Mechanical intestinal obstruction due to isolated diffuse venous malformations in the gastrointestinal tract: A case report and review of literature

BACKGROUND

Isolated gastrointestinal venous malformations (GIVMs) are extremely rare congenital developmental abnormalities of the venous vasculature. Because of their asymptomatic nature, the diagnosis is often quite challenging. However, as symptomatic GIVMs have nonspecific clinical manifestations, misdiagnosis is very common. Here, we report a case of isolated diffuse GIVMs inducing mechanical intestinal obstruction. A literature review was also conducted to summarize clinical features, diagnostic points, treatment selections and differential diagnosis in order that doctors may have a comprehensive understanding of this disease.

CASE SUMMARY

A 50-year-old man presented with recurrent painless gastrointestinal bleeding for two months and failure to pass flatus and defecate with nausea and vomiting for ten days. Digital rectal examination found bright red blood and soft nodular masses 3 cm above the anal verge. Computed tomography showed that part of the descending colon and rectosigmoid colon was thickened with phleboliths in the intestinal wall. Colonoscopy exhibited bluish and reddish multinodular submucosal masses and flat submucosal serpentine vessels. Endoscopic ultrasonography showed anechoic cystic spaces within intestinal wall. The lesions were initially thought to be isolated VMs involving part of the descending colon and rectosigmoid colon. Laparoscopic subtotal proctocolectomy, pull-through transection and coloanal anastomosis and ileostomy were performed. Histopathology revealed intact mucosa and dilated, thin-walled blood vessels in the submucosa, muscularis, and serosa involving the entire colorectum. The patient recovered with complete symptomatic relief during the 52-mo follow-up period.

CONCLUSION

The diagnosis of isolated GIVMs is challenging. The information presented here is significant for the diagnosis and management of symptoms.

Relationship between dendritic cells, interleukin-23 and ulcerative colitis

AIM: To evaluate the expression of dendritic cell (DCs) and interleukin (IL)-23 in ulcerative colitis (UC) to improve the diagnosis and treatment of UC.

METHODS: Sixty UC and 60 irritable bowel syndrome (IBS) colon tissue sections were used to detect the expression of S100⁺ DCs, CD83⁺ DCs and IL-23P19 by immunohistochemistry. The expression of IL-23P19 in the mucosa was compared between acute and chronic stages, between mild and severe type diseases, and between before and after mesalazine treatment in the UC group.

RESULTS: There was a statistical difference in the infiltrated densities of S100⁺ DCs, CD83⁺ DCs and IL-23P19 cells between the UC group and IBS group (27.48 cells/mm² ± 9.23 cells/mm²vs 9.20 cells/mm² ± 3.91 cells/mm², 6.62 cells/mm² ± 2.59 cells/mm²vs 3.20 cells/mm² ± 1.59 cells/mm², 105.97 cells/mm² ± 25.30 cells/mm²vs 32.48 cells/mm² ± 11.61 cells/mm², P < 0.05). In the UC group, there was a statistical difference in the expression of IL-23P19 between acute and chronic stages, between mild and severe type diseases, and between before and after mesalazine treatment (113.83 cells/mm² ± 28.83 cells/mm²vs 49.35 cells/mm² ± 8.11 cells/mm², 75.03 cells/mm² ± 21.39 cells/mm²vs 117.38 cells/mm² ± 28.32 cells/mm², 109.89 cells/mm² ± 25.73 cells/mm²vs 47.25 cells/mm² ± 8.67 cells/mm², P < 0.05).

CONCLUSION: In UC colon tissue, the production of IL-23P19 increases with the increase in the infiltrated density and activity of DCs. The expression of IL-23P19 may be used as an indicator for evaluation of the disease stage, the degree of pathological changes and treatment efficacy in UC.

Helicobacter pylori infection and normal colorectal mucosa-adenomatous polyp-adenocarcinoma sequence: a meta-analysis of 27 case-control studies

AIM

The study aimed to determine whether Helicobacter pylori infection is associated with colorectal adenocarcinoma and to quantify the extent of the risk.

METHOD

A literature search was performed to identify studies published between 1995 and 2012 for relevant risk estimates. Fixed and random effect meta-analytical techniques were conducted for colorectal adenocarcinoma and adenomatous polyp.

RESULTS

Twenty-seven case-controlled studies involving 3450 adenocarcinoma patients, 1304 adenomatous polyp patients and more than 4000 controls were included. Helicobacter pylori was associated with an increased risk of colorectal adenocarcinoma and adenomatous polyp [odds ratio (OR) 1.24, 95% CI 1.12-1.37, P = 0.66; OR 1.87, 95% CI 1.53-2.28, P = 0.81]. There was a significant association between the CagA-positive strain and adenocarcinoma risk (OR 1.22, 95% CI 1.08-1.37, P = 0.05). In addition, there was an increased risk of tubular adenoma and villous adenoma formation (OR 3.06, 95% CI 1.98-4.73, P = 0.14; OR 2.05, 95% CI 0.84-4.97, P = 0.86).

CONCLUSION

The meta-analysis suggests a promoting effect of Helicobacter pylori on the risk of adenocarcinoma. It also suggests that Helicobacter infection might have its influence at the start of the adenomatous polyp disease sequence.

Efficacy of ursodesoxycholic acid in treatment of nonalcoholic fatty liver disease: A meta-analysis

AIM: To evaluate the efficacy and safety of ursodesoxycholic acid in the treatment of nonalcoholic fatty liver disease (NAFLD).

METHODS: Randomized controlled clinical trials comparing the efficacy of ursodesoxycholic acid alone or in combination with other drugs versus other drugs or placebo alone in the treatment of NAFLD were retrieved by searching PubMed, Embase, OVID, Cochrane Library , CNKI, and Wanfang database. Review Manager 5.0 was used for meta-analysis.

RESULTS: Compared to the ursodesoxycholic acid monotherapy group, the drug combination group had significantly improved total effective rate (RR = 1.23, 95%CI: 1.07-1.41, P = 0.004) and decreased serum levels of TC (WMD = -1.69, 95%CI: -2.77--0.62, P = 0.002), TG (WMD = -1.01, 95%CI: -1.59--0.43, P = 0.0006), ALT (WMD = -22.65, 95%CI: -35.27--10.04, P = 0.0004), and AST (WMD =- 21.93, 95%CI: -23.74--20.12, P < 0.00001). The decrease in GGT was significant in both the ursodesoxycholic acid monotherapy group and drug combination group (WMD = -21.96, 95%CI: -35.73--8.18, P = 0.002; WMD = -28.80, 95%CI: -51.85--5.76, P = 0.01). There was no statistically significant difference in the incidence of adverse reactions (RR = 2.26, 95%CI: 0.88-5.83, P = 0.09).

CONCLUSION: Ursodesoxycholic acid is effective and safe in the management of NAFLD, and better efficacy can be achieved when it is combined with other positive agents.

Role of gut barrier function in the pathogenesis of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver disease, and its incidence is increasing year by year. Many efforts have been made to investigate the pathogenesis of this disease. Since 1998 when Marshall proposed the conception of "gut-liver axis", more and more researchers have paid close attention to the role of gut barrier function in the pathogenesis of NAFLD. The four aspects of gut barrier function, including physical, chemical, biological and immunological barriers are interrelated closely and related to NAFLD. In this paper, we present a summary of research findings on the relationship between gut barrier dysfunction and the occurrence and development of NAFLD, aiming at illustrating the role of gut barrier function in the pathogenesis of this disease.

Nonsteroidal anti-inflammatory drugs and esophageal inflammation - Barrett's esophagus - adenocarcinoma sequence: a meta-analysis

The incidence of esophageal adenocarcinoma has markedly increased in the last few decades and Barrett's esophagus is regarded as the precursor lesion of this cancer. The aim of the study was to quantify the adenocarcinoma risk associated with nonsteroidal anti-inflammatory drug use and to determine at which stage chemoprevention with this drug is the most effective in esophageal inflammation - Barrett's esophagus - adenocarcinoma sequence. A literature search was performed to identify studies published between 1998 and 2009 for relevant risk estimates. Fixed and random effect meta-analytical techniques were conducted for aspirin, nonaspirin nonsteroidal anti-inflammatory drugs, and all nonsteroidal anti-inflammatory drugs. Four cohort and 10 case-control studies were included. Use of aspirin and nonaspirin nonsteroidal anti-inflammatory drugs in normal population was associated with a reduced risk of adenocarcinoma (odds ratio [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.83; OR: 0.84, 95% CI: 0.72-0.98, respectively). The use of all nonsteroidal anti-inflammatory drugs was associated with a reduced risk of adenocarcinoma (relative risk [RR]: 0.64, 95% CI: 0.42-0.96) in Barrett's esophagus patients. However, no obvious dose-effect relationships were found. In addition, we discovered a reverse association between drugs use and adenocarcinoma risk in people without a history of upper gastrointestinal tract disorders (OR: 0.57, 95% CI: 0.43-0.77, P= 0.12). Our meta-analyses suggest a protective effect of nonsteroidal anti-inflammatory drugs on the risk of adenocarcinoma. Our results also suggest that the drugs might act after the formation of Barrett's epithelium in the esophageal inflammation - Barrett's esophagus - adenocarcinoma sequence.

Endoscopic stent placement for stenosis of the digestive tract: an analysis of 273 cases

AIM: To assess the safety, efficacy and patient satisfaction of endoscopic stent placement for stenosis of the digestive tract.

METHODS: A total of 273 patients with stenosis of the digestive tract were included in the study, of whom 242 had esophageal and cardial stenosis, 24 had gastroduodenal stenosis, 7 had colorectal stenosis; 256 had malignant stenosis, 17 had benign stenosis; 273 had gastrointestinal obstruction symptoms; 15 suffered from esophageal fistula. Endoscopic placement of stents was performed in all patients. The safety, efficacy and patient satisfaction were evaluated after stent placement.

RESULTS: Stents were successfully placed in all patients (100%). Gastrointestinal obstruction symptoms were alleviated in 266 patients (97.4%). Esophageal fistula was successfully closed in 15 patients (100%). Stent-related adverse effects occurred in 156 patients (57.1%), mainly including chest (abdominal) pain in 87 cases (31.9%) and bleeding in 39 cases. Only one patient with malignant esophageal stenosis died of gastrointestinal bleeding after esophageal stent placement. Re-stenosis was detected in 43 patients (15.8%). Approximately 93.8% of patients were satisfied with the treatment.

CONCLUSION: Endoscopic stent placement is an effective and relatively safe treatment for stenosis of the digestive tract and esophageal fistula. The rate of treatment satisfaction is high.

Value of capsule endoscopy and double-balloon endoscopy in the diagnosis of small bowel tumors and Crohn's disease: an analysis of 316 cases

AIM: To evaluate the value of capsule endoscopy and double-balloon endoscopy in the diagnosis of small bowel tumors and Crohn's disease.

METHODS: A total of 316 patients who were suspected of having small bowel diseases were collected in this study. Of these patients, 178 underwent capsule endoscopy, 138 underwent double-balloon endoscopy, and 32 underwent both examinations. The detectable rates and diagnosis rates of small bowel tumors and Crohn's disease achieved using the two methods were compared.

RESULTS: The detectable rate and diagnosis rate of small bowel tumors in patients undergoing capsule endoscopy were 4.5% (8/178) and 1.1% (2/178), respectively. The detectable rate and diagnosis rate of small bowel tumors in patients undergoing double-balloon endoscopy were 18.1% (25/138) and 15.2% (21/138), respectively. There are significant differences in the detectable rate and diagnosis rate of small bowel tumors between patients undergoing capsule endoscopy and those undergoing double balloon endoscopy (both P < 0.01). The detectable rate and diagnosis rate of Crohn's disease in patients undergoing capsule endoscopy were 3.4% (6/178) and 1.7% (3/178), respectively. The detectable rate and diagnosis rate of Crohn's disease in patients undergoing double-balloon endoscopy were 15.9% (22/138) and 10.1% (14/138), respectively. There are significant differences in the detectable rate and diagnosis rate of Crohn's disease between patients undergoing capsule endoscopy and those undergoing double-balloon endoscopy (both P < 0.01). Of 32 patients who underwent both capsule endoscopy and double-balloon endoscopy, 5 patients were diagnosed with small bowel tumors by double-balloon endoscopy and confirmed by pathological examination, 1 was found with small bowel tumors by capsule endoscopy, and 3 were diagnosed with Crohn's disease by both capsule endoscopy and double-balloon endoscopy.

CONCLUSION: Double balloon endoscopy is superior to capsule endoscopy in the diagnosis of small bowel tumors and Crohn's disease. Combination of capsule endoscopy and double-balloon endoscopy can improve diagnosis and reduce misdiagnosis of small intestinal diseases.

Relationship between refractory ulcerative colitis and cytomegalovirus infection

AIM: To explore the relationship between refractory ulcerative colitis (UC) and cytomegalovirus (CMV) infection.

METHODS: Seventy-six patients with inflammatory bowel disease (IBD) diagnosed at Tianjin General Hospital from July 2000 to February 2009 were included in the study. According to the use of corticosteroid or not and therapeutic effect, these patients were divided into two groups: effective group and refractory group. Cytomegalovirus (CMV) infection of the colon was evaluated by immunohistochemistry.

RESULTS: Eleven patients, including three males and eight females, were positive for CMV, while sixty-five patients, including forty males and twenty-five females, were negative for CMV. Of CMV-positive patients, nine belonged to the refractory group, and two belonged to the effective group. The percentage of CMV-positive patients was significantly higher in the refractory group than in the effective group (P < 0.05). CMV-positive patients often suffered from high fever, cervical lymphadenopathy, and splenomegaly. No significant difference was noted in endoscopic and pathological manifestations in patients between the effective group and refractory group. Despite diverse clinical manifestations, abdominal pain and diarrhea were main ones observed in this study. Two CMV-positive patients underwent colectomy due to the occurrence of complication.

CONCLUSION: Refractory inflammatory bowel disease is related to CMV infection. The course of IBD may become more complicated in the presence of CMV infection. It remains to be investigated whether antiviral therapy can improve the sensitivity to corticosteroid therapy in IBD patients with CMV infection.

A meta-analysis of extraintestinal manifestations of inflammatory bowel disease in Mainland China

AIM: To summarize the extraintestinal manifestations of inflammatory bowel disease (IBD) in Mainland China to facilitate prompt and accurate diagnosis of this disease.

METHODS: IBD-related medical literature over the past 30 years was collected by retrospectively searching the Chinese Database of Biology and Medicine (CBM, 1979-01/2008-01). The data concerning the extraintestinal manifestations of IBD were recorded, pooled and statistically analyzed.

RESULTS: A total of 169 articles were retrieved, in which 14,963 cases of ulcerative colitis and 3,659 cases of Crohn's disease were reported. Diverse extraintestinal manifestations were found in approximately 15% of ulcerative colitis patients and 31% of Crohn's disease patients.

CONCLUSION: Besides alimentary tract involvement, inflammatory bowel disease often involves multiple organs simultaneously. This may lead to misdiagnosis and bring difficulties to the clinical diagnosis of the disease.

Mallory-Weiss syndrome: a clinical analysis of 78 cases

AIM: To investigate the clinical characteristic, gastroscopic manifestation and treatment of Mallory-Weiss syndrome (MWS).

METHODS: We retrospectively analyzed the clinical data of 78 MWS patients admitted to hospital from March 2003 to April 2008.

RESULTS: MWS was estimated to account for 6.13% of patients with upper gastrointestinal bleeding. Vomiting after alcohol drinking was the main etiology. Under gastroscope, all tears were longitudinal and common in cardia. The manifestation was correlated with the intervals from pathogenesis to gastroscopic examination (P < 0.05), but not associated with H pylori infection and patients' age. Eight of 78 cases were treated with endoscopic hemostasis and hemorrhage did not relapse; among the 70 cases with medical treatment, only 1 case was found with recurrence of bleeding, but after treatment with endoscopic hemostasis, the bleeding was stopped.

CONCLUSION: Both conservative and endoscopic treatment have favorable efficacy in stopping the bleeding of MWS, and the latter can be performed when the former was of no effect.

Relationship between Helicobacter pylori and ulcerative colitis

Since Warren and Marshall first separated Helicobacter pylori from gastric mucus in patients with chronic gastritis in 1983, our understanding of gastrointestinal tract diseases has risen greatly. The incidence of one of the inflammatory bowel diseases, ulcerative colitis (UC), has gradually risen worldwide, particularly among young people. Twenty research centers in Europe have shown that the annual incidence of UC is 11.2/100 000, that it can occur in every age group, may be related to colon cancer, and has a long disease course and different degrees of severity. There has been a lot of research on UC and H. pylori but little has been done on the relationship between the two. This paper summarizes the current state of related research and development.