Diagnostic challenge of the non-specific presentation of adult intussusception

The following report will discuss the diagnosis and management of non-specific abdominal pain in a 77-year-old woman who presented to a district general hospital in South London. CT imaging demonstrated ileo-colic intussusception with free air and fluid indicating perforation. The images of the specimen clearly show the ileal tumour within the intussusception. Thus, the patient underwent an emergency right hemicolectomy and formation of a double-barrelled ileostomy. Histology subsequently confirmed this was secondary to a colonic adenocarcinoma. This case report is unique as it highlights that intussusception in adults is very difficult to accurately diagnose based on clinical features (due to non-specific findings) and even with radiology can be challenging. This is also the first documented case of the site of perforation not being directly involved with the site of intussusception. The perforation site was in fact distal to the intussusception. At the time of surgery, it was noted that the patient had significantly faecal loading up to her rectum. The resulting closed loop was the cause of her perforation.

PATTERNS AND SEASONAL VARIATION OF INTUSSUSCEPTION IN CHILDREN: A RETROSPECTIVE ANALYSIS OF CASES OPERATED IN A TERTIARY HOSPITAL IN ETHIOPIA

BACKGROUND

Intussusception is one of the frequent causes of bowel obstruction in infants and toddlers (1). It involves invagination of a portion of intestine into another(2-4). The peak age of occurrence is between the age of 4 and 8 months. The aim of this study is to review the pattern of clinical presentation and seasonal variation of intussusception in our hospital, and to analyze the mode and outcomes of treatment.

PATIENTS AND METHODS

This is a four-year retrospective study of children aged 13 years and below who were admitted and treated for intussusception between January 2011 and December 2014 at the pediatric surgery unit of Tikur Anbesa Specialized Hospital (TAH) in Ethiopia. Information on the patients' demographic characteristics, clinical presentation, and month of occurrence as well as the operative findings and outcome were obtained from the pediatric surgery unit record book, patient charts, and the operating theatre registry.

RESULTS

One hundred and thirty six cases of intussusception were admitted to TAH, Addis Ababa over a four year period, of which 130 charts were retrieved and analyzed. Males dominated in the series. Age distribution showed that 59.2% of the cases were ≤ one year old, and 77.7 % were ≤ two years old. Abdominal pain, vomiting, bloody mucoid diarrhea and a mass palpated abdominally and/or rectally were the most common modes of presentations, with the classic triad of abdominal pain, vomiting and bloody mucoid diarrhea occurring in nearly two third of cases. The highest peak of presentation was in the month of June with 18 (13.9%) cases. The mean duration of symptoms before presentation to our hospital was 5.2 days with a range of 1-21 days. Intraoperatively, it was found that ileocolic intussusception was the most common type. Simple reduction without bowel resection was possible in 70.8% of cases. There were 44 (33.9 %) complications, wound site infection being the most common occurring in 20 (15.4%) cases and there were 6 deaths.

CONCLUSION

Intussusception was more common in the wet season. There was delayed presentation with a higher rate of operative management and bowel resection. The mortality rate has decreased significantly compared with a previous study from this institution.

Cytomegalovirus-related necrotising vasculitis mimicking Henoch-Schönlein syndrome

Viral vasculitides have been previously reported in the literature, the role of infections in their pathogenesis ranging from direct cause to trigger event. Here we report the case of a 3-year-old immunocompetent girl who developed a systemic vasculitis leading to ileal perforation, mimicking a full blown picture of Henoch-Schönlein purpura. High dosage steroid treatment was started, with good response. The anatomopathological examination of the resected gastrointestinal tract showed features of necrotising vasculitis and cytomegalovirus (CMV)-related inclusion bodies in the endothelial cells, with direct correlation to vascular damage. The causative role of viral infection was revealed by the presence of CMV DNA in patient's blood and positive IgG titer against the virus. Steroid therapy was then tapered: the patient achieved clinical remission, which still persists after a six-months follow-up. Our report suggests that CMV vasculitis is probably more frequent than previously thought, even in immunocompetent patients, with a protean clinical presentation, mimicking other types of vasculitides.

In vitro smooth muscle contractility before and after relief of experimental obstruction in the rat: application to the surgical management of ileal dilatation

PURPOSE

Bowel dilatation occurs proximal to an obstruction and predisposes to intestinal dysmotility. The present study sought to determine whether or not changes in smooth muscle contractility and the thickness of the proximal, dilated bowel wall can be reversed following relief of the obstruction.

MATERIALS AND METHODS

Three groups of seven male Wistar rats were studied. In 8-week-old animals in a control group and a sham-operated group, a small segment of bowel (designated as R1 for controls and R2 for shams) was resected 5.0 cm from the cecum. In the third (operated) group, a narrow, isoperistaltic intestinal loop was created proximal to an end-to-end anastomosis of the ileum in 4-week-old animals. When these animals were 6 weeks old, the loop was re-anastomosed to the distal small bowel (after resection of the loop's distal portion, referred to as R3). Two weeks later, a small segment of bowel was resected proximal to the anastomosis (R4). We evaluated the thickness of the smooth muscle layers and the in vitro contractile responses of circular smooth muscle ileal strips (R1-R4) to electrical stimulation and pharmacological stimulation (with KCl, acetylcholine (ACh), substance P, N(G)-nitro-l-arginine methyl ester (L-NAME) and histamine).

RESULTS

The amplitudes of contraction in response to electrical and Ach-mediated stimulation were higher for R3 than for R4 (P<0.001), R1 and R2 (both P<0.05). Compared with R1 and R2, the smooth muscle layer was three times as thick in R3 (P<0.001) and 2.5 times as thick in R4 (P<0.01).

CONCLUSION

Our study provides evidence of the possible recovery of intestinal motility (in response to neurotransmitters involved in gut function) after the relief of an obstruction. If ileal motility can conceivably return to normal values, conservative surgical procedures in pediatric patients should be preferred (in order to leave a sufficient length of bowel and avoid short bowel syndrome).

Glucose absorption in small intestinal diseases

Recent developments in the field of diabetes and obesity management have established the central role of the gut in glucose homeostasis; not only is the gut the primary absorptive site, but it also triggers neurohumoral feedback responses that regulate the pre- and post-absorptive phases of glucose metabolism. Structural and/or functional disorders of the intestine have the capacity to enhance (e.g.: diabetes) or inhibit (e.g.: short-gut syndrome, critical illness) glucose absorption, with potentially detrimental outcomes. In this review, we first describe the normal physiology of glucose absorption and outline the methods by which it can be quantified. Then we focus on the structural and functional changes in the small intestine associated with obesity, critical illness, short gut syndrome and other malabsorptive states, and particularly Type 2 diabetes, which can impact upon carbohydrate absorption and overall glucose homeostasis.

Comparison of different methods of intestinal obstruction in a rat model

AIM: To investigate different methods of creating incomplete intestinal obstruction in a rat model and to compare their electrophysiologic, morphologic and histologic characteristics.

METHODS: Rat ileum was partially obstructed by the respective application of: braided silk (penetrated the mesentery and surrounded intestine); half ligation (penetrated directly and ligated 1/2 cross-section of the intestine); wide pipe (6 mm in width, surrounded the intestine); narrow pipe (2 mm in width, surrounded the intestine). A control was also included (no obstruction). Various behavioral and electrophysiologic variables, as well as morphologic and immunohistochemical observations were recorded by blinded investigators at different time points (12, 24, 48, 72 h), including daily general condition, ileal wet weight and circumference, macromorphous and micromorphous intestine, bowel movement capability in vivo and in vitro, slow wave and neural electrical activity, and the number of c-Kit positive interstitial cells of Cajal (ICC).

RESULTS: Despite being of a similar general condition, these methods resulted in different levels of obstruction in each group compared with the control at different time points (12, 24, 48, 72 h). However, these fields of the wide pipe rat showed significantly differences when compared with the other three obstructed groups at 12 to 72 h, including macroscopic and histological presentation, intestinal transit ratio and contractility, circumference and wet weight, amplitude and frequency of nerve electrical discharge and slow wave, and ICC numbers (all P < 0.01).

CONCLUSION: The wide pipe rat method is significantly more reliable and stable than the other methods of obstruction, demonstrating that use of the wide pipe method can be a useful model of incomplete intestinal obstruction.

[Diagnostics and surgical treatment of biliary ileal obstruction]

7 patients with biliary ileal obstruction were operated on during the past 2 years. The article focuses on the features of the clinical presentation and the efficacy of diagnostic means. The surgical tactics and volume of the intervention is suggested. Recommendations on the prevention of the biliary ileus were worked out.

[Optimal surgical tactics in resection of terminal part of ileum]

The possibilities of terminal ileo-ileo, ileo-coeco and ileo-ascendoanastomoses formation in the small bowel resection on urgent indications for ileus and peritonitis were studied up. It was established, that the primary anastomosis formation in these portions is assumed, taking into account intramural hemodynamics, intraintestinal pressure etc. For the prognosis of the intestinal anastomoses insufficiency occurrence it is trustworthy to use transilluminate angiotensiometry and pulsomotorography widely, and for prophylaxis - nasointestinal intubation with decompression, the small bowel sanation and enterosorption, laser-magnetic therapy of anastomotic zone, prolonged intramesenterial lymphotropic therapy.

Cytomegalovirus-associated ileal stricture in a preterm neonate

Gastrointestinal (GI) manifestations of post-natally acquired cytomegalovirus (CMV) in preterm neonates can vary from mild diarrhoea to severe necrotising enterocolitis. However, the suspicion of CMV-related GI disease remains low. Mild CMV disease localised to the GI tract may go undiagnosed initially until a more obvious complication such as strictures manifest. A case of CMV-associated enteritis in an extremely preterm neonate is presented. The diagnosis was established after the histopathology of the surgical specimen showed the presence of CMV inclusion bodies. Testing the stool specimen for CMV to establish the diagnosis when the pathology is limited to the GI tract is also discussed.

Microcirculatory changes in experimental mesenteric longitudinal ulcers of the small intestine in rats

Rats receiving intracolonic administration of indomethacin develop longitudinal ulcers on the mesenteric side of the small intestine that are similar to those seen in the acute phase of Crohn's disease. To investigate the causative role of microcirculatory disturbances and to elucidate the therapeutic effect of antioxidants on this enteropathy in rats, we serially evaluated changes in regional blood flow of the small intestine using laser Doppler perfusion imaging and the colored microsphere injection method. Both methods disclosed stepwise hyperperfusion limited to the mesenteric side of the small intestine following transient ischemia during the initial 30-60 minutes. In addition, both a radical scavenger and a radical production inhibitor significantly ameliorated the mesenteric longitudinal ulcers. We concluded that ischemia-reperfusion on the mesenteric side accompanying excessive production of radicals might be strongly involved in indomethacin-induced longitudinal ulcers of the small intestine in rats.

[Crohn's disease: influence of age at diagnosis on clinical type of disease]

The aim of the study was to examine the influence of age at diagnosis of Crohn's disease on disease site and course in Tunisian patients.

METHODS

All hospital patients for Crohn's disease between 1993 and 2002 were included. They were segregated by age at diagnosis as follows: younger than 20 years, 20-39 years, and 40 years or older. And all patients were classified at the time of the latest visit into one of three subtypes of disease (non complicating, stricturing, and fistulizing) according Vienna's classification. Crohn's disease was devised also by site (ileum, ileocecal, colon and higher site).

RESULTS

Sixty one patients (50.4%) were 20-39 years old and 43 patients (35.5%) were 40 years and older. Colonic involvement was significantly more common (46,5%) in the 40 years and older group compared with 20-39 years group (24.6%) (p = 0.01). The subtype without complication was significantly more common (58.1%) in the 40 years and older group compared with 20-39 years group (39.3%) (p = 0.05). The frequency of the need for surgery for any indication for Crohn's disease didn't differ significantly according to age.

CONCLUSION

In this study, Crohn's disease diagnosed in tunisian patients that were 40 years and older had often a colonic site and a less severe phenotype supporting the concept of genetic heterogeneity.

New hypothesis on the pathogenesis of ileocecal intussusception

PURPOSE

Ileocecal intussusception is a relatively common surgical emergency in infants and young children. The etiology of intussusception is not clearly understood. Nitric oxide (NO) is a major inhibitory neurotransmitter in the enteric nervous system, which causes relaxation of the smooth muscles. In a lipopolysaccharide-induced experimental model of intussusception, altered intestinal motility is shown to be the result of increased NO released from various inflammatory mediators, which in turn leads to increased incidence of intussusception. The aim of this study was to examine the age-related changes in the nitrergic innervation of the ileocecal valve (ICV) to gain insights into the pathogenesis of intussusception.

METHOD

Whole-mount preparations of the myenteric plexus from the ileum, ICV, and proximal colon were stained using NADPH diaphorase histochemistry in newborn piglets (n = 3), 4-week-old (n = 3), 12-week-old (n = 3), and adult pigs (n = 3). Using light microscopy, the number of ganglia per square centimeter, the number of cells per ganglion, and the number of ganglion cells per square centimeter were determined.

RESULTS

There were striking regional and age-related differences in nitrergic innervation of myenteric plexus. Density of nitrergic neurons was significantly higher in the ICV than in the terminal ileum and proximal large bowel in the young animals (P < .001).

CONCLUSION

These findings suggest that the inflammatory reactions that usually precede intussusception may cause overproduction of NO by the nitrergically hyperinnervated ICV causing relaxation of the ICV and thereby facilitating ileocecal intussusception.

Down-Regulation of Hepatic Transporters for BSP in Rats with Indomethacin-Induced Intestinal Injury

Previous reports have demonstrated that an intestinal injury causes hypofunctions of the liver associated with down-regulations of cytochrome P450, but an influence on hepatic transporters remains unclear. Here, we tested hepatic transporter functions in a rat model of bowel injury using indomethacin (IDM). After administration of IDM (8.5 mg/kg, i.p., 3 d), the rats suffered the intestinal impairment indicated by a reduction of alkaline phosphatase activity in mucosa. In vivo pharmacokinetic experiments of bromosulfophthalein (BSP) showed that there was a reduction in its plasma elimination rate and cumulative biliary excretion in IDM-treated rats and systemic and biliary clearances reduced to nearly 50% of the control group. Protein expressions in plasma membrane and mRNA levels of organic anion transporting polypeptide 1b2 (Oatp1b2) and multidrug resistance-associated protein 2 (Mrp2), which play hepatic BSP uptake and biliary excretion, respectively, in the liver were significantly reduced following the IDM treatment. In portal plasma, the levels of proinflammatory cytokines were unchanged, while the level of nitric oxide metabolites (NO2- + NO3-) increased to 6.5-fold that of the control. The time-course on IDM treatment indicated that, firstly, intestinal injury was induced, the NO level increased, and the hepatic Oatp1b2 and Mrp2 expression began to fall followed by an increase in plasma ALT. In conclusion, IDM-induced injury to the small intestine causes the hypofunction of hepatic Oatp1b2 and Mrp2 independently on the hepatic impairment, and NO arising from bowel injury may be one of key factors for it through the remote effect.

Doppler ultrasonographic detection of nutcracker syndrome in a young child with intussusception: a case report

We report on a 2-y-old male with intussusception accompanying nutcracker syndrome detected by renal Doppler ultrasound. Renal Doppler ultrasound revealed a significant difference in the peak velocity between the hilar and aortomesenteric portions of the left renal vein.

CONCLUSION

Renal Doppler ultrasound has been very useful and effective in detecting nutcracker syndrome in a young child.

A survey of perceptions and attitudes among European surgeons towards the clinical impact and management of postoperative ileus

OBJECTIVE

Postoperative ileus (POI) can negatively affect patient recovery and morbidity, yet the lack of an internationally accepted definition and clinical management pathway for this condition suggest POI may be under-recognized as a clinical problem. The purpose of this survey was therefore to assess current attitudes of surgeons towards the clinical impact and management of POI.

SUBJECTS AND METHODS

Telephone interviews were conducted with 230 surgeons from hospitals in the UK, France, Germany, Italy and Spain.

RESULTS

Across Europe, there are differences in the terms surgeons use to refer to delayed recovery of gastrointestinal (GI) function and the symptoms, concerns and risks they associate with this condition. Furthermore, there is marked variation in the attitudes of European surgeons towards minimizing the risk of delayed recovery of GI function and in the strategies to manage POI. Additionally, some of the measures applied most commonly by European surgeons are in contrast to evidence in the literature indicating that they have no benefit for quicker resolution of GI function.

CONCLUSION

The results suggest that there is a need for clearer definition of the factors that constitute POI, increased recognition of the impact of this condition and improved understanding of the most effective peri-/postoperative care for surgical patients.

Comparison between prospective and retrospective evaluation of Crohn's disease activity index

The Crohn's disease activity index (CDAI) is the most widely used measure of clinical disease activity in patients entered into clinical trials. The prospective nature of the CDAI calculation precludes its use as a clinical assessment tool. We compared the retrospective evaluation of the CDAI with the prospective evaluation in a heterogeneous patient population of 100 patients with Crohn's disease. The correlation between the two assessment methods was good with an r-value of 0.84 (p < 0,0001). There was a tendency of patients with a high retrospective CDAI to have a lower prospective CDAI which is explained by intention to treat. This study shows that a retrospective assisted evaluation of the CDAI is as accurate as the traditional prospective evaluation.

Resuscitation-induced gut edema and intestinal dysfunction

BACKGROUND

Mesenteric venous hypertension and subsequent gut edema play a pivotal role in the development of intra-abdominal hypertension. Although gut edema is one cause of intra-abdominal hypertension, its impact on gut function is unknown. The purpose of this study was to create a model of acute hydrostatic gut edema and to evaluate its effect on gut motility and barrier function.

METHODS

The first study, group A, evaluated the effect of gut edema on transit over time using 20 mL/kg 0.9% saline. The second study, group B, focused on the 12-hour time period using 80 mL/kg 0.9% saline. Rats were randomized to superior mesenteric vein partial occlusion (venous hypertension) or sham surgery. At 6, 12, and 24 hours, group A underwent intestinal transit and tissue water weight measurements. At 12 hours, group B underwent tissue water, transit, ileal permeability and resistance, lactate and myeloperoxidase activity, and mucosal injury measurements.

RESULTS

Venous hypertension with fluid resuscitation caused acute hydrostatic gut edema, delayed intestinal transit, increased mucosal permeability to macromolecules, and decreased tissue resistance over time. Mucosal injury was minimal in mesenteric venous hypertension.

CONCLUSION

Acute mesenteric venous hypertension and resuscitation-induced gut edema, in the absence of ischemia/reperfusion injury, is associated with delayed intestinal transit and altered gut barrier function.

[Pathogenetic mechanisms of peritonitis in acute small intestinal obstruction]

Microscopic changes in the walls of strangulated small intestine, morphology of their vascular and resorption elements, adaptive mechanisms were studied in experimental acute small intestinal obstruction. It is demonstrated that the main factor of pathogenesis of peritonitis in strangulate and obstructive small intestinal obstruction is morphofunctional changes of intraorganic microcirculation of the small intestine.

Chagasic enteropathy

Involvement of the hollow organs of the digestive apparatus can occur in patients in the chronic phase of Chagas' disease. The basic mechanism is destruction of neurons of the enteric nervous system. Whereas megaesophagus and megacolon are the most notable and most extensively studied expressions of the digestive form of Chagas' disease, involvement of the small intestine (Chagasic enteropathy) is less frequent and less known than involvement of the two above mentioned entities. Chagasic enteropathy can be responsible for important clinical and laboratory manifestations resembling those of dyspeptic syndrome, intestinal pseudo-obstruction and bacterial overgrowth in the small intestine. Chagasic enteropathy also involves peculiar functional changes, especially those related to motor activity of the organ and to intestinal absorption of carbohydrates. In practice, the diagnosis is based on radiographic documentation of dilation of visceral segments. Treatment consists of clinical control of the above syndromes and, eventually, appropriate surgical operations.

Acetylcholine-related bowel dysmotility in homozygous mutant NCX/HOX11L.1-deficient (NCX-/-) mice-evidence that acetylcholine is implicated in causing intestinal neuronal dysplasia

BACKGROUND/PURPOSE

Homozygous mutant Ncx/Hox11L.1-deficient (Ncx-/-) mice develop mega-ileo-ceco-colon (mega-ICC) with a caliber change in the proximal colon. The authors investigated the mechanism of intestinal dysmotility in these mice.

METHODS

Five-week-old Ncx-/- mice with mega ICC were compared with age-matched BDF1 control mice. Jejunum, ileum, and colon were excised from all mice and 1.0-cm-long strips of each organ, each with a resting tension of 0.5g, were suspended in an organ bath filled with Tyrode's solution at 37 degrees C and bubbled with a mixture of 95% oxygen and 5% carbon dioxide. Contractile responses to acetylcholine chloride (ACh), histamine, serotonin, and barium chloride (BaCl2) were recorded isometrically.

RESULTS

For ACh, Ncx-/- mice had decreased distal colon circular muscle contraction only at lower doses and decreased distal colon longitudinal muscle contraction for all doses compared with controls (P <.05 or P <.01). In the proximal colon, Ncx-/- mice had increased circular muscle contraction only at higher doses and decreased longitudinal muscle contraction only at lower doses compared with controls (P <.01 or P <.05). ACh did not affect jejunum, and there were no significant effects on ileum. There was no response to histamine and serotonin by any part of the bowel, and the response to BaCl2 was the same for both Ncx-/- mice and controls.

CONCLUSIONS

Only ACh differentially affected muscle contraction in Ncx-/- mice in the proximal and distal colon. Thus, ACh is implicated in causing the bowel dysmotility seen in Ncx-/- mice and human IND.

Postoperative ileus: progress towards effective management

The pathogenesis of postoperative ileus (PI) is multifactorial, and includes activation of inhibitory reflexes, inflammatory mediators and opioids (endogenous and exogenous). Accordingly, various strategies have been employed to prevent PI. As single-modality treatment, continuous postoperative epidural analgesia including local anaesthetics has been most effective in the prevention of PI. Choice of anaesthetic technique has no major impact on PI. Minimally invasive surgery reduces PI, in accordance with the sustained reduction in the inflammatory responses, while the effects of early institution of oral nutrition on PI per se are minor. Several pharmacological agents have been employed to resolve PI (propranolol, dihydroergotamine, neostigmine, erythromycin, cisapride, metoclopramide, cholecystokinin, ceruletide and vasopressin), most with either limited effect or limited applicability because of adverse effects. The development of new peripheral selective opioid antagonists is promising and has been demonstrated to shorten PI significantly. A multi-modal rehabilitation programme including continuous epidural analgesia with local anaesthetics, enforced nutrition and mobilisation may reduce PI to 1-2 days after colonic surgery.

The influence of apoptosis of mucosal epithelial cells on intestinal barrier integrity after scald in rats

OBJECTIVE

To study the influence of apoptosis of intestinal epithelial cells occurring as a result of reperfusion after burn shock on the intestinal barrier.

METHODS

Fifty Wistar rats were subjected to a 30% TBSA full thickness burn, and normal saline (40 ml/kg) was given intraperitoneally immediately after the injury (group A). Ten rats served as a sham control group. The experimental group B consisted of 50 rats with identical injuries, but the normal saline was not given until 6h after the injury. Apoptosis of intestinal epithelial cells was verified by DNA fragmentation, DNA agarose gel electrophoresis, TUNEL and electron microscope (EM), and DNA fragmentation rate was expressed as ap%. The D-lactic acid in portal vein blood and intestinal diamine oxidase (DAO) were determined to evaluate the permeability and integrity of intestinal mucosal epithelium.

RESULTS

The ap% of intestinal epithelium group B was higher than in that of group A (P<0.05 or 0.01), and its amplitude peaked at 12h for both groups. Typical DNA ladder pattern was seen in electrophoresis in both groups. Apoptotic cells were discerned on the tips of the ileal villi at 3h postscald by TUNEL and EM in the group B, and they appeared earlier than in the group A. There was a significant positive correlation between the ap% and the level of D-lactic acid (group A: r=0.817, P<0.05; group B: r=0.727, P<0.05). On the other hand, a significant negative correlation was found between the ap% and the DAO values (group A: r=-0.937, P<0.01; group B: r=-0.836, P<0.05).

CONCLUSION

Apoptosis occurred in enterocytes after scald injury this pathological change might contribute to a breach of integrity of intestinal epithelium, leading to a compromise in its barrier function. Delayed fluid resuscitation might lead to an earlier and higher degree of apoptosis of the intestinal epithelial cells.

The vascularity of internal fistulae in Crohn's disease: an in vivo power Doppler ultrasonography assessment

AIM

To evaluate the efficacy of power Doppler sonography (US) in depicting internal fistulae and their vascularity, and to study the characteristics of blood flow within the fistula wall.

PATIENTS AND METHODS

The study involved 45 consecutive patients with Crohn's disease and suspected internal fistulae detected by grey scale US. The fistulae were subsequently evaluated using power Doppler US to reveal any areas of increased vascularity, and the results were compared with radiographic, endoscopic, or intraoperative findings. Whenever feasible, we also performed spectral analysis of blood flow revealed by power Doppler US, calculated its resistance index (RI), and analysed its characteristics, reproducibility, and relationship with biochemical and clinical variables (Crohn's disease activity index, disease duration, location, and abdominal complications).

RESULTS

Power Doppler US revealed vascularity in all of the internal fistulae that where subsequently confirmed by diagnostic procedures. In the case of intra-abdominal abscesses in the vicinity of the fistula, vascular signals were detected mostly around and not within the lesions. The intensity and distribution of the signals differed within the fistulae tracks and had only slight day to day reproducibility; furthermore, there was no significant correlation with clinical or biochemical variables. Spectral analyses of blood flow within the fistulae revealed arterial flow in 96.7% of patients (median RI 0.715). RI was a more reproducible parameter and significantly correlated with clinical (r= 0.54) and biochemical activity (r= 0.56) of CD. It was also higher in fistulae complicated by abscesses.

CONCLUSION

Power Doppler US can reveal the presence of vasculature within the wall of internal fistulae and therefore enhance grey scale US performance. The RI characteristics of blood flow within the fistulae are reproducible and correlate with biochemical and clinical disease activity.

PGE2 triggers recovery of transmucosal resistance via EP receptor cross talk in porcine ischemia-injured ileum

16,16-Dimethyl-PGE2 (PGE2) may interact with one of four prostaglandin type E (EP) receptors, which signal via cAMP (via EP2 or EP4 receptors) or intracellular Ca(2+) (via EP1 receptors). Furthermore, EP3 receptors have several splice variants, which may signal via cAMP or intracellular Ca(2+). We sought to determine the PGE2 receptor interactions that mediate recovery of transmucosal resistance (R) in ischemia-injured porcine ileum. Porcine ileum was subjected to 45 min of ischemia, after which the mucosa was mounted in Ussing chambers. Tissues were pretreated with indomethacin (5 microM). Treatment with the EP1, EP2, EP3, and EP4 agonist PGE2 (1 microM) elevated R twofold and significantly increased tissue cAMP content, whereas the EP2 and EP4 agonist deoxy-PGE1 (1 microM) or the EP1 and EP3 agonist sulprostone (1 microM) had no effect. However, a combination of deoxy-PGE1 and sulprostone stimulated synergistic elevations in R and tissue cAMP content. Furthermore, treatment of tissues with deoxy-PGE1 and the Ca(2+) ionophore A-23187 stimulated synergistic increases in R and cAMP, indicating that PGE2 triggers recovery of R via EP receptor cross talk mechanisms involving cAMP and intracellular Ca(2+).

Influence of disease site and activity on peripheral neutrophil function in inflammatory bowel disease

Reactive oxygen species, released by phagocytes, are involved in tissue injury in inflammatory bowel diseases. The aim of our study was to evaluate peripheral neutrophil function in patients with ulcerative colitis (N = 66) and Crohn's disease (N = 62) with respect to disease activity and extent, using chemiluminometry after three stimuli. Twenty-seven healthy subjects were enrolled as controls. Neutrophils from ulcerative colitis and Crohn's disease patients had a significantly higher response than those from controls following phorbol myristate acetate (86.6 +/- 6.5, 173.8 +/- 11.9, 167.5 +/- 12.2 mV, P < 0.0001), formyl-methionyl-leucyl-phenylalanine (39.5 +/- 3.4, 41.3 +/- 2.7, 58.6 +/- 4.7 mV, P < 0.001), and zymosan (142.6 +/- 10.4, 223.7 +/- 8.9, 231.2 +/- 9.5 mV, P < 0.0001) administration. The increased response was observed during both active disease and remission. The highest chemiluminescence values were found in patients with active ulcerative pancolitis and ileal Crohn's disease. The activation of circulating neutrophils may indicate persistent intestinal inflammation or may be triggered by luminal factors even in the absence of symptoms.

Ileal endometriosis: radiographic findings in five cases

PURPOSE

To determine the radiographic findings in five patients with ileal endometriosis.

MATERIALS AND METHODS

A search of radiology files revealed five patients with surgically proved endometriotic implants in the ileum at enteroclysis (three patients), at small-bowel follow-through (one patient), and at double-contrast barium enema study (one patient). The radiographic findings were reviewed retrospectively. Clinical, surgical, and histopathologic findings were also reviewed.

RESULTS

All five patients were nulliparous women (mean age, 34.4 years; age range, 28-41 years). Four patients presented with abdominal and/or pelvic pain, but only one of these four had cyclic pain that coincided with menstruation. Barium studies revealed endometriotic implants in the terminal ileum within 10 cm of the ileocecal valve in four patients and in the mid-ileum in one. The radiographic findings consisted of extrinsic mass effect with variable spiculation and tethering of folds in two patients, annular lesions with spiculated folds and abrupt or tapered borders in two, and a plaque-like lesion in one. In four patients who underwent double-contrast barium enema studies, associated endometriotic implants were found in the rectosigmoid colon.

CONCLUSION

Ileal endometriosis usually involves the terminal ileum within 10 cm of the ileocecal valve and manifests as a spectrum of findings on barium studies. Ileal endometriosis should therefore be considered when these findings are present in young, nulliparous women with abdominal or pelvic pain.

Typhlitis as a presenting manifestation of acute myelogenous leukemia

We describe a case of typhlitis with onset before diagnosis of acute myelogenous leukemia or initiation of chemotherapy. Typhlitis is usually seen as a complication of chemotherapy for hematologic malignancies. It is being reported with increasing frequency in association with other disease states that produce profound neutropenia.

Ileoileal intussusception associated with coccidiosis in sheep

Postmortem examination of a 3-year-old male Iranian native sheep with a history of anorexia and severe colic, revealed an intussusception of the small intestine, 30 cm proximal to the ileocaecal junction. Scattered hyperplastic lesions were present in the jejunal and ileal mucosa especially in intussuscipien. Microscopic examination of these lesions showed severe papillary hyperplasia of the epithelium associated with developmental stages of coccidia in the epithelial cells. An unusual type of intussusception and the presence of the proliferative nodular form of coccidiosis in the intestinal wall of intussuscipien suggested that coccidiosis could be considered as the possible cause of the problem.

Characterization of two novel proabsorptive peptide YY analogs, BIM-43073D and BIM-43004C

Effective clinical therapy to augment intestinal absorption of water and electrolytes does not exist; the gut hormone, peptide YY (PYY), is a potent proabsorptive agent in animal models. The purpose of our study was to evaluate the effects of two novel PYY analogs, BIM-43073D and BIM-43004C, on intestinal absorption. Dogs with ileal Thiry-Vella fistulae (TVF) were treated with either PYY, BIM-43073D, or BIM-43004C. Administration of BIM-43073D significantly increased water and sodium absorption over baseline and maintained this level of increased absorption for a longer duration than an equimolar dose of PYY. Administration of BIM-43004C significantly increased sodium and water absorption over baseline at a level equal to that of PYY. The novel PYY analogs, BIM-43073D and BIM-43004C, are effective proabsorptive agents with BIM-43073D producing more sustained effects than PYY. These compounds may be clinically useful in the treatment of gut malabsorption in conditions such as cholera, Crohn's disease, and the short-bowel syndrome.

The mechanism of focal intestinal perforations in neonates with low birth weight

Among 36 neonates with intestinal perforations (IP) between 1975 and 1996, 5 had necrotizing enterocolitis (NEC IP) and 10 had focal IPs (FIP). A histologic review of the bowel near the perforations was made to see if there was any difference between cases of NEC IP and FIP. In 1 case of NEC IP, a defect in the musculature was found in addition to disappearance of the mucosal villi and dilated vessels or hemorrhage in the submucosa. Thinning or absence of the intestinal musculature and short villi in the mucosa was observed in 3 cases of FIP, but the acute ischemic changes in FIP were much less than in NEC IP. Hypothesizing that the defective musculature in FIP may be acquired by a vascular accident either before or after birth, we examined the histology of the latest consecutive infants diagnosed as having meconium peritonitis (MP) due to in-utero volvulus and perforation. In the tissue near the perforation, there was an identical focus of thinning and interruption of the musculature while the acute ischemic changes were minimal. We speculate that thinning or absence of the intestinal musculature in FIP may be a result of a transient ischemic event occurring in-utero and that FIP may develop in the damaged intestine after birth when it is fully dilated.

Ileosigmoid knotting in Gondar teaching hospital north-west Ethiopia

A retrospective analysis of nine consecutive cases of ileosigmoid knotting (ISK) that were seen at Gondar hospital from 1993 to 1995 is presented. Ileosigmoid knotting is a condition in which the ileum and the sigmoid entangle each other to form a knot and become gangrenous. It was found that the clinical features of ISK were the results of combination of symptoms and signs of small and large bowel obstruction. The presentations were so dramatic that the majority of patients deteriorated rapidly with 44% (4/9) developing shock because of gangrene of both the ileum and the sigmoid. Abdominal cramps, vomiting and absolute constipation occurred in all patients. Five patients were in shock at the time of presentation and six had peritonitis at the time of surgery. Release of the knot could easily be attained by needle deflation of the sigmoid colon. Hartman's procedure with resection of the sigmoid and ileotransversostomy by closing the distal viable stump of the ileum is recommended. Four patients out of the nine patients died.

Reliability of color Doppler and power Doppler sonography in the evaluation of intussuscepted bowel viability

In two similar cases of irreducible intussusception with wall necrosis and perforation, symptoms had begun 24 h before admission and the plain radiographs showed signs of small-bowel obstruction. The sonographic (US) appearances, however, were different: color Doppler (CD) US showed vascular flow in the intussuscepted bowel in one case and no flow in the other. After radio-clinical assessment, both children underwent surgery and an intestinal resection had to be performed, manual reduction being impossible. The reliability of the US findings and the prognostic value of CD and power Doppler US in determining the viability of the intussuscepted bowel are discussed with a review of the literature.

Enteric neuronal plasticity and a reduced number of interstitial cells of Cajal in hypertrophic rat ileum

BACKGROUND

Partial obstruction of the ileum causes a notable hypertrophy of smooth muscle cells and enteric neurones in the proximally located intestine.

AIMS

To study the expression of neuromessengers in the hypertrophic ileum of rat as little is known about neuromessenger plasticity under these conditions. To investigate the presence of interstitial cells of Cajal (ICC) in hypertrophic ileum.

METHODS

Ileal hypertrophy was induced by circumferential application of a strip of plastic film for 18-24 days. Immunocytochemistry, in situ hybridisation, nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase histochemistry, and ethidium bromide staining were used to investigate the number of enteric neurones expressing neuropeptides and nitric oxide synthase, and the frequency of ICC.

RESULTS

In the hypertrophic ileum several neuronal populations showed changes in their expression of neuromessengers. Myenteric neurones expressing vasoactive intestinal peptide (VIP), pituitary adenylate cyclase activating peptide, and galanin were notably increased in number. In submucous ganglia the number of VIP immunoreactive neurones decreased while those expressing VIP mRNA increased. NADPH diaphorase positive submucous neurones increased dramatically while the number of neuronal type nitric oxide synthase expressing ones was unchanged. The number of ICC decreased notably in hypertrophic ileum.

CONCLUSION

Enteric neurones change their levels of expression of neuromessengers in hypertrophic ileum. ICC are also affected. The changes are presumably part of an adaptive response to the increased work load.

Tapeworm infection is a significant risk factor for spasmodic colic and ileal impaction colic in the horse

The association between the equine intestinal tapeworm Anoplocephala perfoliata and specific types of intestinal disease was investigated by matched case-control study using coprological and serological diagnosis. We have previously shown that the host IgG(T) response to 12/13 kDa antigens of A. perfoliata correlates well with infection intensity, therefore this antibody response was used to investigate the risk of colic at different levels of parasite infection intensity. One hundred and three spasmodic colic cases with an equal number of controls matched for age, breed and gender, and 20 ileal impaction cases each with 2 similarly matched controls were obtained. Cases of spasmodic colic were much more likely (odds ratio = 8.0) to be associated with A. perfoliata infection detected coprologically than controls. Serological diagnosis revealed an increasing risk of spasmodic colic with increasing infection intensity. Calculation of an aetiological fraction suggests that 22% of spasmodic colic cases in this study were tapeworm associated. No significant association was found between colic and strongyle egg count. Conditional logistic regression analysis demonstrated that the relationship between colic and A. perfoliata infection intensity was not confounded by strongyle egg count and there was a linear relationship between infection intensity and the log-odds of spasmodic colic. For cases of ileal impaction, a strong association was found between colic and A. perfoliata as diagnosed by coprological means (odds ratio of 34.0). Serological diagnosis also revealed a strong association that increased with higher levels of infection intensity (odds ratio = 26.0). The aetiological fraction for the ileal impaction data suggests that 81% of the ileal impaction cases in this study were tapeworm associated. This study concludes that A. perfoliata is a significant risk factor for spasmodic colic and ileal impaction colic in the horse; and that the risk of spasmodic colic increases with infection intensity.

[Different mechanisms in intestinal paralysis in edematous and necrotizing pancreatitis of the rat]

The influence of experimental pancreatitis on bowel motility was measured in vivo with the propulsion technique and in vitro as contractility of isolated ileum muscle strips. In edematous pancreatitis, propulsion was reduced but contractility was normal. Both, propulsion and contractility were reduced in necrotizing pancreatitis. The intravenous saline infusion normalized propulsion in edematous pancreatitis but was of no benefit in necrotising pancreatitis. These results indicate that extraintestinal (neuroendocrine) regulation pathways were effected in edematous pancreatitis. Necrotising pancreatitis appears to have an additional profound influence on the intrinsic, intramural regulation of motility.

Glucose-induced intestinal hyperemia is mediated by nitric oxide

Glucose-induced absorptive hyperemia of the intestine has been well demonstrated through microsphere blood flow experiments. We have previously demonstrated that glucose, when applied topically to rat ileal epithelium, restores microvascular vessel diameters and blood flow following Escherichia coli bacteremia or hemorrhage/resuscitation. However, the mechanisms of this hyperemia are not completely understood. We hypothesize that nitric oxide is a mediator of the microvascular response to glucose exposure on the rat intestinal epithelium.

METHODS

Male Sprague-Dawley rats, 200-225 g, were monitored for hemodynamic stability with mean arterial blood pressure and heart rate. A 2-cm segment of the terminal ileum with intact neurovascular supply was exposed for intravital videomicroscopy. Intestinal arteriolar diameters (A1D, inflow; and A3D, premucosal arterioles) and microvascular blood flow (A1Q) were measured following topical application of isoosmotic glucose or saline, with or without l-NAME (LN, 100 mM), a competitive inhibitor of nitric oxide synthase. Statistical analysis was performed by ANOVA followed by Tukey-Kramer honestly significant difference test.

RESULTS

All data are expressed as mean percentage changes from baseline +/- standard error of the mean. Hemodynamic variables did not change during the experimental procedure and there were no significant differences among group baselines. Addition of isotonic glucose to the bath solution caused a significant increase in A3D that persisted throughout the experiment (at 30 min, 19.2 +/- 4.2 vs -3.9 +/- 4.5, P < 0.05). This vasodilation was blocked by topical administration of LN (3.1 +/- 2.9, P < 0.05). A1D remained at baseline levels (saline and glucose) or constricted (LN) in all groups. Topical LN also attenuated A1Q in both the saline and glucose groups.

CONCLUSIONS

These data demonstrate that glucose-induced intestinal hyperemia is primarily characterized by premucosal A3 arteriole dilation in this model and that nitric oxide is a mediator of glucose-induced intestinal hyperemia. These findings suggest that either (1) glucose directly causes endothelial nitric oxide production or (2) epithelial cells transduce a vasodilatory signal through vascular endothelial-derived nitric oxide during postprandial intestinal hyperemia.

Intestinal lymphangiectasia: value of Tc-99m dextran lymphoscintigraphy

Intestinal lymphangiectasia is a common cause of protein-losing enteropathy characterized by diarrhea, generalized edema, enteric protein loss, hypoproteinemia, and lymphopenia. Diagnosis is based on demonstration of enteric protein loss and characteristic small bowel mucosal histology. Various imaging modalities including barium studies, computed tomography, and lymphangiography have had limited clinical use. The authors report a case of intestinal lymphangiectasia in which Tc-99m dextran lymphoscintigraphy played a significant role in the patient management.

Prognosis and management of Crohn's disease in the over-55 age group

The course, prognosis and management of 62 patients with Crohn's disease aged 55 years or over at diagnosis has been reviewed. The distal ileus was the commonest site of disease in the older patient, where the characteristic presentation was acute after initially mild symptoms. Early local resection was often required, particularly where there was diagnostic doubt or suspicion of caecal malignancy. Recurrence rates were much lower in the older patient than after resection in younger patients. Medical treatment played a minor role in the management of patients with distal ileal disease, in part because stricture formation was present at diagnosis and the acute nature of symptoms at presentation led to early surgical treatment. Colonic Crohn's disease was usually confined to the distal or left side of the colon and initially could be difficult to distinguish from diverticular disease. Extensive colonic Crohn's disease was rare. The apparently limited disease was not necessarily associated with a good prognosis, since disease at this site sometimes progressed rapidly, necessitating urgent surgical resection. Medical treatment (corticosteriod therapy, with or without azathioprine) was usually effective initially for treatment of symptomatic colonic Crohn's disease, but sustained remission was rare. Those patients with persistent symptoms were restored to good health with surgical treatment but at a price, in that nearly half eventually required a permanent stoma.

Ileo-cecal junction: a valve or a sphincter? An experimental study in the opossum

The characteristics of the ileo-junction (UIC) were examined in seven opossums in vivo, and the effect of the UIC on colo-ileal reflux in eight opossums in vitro. Electromyography and intraluminal manometry were studied during intestinal distensions, and administration of phenylephrine, isoproterenol and carbachol. In vitro studies used preparations of ileum, UIC, and colon, attached to a propulsion evaluation system. Fluid flow across the UIC was studied basally and after phenylephrine, isoproterenol and carbachol. A high pressure zone in the UIC was not observed in vivo. Colonic distension increased the pressure and electrical spike bursts in the ileum and UIC, while ileal distension had the opposite effect. Myoelectric and contractile activities were inhibited by adrenergic agonists and stimulated by carbachol. In vitro studies demonstrated aborally migrating ileal contractions initiated by fluid injections into the ileum, and cecal contractions elicited by fluid injections into the colon. The UIC only prevented colo-ileal reflux when it was undergoing contraction as part of ileal or colonic activity. These findings suggest that the opossum UIC does not have valvular properties and ileal fluid propulsion is the main factor in the prevention of colo-ileal reflux.

Intussusception in an adult secondary to an inverted Meckel's diverticulum

Intussusception secondary to an inverted Meckel's diverticulum is considered to be a rare occurrence. The pathophysiology of the disease process results in a complicated clinical picture of chronic abdominal pain, lower gastrointestinal bleeding, and recurrent obstructive symptoms that may lead to an unnecessary delay in diagnosis. A case of an inverted Meckel's diverticulum as a lead point for an ileocolic intussusception in an adult is presented. The methods of diagnosis and the salient concepts in the surgical management of intussusception are discussed. Special features regarding the pathophysiology and treatment of an inverted Meckel's diverticulum acting as an intussusception are also reviewed.

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.

The natural history of meconium peritonitis diagnosed in utero

The authors reviewed their experience with meconium peritonitis (MP) diagnosed in utero to define criteria for prenatal and postnatal management. Prenatal diagnosis was made by identifying abdominal calcification on serial ultrasound examinations in nine fetuses, between 18 and 37 weeks' gestation. Cases without associated bowel abnormalities were considered "simple MP" and those with bowel abnormalities were considered "complex MP." Five cases of simple MP were identified at 18, 23, 30, 34, and 37 weeks' gestation. These five fetuses were delivered at term and had normal abdominal examinations. Abdominal radiographs were obtained in three showing normal bowel gas patterns, and abdominal calcifications in only two. All five patients were fed uneventfully. Four cases of complex MP were identified at 26, 26, 31, and 31 weeks' gestation. All four fetuses had dilated loops of bowel. Two of the four had meconium cysts, one of which was associated with ascites and the other with polyhydramnios. Shortly after birth both infants with meconium cysts required ileal resection and ileostomy for ileal atresia and ileal perforation, respectively. The remaining two infants had no evidence of dilated bowel, meconium cyst, or ascites on postnatal radiograph and were fed uneventfully. These data suggest that only 22% of fetuses with a prenatal diagnosis of MP develop complications that require postnatal operation. Gestational age at diagnosis does not correlate with postnatal outcome. Fetuses with complex MP are at increased risk for postnatal bowel obstruction and perforation.

Indomethacin-induced lesion modifies contractile activity in rat small intestines

BACKGROUND

Indomethacin induces intestinal lesions. The change in contractility of segments with lesions was studied.

METHODS

Motility was recorded in segments with lesions isolated from the rat small intestine 24 h after a subcutaneous injection of indomethacin (20 mg/kg).

RESULTS

Concentration-contraction curves for acetylcholine shifted leftward independently of the degree of severity of lesions, but the curves for carbachol and 5-hydroxytryptamine did not. Contractions produced by intramural nerve stimulation were enhanced in segments with no visible damage but decreased with progression of lesions. Neostigmine augmented them in normal rats but not in indomethacin-treated rats. The peristaltic activity was enhanced in segments with no visible lesions.

CONCLUSIONS

The results suggest that treatment of the rat with indomethacin enhances contractility of the small intestine owing to diminution of acetylcholinesterase activity independently of the degree of lesions and reduces it owing to decreased responsiveness of enteric neurons with the progression of lesions.