The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function

BACKGROUND

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed.

METHODS

Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018.

KEY RECOMMENDATIONS

The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

CONCLUSIONS AND INFERENCES

This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.

[Second-generation colon capsule in small bowel and colon disorders in pediatrics]

BACKGROUND

Aim of the study was to assess the diagnostic yield of second-generation colon capsule in pediatric gastrointestinal diseases.

PATIENTS AND METHODS

Five patients with different symptoms of gastrointestinal diseases were included in the study. Among them were: suspicion on diffuse polyposis, intestinal bleeding, lymphangiectasia and inflammatory bowel disease. Image interpretation was made by experienced capsule users, previously trained on small bowel capsule and first generation colon capsule. Lesions or abnormal changes of the mucosa identified on capsule endoscopy served as indications for colonoscopy or esophagogastroduodenoscopy with biopsy or polypectomy if needed.

RESULTS

Standard white light endoscopy was made in all children without any adverse events. Second-generation colon capsule allows diagnosing Crohn's disease in small intestine and colon, limphangiectasia of the ileum, single rectosigmoid polyp and diffuse polyposis of the colon.

CONCLUSION

Second-generation colon capsule can be used as non-invasive screening method in children without serious complications, thus allowing to differentiate indications for traditional white light endoscopy, which is usually made under general anesthesia in pediatrics.

[Interintestinal anastomoses formation using permanent magnet in surgical treatment of children with intestinal stomas]

It was analyzed the results of treatment of 48 children aged from 1 month to 14 years. In these observations by the 6th - 7th days after doubleintestinalstoma formation magnetic dies with inductance from 300 to 360 mTl and energy force at least 255 kJ/m3 were introduced into lumen of afferent and efferent intestinal loops. Attractive or compression force between dies was 600 g, i.e. force per 1 cm2 was 200 g according to dies' surface 1.12.83.0 cm. Magnets are not only surgical instruments but also physiotherapeutic devices improving microcirculation and stimulating regeneration in the area of anastomosis. Interintestinal anastomosis has been completely formed for 5-7 days. Thereafter magnetic dies have been removed. Stool was normalized in 45 of 48 observations after surgery (1-3 times daily). Intestinal discharge from ileostomy reduced to minimal amount. In 2 patients irregular bowel movements was observed due to adhesive stenosis of interintestinal anastomosis. Magnetic dies can't be established in 1 case due to adhesive process. Hospital stay was from 10 to 25 days in 41 children. 7 patients were discharged for outpatient treatment later. All children were under observation for the period 2-4 months after discharge. Signs of hypotrophy including body weight deficit within 10% of age norm were diagnosed only in 3 children with prematurity degree I-II. Hereafter children were repeatedly hospitalized; intestinal stomas were surgically removed using conventional technique. Thus complete convalescence was obtained.

[Prevention of incompetence of sutures of intestinal anastomoses by the method of permanent intramesenteric blockade and lymphotropic therapy]

The author considers results of inestigation for studying an efficiency of permanent intramesenteric (retroperitoneal) blockade and applying lymphotropic therapy for prevention of incompetence of sutures of intestinal anastomosis against the background of diffuse peritonitis and acute intestinal obstruction. An infusion was carried out 4-6 times a day with a special solution (novocain 0.5% (7 ml/kg/day); heparin (150 units/kg/days); proserin (0.03 mg/kg/day) and seftriakson (15 mg/kg/days)) in order to obtain the effect of permanent intramesenteric blockade and lymphotropic therapy. The solution is administered by droplet injection with the rate 100-120 drops a minute (80-120 ml per each infusion). Due to the application of the given method the frequency of cases of the incompetent sutures of intestinal anastomoses in patients of the main group decreased from 15.5% to 3.4% (X2 = 16.2; p < 0.001) as compared with the other patients.

Spectrum of colonoscopy findings in Ile-Ife Nigeria

AIMS AND OBJECTIVES

Lower gastrointestinal (LGI) diseases are the leading causes of morbidity and mortality worldwide. Colonoscopy holds an important place in screening, diagnosing and treatment of these conditions. In Nigeria, as in many other developing countries, the facility for performing colonoscopy is rarely available. This prospective report seeks to evaluate the demographic data of patients presenting for colonoscopy, the pattern and validity of referral diagnosis versus colonoscopy findings in Ile-Ife, Nigeria.

SUBJECTS AND METHODS

All patients who had colonoscopy procedure done in the Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex between January 2007 and December 2011 were included in the study.

RESULTS

During the study period, colonoscopy was carried out in 320 patients. One hundred and eighty two (56.9%) were males, while 138 (43.1%) were females. The median age was 59.5 years. Their ages ranged from 2-87 years. The most common indications were lower gastrointestinal bleeding and change in bowel habit which together accounted for 79.0%. No abnormality was seen in 93(29.1%) patients. Abnormal endoscopic findings included 66(20.6%) patients who had haemorrhoids, 50(15.6%) cases colorectal cancer, 33 (10.3%) patients had benign polyps and (30 (9.4%) patients had diverticular disease. Other findings were colitis, inflammatory bowel disease, rectovaginal fistula, vascular ectasia and extra luminal compression. Haemorrhoids, diverticulosis and polyps were the most common findings in patients presenting with lower gastrointestinal bleeding.

CONCLUSION

This present report showed that colonoscopy is a cheap, safe and effective method of investigating lower gastrointestinal disease in Ile-Ife, Nigeria. When the indication is based on symptoms, the diagnostic yield could be as high as 90%. The common causes of lower gastrointestinal bleeding in Ile-Ife, Nigeria include haemorrhoids, diverticulosis and polyps.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Internal hernias: anatomical basis and clinical relevance

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

Gastric-and-intestinal mixed-type intestinal metaplasia: aberrant expression of transcription factors and stem cell intestinalization

Helicobacter pylori plays a causative role in the development of chronic atrophic gastritis, intestinal metaplasia (IM), and stomach cancer. Although IM has long attracted attention as a putative preneoplastic lesion for stomach cancers, its clinicopathologic significance has yet to be clarified in detail. Using gastric and intestinal epithelial cell markers, IM was here divided into two major types: a gastric-and-intestinal (GI) mixed type and a solely intestinal (I) type. In the former, gastric and intestinal phenotypic markers appeared not only at the glandular but also at the cellular level. Furthermore, neuroendocrine cells also showed intestinalization along with their exocrine counterparts. In animal models, GI-type IM was found to appear first, followed by the solely I type. Summarizing these data, it was suggested that IM might be caused by the gradual intestinalization of stem cells from the GI to the I type. The molecular mechanisms of IM include the ectopic expression of CDX1, CDX2, OCT-1, and members of the Erk pathway. Suppression of the expression of gastric transcription factors such as SOX2, genes that are involved in the Sonic hedgehog pathway, and RUNX3, a tumor suppressor gene, could be additional relevant alterations. The expression of PDX1 may also be associated with pseudopyloric gland metaplasia and IM. Detailed analysis of gene regulation may shed light on the molecular bases of gastric lesions, leading to strategies for chemoprevention.

New classification of hypoganglionosis: congenital and acquired hypoganglionosis

AIM

Hypoganglionosis has been associated with fewer intestinal ganglion cells. However, current reports questioned the validity of this clinical entity. The aim of this study is to demonstrate the existence of hypoganglionosis.

MATERIALS AND METHODS

We have experienced 24 cases of functional intestinal obstruction with abnormalities of the intestinal ganglia. A precise histological examination was performed using quantitative morphometric studies. These results were compared with age-matched controls (n = 13).

RESULTS

Based on histological examination, disorders in the ganglion cells could be classified into 3 categories: immaturity of ganglia (n = 13), congenital hypoganglionosis (n = 7), and acquired hypoganglionosis (n = 4). In congenital hypoganglionosis, the number as well as the size of ganglion cells are small at birth. The size of ganglion cells tends to increase over time, but their numbers do not increase; as a result, the symptoms of dysmotility do not improve. On the other hand, acquired hypoganglionosis is late onset and characterized as a degeneration of ganglion cells and gliosis histologically. After performing a resection of the affected bowel, the prognosis is usually good.

CONCLUSION

Congenital and acquired hypoganglionosis are 2 distinct entities. The histological findings as well as the clinical characteristics of these 2 types of hypoganglionosis are different.

Intestinal neurofibromatosis is a subtype of familial GIST and results from a dominant activating mutation in PDGFRA

BACKGROUND & AIMS

Intestinal neurofibromatosis (Online Mendelian inheritance in Man database number 162220) is an alternate form of neurofibromatosis. Patients present with neurofibromas limited to the intestine in the absence of any other typical features of NF1 and NF2. At present, the molecular basis of intestinal neurofibromatosis remains elusive. The aim of the present study was to find the gene responsible for intestinal neurofibromatosis and to characterize functionally the mutation.

METHODS

Three candidate genes (NF1, KIT, and PDGFRA) were screened for mutations in 3 sisters diagnosed with intestinal neurofibromatosis. Five tumors were available for pathologic examination. Activation (phosphorylation) of PDGFRalpha was subsequently tested by Western blot analysis on a transfected 293T and Ba/F3 cell line.

RESULTS

We found an inherited mutation (Y555C) in the juxtamembrane domain of PDGFRA in the affected individuals. The Y555C mutation leads to autophosphorylation and thus activation of PDGFRalpha. These observations confirm that PDGFRalpha(Y555C) is an oncogenic kinase. The clinical phenotype in the reported family resembles the syndrome of familial gastrointestinal stromal tumors (familial GIST). Somatic activating mutations in KIT and PDGFRA are frequent in sporadic GISTs, and mutations in both genes have also been described in familial GISTs. The tumors in the reported family are morphologically identical to intestinal neurofibromas, but, immunohistochemically, they do not express S100 or any of the known GIST markers.

CONCLUSIONS

The inherited PDGFRA mutation in the reported family shows that intestinal neurofibromatosis is allelic to familial GIST caused by PDGRA mutations. We therefore propose that these tumors be classified as familial KIT-negative gastrointestinal stromal tumors.

Recovery From Liver Dysfunction After Adult Isolated Intestinal Transplantation Without Liver Grafting

PURPOSE

We sought to evaluate liver function recovery after isolated intestinal transplantation in adults with irreversible intestinal failure.

PATIENTS AND METHODS

Over a 5-year period, we transplanted 34 adult patients, 25 of whom received an isolated intestinal graft, 4 a multivisceral graft without a liver, and 5, a multivisceral graft with a liver. Among the group of patients transplanted with the isolated graft we selected 14 recipients with pretransplant liver dysfunction, namely, a serum bilirubin >2 mg/dL (normal value: 1.2) and/or transaminases >100 IU/mL (NV, 37/40). Other inclusion criteria were total parenteral nutrition, period > 3 months, no diagnosis of portal hypertension or cirrhosis. Two patients had biopsy-proven liver fibrosis.

RESULTS

At discharge, all patients recovered liver function to normal values: mean bilirubin blood level was 0.9 +/- 0.96 mg/dL (range: 0.3-1.6) and mean transaminases were 26 +/- 9 and 31 +/- 18 IU/mL (range: 10-44/27-65). After a mean follow-up of 2 years, only one patient has an elevated alanine aminotransferase level without clinical signs of liver disease. Type of pretransplant liver disease did not impact on survival rates.

CONCLUSION

In selected cases, an isolated intestinal or a multivisceral graft without a liver can represent a "liver salvage therapy" for an early failing liver in patients with irreversible intestinal failure. Pretransplant liver disease is not a negative prognostic factor.

Quality of life on home parenteral nutrition or after intestinal transplantation

AIM

We compared the health related quality of life (HRQOL) of stable patients on home parenteral nutrition (HPN) and of patients who underwent successful intestinal transplantation (ITx).

METHODS

HRQOL was evaluated by the non-disease-specific Short Form 36 instrument, which examines eight specific domains and scores them on a scale of 0% to 100%. Patient scores were standardized for the sex-matched and age-matched group scores of the healthy population by calculating the Z-score (reduced value: Z-score < -1).

RESULTS

Eighteen patients on HPN and 12 patients who underwent ITx were studied. The two groups did not differ for primary intestinal disease, cause of intestinal failure, presence of a stoma, body mass index, and employment and marital status. HPN Z-scores were physical functioning -2.3, physical role -1.5, body pain -1.0, general health -1.2, vitality -0.5, social functioning -0.9, emotional role -0.7, and mental health 0.0. ITx Z-scores were physical functioning -1.7, physical role -0.8, body pain 0.0, general health -0.4, vitality 0.0, social functioning -0.4, emotional role -0.3, and mental health 0.0. Only the body pain Z-scores differed significantly (P = .012).

CONCLUSIONS

The value of the physical components of the SF-36 was reduced in all the components in the HPN patients and in the physical functioning component in the ITx patients. The mental health components were normal in both. Successful ITx showed a better subjective physical health feeling than stable HPN.

Factors Influencing Outcome After Intestinal Transplantation in Children

We evaluated 131 patients (6 months-14 years) who experienced 21 deaths before listing, 11 continuing on the waiting list, 38 well on home parenteral nutrition, 6 off parenteral nutrition and 59 transplanted (20 girls) aged 2.5 to 15 years, (18 >7 years). They received cadaveric isolated intestine (ITx, n = 31) or liver-small bowel (LITx, n = 32), including right colon (n = 43; 23 LITx) for short bowel (n = 19), enteropathy (n = 20), Hirschsprung (n = 14), or pseudo-obstruction (n = 6). Treatment included tacrolimus, steroids, azathioprine, or interleukin-2 blockers. After 6 months to 10.5 years, the patient and graft survivals were 75% and 54%. Sixteen patients (10 LITx) died within 3 months from surgery (n = 3), bacterial (n = 5) or fungal (n = 6) sepsis, or posttransplant lymphoproliferative disorder (n = 2). Rejection occurred in 27 patients, including 10 steroid-resistant episodes requiring antilymphoglobulins. The grafts were removed due to uncontrolled rejection in seven ITx recipients. Surgical complications were observed in 38 recipients (25 LSBTx) within 2 months, including bacterial (n = 22) or fungal (n = 11) sepsis, cytomegalovirus disease (n=12), adenovirus (n = 11), or posttransplant lymphoproliferative disorder (n = 12). Forty-two children (19 LSBTx) are alive. Weaning from parenteral nutrition was achieved after 42 days (median). Factors related to death or graft loss were pre-Tx surgery (P < .01), pseudo-obstruction (P < .01), age over 7 years (P < .03), fungal sepsis (P < .03), steroid resistant rejection (P < .05), hospitalized versus home patient (P < .01), and retransplantation (P < .05). Colon transplant did not affect the outcome. Interleukin-2 blockers improved isolated ITx (P < .05). Early referral and close monitoring of intestinal failure and related disorders are mandatory to achieve successful ITx.

Is Serum Gentamicin Level a Good Predictor of Graft Injury in Intestinal Transplantation?

INTRODUCTION

Following intestinal transplant (SBT), the early diagnosis and treatment of rejection is a major management aim. The diagnosis of rejection is based on histology of stomal biopsies. Oral gentamycin (2.5 mg/kg) was used for selective decontamination of the digestive system. Our hypothesis was that gentamycin might be absorbed in the presence of graft dysfunction.

AIM

Our goal was to assess the correlation between serum gentamycin level and the health of the intestinal graft.

SUBJECTS AND METHODS

Among 33 SBT performed from 1993 to 2005, serum gentamycin levels were performed once weekly or more often when there was a suspicion of rejection. All data were analyzed retrospectively.

RESULTS

Adequate trough levels were achieved for only 23 patients, six of whom had histologically proven rejection and only one did not have a raised gentamycin content. Five patients with raised levels but no rejection included two with severe intestinal ischemia and three with bowel obstruction/ileus. Four of the five patients required laparotomies.

CONCLUSION

We concluded that in our study raised serum gentamycin levels were a good predictor of rejection or significant injury to the graft.

Renal Dysfunction Following Adult Intestinal Transplant Under Tacrolimus-Based Immunosuppression

We analyzed data from the records of 24 adult patients who survived more than 2 years after intestinal transplantation performed between 1995 and 2002 under tacrolimus-based immunosuppression. Ages ranged from 19.3 to 59.2 years old (median 32.1 years). Tacrolimus cumulative level was defined as a sum of weekly average tacrolimus level over time. Kidney function was evaluated by the 6-month average serum creatinine level. Estimated creatinine clearance was calculated with the Cockcroft-Gault formula. Student's t test was used for analysis. Primary diseases were mesenteric thrombosis (n = 7), trauma (n = 4), Crohn's (n = 3), Gardner's (n = 5), and others (n = 7). Procedures were isolated intestinal transplant (n = 10), liver and intestine (n = 1), multivisceral transplant (n = 9), or modified multivisceral transplant (n = 4). Cumulative tacrolimus levels ranged between 1161 and 8623 ng*day/mL (median 4132 ng*day/mL) at 0 to 12 months. Pretransplant kidney function as mean creatinine clearance was 114 mL/min per 1.73 m(2) (n = 24). Creatinine clearance decreased to a mean of 49.6 mL/min per 1.73 m(2) (43.5% of pretransplant) at 2 years (P < .0001). The average creatinine clearance at 18 to 24 months in each patient with a cumulative tacrolimus level <4500 ng*day/mL was 63% +/- 25% of preoperative creatinine clearance. In patients with a cumulative tacrolimus level >4500 ng*day/mL, it was 34% +/- 17%. Cumulative tacrolimus level >4500 ng ng*day/mL was significantly associated with a decreased creatinine clearance at 2 years (P = .006). Renal function decreased significantly after intestinal transplantation in adults. Cumulative tacrolimus level in the first year affected renal function at 2 years.

Prenatal bowel dilatation and the subsequent postnatal management

The presence of dilated bowel loops antenatally suggests fetal bowel obstruction. Neonatal intestinal obstruction can have different variations in presentation depending on the level and extent of obstruction. Some of these conditions can be diagnosed antenatally. Antenatal detection of surgically correctable anomalies would ideally reduce perinatal morbidity and mortality by allowing a planned delivery with early resuscitation and prompt surgical intervention. Duodenal atresia is the most common intestinal atresia diagnosed in a fetus. Presently there are no significant abnormalities of the fetal gastrointestinal tract that benefit from fetal intervention. However a thorough understanding of the disease processes is necessary for diagnosis and treatment of intestinal obstruction. With advances in neonatal intensive care and management there has been a significant decrease in mortality rates of neonates with intestinal obstruction.

Capsule endoscopy in clinical routine in patients with suspected disease of the small intestine: a 2-year prospective study

OBJECTIVE

Capsule endoscopy is a promising method for examining the small intestine. The study was performed to evaluate the use of capsule endoscopy in clinical routine in patients with suspected disease of the small intestine.

MATERIAL AND METHODS

Consecutive patients with clinically suspected disease of the small intestine referred for capsule endoscopy between 1 January 2003 and 31 December 2004 were included in the study. All patients had previously completed a conventional diagnostic work-up with upper and lower endoscopy as well as abdominal CT scan or small-bowel enteroclysis.

RESULTS

A total of 167 patients were referred during the time period and 195 procedures were performed. Seventeen (8.7%) of the procedures were unsuccessful, with no visualization of the small bowel. In the remaining procedures the caecum was reached in 83%. The reason for referral was gastrointestinal bleeding (30%), iron-deficiency anaemia (25%), abdominal pain (15%), diarrhoea (13%) and Crohn's disease (12%). Pathology was found in 27% of the patients, with the highest diagnostic yield in patients referred for Crohn's disease (60%) and the lowest yield (4%) in patients referred for abdominal pain. There were no complications, with the exception of one patient referred for Crohn's disease who had transient abdominal pain during the procedure.

CONCLUSIONS

Capsule endoscopy is a safe and well-tolerated procedure. In unselected patients with clinically suspected disease of the small intestine, the procedure gives additional information to conventional diagnostic procedures in 27% of patients. Incomplete examination of the small intestine was frequent in our group of patients.

Multidetector–row CT enteroclysis: indications and clinical applications

This paper examines the diagnostic potential of multislice computed tomography enteroclysis (MSCT-E) to detect and assess different diseases affecting the small bowel, emphasising the increasingly important role assumed by the technique in the study of this anatomical region. After a short summary of the technical aspects, we discuss the different findings that can be observed during an MSCT-E study and that enable detection of small-bowel disease and, if necessary, assessment of the extent and stage of disease.

Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium

BACKGROUND

Loss of vascular access in patients with intestinal failure is considered an indication for intestinal transplantation. Such patients often have one or more occluded vein sites. Venous access could be classified according to the number of occluded vessels, to facilitate pre- and postoperative management.

METHODS

At the VIIIth International Small Bowel Transplant Symposium in September 2003, a new classification of vascular access in patients who were candidates for bowel transplant was proposed. The classification was then applied to stratify all patients that underwent intestinal transplantation at the University of Miami between 1998 and 2003. Data were collected on Doppler ultrasonography, angiography, and vein angioplasty in such patients.

RESULTS

A total of 106 cases in 91 patients were included in the study. Based on Doppler ultrasound results, 51.9% of patients fell into class I (no thrombosed vessels), 21.7% were in class II (one occluded vessel, or positive risk factors for thrombosis), 24.5% were in class III (multiple thrombosed vessels), and 1.9% were in class IV (all vessels thrombosed). Fifteen percent of the patients required preoperative angiography to better evaluate venous access. Most of the patients that required angiography were in class III or IV, and 53.3% of patients requiring angiography needed additional venous angioplasty to achieve access.

CONCLUSIONS

All patients that are referred for intestinal transplantation should undergo preliminary mapping of their venous access by Doppler ultrasound and then be assigned to a vascular access class. Those patients with multiple thrombosed vessels (class III and above) should be strongly considered for additional angiographic evaluation.

Immunosuppression following intestinal transplantation

Acute rejection is still the main risk factor following intestinal transplantation. Potent immunosuppression decreases rejection frequency, but may increase immunosuppression-related complications. Isolated small intestinal transplantation was performed in 14 adult patients with short bowel syndromes. Immunosuppression included tacrolimus and rapamycin in combination with steroids for 6 months after ATG or daclizumab induction therapy. In addition to protocol biopsies, cellular immune status and soluble immune parameters were used to guide immunosuppression. CMV and EBV markers were determined on a routine basis. Ten of 14 patients (71%) survived for 1 to 38 months (median 26 months). Eight patients are at home, in good physical condition, completely on enteral nutrition. Among the 5 patients (36%) who developed acute rejection, 2 patients with early postoperative events underwent graft removal and 1 patient died due to multiple organ failure. Two patients developed severe acute rejection episodes at 10 and 24 months following transplantation. Both patients recovered following OKT3 rescue therapy and increased baseline immunosuppression with repeated methylprednisolone and infliximab treatment. Infections included peritonitis (n = 3), pneumonia (n = 3), central line infection (n = 5), urinary tract (n = 2), CMV (n = 2), and EBV (n = 4). Two patients developed anastomotic leaks at the esophageal and coloanal anastomosis. In conclusion, acute rejection episodes can be controlled by potent immunosuppression using tacrolimus in combination with rapamycin. Immunosuppression-associated complications, including infections, were in an acceptable range. However, even late after transplantation, reduction in immunosuppression may lead to severe rejection without major clinical symptoms.

[Functional gastrointestinal diseases. More reliable diagnosis using new criteria. Modification required in primary care, however]

The diagnosis of functional gastrointestinal disorders is symptom based. New viewpoints go beyond the old concept of a disease-based reductionistic model, according to which effort is directed toward identifying a single underlying biological etiology, to a more integrated biopsychosocial model of illness. "Rome II: A Multinational Consensus Document on Functional Gastrointestinal Disorders" is an attempt to condense present knowledge into a practical systematic manual. Whereas the ordinary clinician may benefit from it in the understanding of the often confusing accumulation of alternating bowel complaints, its main area of application will be international studies. It will also serve as a basis for taking the concept of functional gastrointestinal disorders further.

The effects of high-dose ibuprofen and pancreatic enzymes on the intestine of the rat

BACKGROUND

High-dose ibuprofen therapy limits the progression of lung disease in patients with cystic fibrosis. However, ibuprofen increases intestinal permeability, which potentiates intestinal damage caused by high-dose pancreatic enzyme treatment, as was shown in a previous study by this group. In the present study, the combined effects of ibuprofen and pancreatic enzyme treatment on the intestine and liver were examined.

METHODS

Using a chronically catheterized rat model, high-dose ibuprofen (60 mg/kg x day in two doses), with or without pancreatic enzyme treatment was infused into gastric and duodenal catheters, respectively, for 20 days. Six groups were studied: control group; ibuprofen treatment alone; pancreatic enzyme treatment alone (two groups: normal dose, 10,000 U lipase/kg x day and high dose, 40,000 U lipase/kg x day); and ibuprofen combined with pancreatic enzyme (two groups: ibuprofen with high-dose pancreatic enzyme and ibuprofen and low-dose pancreatic enzyme). After treatment, rats were autopsied, and complete histologic analyses of the entire intestine and liver were performed.

RESULTS

Ibuprofen caused mild ulceration of the small intestine in 50% of rats. Pancreatic enzyme treatment alone did not induce ulceration of the intestine. The combination of pancreatic enzyme and ibuprofen treatment increased the severity of the ulcers in the small intestine but not the number of ulcers or the percentage of rats affected. Ibuprofen treatment alone did not cause ulcers in the large intestine, but with the addition of pancreatic enzymes, ulceration and fibrosis were present.

CONCLUSIONS

Ibuprofen at doses used to limit progression of cystic fibrosis lung disease caused enteropathy in 50% of rats. There was synergism between ibuprofen and pancreatic enzyme treatment in the production of severe ulcers. Ulcers in the cecum and colon were increased with combined ibuprofen and pancreatic enzyme treatment compared with incidence in control animals.

[Gram-negative enteric bacteremia in children in the Negev (1989-1994)]

During 1989-1994, there were 322 episodes of Gram-negative enteric bacteremia in 308 children. The incidence increased from 31/100,000 in children younger than 15 years of age during 1989-1991, to 50/100,000 during 1992-1994. The most common pathogens were Klebsiella, E. Coli, Salmonella and Enterobacter. 39% of episodes were nosocomial and a significant increase was recorded for each species during the last 3 years of the study. Klebsiella represented the most common pathogen causing nosocomial bacteremia, while E. coli and Salmonella were the main pathogens causing community-acquired bacteremia. In this study in southern Israel, the incidence of Gram-negative enteric bacteremia was significantly higher in Bedouin children, with the exception of bacteremia due to Salmonella, which occurred mainly in Jewish children.

Intestinal vascular anomalies in children

Vascular anomalies are an uncommon cause of gastrointestinal bleeding in childhood. Confusing nomenclature has made objective comparisons of published cases difficult and has interfered with an established consensus regarding diagnosis and therapeutic modalities. The purpose of this study was to clarify the situation by reviewing the records of all children who had intestinal vascular anomalies who were referred to our institution from 1975 to 1995. Thirteen lesions were identified in nine children (five boys and four girls). The median age at clinical onset was 8 years. Only two patients presented with a complex syndrome (Klippel-Trenaunay, 1; Osler-Rendu-Weber, 1). Diagnosis, location, and extension of these anomalies was only possible by angiography, which indicated that seven patients had isolated venous malformations and two had arteriovenous malformations. Because the lesions did not involve the serosa, intraoperative localization was a major problem. The main findings were a few slightly dilated mesenteric veins. Treatment was conservative in four children and surgical in five. Pathological findings on resected bowel demonstrated dilated and abnormal veins in the mucosa and submucosa. Selective angiography should not be delayed in patients with gastrointestinal bleeding if results of all other investigations are negative. Because these lesions are rarely recognizable on operative inspection, precise preoperative angiographic localization of intestinal vascular anomalies is essential to allow for a safe and limited resection of the involved bowel segment. Based on a better understanding of the natural history of these lesions, a classification of vascular anomalies of intestines in children is proposed.

[Endoparasites of donkeys and horses kept in communal housing in Upper Bavaria; species spectrum and incidence]

In this epidemiological study of endoparasites 37 donkeys and 23 horses were included, which were examined coproscopically in regular intervals over a 15 month period. The animals derived from ten farms, in which regular prophylactic treatments with anthelmintics had been practiced at least for two years before this investigation. This study revealed the presence of at least twelve parasite species in donkeys, Eimeria leuckarti, Gasterophilus intestinalis, Fasciola hepatica, Anoplocephala perfoliata, Strongyloides westeri, Parascaris equorum, Dictyocaulus arnfieldi, Trichostrongylus axei and small strongyles, whose third stage larvae were characterized by eight, twelve, 16 or 18 intestinal cells. At least four parasite species were established in horses, E. leuckarti, G. intestinalis, P. equorum and small strongyles, whose third stage larvae were provided with eight intestinal cells. Infections with E. leuckarti, S. westeri and P. equorum were encountered in foals only and with D. arnfieldi in 16.2% of the donkeys. Incidences for small strongyles were highest, exhibiting neither age- and farm-dependent nor host species-dependent differences and amounting to 91.9% in donkey and 86.6% in horses. Considering all donkeys and horses, 35.1% and 43.5%, respectively, were infected at least with two, and 29.7% and 4.3%, respectively, with three parasite species. The species composition of the endoparasite fauna was always dominated by small strongyles. This field study indicates that the species composition of the endoparasite fauna in comparison to former investigations has not or only slightly changed in spite of widespread use of broad-spectrum anthelmintics for years. In addition, it has to be considered that donkeys continue to act as reservoir of D. arnfieldi and as source of infection for horses.

Infantile colic--less common than previously estimated?

A two-part population-based study investigating the occurrence of infantile colic was undertaken, in which 92% of mothers with newborn healthy infants were reached. In the prospective part 152 mothers ("diary group") registered crying and fussing in their infants during 12 weeks. In the retrospective part 224 mothers ("interview group") were contacted by telephone at an infant age of 5-7 months. The colic occurrence was determined according to four different definitions; the rate varied from 3.3 to 17.1%. The classical "Wessel-type" colic was present in 9.3%. Colic defined as "crying seen as a problem by parent" was present in 12.1% of the "interview group", but in only 3.3% of the "diary group". Some earlier studies may have overestimated colic occurrence. Another possibility is an actual decline. The contributive part of preventive measures is discussed.

Foreign material in postoperative adhesions

OBJECTIVE

The authors determined the prevalence of foreign body granulomas in intra-abdominal adhesions in patients with a history of abdominal surgery.

PATIENTS AND METHODS

In a cross-sectional, multicenter, multinational study, adult patients with a history of one or more previous abdominal operations and scheduled for laparotomy between 1991 and 1993 were examined during surgery. Patients in whom adhesions were present were selected for study. Quantity, distribution, and quality of adhesions were scored, and adhesion samples were taken for histologic examination.

RESULTS

In 448 studied patients, the adhesions were most frequently attached to the omentum (68%) and the small bowel (67%). The amount of adhesions was significantly smaller in patients with a history of only one minor operation or one major operation, compared with those with multiple laparotomies (p < 0.001). Significantly more adhesions were found in patients with a history of adhesions at previous laparotomy (p < 0.001), with presence of abdominal abscess, hematoma, and intestinal leakage as complications after former surgery (p = 0.01, p = 0.002, and p < 0.001, respectively), and with a history of an unoperated inflammatory process (p = 0.04). Granulomas were found in 26% of all patients. Suture granulomas were found in 25% of the patients. Starch granulomas were present in 5% of the operated patients whose surgeons wore starch-containing gloves. When suture granulomas were present, the median interval between the present and the most recent previous laparotomy was 13 months. When suture granulomas were absent, this interval was significantly longer--i.e., 30 months (p = 0.002). The percentage of patients with suture granulomas decreased gradually from 37% if the previous laparotomy had occurred up to 6 months before the present operation, to 18% if the previous laparotomy had occurred more than 2 years ago (p < 0.001).

CONCLUSIONS

The number of adhesions found at laparotomy was significantly larger in patients with a history of multiple laparotomies, unoperated intra-abdominal inflammatory disease, and previous postoperative intra-abdominal complications, and when adhesions were already present at previous laparotomy. In recent adhesions, suture granulomas occurred in a large percentage. This suggests that the intra-abdominal presence of foreign material is an important cause of adhesion formation. Therefore intra-abdominal contamination with foreign material should be minimized.

The changing pattern of intussusception in northern Nigeria: an analysis of 85 consecutive cases

In many regions of Africa intussusception is the most common cause of intestinal obstruction next to strangulated hernia. More recent reports seem to indicate a change in the clinical pattern of the disease. This retrospective analysis covering a period of ten years is of 85 patients aged between 11 weeks and 50 years. There were 65 males and 20 females; 69 were children between 1 month and 15 years. The anatomical pattern of the disease has changed from being of the caecocolic type to the ileocolic variety while the pathology of the disease has remained largely unidentified. 32 patients had the ileocolic variety. 20 were ileocaecal, 14 colo-colic, 8 caecocolic, 8 ileo ileal, 2 jejuno jejunal, and 1 jejuno ileal. There were 2 ileal and 4 colonic neoplasms. There was a high rate of bowel resection (54/85) and 8 deaths.