CT identified the vascular injury secondary to intestinal obstruction in 11/12 patients (91%). In one case it was not possible to diagnose mild ischemia, which was found of surgery. CT findings were: loops distention in all the cases; wall thickening in 11 cases with intramural gas in 8 cases and slight contrast enhancement in 1 case; ascites in 2 cases; mesenteric edema in 9 cases; gas at the mesenteric root in 1 case. In the control group, small bowel obstruction was diagnosed with CT in all cases based on the presence of distended loops up to the occlusion site. Parietal alterations above the lesion were never found.

CONCLUSION

CT is a sensitive tool for diagnosing small bowel obstruction and for assessing the site and cause of obstruction. CT plays a pivotal diagnostic role in vascular complications, giving very important indications for a correct treatment.

Changes of angiogenesis and tumor cell apoptosis during colorectal carcinogenesis

Activation of the angiogenic process occurs during tumorigenesis, as does disturbance of cell proliferation and apoptosis. Seeking a potential correlation, we investigated tumor cell apoptosis, proliferation, and angiogenesis in the adenoma-carcinoma sequence of colorectal carcinogenesis using an in situ apoptosis detection kit and MIB-1 and anti-CD34 antibodies in 27 adenomas with low dysplasia, 17 adenomas with high dysplasia, and 26 carcinomas in adenoma, as well as assessed p53 and bcl-2 expressions. The results showed that the potential for apoptosis was augmented, paralleling the increment of proliferation, in adenomas with low dysplasia but diminished when adenomas progressed from low dysplasia to high dysplasia and cancer. A gradual increment of microvessel density was observed during the progression with an increase during transition from low dysplasia to high dysplasia and cancer. Correlation coefficient test showed an inverse correlation between apoptotic index and microvessel density when all of the lesions were taken into account. No apparent impact of aberrant p53 on angiogenesis or bcl-2 on apoptosis was observed in this study. These results suggest that the angiogenesis initiates during transition from low dysplasia to high dysplasia and cancer, which may, in turn, contribute to the reduction of tumor cell apoptosis during colorectal carcinogenesis.

Giant cell phlebitis as a cause of large intestinal stricture

Although arteritis of the gastrointestinal tract is well known, an isolated phlebitis without associated arteritis of the colon and cecum is rare. We describe a distinct form of giant cell phlebitis in a 16-year-old girl causing ischemic stricture of the large intestine. She presented with subacute intestinal obstruction and was suspected of suffering from tuberculosis. However, histopathologic examination showed giant cell phlebitis, the arterioles and arteries being spared. Although this is an extremely rare form of nonprogressive vasculitis, it should be considered in the differential diagnosis of strictures in the large intestine, especially in the young.

[Intramural blood vessels of the large intestine of the horse (Equus przewalskii f. caballus)]

The vascular system of the large intestine of 12 horses was examined by means of vascular corrosion casts, histology and transmission electron microscopy providing the following results. The Aa. et Vv. breves et longae leave the mesenteric vessels, respectively the subserously on the teniae lying cecal vessels to reach the tela subserosa at the mesenteric margin. The short vessels enter the deeper layers of the wall instantly, whereas the Aa. et Vv. longae move towards the submucosa by penetrating the muscular layers after a variable subserous course. The tela submucosa contains an arterial and a venous vascular plexus. In broader areas of the submucosa a three-dimensional vascular network can be found. This consists of a deep and a superficial vascular plexus, which are closely interconnected. The deep plexus is applied to the inner circular muscles, whereas the superficial plexus is adjacent to the muscularis mucosae. The (deep) arterial plexus receives its afflux from the Aa. breves et longae and supplies parts of the circular muscle layer with recurrent muscle branches. The vascularisation of the mucosa also originates from the submucosal (superficial) plexus. In the basal tunica mucosa, the ascending arteries form a transversal network from which arterioles branch into periglandular capillaries around each Lieberkühn crypt. Close to the lumen, a polygonal subepithelial capillary system is formed. The capillaries turn into postcapillary venules immediately below the epithelium of the mucosal surface. Veins move vertically through the submucosa to enter the submucosal plexus after few inflowing side branches. Branches of the subserous-submucosal connections form an intermuscular plexus between the circular and longitudinal muscular layer. This plexus supplies the capillaries of the tunica muscularis. The subepithelial capillaries are predominantly lined with a fenestrated endothelium, whereas the capillaries of the pericryptal mucosa mainly show a continuous endothelial lining. The latter contain multiple vesicles, which may fuse in order to form transcytoplasmic channels. Sphincter-like muscle bundles at the transition points from capillaries to venules may provide hemodynamic regulatory structures in the submucosa of the horse. Veins with circumferential cushions of smooth muscle fibres, so-called 'throttle veins', are also found.

Effects of hemodilution on splanchnic perfusion and hepatorenal function. I. Splanchnic perfusion

Perfusion of intestinal organs increases in response to acute normovolemic hemodilution (ANH). However, detailed studies on distribution of regional splanchnic organ perfusion during ANH are lacking. We therefore carried out this study to test the hypothesis that ANH does not cause disturbance of physiologic patterns of regional splanchnic organ blood flow. After governmental permission, 22 anesthetized dogs were instrumented to allow invasive hemodynamic measurements and intracardial injection of radioactive microspheres (diameter 15 micro m) for determination of regional organ perfusion. Measurements were made at baseline (hematocrit 37 +/- 3%) and after ANH with 6% hydroxyethyl starch (mol. wt. 200000 / 0.5) to hct 20 +/- 1%. After completion of the protocol, splanchnic organs were removed and dissected into small samples according to anatomical and functional principles. Regional perfusion was determined based on the microsphere content of each sample. Hepatic, intestinal, and pancreatic blood flow increased with ANH. Hepatic arterial blood flow rose by 86%, whereas portal venous perfusion increased by 28%. Small intestine mucosal perfusion was augmented by 68% while the non-mucosal tissue compartment of the gut wall received 32% more blood flow after ANH which is in proportion to the increase in cardiac index after ANH. This redistribution of intestinal flow might be the basis for the preservation of tissue oxygenation during moderate isovolemic anemia.

[Intramural vascular system of the large intestine of mammals. A study of the literature]

From a morphological point of view, too, the summarizing synopsis of the intramural vascular system of the large intestine of mammals shows, that the functional aspect is prominent. As in other studied species the exclusively on the epithelial side existing 'fenestrated endothelium' of the pericryptal and subepithelial capillaries is doubtless the most important structural mark of the large intestinal function, too. Moreover, the direction of the mucosal capillary blood flow informs, that at first the release of the essential substances for the glandular secretion will take place, before epithelial transports concerning the resorption occur. As for the hemodynamic regulatory structures in the wall of the blood-vessels there are obviously differences in their existence depending on the species, respectively they are completely absent such as in the ruminants. Finally, it should be mentioned, that arterio-venous anastomoses could not be detected.

Large intestinal lymphocytic phlebitis and venulitis in chronic ulcerative colitis

Colonic vasculitis is seen in Crohn's disease and as a component of primary systemic vasculitis. It has rarely been described in chronic ulcerative colitis. Here we report a case of ulcerative colitis with prominent transmural lymphocytic phlebitis and venulitis. Although this is, to our knowledge, the first description of such an association, its recognition is important if confusion with other entities is to be avoided. The etiology of the vascular changes is unclear but they may be a secondary phenomenon induced by antigens, toxins or cytokines draining from the inflamed mucosa.

[Reconstructive plastic surgery of the esophagus in children]

The article presents the authors' experiences with reconstructive-plastic operations of the esophagus in children. The esophagoplasty was performed in 60 patients with congenital and acquired diseases. Among the congenital diseases are esophageal atresia, short esophagus and Barrett's esophagus, the acquired diseases include postburn scarry injuries. The optimum method of creation of the artificial esophagus are described. Of great significance are thought to be angiosurgical and microsurgical methods of cutting out the intestinal transplants. Cases of free autotransplantation of the intestinal segments for the substitution of the injured esophagus are described. Positive results were obtained in most cases.

Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis

BACKGROUND

Acute venous mesenteric ischaemia is rare and there is no standard conservative or operative treatment.

METHODS

The results of surgical treatment for acute mesentericoportal thrombosis were retrospectively analysed in 31 patients. The thrombotic occlusion affected the superior mesenteric vein in 19 patients, the portal vein in eight and both vessels in four. Surgical treatment comprised venous thrombectomy (nine patients), bowel resection (17), a combination of thrombectomy and bowel resection (two), distal splenorenal shunt (one) and simple laparotomy (two).

RESULTS

When the mesentericoportal blood flow was restored, the mortality rate was lower, but not significantly so, than after bowel resection alone (two of nine versus seven of 17). In addition to thrombectomy, local thrombolysis with recombinant tissue plasminogen activator was performed in five patients via a catheter placed into a distal mesenteric vein and all survived. The overall hospital mortality rate was 11 (35 per cent) of 31.

CONCLUSION

An active approach should be encouraged in patients with this condition employing thrombectomy in addition to bowel resection. Early results are encouraging and local thrombolysis warrants further study.

Immunocytochemical expression of the 70 kD heat shock protein in ischaemic bowel disease

Heat shock proteins (HSPs) are a family of polypeptides which are induced in response to diverse forms of cell injury including hyperthermia, anoxia, ethanol, heavy metals, and others, with a presumably protective function. Among several species of HSPs, the 70 kD protein (HSP70) is the most abundant and consistently induced in mammalian cells. Anti-HSP70 monoclonal antibody and a standard immunocytochemical method were used to study the expression of HSP70 in 28 surgical specimens of small and large intestines from patients with ischaemic bowel disease. Strong immunoreactivity was observed in viable, regenerating cells of both the crypt and surface epithelium within or adjacent to the necrotic foci in 86 per cent of the ischaemic bowel specimens. Staining was mostly cytoplasmic, but focally both cytoplasmic and nuclear. Smooth muscle cells of the muscularis mucosae in the ischaemic areas of some cases also showed immunoreactivity. On the other hand, HSP70 was not expressed in control specimens of small and large intestine or in colonic specimens of Crohn's disease, ulcerative colitis, and adenocarcinoma. These findings suggest a possible role of HSP70 in intestinal epithelial and smooth muscle cell response to ischaemic injury, especially in the recovery phase.

Alveolar hydatid cyst (AHC): inflammation-induced reactive gastrointestinal (GL) amyloidosis in AHC-infected mice and chemical characterization of the GL amyloid

A high incidence of GI amyloidosis has been described in patients with various forms of systemic amyloidosis but its evolution and progression in different subregions of the GI tract are not well documented. These aspects including the chemical nature of GI amyloid were examined in the AHC mouse model of inflammation-associated reactive amyloidosis. C57BL/6 mice were infected intraperitoneally with 250 AHC. Paraffin sections from the stomach and the small and large intestines of AHC mice were stained at different time intervals with Congo red or immunocytochemically with monospecific RAA. The submucosal blood vessels at 1 week postinfection were found to be the first target of amyloid deposition. With time the amyloid deposits extended to the mucosa and the Peyer's patches and immunoreacted with RAA; ileum was the most severely affected region. Amyloid was extracted from the GI tract and purified by size exclusion chromatography using 5 M guanidine-formic acid, pH 3. The purified amyloid was identified by Western blotting using RAA and by partial N-terminal microsequencing up to 10 cycles. The GI amyloid showed homology with murine SAA2, although SAA2 mRNA is not expressed in murine GI tract. These results shows that (a) the GI amyloid is derived, similar to that of splenic/hepatic amyloid, from circulating SAA2 and (b) the GI tract submucosal blood vessels are the first target of AA deposition. The data also suggest that AA-mediated damage to the submucosal blood capillaries may lead to SAA leakage followed by cascading of AA deposition in other layers of the GI tract.

[Vascular system in the large intestine of the dog (Canis lupus f. familiaris)]

The vascular system of the large intestine of 10 dogs was examined by means of vascular corrosion casts, histology and transmission-electron microscopy. The tela submucosa contains an arterial and a venous vascular plexus. In broader areas of the submucosa, a deep and a superficial vascular plexus, which are interconnected, can be found. The plexus are orientated parallel to the layers of the intestinal wall. On the one hand, these vessels naturally provide self-sufficiency and drainage of the submucosa, and, moreover, direct branches to the stratum circulare of the muscular layer. On the other hand, the submucosal vascular plexus is the 'distributional network' for the functional plexus of the tunica mucosa. The arteries, which ascend to the tunica mucosa, supply a flat arterial network underneath the intestinal glands. Bundles of only a few arteriolae originate from this in order to supply the pericryptal capillaries. In the vicinity of the cryptal orifices, these turn into a network of subepithelial capillaries, which is post-connected to the periglandular capillary plexus. From this 'terminal circulatory pathway', the blood is drained off by veins that enter the submucosal plexus. It is characteristic that the postcapillary venules often begin as part of the capillary network. As in other species, the subepithelial capillaries are pre-dominantly lined with a 'fenestrated endothelium', whereas the capillaries of the pericryptal areas show a continuous endothelium. The latter contains multiple vesicles that may fuse in order to form transcytoplasmic channels as a morphological equivalent for transcappillar-epithelial and vice versa occurring transport of substances.

[The blood vessel system of the large intestine of swine (Sus scrofa f. domestica)]

The circulatory system of the large intestine of 27 pigs was examined by means of corrosion anatomy (vascular casts), histology and electron microscopy. The results were as follows: The Aa. et Vv. breves et longae leave the mesenteric vessels and reach the wall of the intestine at the mesenteric margin. The short vessels enter the deeper layers of the wall, whereas the Aa. et Vv. longae, by taking a variable subserous course, reach the submucosa after penetrating the muscular layers. The tela submucosa contains an arterial and a venous vascular plexus. Where the submucosa is larger, there is a three-dimensional vascular network, a deep and superficial vascular plexus that are closely interconnected. The deep plexus is applied to the inner circular muscles, whereas the superficial plexus is adjacent to the muscularis mucosae. The deep arterial plexus receives its afflux from the Aa. breves et longae and provides part of the circular muscle layers with recurrent muscle branches. The vascularization of the mucosa is derived from the (superficial) submucosal plexus. The arteries that ascend the tunica mucosa ramify, in the form of a brush, into some arterioles. In the basal part of the mucosa, they turn into a periglandular capillary system, i.e. a network around each Lieberkühn crypt. Close to the lumen, a polygonal subepithelial capillary system is formed. Below the epithelium of the mucosal surface, the capillaries turn into postcapillary venules. These are running vertically through the submucosa, with few inflowing side branches, and finally enter the submucosal plexus An intermuscular plexus is formed by anastomoses between the circular and the longitudinal muscular layers from the branches of the subserous-submucosal connections. This intermuscular plexus provides the capillaries for the tunica muscularis. The subepithelial capillaries are, above all, furnished with a so-called fenestrated endothelium, whereas the capillaries of the pericryptal mucosa mainly show a continuous endothelium. The latter contains multiple vesicles that can fuse to form transcytoplasmic channels. In the wall of the large intestine of the pig, there are no sure indications as to the existence of either arterio-venous anastomoses or haemodynamic regulatory structures.

[Intramural blood vessel system of the large intestine of domestic ruminants]

The vascular system of the large intestine of 15 cattle, 10 sheep and 5 goats has been examined by means of corrosion vascular casts, histology and electron microscopy. The results are as follows: The course and ramification of the intestinal vessels are identical in the caecum, colon and rectum. Furthermore, as expected, amongst the species studied no substantial differences in the vascular architecture of the large intestinal wall could be determined. The extramural vessels reach the wall of the intestine at the mesenteric margin. Their branches build arterial or venous networks in the tela subserosa, which then divide into branches in the direction of the antimesenteric region. The connections between the blood vessels of the tela subserosa and the tela submucosa as well as the branches to the muscular layers emerge from these networks. In the tela submucosa an arterial and venous system can be found. The obvious vascular arrangement in the submucosa is arranged not only parallel to the stratum circulare of the tunica muscularis but also along the prevailing direction of the lamina muscularis mucosae. From this arrangement both a deep and a superficial submucosal vascular plexus can be denominated. The recurrent branches for the circular muscle layer as well as the afferent and efferent vessels of the mucosa originate from submucosal arteries and veins. The arterioles of the tunica mucosa branch at the level of the basal crypts into a periglandular capillary system running close to the lumen into a subepithelial capillary system. Here the capillaries drain into venules which advance to the region of the intestinal glands and consequently drain into collecting veins in the submucosa. Capillaries of the subepithelial lamina propria mucosae are furnished with continuous or fenestrated endothelial linings as the morphological equivalent of the secretory or resorption processes, respectively. In the walls of the large intestine of the bovine, sheep and goat there are neither arterio-venous anastomoses nor hemodynamic regulatory structures such as sphincters or so-called throttle veins at the points of transition from capillaries to venules. These results are in accord with the findings in the small intestine of domestic ruminants (Hummel 1980).

[Nonobstructive intestinal ischemia]

Acute or chronic intestinal ischaemia can be the consequence of either intrinsic vascular disease, systemic disease, drugs or surgical procedures. In one quarter of the patients with intestinal ischemia, no major vascular obstructions can be detected. Very rarely, the cause of ischaemia is splanchnic vasoconstriction due to cardiac arrhythmias or sepsis. The bowel becomes ischaemic as a result of underperfusion. The clinical picture resembles the one of occlusive intestinal ischaemia. From the pathological standpoint, the ischaemia is more intense on the antimesenteric border of the bowel and the lesions are more advanced in the mucosal than in the serosal layer. Often, the ischaemia involves other organs too: liver, spleen or gallbladder. The reconstructive vascular procedures are inefficient, the only therapeutical options remains the resection of the infarcted bowel, together with other organs involved in the ischaemic process. The mortality rate approaches 90%.