The pathophysiological impact of intra-abdominal hypertension in pigs

BACKGROUND

Intra-abdominal hypertension and abdominal compartment syndrome are common with clinically significant consequences. We investigated the pathophysiological effects of raised IAP as part of a more extensive exploratory animal study. The study design included both pneumoperitoneum and mechanical intestinal obstruction models.

METHODS

Forty-nine female swine were divided into six groups: a control group (Cr; n = 5), three pneumoperitoneum groups with IAPs of 20mmHg (Pn20; n = 10), 30mmHg (Pn30; n = 10), 40mmHg (Pn40; n = 10), and two mechanical intestinal occlusion groups with IAPs of 20mmHg (MIO20; n = 9) and 30mmHg (MIO30; n = 5).

RESULTS

There were significant changes (p<0.05) noted in all organ systems, most notably systolic blood pressure (SBP) (p<0.001), cardiac index (CI) (p = 0.003), stroke volume index (SVI) (p<0.001), mean pulmonary airway pressure (MPP) (p<0.001), compliance (p<0.001), pO2 (p = 0.003), bicarbonate (p = 0.041), hemoglobin (p = 0.012), lipase (p = 0.041), total bilirubin (p = 0.041), gastric pH (p<0.001), calculated glomerular filtration rate (GFR) (p<0.001), and urine output (p<0.001). SVV increased progressively as the IAP increased with no obvious changes in intravascular volume status. There were no significant differences between the models regarding their impact on cardiovascular, respiratory, renal and gastrointestinal systems. However, significant differences were noted between the two models at 30mmHg, with MIO30 showing worse metabolic and hematological parameters, and Pn30 and Pn40 showing a more rapid rise in creatinine.

CONCLUSIONS

This study identified and quantified the impact of intra-abdominal hypertension at different pressures on several organ systems and highlighted the significance of even short-lived elevations. Two models of intra-abdominal pressure were used, with a mechanical obstruction model showing more rapid changes in metabolic and haematological changes. These may represent different underlying cellular and vascular pathophysiological processes, but this remains unclear.

The Heart of the Killer Whale: Description of a Plastinated Specimen and Review of the Available Literature

Simple Summary

The killer whale (Orcinus orca, Linnaeus, 1958) is an odontocete and is the largest member of the family Delphinidae. Free-ranging animals are capable of considerable physical efforts, either as acute bursts or sustained speeds during foraging, diving or protracted long-distance migrations. In this article, the morphology of a plastinated heart of a killer whale and functional adaptations of the gross anatomy in the context of a variety of physiologic demands is evaluated. The four chambers, their content, respective openings and communicating passages are defined based on a specimen used for plastination and thus available for extended and detailed anatomic studies.

Abstract

The killer whale (Orcinus orca, Linnaeus, 1958) is the largest extant delphinid. Despite its worldwide distribution in the wild and in dolphinariums, its anatomy remains relatively poorly described. In the present study, we describe the detailed morphology of a plastinated killer whale heart. The gross description of the arteries and veins reaching the organ and its coronary vessels are reported. Additional endoscopy and CT (computed tomography) scanning were performed to provide extensive measurements of its parts. In many aspects, the killer whale heart conformed to other delphinid heart descriptions, including position, relative size and shape and specific features such as extensive papillary muscles, trabecular endocardium and trabecula septomarginalis. These characteristics are representative of the delphinid family, suggesting that its functions and capacities are similar to that of other, smaller, dolphins and help understand the conditions in which these predators exert their remarkable physical performance necessary for their survival.

Mimicking the temperature gradient between the sow's oviduct and uterus improves in vitro embryo culture output

This work was designed to determine temperature conditions within the reproductive tract of the female pig and study their impact on ARTs. Temperatures were recorded using a laparo-endoscopic single-site surgery assisted approach and a miniaturized probe. Sows and gilts were used to address natural cycle and ovarian stimulation treatments, respectively. According to in vivo values, IVF was performed at three temperature conditions (37.0°C, 38.5°C and 39.5°C) and presumptive zygotes were cultured in these conditions for 20 h, while further embryo culture (EC) (21-168 h post-insemination) was maintained at 38.5°C. After 20 h, different fertility parameters were assessed. During EC, cleavage and blastocyst stages were evaluated. Sperm membrane fluidity at the experimental temperatures was studied by using differential scanning calorimetry and fluorescence recovery after photobleaching techniques. An increasing temperature gradient of 1.5°C was found between the oviduct and uterus of sows (P < 0.05) and when this gradient was transferred to pig in vitro culture, the number of poly-nuclear zygotes after IVF was reduced and the percentage of blastocysts was increased. Moreover, the temperature transition phase for the boar sperm membrane (37.0°C) coincided with the temperature registered in the sow oviduct, and sperm membranes were more fluid at 37.0°C compared with those of sperm incubated at higher temperatures (38.5°C and 39.5°C). These data suggest that there may be an impact of physiological temperature gradients on human embryo development.

Reproductive fluids, used for the in vitro production of pig embryos, result in healthy offspring and avoid aberrant placental expression of PEG3 and LUM

Background

In vitro embryo production (IVP) and embryo transfer (ET) are two very common assisted reproductive technologies (ART) in human and cattle. However, in pig, the combination of either procedures, or even their use separately, is still considered suboptimal due to the low efficiency of IVP plus the difficulty of performing ET in the long and contorted uterus of the sow. In addition, the potential impact of these two ART on the health of the offspring is unknown. We investigated here if the use of a modified IVP system, with natural reproductive fluids (RF) as supplements to the culture media, combined with a minimally invasive surgery to perform ET, affects the output of the own IVP system as well as the reproductive performance of the mother and placental molecular traits.

Results

The blastocyst rates obtained by both in vitro systems, conventional (C-IVP) and modified (RF-IVP), were similar. Pregnancy and farrowing rates were also similar. However, when compared to in vivo control (artificial insemination, AI), litter sizes of both IVP groups were lower, while placental efficiency was higher in AI than in RF-IVP. Gene expression studies revealed aberrant expression levels for PEG3 and LUM in placental tissue for C-IVP group when compared to AI, but not for RF-IVP group.

Conclusions

The use of reproductive fluids as additives for the culture media in pig IVP does not improve reproductive performance of recipient mothers but could mitigate the impact of artificial procedures in the offspring.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40104-020-00544-0.

In vivo measurement of pH and CO2 levels in the uterus of sows through the estrous cycle and after insemination

The pH-CO₂-HCO₃^- system is a ubiquitous biological regulator with important functional implications for reproduction. Knowledge of the physiological values of its components is relevant for reproductive biology and the optimization of Assisted Reproductive Technologies (ARTs). However, in situ measurements of these parameters in the uterus are scarce or null. This study describes a non-invasive method for in situ time-lapse recording of pH and CO₂ within the uterus of non-anesthetized sows. Animals were at three different reproductive conditions, estrous with no insemination and two hours after insemination, and diestrous. From pH and CO₂ data, HCO₃^- concentration was estimated. The non-invasive approach to the porcine uterus with novel optical probes allowed the obtaining of in situ physiological values of pH, CO₂, and HCO₃^-. Variable oscillatory patterns of pH, CO₂ and HCO₃^- were found independently of the estrous condition. Insemination did not immediately change the levels of uterine pH, CO₂ (%) and HCO₃^- concentration, but all the values were affected by the estrous cycle decreasing significantly at diestrous condition. This study contributes to a better understanding of the in vivo regulation of the pH-CO₂-HCO₃^- system in the uterus and may help to optimize the protocols of sperm treatment for in vitro fertilization.

[Hypokalemic periodic paralysis: a systematic review of published case reports]

INTRODUCTION

Hypokalemic periodic paralysis is a neuromuscular disease characterized by a combination of flaccid paralysis episodes (or muscular weakness) that are related to low levels of potassium in blood. As a consequence of its low prevalence, there are still clinical and management aspects to characterize.

PATIENTS AND METHODS

A systematic review of the clinical cases published in the last decade has been developed by analyzing demographic and genetic features, the episodes' characteristics, the received treatments, the response to them and also, the differences and evolution of patients depending on the most prevalent genetic alterations: CACNA1S and SCN4A.

RESULTS

A total of 33 articles were included, allowing 40 individuals to be reviewed. The average age of onset of symptoms was 15.3 ± 9.7 years. The most frequent altered gene was CACNA1S in 20 (60.5%) cases. It was observed that subjects presenting an alteration of the gene responsible for the calcium channel, CACNA1S, presented lower serum potassium levels, own triggers and a higher proportion of subjects showing dyspnea during the crisis. Only 50% of the subjects respond to classical oral treatment with acetazolamide. Potassium-sparing diuretics and antiepileptics drugs emerge as an alternative.

CONCLUSION

Hypokalemic periodic paralysis has an heterogeneous clinical expression with phenotypic differences linked to different genetic mutations. The common preventive treatment response is suboptimal. Prospective studies are needed to discern the best therapeutic option based on genetic load.

Plastinated macroparasites, an alternative resource for use in practical lessons

The plastination technique is a recently developed option to preserve biological tissues widely used in human and veterinary anatomy. This process allows one to obtain real, safe, clean, dry, resistant and permanently stable material without any additional treatment or maintenance. All these advantages are associated with the rapid expansion of plastination during recent decades in a high number of educational institutions. However, the studies of parasite conservation through plastination are scarce, although the material obtained has a high quality, as prior references have shown. In this study, 141 students of veterinary medicine and pharmacy university degrees used, in a blind study, plastinated specimens (experimental group) or wet specimens (control group) during three consecutive practical sessions. Afterwards all the students completed anonymous questionnaires on both knowledge and satisfaction. The results demonstrated that plastinated parasites are a valid and satisfactory alternative to be used as a teaching/learning tool during practical lessons. Moreover, with regard to the knowledge of morphological structures, the results from the questionnaire of assimilated knowledge showed no differences between the use of plastinated and formaldehyde-preserved parasites.

Laparoscopic longitudinal pancreaticojejunostomy for chronic pancreatitis: Systematic review of the literature

BACKGROUND

Longitudinal pancreaticojejunostomy, also known as modified Puestow or Partington-Rochelle procedure, is a technique for the treatment of chronic pancreatitis. It is usually performed by laparotomy, but in a very small number of cases it has been performed using a laparoscopic or robot-assisted approach. We carried out a systematic literature review to clarify the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ).

METHODS

Adhering to the PRISMA guidelines, a systematic search for LLPJ was performed in PubMed, Embase, and Cochrane Library, for articles published up to 31 December 2017.

RESULTS

357 articles were evaluated for eligibility and 17 were included for critical appraisal: eight case reports, eight retrospective case series, and one series of cases and controls without randomization. All of them had a grade of recommendation C and a level of evidence 4 according to the CEBM. Patients were relatively young (mean age 37 years), with a slight preponderance of males (ratio 1.3: 1). All had long-standing disease, ERCP prior to surgery and a dilated pancreatic duct (mean 11 mm). The surgery was usually performed laparoscopically using four trocars; the conversion rate was low (5%), bleeding was minimal, the morbidity rate was 11% and no mortality was reported. Mean hospital stay was 5.6 days. The follow-up period varied but was usually short (less than two years). The results for pain control were very good since 90% of patients reported no pain, although visual analog scales were rarely used.

CONCLUSIONS

In conclusion, LLPJ seems to be a safe, feasible and effective technique in patients with chronic pancreatitis. However, the number of descriptions published to date is very small, and there are no studies with high scientific evidence comparing LLPJ with open surgery or with endoscopic treatment that would allow us to draw firmer conclusions at the present time.

106 Comparative growth rates and haematological parameters from calves born by transfer of vitrified invitro-produced embryos and stepbrother calves born by AI

Assisted reproductive technologies (ART) are being extensively used to produce cattle offspring. However, as shown by Siqueira et al. (2017 J. Dairy Sci. 100, 5899-5908; https://doi.org/10.3168/jds.2016-12539), phenotypical and performance differences between cows derived from distinct ART can be found at different stages of development. Thus, in an attempt to mimic the natural environment, reproductive fluids (oviductal (SOF) and uterine fluids) were added as supplementation to embryo culture media. Our hypothesis was that this improved culture media would produce calves more similar to the ones produced by AI. Invitro-produced (IVP) beef embryos were produced using SOF media supplemented with reproductive fluids (RF) or standard protocol (BSA), vitrified and later warmed and transferred to synchronized dairy recipients. Simultaneously, other dairy recipients were inseminated (AI) with the same bull used to produce IVP embryos. A total of 19 calves are included in this study (RF n=5, BSA n=7, AI n=7). Calves that did not reach 45 days of life were excluded from these data. All animals received the same feeding and housing conditions. Calves were examined at Days 0, 3, 7, 15, 30, and 45 of life. Each examination included weight, height at withers, thorax circumference, heart and respiratory rates, body temperature, and a blood sample from the jugular vein to perform a general haematological analysis (Siemens ADVIA 120) and glucose levels. A non-parametric test (Mann-Whitney U) was used to compare paired samples, with significance assumed when P&lt;0.05. Since day is a factor that influences growth, it was assumed as a fixed factor, and data were analysed per day. In terms of growth development, AI calves were significantly taller than BSA calves in all days, and in general taller than RF calves, with the exception of Days 3 and 7. Thorax circumference was significantly smaller for BSA versus AI calves only on Days 15 and 45. Respiratory rate was higher for RF calves at birth and for BSA calves at Day 3 when both were compared with AI calves, but we found no difference between them. Heart rate was higher for RF calves on Day 7 compared with BSA and AI, and higher again on Day 15 compared with AI. Regarding haematological parameters, significant differences were found on Day 0, with platelet counts being lower for BSA calves. On Day 7, mean corpuscular volume from AI calves was lower than either BSA or RF calves, and on Day 15, eosinophils were lower for RF calves compared with AI. At Day 30, white blood cells and lymphocyte concentration were lower for BSA than for AI calves. Glucose levels were higher for RF calves than for AI calves on Day 45. Overall, all haematology and clinical values seem to match the values of healthy calves (Brun-Hansen et al. 2006 Vet. Clin. Pathol. 35, 182-187; https://doi.org/10.1111/j.1939-165X.2006.tb00111.x), and the differences found were not clinically relevant. In conclusion, at the moment and from the analysed criteria of development during the first 45 days of life, there seems to exist no difference between calves born by IVP with RF as supplement to culture media and their invitro or invivo controls.

E12 technique: Conventional epoxy resin sheet plastination

Epoxy plastination techniques were developed to obtain thin transparent body slices with high anatomical detail. This is facilitated because the plastinated tissue is transparent and the topography of the anatomical structures well preserved. For this reason, thin epoxy slices are currently used for research purposes in both macroscopic and microscopic studies. The protocol for the conventional epoxy technique (E12) follows the main steps of plastination-specimen preparation, dehydration, impregnation and curing/casting. Preparation begins with selection of the specimen, followed by freezing and slicing. Either fresh or fixed (embalmed) tissue is suitable for epoxy plastination, while slice thickness is kept between 1.5 and 3 mm. Impregnation mixture is made of epoxy E12 resin plus E1 hardener (100 ppw; 28 ppw). This mixture is reactive and temperature sensitive, and for this reason, total impregnation time under vacuum at room laboratory temperature should not last for more than 20-24 hr. Casting of impregnated slices is done in either flat chambers or by the so-called sandwich method in either fresh mixture or the one used for impregnation. Curing is completed at 40°C to allow a complete polymerization of the epoxy-mixture. After curing, slices can be photographed, scanned or used for anatomical study under screen negatoscope, magnification glass or fluorescent microscope. Based on epoxy sheet plastination, many anatomical papers have recent observations of and/or clarification of anatomical concepts in different areas of medical expertice.

Plastination-A scientific method for teaching and research

Over the last four decades, plastination has been one of the best processes of preservation for organic tissue. In this process, water and lipids in biological tissues are replaced by polymers (silicone, epoxy, polyester) which are hardened, resulting in dry, odourless and durable specimens. Nowadays, after more than 40 years of its development, plastination is applied in more than 400 departments of anatomy, pathology, forensic sciences and biology all over the world. The most known polymers used in plastination are silicone (S10), epoxy (E12) and polyester (P40). The key element in plastination is the impregnation stage, and therefore depending on the polymer that is used, the optical quality of specimens differs. The S10 silicone technique is the most common technique used in plastination. Specimens can be used, especially in teaching, as they are easy to handle and display a realistic topography. Plastinated silicone specimens are used for displaying whole bodies, or body parts for exhibition. Transparent tissue sections, with a thickness between 1 and 4 mm, are usually produced by using epoxy (E12) or polyester (P40) polymer. These sections can be used to study both macroscopic and microscopic structures. Compared with the usual methods of dissection or corrosion, plastinated slices have the advantage of not destroying or altering the spatial relationships of structures. Plastination can be used as a teaching and research tool. Besides the teaching and scientific sector, plastination becomes a common resource for exhibitions, as worldwide more and more exhibitions use plastinated specimens.

P40 polyester sheet plastination technique for brain and body slices: The vertical and horizontal flat chamber methods

The P40 technique produces high-quality brain and body slices and is the user-friendliest of the polyester techniques. The P40 polyester technique follows the same classical steps for plastination. That is, preparation of the specimen, fixation (optional), dehydration by freeze substitution, forced impregnation and curing. Two methods used to prepare two different types of specimens, that is, brain slices and body slices are described. Each method has its own characteristics depending on the specimen type used. Brain slices were used to illustrate the vertical small chamber method while the body slices were used to illustrate the horizontal large chamber method. The brain slices obtained using P40 are of very good quality presenting good contrast between grey and white matter. The body slices are also of very good quality. The physical appearance of these slices makes them an exceptional instrument for diagnostic imaging and anatomical correlation. Body slices prepared with P40 retain the natural colour of the tissue and preserve the anatomical relationships.

The International Society for Plastination

The International Society for Plastination (ISP) was conceived as a means of defining plastination as an area of professional activity and serving as an agency for disseminating information relative to the art and science of plastination. In this paper, we present the purpose of ISP, the Journal of Plastination, the Plastination Index and the different international meetings organised by ISP.

Mimicking physiological O2 tension in the female reproductive tract improves assisted reproduction outcomes in pig

STUDY QUESTION

Is O2 tension in the pig oviduct and uterus affected by the estrous cycle stage and the animal's age, and can the outcome of in vitro embryo development be improved by mimicking these physiological values?

SUMMARY ANSWER

O2 tension within the pig reproductive organs is affected by the animal's age, and values close to those measured in vivo have a positive impact on embryo development and quality when used during IVF and embryo culture (EC).

WHAT IS KNOWN ALREADY

To obtain a healthy embryo in vitro, it is necessary to adopt a culture microenvironment that approximates physiological conditions. Despite advances in surgical procedures and sensitive probes that allow accurate assessment of in vivo O2 tension, few such studies have been conducted recently in mammals. In addition, no reference values of physiological O2 tension in the reproductive tract exist for large animal models such as pig, and the effect of O2 tension on ART outcomes is unknown.

STUDY DESIGN, SIZE, DURATION

This study was conducted in pigs. We measured oviductal and uterine O2 tension (n = 29 and 13, respectively) and then examined how the use of the physiological values in pig IVF and EC affected pig ART output (n = 1447 oocytes).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The oviductal and uterine O2 tension at the different stages of the estrous cycle was monitored using a laparo-endoscopic single-site surgery (LESS) assisted approach along with a flexible and thin miniaturized luminescent probe. Two groups of pigs, Large-white × Landrace breed, were used: for the first group, 16 pre-pubertal gilts (5 months old and 95 kg) were induced to ovulate with equine chorionic gonadotropin (eCG) and human chorionic gonadotropin (hCG); in the second group 13 mature sows (24-48 months and 185 kg) were used. IVF and EC were performed at two different O2 tensions: Atmospheric O2 (20%) and the mean in vivo value measured (7%). At 18-20 h post-insemination (hpi), a small sample of presumptive zygotes were fixed, stained and examined under epifluorescence microscopy to assess the fertilization rates. At 48 hpi, cleavage was evaluated under the stereomicroscope. Finally, at 180 hpi, development to the blastocyst stage was quantified, blastocyst morphology was assessed, and embryos were fixed and stained to count the mean cell number per blastocyst.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean O2 content within the pig oviduct and uterus was always lower than in ambient air. The average O2 percentage was higher in gilts (10.0%) than in sows (7.6%) (P < 0.0001). The cleavage rate of porcine in vitro fertilized embryos maintained under 7% O2 during IVF and EC was significantly higher (60.0 ± 2.3) compared with those cultured under 20% O2 (32.0 ± 2.2) (P < 0.05). An increase in the number of cells in embryos cultured under the low O2 concentration (88.9 ± 5.9) was observed compared to those cultured under 20% O2 (59.0 ± 5.0) (P < 0.05).

LARGE SCALE DATA

None.

LIMITATIONS, REASONS FOR CAUTION

Although minimally invasive surgery was used the effect of anesthesia and manipulations on O2 tension within the organs are unknown.

WIDER IMPLICATIONS OF THE FINDINGS

Using physiological oxygen concentrations in IVF/EC could improve ART outcomes.

STUDY FUNDING AND COMPETING INTEREST(S)

This study was funded by Spanish Ministry of Economy and Competitiveness (MINECO) and European Regional Development Fund (FEDER). Grants AGL2012-40180-C03-01 and AGL2015-66341-R. The authors declare no conflict of interest.

Preservation of macroparasite species via classic plastination: an evaluation

Plastination is a preservation method for biological specimens, with important advantages over classic conservation techniques with formaldehyde or alcohol. Plastinated specimens are dry, odourless, and free of carcinogenic and toxic solutions. There are only few references about the plastination of parasites. Moreover, there is no information on the effect of plastination on the morphology and morphometry of these animals. The aim of this study was to define a plastination protocol to preserve various species of parasites, namely the nematodes Parascaris equorum (Goeze, 1782); Ascaris suum Goeze, 1782 and Dirofilaria immitis (Leidy, 1856); the acanthecephalan Macracanthorhynchus hirudinaceus (Pallas, 1781); the trematodes Fasciola hepatica Linnaeus, 1758 and Dicrocoelium dendriticum (Rudolphi, 1819) and the tapeworm Taenia sp. in the best morphological and morphometric conditions. Results showed that some individuals suffered collapse (P. equorum, A. suum, and D. dendriticum). However, other parasites presented good results with almost no change after plastination (D. immitis, M. hirudinaceus and F. hepatica). In conclusion, conventional plastination allowed anatomical preservation of all helminths tested, but modifications to the protocol are needed to prevent collapse.

Intestinal histopathological changes in a porcine model of pneumoperitoneum-induced intra-abdominal hypertension

BACKGROUND

Low splanchnic perfusion is an immediate effect of pneumoperitoneum-induced intra-abdominal hypertension (IAH). Anatomical structure results in the intestinal mucosa being the area most sensitive to hypoperfusion. The relationship between intestinal injury and clinical parameters of tissue perfusion [abdominal perfusion pressure (APP), gastric intramucosal pH (pH_i) and lactic acid (Lc)] has not been previously studied. This study aimed to monitorize intestinal pathogenesis through sequential ileal biopsies and to measure APP, pH_i, and Lc levels at different pneumoperitoneum-induced intra-abdominal pressures (20, 30, and 40 mmHg) to evaluate the potential relationships between them.

MATERIALS AND METHODS

Fifty pigs were divided into four groups; a control group (C) and three experimental groups with different pneumoperitoneum-induced levels [20 mmHg (G20), 30 mmHg (G30), and 40 mmHg (G40)], that were maintained for 3 and 5 h. APP, pH_i, and Lc were measured and ileal biopsies taken laparoscopically every 30 min. The mucosal damage was graded using the standardized Park's Score and animals were classified as injured (I+) or uninjured (I-).

RESULTS

Different histopathological lesions were observed in groups G20, G30, and G40 but no damage observed in group C. A 33.3% of animals in G20 and G30 were I+ after 3 h, while 93.3% were injured in G40. After 5 h, histopathological lesions were no longer seen in some animals in G20 and only 10% were I+. Conversely, in G30 I+ pigs increased to 80% while those in G40 remained at 93.3% I+. The I+ animals had significantly lower APP and pH_i than those I-. Lc was the clinical parameter that showed the earliest differences, with significantly higher figures in I+ animals.

CONCLUSIONS

The evolution of intestinal injuries from pneumoperitoneum-induced IAH depends on the degree of IAP. These damages may be associated with decreases in APP and pH_i, and increases in Lc.

Evidences supporting the vascular etiology of post-double balloon enteroscopy pancreatitis: Study in porcine model

Double balloon enteroscopy (DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.

[Diagnosis agreement between capsule endoscopy and double-balloon enteroscopy in obscure gastrointestinal bleeding at a referral center]

BACKGROUND AND AIM

Capsule endoscopy and double balloon enteroscopy are well-recognized procedures in obscure gastrointestinal bleeding, with many factors that may influence their diagnosis yield. The aim of the present study was to characterize the degree of agreement between both techniques with focus on the type of lesion in a large cohort of patients at a referral center.

MATERIAL AND METHOD

One thousand two hundred and nine capsules were administered in 1,078 patients and 381 enteroscopies were performed in 361 patients with obscure-gastrointestinal bleeding from 2004 to 2014.

RESULTS

Both procedures were carried out in 332 patients (mean age: 65.22 +/- 15.41, 183 men) and they have a similar diagnosis yield (70.5% vs. 69.6%, p = 0.9). Overall enteroscopy diagnosis yield was higher within patients with a previous positive capsule endoscopy (79.3% vs. 27.9%, p < 0.001). The degree of agreement was very good for polyps (0.89 [95% CI: 0.78-0.99]), good for vascular lesions (0.66 [95% CI: 0.55-0.77]) and tumors(0.66 [95% CI: 0.55-0.76]) and moderate for ulcers (0.56 [95% CI: 0.46-0.67]). Diverticula (0.39 [95% CI: 0.29-0.5]) achieved a fair agreement. The results of CE and DBE differed in 73 patients (22%).

CONCLUSIONS

The present study confirms that although overall diagnostic yield by capsule endoscopy and double-balloon enteroscopy is similar, there are many factors which can modify these values, mainly the type of lesion.

Effect of the manipulation of the duodenal papilla during double balloon enteroscopy

AIM: To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of pancreatitis.

METHODS: Four groups of pigs were used: Group papilla (GP), the overtube’s balloon was inflated in the area of the papilla; GP + double balloon enteroscopy (GP + DBE), the overtube’s balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE (GDBE), DBE was carried out after insuring the balloon’s inflation far from the pancreatic papilla; and Group control (GC). Serum concentrations of amylase, lipase and C-reactive protein (CRP) were evaluated. Pancreases were processed for histopathology examination.

RESULTS: Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP (59.2% higher) and were moderately higher in groups GP + DBE and GDBE (22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + DBE.

CONCLUSION: The manipulation of the duodenal papilla by the inflated overtube’s balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.

Enteroendocrine cells: a review of their role in brain-gut communication

BACKGROUND

Specialized endoderm-derived epithelial cells, that is, enteroendocrine cells (EECs), are widely distributed throughout the gastrointestinal (GI) tract. Enteroendocrine cells form the largest endocrine organ in the body and play a key role in the control of GI secretion and motility, the regulation of food intake, postprandial glucose levels and metabolism. EECs sense luminal content and release signaling molecules that can enter the circulation to act as classic hormones on distant targets, act locally on neighboring cells and on distinct neuronal pathways including enteric and extrinsic neurons. Recent studies have shed light on EEC sensory transmission by showing direct connections between EECs and the nervous system via axon-like processes that form a well-defined neuroepithelial circuits through which EECs can directly communicate with the neurons innervating the GI tract to initiate appropriate functional responses.

PURPOSE

This review will highlight the role played by the EECs in the complex and integrated sensory information responses, and discuss the new findings regarding EECs in the brain-gut axis bidirectional communication.

Plastination in Anatomy Learning: An Experience at Cambridge University

Due to lack of objective data, the benefits of using plastination in combination with wet dissection in teaching gross anatomy are unknown. The aim of this study was to obtain objective evidence from students regarding the effectiveness of combining plastinated specimens (PS) with an established gross anatomy education program at Cambridge University that uses wet cadaver dissection and small-group tutorials. For a complete academic year, a total of 135 PS were used alongside wet cadaver dissections. The PS were also available for small-group tutorials. An anonymous closed questionnaire, using a 5-point numerical-estimation Likert scale, was used to gather information relating to the effectiveness of the PS. The level of student satisfaction with the combined use of wet dissections and PS was high, although higher (p<.05) for second-year students (98.4%) than for first-year students (95.5%). Students felt the specimens allowed them to see details that were often more difficult to identify in their dissections, for instance nerves. Voluntary use of PS was higher (p<.01) for second-year students (96.9%), who had previously experienced anatomy teaching with cadaver dissection alone, than for first-year students (77.7%). Overall, 97.7% of all students thought that the PS helped them understand and learn anatomy. All students surveyed (100%) recommended the use of PS in the future. Students considered the use of PS in the dissection room combined with wet cadaver dissection to be beneficial when learning anatomy, particularly when combined with their use during small-group tutorials.

Mechanical Intestinal Obstruction in a Porcine Model: Effects of Intra-Abdominal Hypertension. A Preliminary Study

Introduction

Mechanical intestinal obstruction is a disorder associated with intra-abdominal hypertension and abdominal compartment syndrome. As the large intestine intraluminal and intra-abdominal pressures are increased, so the patient’s risk for intestinal ischaemia. Previous studies have focused on hypoperfusion and bacterial translocation without considering the concomitant effect of intra-abdominal hypertension. The objective of this study was to design and evaluate a mechanical intestinal obstruction model in pigs similar to the human pathophysiology.

Materials and Methods

Fifteen pigs were divided into three groups: a control group (n = 5) and two groups of 5 pigs with intra-abdominal hypertension induced by mechanical intestinal obstruction. The intra-abdominal pressures of 20 mmHg were maintained for 2 and 5 hours respectively. Hemodynamic, respiratory and gastric intramucosal pH values, as well as blood tests were recorded every 30 min.

Results

Significant differences between the control and mechanical intestinal obstruction groups were noted. The mean arterial pressure, cardiac index, dynamic pulmonary compliance and abdominal perfusion pressure decreased. The systemic vascular resistance index, central venous pressure, pulse pressure variation, airway resistance and lactate increased within 2 hours from starting intra-abdominal hypertension (p<0.05). In addition, we observed increased values for the peak and plateau airway pressures, and low values of gastric intramucosal pH in the mechanical intestinal obstruction groups that were significant after 3 hours.

Conclusion

The mechanical intestinal obstruction model appears to adequately simulate the pathophysiology of intestinal obstruction that occurs in humans. Monitoring abdominal perfusion pressure, dynamic pulmonary compliance, gastric intramucosal pH and lactate values may provide insight in predicting the effects on endorgan function in patients with mechanical intestinal obstruction.

Quantitative evaluation of the vasculature supplying the oviduct in pre-pubertal and sexually mature sows

The present work was aimed at characterizing the regional vascularization of the oviduct in the pig to ascertain whether the number of terminal mesosalpingeal arterioles supplying the isthmus and ampulla is influenced by reproductive maturity and state of the estrous cycle. The total number of terminal arterioles (NTA) in the mesosalpinx was quantified under a stereomicroscope in latex injected ex-vivo reproductive tracts from pre-pubertal (n = 10) and mature sows (n = 34), the latter allocated into three phases of the estrous cycle: follicular (n = 12); early luteal (n = 11); and late luteal (n = 11). The NTA and density of terminal arterioles (DTA) changed little between pre-pubertal and mature sows or among sows of different reproductive status (P > 0.05). Conversely, both in pre-pubertal and mature sows the isthmus showed higher DTA (P < 0.001) than the ampulla. It is concluded that the pattern of vascularization supplying the porcine oviduct is essentially established before the onset of puberty so that neither cyclical changes coupled with the estrous cycle nor regional variations between the isthmus and ampulla are likely at the level of the terminal arterioles supplying the oviduct during the reproductive life.

An endoscopic technique for treating symptomatic distal jejunum obstruction by leaving the overtube in place

Double balloon enteroscopy has a limitation for positioning an enteral stent in the distal jejunum through its long, narrow biopsy channel. When the distal end of its overtube is left in place close to the neoplasia with the enteroscope removed, if we push an enteral stent introduction system, it tends to form loops so the techniquecannot be performed with this instrument. However, the double balloon colonoscope has a shorter overtube length and using the same push-and-pull technique we can reach the distal jejunum with this instrument by inserting the delivery stent system without loops through its overtube. We present a patient with neoplastic obstruction in the distal jejunum with resolution of his symptoms after positioning an enteral stent.

Role of double-balloon enteroscopy in malignant small bowel tumors

AIM: To assess the double-balloon enteroscopy (DBE) role in malignant small bowel tumors (MSBT).

METHODS: This is a retrospective descriptive study performed in a single center. All consecutive patients who underwent a DBE with final diagnosis of a malignant neoplasm from 2004 to 2014 in our referral center were included. Patient demographic and clinical pathological characteristics were recorded and reviewed. MSBT diagnosis was achieved either by DBE directed biopsy with multiple tissue sampling, endoscopic findings or histological analysis of surgical specimen. We have analyzed double-balloon enteroscopy impact in outcome and clinical course of these patients.

RESULTS: Of 627 patients, 28 (4.5%) (mean age = 60 ± 17.3 years) underwent 30 procedures (25 anterograde, 5 retrograde) and were diagnosed of a malignant tumor. Patients presented with obscure gastrointestinal bleeding (n = 19, 67.9%), occlusion syndrome (n = 7, 25%) and diarrhea (n = 1, 3.6%). They were diagnosed by DBE biopsy (n = 18, 64.3%), histological analysis of surgical specimen (n = 7, 25%) and unequivocal endoscopic findings (n = 2, 7.1%). Gastrointestinal stromal tumor (n = 8, 28.6%), adenocarcinoma (n = 7, 25%), lymphoma (n = 4, 14.3%), neuroendocrine tumor (n = 4, 14.3%), metastatic (n = 3, 10.7%) and Kaposi sarcoma (n = 1, 3.6%) were identified. DBE modified outcome in 7 cases (25%), delaying or avoiding emergency surgery (n = 3), modifying surgery approach (n = 2) and indicating emergency SB partial resection instead of elective approach (n = 2).

CONCLUSION: DBE may be critical in the management of MSBT providing additional information that may be decisive in the clinical course of these patients.

Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding?

BACKGROUND AND AIM

There are few data concerning emergency double-balloon enteroscopy (DBE) and its usefulness in the management of severe acute obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to evaluate emergency DBE and capsule endoscopy (CE) in patients with overt OGIB, analyzing the feasibility of this combined approach.

METHODS

Emergency DBE in patients with overt OGIB was defined as performance within 24 h of symptom onset. We reported 27 patients (16 men, mean age: 64.6 ± 17.9 years) with overt severe bleeding who underwent 29 emergency DBE (22 anterograde, 7 retrograde). Of 27 patients, 16 (59.3%) underwent CE with real time (RT) viewing.

RESULTS

Patients were diagnosed with the following: Dieulafoy's lesion (DL; n = 11, 40.7%), angioectasia (n = 7, 25.9%), tumors (n = 4, 14.8%), diverticulum (n = 3, 11.1%), ulcers (n = 2, 7.4%). We diagnosed 23 lesions amenable to endoscopic hemostasis and successfully treated 21 of them (77.8%). DL detection rate was statistically higher in the emergency DBE group than in OGIB patients with DBE done 24 h after symptom onset (40.7% vs 0.9%, respectively, P < 0.001). Combined approach with RT viewing by CE correctly modified DBE management in four patients (25%).

CONCLUSIONS

Emergency DBE is feasible, safe and effective in acute OGIB and may avoid major surgery, diagnosing and successfully treating most patients. Combined approach with RT viewing by CE is especially useful to identify recurrent bleeding vascular lesions such as DL that may be easily misdiagnosed by non-emergency DBE.

Ischemic etiopathogenesis as the possible origin of post-double baloon enteroscopy pancreatitis. A porcine model study

The aim is to evaluate the pancreatic vascular-ischemic effects related to double balloon enteroscopy in the porcine model as a possible etiopathogenesis of post-enteroscopic pancreatitis. For this reason we carry out two independent experiments in a porcine animal model. In the first arm protocol (group I), 10 animals underwent 90 minutes of oral enteroscopy with 7 days follow-up.The levels of amylase, lipase and C-reactive protein were measured at T0 basal-T1 -90 min, T2-24, T3-7 days. Also we perform upper gastrointestinal endoscopy in a control group. At 7 days, the animals of experimental protocol-I had their pancreases removed for a pathological and immunohistochemical study to evaluate vascular epithelial growth factor (VEGF) expression.The second experimental protocol in this study aims to evaluate possible changes in vascular topography due to the double balloon enteroscopy (DBE). Group-II (10 animals) underwent oral enteroscopy and selective angiography of the cranial mesenteric artery and celiac trunk. None of the group I or control group animals presented pancreatitis, although the biochemical results for group-I showed increases in the levels of amylase, lipase and C reactive protein at 24 hours. The microscopic study for group-I showed pancreatic necrotic foci and positive VEGF expression, though these changes were not expressed in the control group.These foci were found in 50% of the group I animals and in relation to the total of the parenchyma were quantified at 6% of the pancreas. The results for group-II showed that the enteroscopy caused mobilization of the mesenteric vascular axis, with signs of both intestinal and pancreatic hypoperfusion. The conclusions of this study are that, after enteroscopy in the porcine model, pancreatic necrotic foci are produced, in addition to ischemic phenomena causing VEGF expression. This could be related to episodes of visceral hypoperfusion caused by vascular alterations on a topographic level. This can be related to the possible ischemic etiopathogenesis described for post-enteroscopic pancreatitis.

Carbon dioxide insufflation safety in double-balloon enteroscopy: an experimental animal study

AIM

The aim of the present study was to assess the safety and efficacy of CO(2) during double-balloon enteroscopy (DBE) in an experimental animal model study. In this study, insufflation with room air and with CO(2) was compared.

METHODS

Twenty healthy swines were used. The animals were randomly allocated to two groups. The room air-DBE group was insufflated with room air, whereas the CO(2)-DBE group was insufflated with CO(2). Endoscopy duration was 90 min. The following parameters were measured during the study (basal, 30 min, 60 min, 90 min): invasive hemodynamic parameters, ventilatory parameters, arterial blood gases, exploration depth, as well as biochemical tests. Residual gas was evaluated at the end of DBE, at 180 min and 24 h after DBE.

RESULTS

During the endoscopic exploration none of the animals showed hemodynamic, ventilatory or arterial blood gas alterations in the normal reference range for the swine species. The CO(2) group showed statistically significant differences over the room air group with lower post-procedure residual gas and greater depth of the small bowel explored.

CONCLUSION

The use of CO(2) for insufflation during DBE was safe and no complications associated with CO(2) were observed. In addition, the use of CO(2) offers benefits over the use of room air for insufflation during DBE.

Anatomical study of fibrous structures of the medial aspect of the canine elbow joint

Forces exerted by fibrous structures on the medial aspect of the canine elbow joint have been reported to be involved in elbow pathology. The purpose of this paper is to assess the relationships of the ligamentous and muscular structures of this region of the canine elbow joint, and how they relate to the medial coronoid process. Six cadavers of adult German shepherd cross-breed dogs were used in this study to make intra-articular and vascular injections of this region. Some joints were dissected and some were frozen to saw sagittal or dorsal cryosections to assess the relationships of the myotendinous structures. The brachialis muscle tendon passed through the division of the bicipital tendon of insertion which formed a fibrous tendon sheath that was reinforced by the oblique ligament. The biceps' brachii's main insertion is the radial tuberosity where it inserts along with the cranial branch of the oblique ligament and the cranial branch of the medial collateral ligament. Rotational and compression forces exerted by the insertion of the biceps brachii-brachialis tendon complex onto the ulna might influence medial coronoid disease. Therefore, sectioning these tendons could be considered as a treatment for medial coronoid disease.

Validity of insertion depth measurement in double-balloon endoscopy

BACKGROUND AND STUDY AIMS

In double-balloon enteroscopy (DBE) the use of a reliable and practical method to calculate the insertion depth of the endoscope could help to improve diagnosis accuracy and optimize the effort and cost of the technique. The objectives of this work were to compare and evaluate two methods of estimating the insertion depth and to obtain a descriptive model capable of representing the exploration dynamics and efficiency in terms of advanced distance and time.

METHODS

Oral DBE was performed in 25 pigs. Insertion depth was calculated during the procedure by: 1) estimation of time and distance for each push and pull cycle during progression; and 2) estimation of distance during withdrawal. At the maximum insertion depth a tattoo was placed, and the observed measures for the two methods were compared with the distance between the pylorus and the mark after euthanasia and necropsy of the animals 1 week after DBE.

RESULTS

The average insertion depth during progression, withdrawal, and after necropsy was 324.92 cm, 317.23 cm, and 342.05 cm, respectively (P Anova = 0.72). The Pearson correlation coefficient (r > 0.85; P < 0.001) and paired Brand - Altman plots demonstrated high agreement between progression and necropsy (0.03 % difference) and between withdrawal and necropsy (6.9 % difference). The exploration dynamics and efficiency in terms of advanced distance per cycle and time fitted to potential and logarithmic regression models, respectively.

CONCLUSIONS

Measurement of insertion depth in vivo was validated in the porcine model during progression and withdrawal. Estimation during progression was more accurate and allowed exploration dynamics and efficiency to be plotted, which might be used as approximate reference values for humans.

Effects of pneumoperitoneum and body position on the morphology of the caudal cava vein analyzed by MRI and plastinated sections

BACKGROUND

Pneumoperitoneum and patient positioning are essential factors during laparoscopic surgical procedures. They cause hemodynamic and anatomical changes in several abdominal organs among which the caudal cava vein (CCV) is involved. Hemodynamic changes in this vein (decreased venous return) have been described in the porcine model, but how the vein morphology and size is affected at different abdominal levels is unknown. We sought to assess the morphological and morphometrical changes in the CCV of the pig caused by pneumoperitoneum and the reverse Trendelenburg position by in vivo magnetic resonance imaging (MRI).

METHODS

Six pigs were scanned via MRI under four situations: S1, control (no pneumoperitoneum); S2, control in the reverse Trendelenburg position; S3, pneumoperitoneum (14 mmHg); and S4, pneumoperitoneum in the reverse Trendelenburg position. MRI and plastinated body sections were used to evaluate the topography, morphology and cross-sectional area of the CCV.

RESULTS

Two portions of the CCV were differentiated: a prehepatic portion (located between the vertebral levels L1-T15) with flat and irregular morphology, and a hepatic portion (between T14-T11) that was almost rounded. The reverse Trendelenburg position caused an increase in the lumen affecting mainly the prehepatic portion, while pneumoperitoneum caused a decrease in the total vascular lumen, exerting a greater effect on the hepatic portion. The combination of both situations resulted in a further decrease in the vascular area and global morphological changes.

CONCLUSIONS

The pneumoperitoneum and reverse Trendelenburg position caused morphological and morphometrical changes in the prehepatic and hepatic portions of the CCV, which should assist in gaining a better understanding of the hemodynamic changes described in the literature.

Effect of double-balloon enteroscopy on pancreas: an experimental porcine model

AIM

To evaluate the effect of double-balloon enteroscopy (DBE) on pancreas histology and levels of pancreatic enzymes.

METHODS

Conventional upper gastrointestinal endoscopy was performed on five control pigs. Oral DBE was performed with an EN-450T5 enteroscope on 20 pigs. Two experimental groups (10 pigs each) were defined according to DBE duration: 90 min for Group 1 and 140 min for group 2. During oral insertion, the balloons were not inflated in the descending part of the duodenum to avoid the minor duodenal papilla. Serum amylase, lipase and C-reactive protein (CRP) levels were monitored before the procedure and repeated every 30 min until the exploration was finished, as well as 24 h and 7 d after. After the procedure and for a total of 7 d, the pigs were observed twice a day for signs of decreased activity, irritability, vomiting or anorexia. Gross and microscopic examination of the pancreas was performed on day 7.

RESULTS

All animals tolerated DBE without clinical manifestations of acute pancreatitis. Experimental groups had higher levels of enzymes than the control group at 24 h. Throughout the exploration, the amylase levels increased significantly above the baseline 24 h after DBE, although the increase was not statistically significant and did not reach 20% of the baseline. An increase in lipase and CRP was observed at 24 h after the procedure, although by day 7, all enzymatic levels had returned to baseline. No differences between groups 1 and 2 were found for any enzyme and sampling site during and after the procedure. Similarly, no correlation between insertion depth and enzyme levels was observed. Direct in situ and post-removal inspection of the pancreas did not show any evidence of fluid collection, abscesses or hemorrhage. Histological examination of the pancreas from groups 1 and 2 revealed the existence of focal areas (0.14-0.26 mm2) of ischemic necrosis in 47.4% of the animals. In the pigs with damaged pancreas, the left lobe (tail) was always affected. However, this only happened in 83.3% of the samples from the right lobe (head) and in 33.3% of the samples from the body of the pancreas. Significant differences were found between the left lobe (tail) and the body for the percentage of affected pancreas. Both the size of the lesions and the percentage of affected pancreas were higher in the left pancreatic lobe (tail). The presence of the lesions was not related to the exploration length.

CONCLUSION

The increase in pancreatic enzymes after DBE could be related to focal points of pancreatic ischemic necrosis due to mechanical stress.

Anatomy of the temporomandibular joint in the cat: a study by microdissection, cryosection and vascular injection

The minute anatomy of the temporomandibular joint (TMJ) is of great clinical relevance in cats owing to a high number of lesions involving this articulation. However, the precise anatomy is poorly documented in textbooks and scientific articles. The aim of this study was to describe, in detail, the TMJ anatomy and its relationship with other adjacent anatomical structures in the cat. Different anatomical preparations, including vascular and articular injection, microdissection, cryosection and plastination, were performed in 12 cadaveric cats. All TMJ anatomical structures were identified and described in detail. A thorough understanding of the TMJ anatomy is essential to understand the clinical signs associated with TMJ disorders, to locate lesions precisely and to accurately interpret the results in all diagnostic imaging techniques.

Characterization of oral double balloon endoscopy in the dog

Exploration of the canine small intestine using conventional endoscopy is restricted to the duodenum and/or the ileum. Double balloon endoscopy (DBE) is a 'push and pull' technique that has been described in humans and permits a complete exploration of the small intestine. In this study, oral DBE was performed on 12 healthy dogs (10-34kg) to characterize for the first time the efficiency, exploration dynamics and safety of the technique. DBE was successful in 83% of dogs; the average estimated insertion depth of the endoscope was 287±36cm, and the average duration of the exploration was 84±8min. No complications or relevant adverse clinical effects were observed, and there was no indication of post-procedure pancreatitis based on serology of two specific markers of pancreatitis (amylase and lipase) and the immediate nonspecific inflammatory mediator C-reactive protein. The study showed that oral DBE is viable and safe in the dog, allowing for the diagnosis and treatment of gastrointestinal diseases deep in the small intestine to an extent that has not previously been possible using conventional endoscopy.

A Case of Lymphocytic-Plasmacytic Jejunitis Diagnosed by Double-Balloon Enteroscopy in a Dog

A 3 yr old male English setter dog was presented for evaluation of a 6-wk history of intermittent diarrhea. After standard gastroduodenoscopy and colonoscopy showed normal mucosa, double-balloon endoscopy (DBE) was used via both oral and anal approaches. Gross changes consistent with inflammation in the jejunum were seen, and biopsy specimens were obtained. Histologic analysis confirmed a diagnosis of lymphocytic-plasmacytic jejunitis. Clinical remission of the disease occurred after 3 mo of therapy with prednisone, metronidazole, and a novel protein diet. Use of DBE has not been previously reported in dogs with inflammatory bowel disease, and isolated lymphocytic-plasmacytic jejunitis has not been described. The described cases of intestinal inflammatory disease diagnosed by conventional endoscopy were related to pathologic changes in the duodenum, ileum or colon, but not the jejunum. The main advantage of the DBE technique allowed examination of portions of the small intestine (jejunum) that were not commonly accessible by standard endoscopic techniques, and permitted a minimally invasive collection of biopsy samples compared with surgical biopsy. This case highlights the need to consider using DBE in animals with gastrointestinal disorders, whose symptoms are not readily explained by routine tests, conventional endoscopy, and dietary or therapeutic trials.