Hyperspectral imaging combined with blood oxygen saturation for in vivo analysis of small intestinal necrosis tissue

Acute mesenteric ischemia (AMI) is a clinically significant vascular and gastrointestinal condition, which is closely related to the blood supply of the small intestine. Unfortunately, it is still challenging to properly discriminate small intestinal tissues with different degrees of ischemia. In this study, hyperspectral imaging (HSI) was used to construct pseudo-color images of oxygen saturation about small intestinal tissues and to discriminate different degrees of ischemia. First, several small intestine tissue models of New Zealand white rabbits were prepared and collected their hyperspectral data. Then, a set of isosbestic points were used to linearly transform the measurement data twice to match the reference spectra of oxyhemoglobin and deoxyhemoglobin, respectively. The oxygen saturation was measured at the characteristic peak band of oxyhemoglobin (560 nm). Ultimately, using the oxygenated hemoglobin reflectance spectrum as the benchmark, we obtained the relative amount of median oxygen saturation in normal tissues was 70.0 %, the IQR was 10.1 %, the relative amount of median oxygen saturation in ischemic tissues was 49.6 %, and the IQR was 14.6 %. The results demonstrate that HSI combined with the oxygen saturation computation method can efficiently differentiate between normal and ischemic regions of the small intestinal tissues. This technique provides a powerful support for internist to discriminate small bowel tissues with different degrees of ischemia, and also provides a new way of thinking for the diagnosis of AMI.

Thalidomide for Recurrent Bleeding Due to Small-Intestinal Angiodysplasia

BACKGROUND

Recurrent bleeding from the small intestine accounts for 5 to 10% of cases of gastrointestinal bleeding and remains a therapeutic challenge. Thalidomide has been evaluated for the treatment of recurrent bleeding due to small-intestinal angiodysplasia (SIA), but confirmatory trials are lacking.

METHODS

We conducted a multicenter, double-blind, randomized, placebo-controlled trial to investigate the efficacy and safety of thalidomide for the treatment of recurrent bleeding due to SIA. Eligible patients with recurrent bleeding (at least four episodes of bleeding during the previous year) due to SIA were randomly assigned to receive thalidomide at an oral daily dose of 100 mg or 50 mg or placebo for 4 months. Patients were followed for at least 1 year after the end of the 4-month treatment period. The primary end point was effective response, which was defined as a reduction of at least 50% in the number of bleeding episodes that occurred during the year after the end of thalidomide treatment as compared with the number that occurred during the year before treatment. Key secondary end points were cessation of bleeding without rebleeding, blood transfusion, hospitalization because of bleeding, duration of bleeding, and hemoglobin levels.

RESULTS

Overall, 150 patients underwent randomization: 51 to the 100-mg thalidomide group, 49 to the 50-mg thalidomide group, and 50 to the placebo group. The percentages of patients with an effective response in the 100-mg thalidomide group, 50-mg thalidomide group, and placebo group were 68.6%, 51.0%, and 16.0%, respectively (P<0.001 for simultaneous comparison across the three groups). The results of the analyses of the secondary end points supported those of the primary end point. Adverse events were more common in the thalidomide groups than in the placebo group overall; specific events included constipation, somnolence, limb numbness, peripheral edema, dizziness, and elevated liver-enzyme levels.

CONCLUSIONS

In this placebo-controlled trial, treatment with thalidomide resulted in a reduction in bleeding in patients with recurrent bleeding due to SIA. (Funded by the National Natural Science Foundation of China and the Shanghai Municipal Education Commission, Gaofeng Clinical Medicine; ClinicalTrials.gov number, NCT02707484.).

Obscure Gastrointestinal Bleeding Caused by a Small Intestinal Lymphatic-venous Malformation: A Case Report with a Literature Review

A 44-year-old woman presented with severe anemia. We strongly suspected gastrointestinal bleeding; however, esophagogastroduodenoscopy, colonoscopy, and computed tomography showed no bleeding sources. Video capsule endoscopy revealed an actively bleeding submucosal lesion within the jejunum. Double-balloon enteroscopy revealed a 20-mm continuously bleeding submucosal lesion in the distal jejunum. We suspected small intestinal vascular malformation and performed surgical resection. The resected specimen pathologically comprised dilated, thin-walled lymphatic channels and blood vessels involving the small intestinal submucosa. Therefore, the patient was diagnosed with small intestinal lymphatic-venous malformation. Postoperatively, the patient recovered well, and recurrence was not observed.

[Evaluation of resistance to transient occlusion of anterior mesenteric artery under the influence of the course of mineral water enriched with selenium (experimental research)]

OBJECTIVE

To evaluate the effect of the preventive course of drinking mineral water enriched with selenium on the processes of resistance to the damaging action of reversible occlusion of the anterior mesenteric artery based on the comparison of intestinal morphological changes in the experiment.

MATERIAL AND METHODS

There has been modeled ischemic reperfusion injury of the intestinal wall according to H. Ikeda and co-authors using reversible occlusion of the anterior mesenteric artery with 33 outbred male rats. The rats were divided into four groups by block randomization: the 1^st group - intact animals (n=7) - without an exposure; the control group - sham operated animals (n=6); the group of comparison (n=7) - with a model-operation; the experimental group (n=11) - animals with a model operation that had courses of intragastric watering of bottled sulfate-chloride-hydrocarbonate-sodium low-mineralized (2.2 g/l) drinking mineral water «Psyzh» enriched with selenium. Biopsies of the small intestine were taken for histological examination.

RESULTS

Histological examination of the small intestine of experimental animals determines various degrees of severity of damage: on average, the animals of the experimental group on the scale of C.J. Chiu (1970) had the lowest degree of severity of pathological changes, the animals of the group of comparison - 1.4 times higher (p=0.02). That is, the effect of a preventive course of mineral water «Psyzh» enriched with selenium was manifested in the formation of resistance to the damaging effect of reversible occlusion of the anterior mesenteric artery; in the presence of ischemic reperfusion damage to the intestinal wall, comparable in severity to changes with the animals without prevention, the most significant positive effect was realized in the containment of reactive changes.

CONCLUSION

The effect of the preventive course of drinking mineral water «Psyzh» enriched with selenium manifested itself in the formation of resistance to the damaging effect of reversible occlusion of the anterior mesenteric artery, which is the basis for introducing this technique into clinical practice in order to prevent the development of reperfusion injuries of the intestine.

[A man with abdominal pain after esophageal surgery]

A 66-year-old man is evaluated in the Emergency Department for abdominal pain and vomiting since 2 days. Medical history showed esophageal resection because of an esophageal carcinoma. On physical examination there was tenderness of the right hemi-abdomen. A CT-angiography-chest/abdomen proved intrathoracically located small intestines with signs of ischemia.

Predicting Intestinal Ischaemia in Patients with Adhesive Small Bowel Obstruction: A Simple Score

BACKGROUND/AIMS

Intestinal ischaemia (II) is the most critical factor to determine in patients with adhesive small bowel obstruction (ASBO) because intestinal ischaemia could be reversible. The aim of this study was to create a clinicoradiological score to predict II in patients with ASBO.

METHODS

We conducted a retrospective study including 124 patients with ASBO. Logistic regression analysis was used to identify predictive factors of II. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic curves.

RESULTS

Six independent predictive factors of II were identified: age, pain duration, body temperature, WBC, reduced wall enhancement and segmental mesenteric fluid at CT scan. According to the regression, coefficient points were assigned to each of the variables associated with II. The estimated rates of II were calculated for the total scores ranging from 0 to 24. The AUC of this clinicoradiological score was 0.92. A cut-off score of 6 was used for the low-probability group (the risk of II was 1.13%). A score ranging from 7 to 15 defined intermediate-probability group (the risk of II was 44%). A score ≥16 defined high-probability group (100% of patients in this group had II).

CONCLUSIONS

We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score exceeded 0.90). This score is reliable and reproducible, so it can help surgeon to prioritize patients with II for surgery because ischaemia could be reversible, avoiding thus intestinal necrosis.

EGFR in enterocytes & endothelium and HIF1α in enterocytes are dispensable for massive small bowel resection induced angiogenesis

Background

Short bowel syndrome (SBS) results from significant loss of small intestinal length. In response to this loss, adaptation occurs, with Epidermal Growth Factor Receptor (EGFR) being a key driver. Besides enhanced enterocyte proliferation, we have revealed that adaptation is associated with angiogenesis. Further, we have found that small bowel resection (SBR) is associated with diminished oxygen delivery and elevated levels of hypoxia-inducible factor 1-alpha (HIF1α).

Methods

We ablated EGFR in the epithelium and endothelium as well as HIF1α in the epithelium, ostensibly the most hypoxic element. Using these mice, we determined the effects of these genetic manipulations on intestinal blood flow after SBR using photoacoustic microscopy (PAM), intestinal adaptation and angiogenic responses. Then, given that endothelial cells require a stromal support cell for efficient vascularization, we ablated EGFR expression in intestinal subepithelial myofibroblasts (ISEMFs) to determine its effects on angiogenesis in a microfluidic model of human small intestine.

Results

Despite immediate increased demand in oxygen extraction fraction measured by PAM in all mouse lines, were no differences in enterocyte and endothelial cell EGFR knockouts or enterocyte HIF1α knockouts by POD3. Submucosal capillary density was also unchanged by POD7 in all mouse lines. Additionally, EGFR silencing in ISEMFs did not impact vascular network development in a microfluidic device of human small intestine.

Conclusions

Overall, despite the importance of EGFR in facilitating intestinal adaptation after SBR, it had no impact on angiogenesis in three cell types–enterocytes, endothelial cells, and ISEMFs. Epithelial ablation of HIF1α also had no impact on angiogenesis in the setting of SBS.

Prenatal over- and undernutrition differentially program small intestinal growth, angiogenesis, absorptive capacity, and endocrine function in sheep

The aim was to test the hypothesis that prenatal under- and overnutrition in late gestation can program small intestinal (SI) growth, angiogenesis, and endocrine function to predispose for a hyperabsorptive state, thereby increasing the susceptibility to the adverse effects of an early postnatal obesogenic diet. Twin-pregnant ewes were exposed to adequate (NORM), LOW (50% of NORM), or HIGH (150% energy and 110% protein of NORM) diets through the last trimester (term ~147 days). From 3 days to 6 months of age, their lambs were fed either a moderate (CONV) or a high-carbohydrate high-fat (HCHF) diet. At 6 months of age, responses in plasma metabolites and insulin to refeeding after fasting were determined and then different segments of the SI were sampled at autopsy. Prenatal overnutrition impacts were most abundant in the duodenum where HIGH had increased villus amplification factor and lowered villi thickness with increased IRS-1 and reduced GH-R expressions. In jejunum, HIGH lambs had an increased expression of Lactate gene and amplified when exposed to HCHF postnatally. Specifically, in LOW, sensitivity to HCHF was affected in ileum. Thus, the mismatching LOW-HCHF nutrition increased expressions of angiogenic genes (VEGF, VEGF-R1, ANGPT1, RTK) and increased mucosa layer (tunica mucosa) thickness but reduced muscle layer (Tunica muscularis) thickness. The SI is a target of prenatal nutritional programming, where late gestation overnutrition increased and shifted digestive capacity for carbohydrates toward the jejunum, whereas late gestation undernutrition predisposed for ileal angiogenesis and carbohydrate and fat hyperabsorptive capacity upon subsequent exposure to postnatal obesogenic diet.

PTEN-induced kinase 1-induced dynamin-related protein 1 Ser637 phosphorylation reduces mitochondrial fission and protects against intestinal ischemia reperfusion injury

BACKGROUND

Intestinal ischemia reperfusion (I/R) occurs in various diseases, such as trauma and intestinal transplantation. Excessive reactive oxygen species (ROS) accumulation and subsequent apoptotic cell death in intestinal epithelia are important causes of I/R injury. PTEN-induced putative kinase 1 (PINK1) and phosphorylation of dynamin-related protein 1 (DRP1) are critical regulators of ROS and apoptosis. However, the correlation of PINK1 and DRP1 and their function in intestinal I/R injury have not been investigated. Thus, examining the PINK1/DRP1 pathway may help to identify a protective strategy and improve the patient prognosis.

AIM

To clarify the mechanism of the PINK1/DRP1 pathway in intestinal I/R injury.

METHODS

Male C57BL/6 mice were used to generate an intestinal I/R model via superior mesenteric artery occlusion followed by reperfusion. Chiu’s score was used to evaluate intestinal mucosa damage. The mitochondrial fission inhibitor mdivi-1 was administered by intraperitoneal injection. Caco-2 cells were incubated in vitro in hypoxia/reoxygenation conditions. Small interfering RNAs and overexpression plasmids were transfected to regulate PINK1 expression. The protein expression levels of PINK1, DRP1, p-DRP1 and cleaved caspase 3 were measured by Western blotting. Cell viability was evaluated using a Cell Counting Kit-8 assay and cell apoptosis was analyzed by TUNEL staining. Mitochondrial fission and ROS were tested by MitoTracker and MitoSOX respectively.

RESULTS

Intestinal I/R and Caco-2 cell hypoxia/reoxygenation decreased the expression of PINK1 and p-DRP1 Ser637. Pretreatment with mdivi-1 inhibited mitochondrial fission, ROS generation, and apoptosis and ameliorated cell injury in intestinal I/R. Upon PINK1 knockdown or overexpression in vitro, we found that p-DRP1 Ser637 expression and DRP1 recruitment to the mitochondria were associated with PINK1. Furthermore, we verified the physical combination of PINK1 and p-DRP1 Ser637.

CONCLUSION

PINK1 is correlated with mitochondrial fission and apoptosis by regulating DRP1 phosphorylation in intestinal I/R. These results suggest that the PINK1/DRP1 pathway is involved in intestinal I/R injury, and provide a new approach for prevention and treatment.

Small intestinal hemolymphangioma treated with enteroscopic injection sclerotherapy: A case report and review of literature

BACKGROUND

Hemolymphangiomas are rare malformations composed of both lymphatic and vascular vessels and are located in the pancreas, spleen, mediastinum, etc. Small intestinal hemolymphangioma is extremely rare and often presents as obscure gastrointestinal bleeding. It is rarely diagnosed correctly before the operation. Endoscopic injection sclerotherapy is usually used as a management of bleeding in esophageal varices and was occasionally reported as a treatment of vascular malformation. The treatment of small intestinal hemolymphangioma with enteroscopic injection sclerotherapy has not been reported.

CASE SUMMARY

A 42-year-old male complained of recurrent episodes of melena and dizziness, fatigue and reduced exercise capacity for more than 2 mo. Gastroduodenoscopy and blood test revealed a gastric ulcer and anemia. Treatment with oral proton-pump inhibitors and iron did not improve symptoms. We then performed a capsule endoscopy and anterograde balloon-assisted enteroscopy and revealed a hemolymphangioma. Considering it is a benign tumor without malignant potential, we performed enteroscopic injection sclerotherapy. He was discharged 4 days later. At follow-up 3 mo later, the melena disappeared. Balloon-assisted enteroscopy revealed an atrophied tumor atrophied and no bleeding. Argon plasma coagulation was applied to the surface of the hemolymphangioma to accelerated healing. When he returned for follow-up 1 year later, anemia was resolved and the tumor had been cured.

CONCLUSION

Balloon-assisted enteroscopy and capsule endoscopy are effective methods for diagnosis of hemolymphangioma. Enteroscopic injection sclerotherapy is an effective treatment.

Which Distant Organ is Most Affected by Lower Extremity Ischemia-Reperfusion?

BACKGROUND

It has been experimentally shown that reperfusion injury occurs in many remote organs after ischemia-reperfusion (I/R) of the lower extremity. However, which distant organ is affected more after I/R of the lower extremity has not been investigated. In this study, we investigate which remote organ is predominantly affected after lower extremity I/R.

METHODS

Twenty male Sprague-Dawley rats were randomly divided into 2 groups: sham (group 1) and lower extremity I/R (group 2). In group 2, 1 hr of ischemia of the left lower extremity was followed by 24 hr of reperfusion of the limb. After reperfusion, the lung, liver, kidney, heart, and small intestine tissues were harvested in both groups.

RESULTS

In the I/R group, the malondialdehyde levels were significantly higher in the heart and small intestine tissues than those in other tissues (P < 0.05). In addition, in the I/R group, the glutathione and glutathione peroxidase activities were also higher in the heart tissues than those in other tissues (P < 0.05). However, these results were not significant because the malondialdehyde, glutathione, and glutathione peroxidase levels of the heart tissues in the control group were higher than those of the other tissues. Therefore, no statistically significant difference was found between the tissues in terms of the histological damage score we created and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cell numbers.

CONCLUSIONS

There was no difference in the severity of reperfusion injury between the tissues we examined after lower extremity I/R. This suggests that every distal organ should be carefully monitored after lower extremity I/R.

Exercise induces tissue hypoxia and HIF-1α redistribution in the small intestine

BACKGROUND

Exercise induces blood flow redistribution among tissues, leading to splanchnic hypoperfusion. Intestinal epithelial cells are positioned between the anaerobic lumen and the highly metabolic lamina propria with an oxygen gradient. Hypoxia-inducible factor (HIF)-1α is pivotal in the transcriptional response to the oxygen flux.

METHODS

In this study, the pimonidazole hydrochloride staining was applied to observe the tissue hypoxia in different organs, which might be affected by the blood flow redistribution. The HIF-1α luciferase reporter ROSA26 oxygen-dependent degradation domain (ODD)-Luc/⁺ mouse model (ODD domain-Luc; female, n = 3-6/group) was used to detect the HIF-1α expression in the intestine. We used 3 swimming models: moderate exercise for 30 min, heavy-intensity exercise bearing 5% bodyweight for 1.5 h, and long-time exercise for 3 h.

RESULTS

We found that 1 session of swimming at different intensities could induce tissue hypoxia redistribution in the small intestine, colon, liver and kidney, but not in the spleen, heart, and skeletal muscle. Our data showed that exercise exacerbated the extent of physiological hypoxia in the small intestine. Next, using ODD-Luc mice, we found that moderate exercise increased the in vivo HIF-1α level in the small intestine. The post-exercise HIF-1α level was gradually decreased in a time-dependent manner. Interestingly, the redistribution of tissue hypoxia and the increase of HIF-1α expression were not related to the exercise intensity and duration.

CONCLUSION

This study provided evidence that the small intestine is the primary target organ for exercise-induced tissue hypoxia and HIF-1α redistribution, suggesting that HIF-1α may be a potential target for the regulation of gastrointestinal functions after exercise.

Massive Bleeding from a Small Intestinal Submucosal Tumor-like Arterial Malformation: An Unclassifiable Vascular Lesion Revealed by a Detailed Pathological Evaluation

A 53-year-old woman presented with repeated copious bloody stool. Small bowel capsule endoscopy revealed a submucosal tumor (SMT)-like lesion, with erosion of the surface, in the first third of the small bowel. Balloon-assisted small intestinal endoscopy also revealed a pulsatile SMT-like lesion with an exposed vessel on the surface. This unknown lesion was surgically resected. The histopathological findings of the resected SMT-like lesion showed a dilated artery with thrombosis blockage and recanalization. Since this case could not be classified as any of the small intestinal vascular lesion patterns endoscopically, its classification will require the accumulation of further cases.

Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos)

BACKGROUND AND AIMS

Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs.

METHODS

This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016).

RESULTS

Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding.

CONCLUSIONS

DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Small Bowel Bleeding: A Challenging Diagnosis

The small intestine is an uncommon site for acute gastrointestinal (GI) bleeding. However, it is responsible for most cases in which the etiology of bleeding is not identified through endoscopy or colonoscopy. Despite great advances in technology, small bowel bleeding (SBB) is often a challenging diagnosis, requiring multiple blood transfusions, diagnostic procedures, and re-admissions. Consequently, it increases comorbidities, complications, and costs to the health care system. The presentation of SBB is diverse, and the etiology is dependent on the patient's age. It may require aggressive resuscitation and immediate bleeding-site localization for proper and successful care. The management is based on the etiology, the available technology, and physician expertise. We present a case of SBB in which multiple imaging and endoscopic procedures were required to identify the culprit lesion. Additionally, we review the most common etiologies, radiologic modalities, and endoscopic procedures available.

Optimized protocol of multiple post-processing techniques improves diagnostic accuracy of multidetector computed tomography in assessment of small bowel obstruction compared with conventional axial and coronal reformations

BACKGROUND

Axial and coronal reformations have been a widely used image post-processing protocol for the ordinary multidetector computed tomography (MDCT) examination of patients with small bowel obstruction (SBO) or other abdominal diseases. The diagnostic accuracy of MDCT for assessing SBO is expected to be further improved through the use of multiple post-processing techniques.

AIM

To systemically evaluate the diagnostic accuracy and efficiency of an optimized protocol using multiple post-processing techniques for MDCT assessment of SBO and secondary bowel ischemia.

METHODS

This retrospective cross-sectional study included 106 patients with clinically suspected SBO. Two readers applied three protocols to image post-processing and interpretation of patients’ MDCT volume data. We compared the three protocols based on time spent, number of images, diagnostic self-confidence, agreement, detection rate, and accuracy of detection of SBO and secondary bowel ischemia.

RESULTS

Protocol 2 resulted in more time spent and number of images than protocols 1 and 3 (P < 0.01), but the results of the two readers using the same protocol were not different (P > 0.05). Using protocol 3, both readers added multiple post-processing techniques at frequencies of 29.2% and 34.9%, respectively, for obstruction cause, and 32.1% and 30.2%, respectively, for secondary bowel ischemia. Protocols 2 and 3 had higher total detection rates of obstruction cause and secondary bowel ischemia than protocol 1 (P < 0.01), but no difference was detected between protocols 2 and 3 (P > 0.05). The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of protocols 2 and 3 were superior to those of protocol 1 for evaluating obstruction cause and secondary bowel ischemia.

CONCLUSION

Our optimized protocol of multiple post-processing techniques can both guarantee efficiency and improve diagnostic accuracy of MDCT for assessing SBO and secondary bowel ischemia.

Hybrid Therapy Consisting of Bowel Resection and Fluoroscopic-Assisted Balloon Thrombectomy for Small Bowel Infarction Caused by Acute Mesenteric Venous Thrombosis

BACKGROUND

To investigate the effect of bowel resection combined with fluoroscopic-assisted balloon thrombectomy for small bowel infarction caused by acute mesenteric venous thrombosis (AMVT).

METHODS

Between June 2016 and August 2017, nine patients (seven males and two females; range, 40-73 years; mean, 55.11 ± 10.08 years) with small bowel infarction caused by AMVT underwent bowel resection combined with fluoroscopic-assisted balloon thrombectomy. The demographics, risk factors, therapeutic effect, complications, mortality, and follow-up of the study population were assessed.

RESULTS

The effective rate was 100% with substantial clinical improvement in symptoms. All patients underwent small bowel resection with primary anastomosis. The length of bowel resection ranged from 60 to 170 cm (108.67 ± 35.05). In none of the cases there was surgery with second look. The patients were discharged 13-42 days (20.11 ± 8.75) after admission without perioperative complication or death. The follow-up period was 8-21 months (12.89 ± 4.65), and the follow-up rate was 100%. All patients returned to normal activities, regained lost body weight, and remained asymptomatic during the follow-up period.

CONCLUSIONS

The combination therapy of bowel resection and fluoroscopic-assisted balloon thrombectomy is technically feasible and may be beneficial for small bowel infarction caused by AMVT in removing a thrombus efficiently, relieving symptoms rapidly, averting second-look surgery, lowering extensive surgical resections, and improving the prognosis.

[Internal herniation underneath the left external iliac artery after radical prostatectomy with extensive lymph node dissection]

A 65-year-old male underwent acute surgery because of a partly ischaemic small intestine due to internal herniation underneath the left external iliac artery. The iatrogenic defect in the peritoneum was created 15 months earlier, when the patient had a robot-assisted radical prostat-ectomy with pelvic lymph node dissection performed. The ischaemic small bowel was resected under a laparotomy, and creation of a temporary stoma was necessary. The peritoneal defect was left open. The patient recovered, and the stoma was surgically closed two months later.

Nicotinamide riboside has protective effects in a rat model of mesenteric ischaemia-reperfusion

Acute mesenteric ischaemia is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischaemia and eventual gangrene of the bowel wall. Although relatively rare, it is a potentially life-threatening condition. The maintenance of haemodynamic stability, along with adequate oxygen saturation, and the correction of any electrolyte imbalance, are of the utmost importance. However, nicotinamide adenine dinucleotide (NAD) biosynthesis modulation by precursor introduction can also be a powerful tool for preventing injury. Nicotinamide riboside is a pyridine-nucleoside form of vitamin B3 that functions as a precursor to NAD+ . The present study investigated nicotinamide riboside's effect on endothelium functional state, microcirculation and intestinal morphology in acute mesenteric ischaemia and reperfusion. Mesenteric ischaemia was simulated after the adaptation period (15 minutes) by occluding the superior mesenteric artery for 60 minutes, followed by a reperfusion period of 30 minutes. The functional state of intestinal microcirculation was evaluated by laser Doppler flowmetry. Endothelial functional activity was studied by using wire myography. Intestinal samples were stained with haematoxylin and eosin for histological analysis. The results revealed that nicotinamide riboside protects the intestinal wall from ischaemia-reperfusion injury, as well as improving the relaxation function of mesenteric vessels. Nicotinamide riboside's protective effect in small intestine ischaemia-reperfusion can be used to reduce ischaemia-reperfusion injury, as well as to preserve intestinal grafts until transplant.

Indocyanine Green Tissue Angiography Can Reduce Extended Bowel Resections in Acute Mesenteric Ischemia

PURPOSE

Surgical exploration and bowel resection are frequently required for treating non-occlusive mesenteric ischemia. Intraoperative evaluation of intestinal perfusion is subjective and challenging. In this feasibility study, ICG fluorescence angiography was performed in order to evaluate intestinal perfusion in patients with acute mesenteric ischemia.

METHODS

This is a retrospective analysis of 52 patients who were operated for acute mesenteric ischemia using ICG fluorescence angiography. Patients with occlusive disease requiring recanalization were excluded. The SPY and PinPoint imaging systems were used for open and laparoscopic surgery, respectively. Intraoperative macroscopic assessment of perfusion was compared with the ICG angiography results.

RESULTS

Surgical exploration was performed for ischemia of the colon (n = 12), the small bowel (n = 23), or both (n = 16). One patient had ischemia of the esophagus and stomach. All patients had a preoperative CT angiography to rule out stenosis or occlusion of the mesenteric vessels. In 18 cases (34.6%), ICG fluorescence angiography provided information that was supplemental to macroscopic evaluation, but most patients did not survive the postoperative course. However, in six of those cases (11.5%), ICG angiography led to a major change in operative strategy resulting in a significant clinical benefit for those patients. For two cases, ICG fluorescence produced false negative results.

DISCUSSION

ICG tissue angiography is feasible and technically reliable for evaluating intestinal perfusion in acute mesenteric ischemia and led to a significant clinical benefit in 11% of our patients. A relevant discrepancy between surgical visual assessment and fluorescence angiography was found in 35% of the cases, which may help to define resection margins more accurately and thus support surgical decision-making.

Evaluation of the NMR-MOUSE as a new method for continuous functional monitoring of the small intestine during different perfusion states in a porcine model

Objective

The study aim was to evaluate a small low-field NMR (nuclear magnetic resonance) scanner, the NMR-MOUSE^®, for detecting changes in intestinal diffusion under different (patho-) physiological perfusion states.

Methods

Laparotomy was performed on 8 female landrace pigs (body weight 70±6 kg) and the feeding vessels of several intestinal loops were dissected. Successively, the intestinal loops were examined using O2C (oxygen to see, LEA Medizintechnik GmbH, Giessen, Germany) for microcirculatory monitoring and the NMR-MOUSE^® for diffusion measurement (fast and slow components). On each loop the baseline measurement (physiological perfusion) was followed by one of the following main procedures: method 1 –ischemia; method 2 –flow reduction; method 3 –intraluminal glucose followed by ischemia; method 4 –intraluminal glucose followed by flow reduction. Additionally, standard perioperative monitoring (blood pressure, ECG, blood gas analyses) and histological assessment of intestinal biopsies was performed.

Results

There was no statistical overall time and method effect in the NMR-MOUSE measurement (fast component: p_time = 0.6368, p_method = 0.9766, slow component: p_time = 0.8216, p_method = 0.7863). Yet, the fast component of the NMR-MOUSE measurement showed contrary trends during ischemia (increase) versus flow reduction (decrease). The slow-to-fast diffusion ratio shifted slightly towards slow diffusion during flow reduction. The O2C measurement showed a significant decrease of oxygen saturation and microcirculatory blood flow during ischemia and flow reduction (p < .0001). The local microcirculatory blood amount (rHb) showed a significant mucosal increase (p_{Clamping(method 1)} = 0.0007, p_{Clamping(method 3)} = 0.0119), but a serosal decrease (p_{Clamping(method 1)} = 0.0119, p_{Clamping(method 3)} = 0.0078) during ischemia. The histopathological damage was significantly higher with increasing experimental duration and at the end of methods 3 and 4 (p < .0001,Fisher-test).

Conclusion

Monitoring intestinal diffusion changes due to different perfusion states using the NMR-MOUSE is feasible under experimental conditions. Despite the lack of statistical significance, this technique reflects perfusion changes and therefore seems promising for the evaluation of different intestinal perfusion states in the future. Beforehand however, an optimization of this technology, including the optimization of the penetration depth, as well as further validation studies under physiological conditions and including older animals are required.

Effective of laparoscopy for post-operative small bowel adhesion in children

AIM

The aim of this paper is to report a case of a child with adhesive small bowel obstruction treated by laparoscopic ap-proach.

CASE REPORT

A 13-year old patient developed a small bowel obstruction caused by adhesion. He was successfully treated by laparoscopic adhesiolysis and was discharged from the hospital on the 7th post-operative day in satisfacto-ry condition.

DISCUSSION

this disease is treated by laparoscopy very rarely, especially in children. In patients without comorbidities, such as pulmonary or cardiovascular diseases, laparoscopic approach could be considered as the first approach in children because the patient has the advantage of less pain and short hospitalization.

CONCLUSION

Until clinical trials will address guidelines, when possible, laparoscopic approach should be attempted.

Benign pneumatosis intestinalis with massive portomesenteric venous gas in a very old man. A case report

INTRODUCTION

Pneumatosis intestinalis (PI) is described as the presence of air within bowel wall. PI aetiology is various: it can be associated with non-urgent or life-threatening conditions. Clinical management is based on physical examination, blood tests and radiology, in particular abdominal CT. The cause of PI suggests the correct therapy. When PI is linked to gas in portal and mesenteric venae (PMVG), bowel ischemia or infarction is possible, and surgery needed.

CASE REPORT

A 91 years-old man was admitted to Emergency Department reporting abdominal pain and vomit. Acute abdominal symptoms, radiological finding of small bowel PI with massive PMVG, severe neutrophilia, and high serum lactate forced us to perform exploratory laparotomy, from which it was observed a diffuse band-like pneumatosis of all the small bowel and mesentery without ischemic or peritonitis signs. The patient was imposed to fast and treated with oxygen, intravenous fluid and antibiotic therapy, without performing further surgery, and was discharged to a rehabilitation facility after symptomatology resolution.

DISCUSSION

Scientific literature underlines the importance of PMVG to consider as critic a patient with PI, but it is always essential to assess also physical examination, vital parameters, and blood exams. In our case, several signs were suggestive for bowel infarction: its absence and the swift recovery of the patient were unexpected.

CONCLUSION

Although non-surgical treatment is recommended for primary PI of unknown aetiology, in case physical examination and radiological signs aren't decisive surgery is necessary to rule out bowel infarction. This case stresses the difficulty of PI management.

[Gastric Bypass: Weight Loss with Complications]

Gastric Bypass: Weight Loss with Complications Abstract. Roux-en-Y gastric bypass (RYGBP) is the most often performed bariatric operation worldwide with internal hernia as one of the main long-term complications. To our knowledge, we report the first case of post-ischemic small-bowel strictures observed after a successful operation of an internal hernia after RYGBP. During emergency surgery a Petersen and a Brolin hernia were diagnosed and repaired. The initially ischemic small intestine was recovered. However, a week later the patient presented herself again due to ischemia-induced small-bowel strictures. These were treated successfully by endoscopic balloon dilatation.

Induction of gut proteasome activity in hemorrhagic shock and its recovery by treatment with diphenyldihaloketones CLEFMA and EF24

Multiorgan failure in hemorrhagic shock is triggered by gut barrier dysfunction and consequent systemic infiltration of proinflammatory factors. Our previous study has shown that diphenyldihaloketone drugs 4-[3,5-bis[(2-chlorophenyl)methylene]-4-oxo-1-piperidinyl]-4-oxo-2-butenoic acid (CLEFMA) and 3,5-bis[(2-fluorophenyl)methylene]-4-piperidinone (EF24) restore gut barrier dysfunction and reduce systemic inflammatory response in hemorrhagic shock. We investigated the effect of hemorrhagic shock on proteasome activity of intestinal epithelium and how CLEFMA and EF24 treatments modulate proteasome function in hemorrhagic shock. CLEFMA or EF24 (0.4 mg/kg) were given 1 h after withdrawing 50% of blood from Sprague-Dawley rats; no other resuscitation was provided. After another 5 h of compensation, small gut was collected to process tissue for proteasome activity, immunoblotting, and mRNA levels of genes responsible for unfolded-protein response (XBP1, ATF4, glucose-regulated protein of 78/95 kDa, and growth arrest and DNA damage inducible genes 153/34), polyubiquitin B and C, and immunoproteasome subunits β type-8 and -10 and proteasome activator subunit 1. We found that hemorrhagic shock induced proteasome activity in gut tissue and reduced the amounts of ubiquitinated proteins displayed on antiubiquitin immunoblots. However, simultaneous induction of unfolded-protein response or immunoproteasome genes was not observed. CLEFMA and EF24 treatments abolished the hemorrhagic shock-induced increase in proteasome activity. Further investigations revealed that the induction of proteasome in hemorrhagic shock is associated with disassembly of 26S proteasome; CLEFMA and EF24 prevented this disassembly. Consistent with these data, CLEFMA and EF24 reduced hemorrhagic shock-induced degradation of 20S substrate ornithine decarboxylase in gut tissue. These results suggest that activated proteasome plays an important role in ischemic gut pathophysiology, and it can be a druggable target in shock-induced gut dysfunction. NEW & NOTEWORTHY Ischemic injury to the gut is a trigger for the systemic inflammatory response and multiple organ failure in trauma and hemorrhagic shock. We show for the first time that hemorrhagic shock induces the gut proteasome activity by engendering 26S proteasome disassembly. Diphenyldihaloketones 4-[3,5-bis[(2-chlorophenyl)methylene]-4-oxo-1-piperidinyl]-4-oxo-2-butenoic acid and 3,5-bis[(2-fluorophenyl)methylene]-4-piperidinone treatment prevented the 26S disassembly. Understanding the role of proteasome in shock-associated gut injury will assist in the development of therapeutic means to address it.

Morbid obesity and type 2 diabetes alter intestinal fatty acid uptake and blood flow

AIMS

Bariatric surgery is the most effective treatment to tackle morbid obesity and type 2 diabetes, but the mechanisms of action are still unclear. The objective of this study was to investigate the effects of bariatric surgery on intestinal fatty acid (FA) uptake and blood flow.

MATERIALS AND METHODS

We recruited 27 morbidly obese subjects, of whom 10 had type 2 diabetes and 15 were healthy age-matched controls. Intestinal blood flow and fatty acid uptake from circulation were measured during fasting state using positron emission tomography (PET). Obese subjects were re-studied 6 months after bariatric surgery. The mucosal location of intestinal FA retention was verified in insulin resistant mice with autoradiography.

RESULTS

Compared to lean subjects, morbidly obese subjects had higher duodenal and jejunal FA uptake (P < .001) but similar intestinal blood flow (NS). Within 6 months after bariatric surgery, obese subjects had lost 24% of their weight and 7/10 diabetic subjects were in remission. Jejunal FA uptake was further increased (P < .03). Conversely, bariatric surgery provoked a decrease in jejunal blood flow (P < .05) while duodenal blood flow was preserved. Animal studies showed that FAs were taken up into enterocytes, for the most part, but were also transferred, in part, into the lumen.

CONCLUSIONS

In the obese, the small intestine actively takes up FAs from circulation and FA uptake remains higher than in controls post-operatively. Intestinal blood flow was not enhanced before or after bariatric surgery, suggesting that enhanced intestinal FA metabolism is not driven by intestinal perfusion.

[Gastrografin as a prognostic and therapeutic medium; use for small bowel obstruction, but not for closed loop obstruction]

Timely recognition and treatment of small bowel obstruction is of great importance for the course of the disease. Complete obstruction of the small bowel can lead to serious complications such as bowel ischaemia and perforation. Gastrografin, which is traditionally used as an oral contrast agent in imaging diagnostics, is of prognostic and therapeutic value in patients presenting with adhesive small bowel obstruction. CT is necessary to rule out closed loop obstruction or other than adhesive causes of the bowel obstruction before using Gastrografin. Patients with closed loop obstruction can rapidly develop bowel ischaemia and immediate surgery is indicated once diagnosed. Awaiting clinical resolution of the small bowel obstruction without surgery is justified when closed loop obstruction has been ruled out, there are no signs of bowel ischaemia and an abdominal radiograph within 4-24 hours after administration of Gastrografin shows the oral contrast in the colon.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

Methamphetamine consumption and life-threatening abdominal complications: A case report

RATIONALE

Methamphetamine (METH) abuse is increasing rapidly all over the world and becoming a significant public health concern in China. However, abdominal complications secondary to METH abuse are usually overlooked. We describe an unusual case of gangrenous cholecystitis and small intestinal ischemia due to METH abuse.

PATIENT CONCERNS

In this report, a 44-year-old male patient with abdominal pain and hematochezia has a history of crystal meth abuse.

DIAGNOSIS

The patient was diagnosed as septic shock, paralytic ileus, gangrenous cholecystitis, and small intestinal ischemia due to METH abuse based on computed tomography (CT) scan, endoscopy examination, laparotomy, and pathology.

INTERVENTIONS

Antishock treatment, broad-spectrum antibiotics, and exploratory laparotomy were given.

OUTCOMES

The patient survived. Six months later, he tolerated oral intake and stopped using crystal METH.

LESSONS

Visceral ischemia should be considered if an adult patient with a history of METH abuse is accompanied by abdominal pain and hematochezia.

Distal Duodenogastrostomy or Proximal Jejunogastrostomy in the Management of Ultra-Short Bowel

Inflammatory bowel disease, vascular disease, volvulus, adhesions, or abdominal trauma may necessitate extensive small-bowel resection resulting in an ultra-short distal duodenal or jejunal stump. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel continuity restoration is hazardous or not possible at all, a distal duodenogastrostomy or proximal jejunogastrostomy in combination with drainage of the stomach is an option to prevent stump leakage. Although successful, this distal duodenogastrostomy has been described only in very few patients and in older records. We reintroduced this technique and describe a recent series of patients that confirms its usefulness in certain conditions. The technique of the distal duodenogastrostomy or proximal jejunogastrostomy with gastric drainage was used for the management of the difficult distal duodenum stump in five critically ill patients undergoing extensive bowel resection. Four patients with small-bowel ischemia and one patient suffering from perforating Crohn's disease and small-bowel volvulus were treated  successfully. The gastrostomies were subsequently converted to a duodenotransversostomy (in two patients) or the patients underwent small-bowel transplantation (two patients). One patient still has a jejunogastrostomy just after the duodenal-jejunal transition. In all five patients, the distal duodenogastrostomy or proximal jejunogastrostomy in combination with gastric drainage functioned well up to restoration of bowel continuity. In one patient, distal duodenogastrostomy and transabdominal gastric drainage functioned well for 5 years. No anastomotic leakage occurred. This procedure provides a feasible solution for an ultra-short bowel at emergency laparotomy. It enhances the surgical armamentarium and provides treatment options for these patients that were perhaps previously deemed unsalvageable.

Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center

AIM

To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation.

METHODS

All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation).

RESULTS

A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients.

CONCLUSION

The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.

[ABOUT THE ROLE OF DIGESTIVE TRACT DECOMPRESSION IN PATIENTS WITH ACUTE BOWEL OBSTRUCTION. MISTAKES, COMPLICATIONS AND THEIR PREVENTION]

The purpose of the work is improvement in treatment of patients with acute small bowel obstruction by justification for gastrointestinal decompression and different methods of small intestine intubation for effective evacuation of itscontents. We conducted morphological and morphometric study of the small intestine in 53 white rats. It was established that acute small bowel obstruction causes expansion of all parts of small bowel microvasculature with significant lesions of venous structures. We revealed thinning of intestinal muscular layer 2.15 timesand increase of submucosallayer 1.65 times. Changesin nuclear/cytoplasmic ratioof these structures showed tension and instability in structural homeostasis at cellular level. These changes lead to malabsorption and require evacuation of intestinal pathological contents. We analyzed 30 medical records of patients who died from acute small bowel obstruction. Decompression was performed only in 60.71% ofall cases and in 50.0% of re-laparotomy cases. The cause of death in 80.0% was syndrome of multiple organ failure due to progressiveintoxication caused by functional obstruction of the small intestine. 196 patients were operated. In 50% of cases nasointestinal intubation was used for small bowel decompression, in 11.22% - intraoperative one-stage evacuation of intestinal contents and in 3.57% - "open" methods of intestinal drainage. We drew attention to problems and errorsin performingsmall bowel intubation. We offered some variants of intubation using different probes according to the operating situation and aim of intubation. Design of probe for intubation and method of enterostomy was suggested. We also offered an algorithm for selectionof small intestinal decompression method in patients with acute small bowel obstruction depending on the operating situation. We emphasizethat intestinal decompression in patients with acute small bowel obstruction improves the results of surgery.

A Smart Capsule System for Automated Detection of Intestinal Bleeding Using HSL Color Recognition

There are no ideal means for the diagnosis of intestinal bleeding diseases as of now, particularly in the small intestine. This study investigated an intelligent intestinal bleeding detection capsule system based on color recognition. After the capsule is swallowed, the bleeding detection module (containing a color-sensitive adsorptive film that changes color when absorbing intestinal juice,) is used to identify intestinal bleeding features. A hue-saturation-light color space method can be applied to detect bleeding according to the range of H and S values of the film color. Once bleeding features are recognized, a wireless transmission module is activated immediately to send an alarm signal to the outside; an in vitro module receives the signal and sends an alarm. The average power consumption of the entire capsule system is estimated to be about 2.1mW. Owing to its simplicity, reliability, and effectiveness, this system represents a new approach to the clinical diagnosis of intestinal bleeding diseases.

Predictors of Ischemic Bowel in Patients with Small Bowel Obstruction

Preoperative diagnosis of ischemic bowel in patients with small bowel obstruction (SBO) is a clinical challenge. The aim of this study was to identify preoperative variables associated with ischemic bowel found at operative exploration. We performed a 5-year retrospective review of patients admitted to a university affiliated, county funded hospital who underwent exploratory laparoscopy or laparotomy for SBO. Patients were excluded if they had a known preoperative malignancy or hernia on physical examination. Multivariate logistic regression was used to determine factors independently associated with bowel ischemia or ischemic perforation. One hundred and sixteen patients underwent exploratory surgery for SBO. Mean age was 52 ± 14 years and most were male [64 (55.2%)]. Adhesions [92 (79.3%)] were the most common etiology of obstruction. Leukocytosis (P = 0.304) and acidosis (P = 0.151) were not significantly associated with ischemia or ischemic perforation. In addition, history of prior SBO (P = 0.618), tachycardia (P = 0.111), fever (P = 0.859), and time from admission to operation (P = 0.383) were not predictive of ischemic bowel. However, hyponatremia (≤134 mmol/L) and CT scan findings of wall thickening or a suspected closed loop were independently associated with bowel ischemia. Awareness of these predictors should heighten the concern for ischemic bowel in patients presenting with SBO.

Morphologic and histopathologic changes in the bowel after super-selective transcatheter embolization for focal lower gastrointestinal hemorrhage

Purpose: To evaluate the safety of superselective arterial embolization therapy in the lower gastrointestinal tract. The sequelae on normal enteric tissue in lower gastrointestinal arterial embolization were retrospectively reviewed.

Material and Methods: To control hemorrhage and tumor blood supply, 14 patients were treated by superselective transcatheter embolization at different levels of the colonic and small intestine vessels via the superior and inferior mesenteric arteries using microcoils and/or gelatin sponge. Normal enteric tissues in the embolized areas were analyzed for the occurrence of ischemic changes by clinical follow-up, colonoscopy, and surgery.

Results: Normal bowel function was preserved in 13 patients. In 1 patient treated with numerous gelatin sponge particles delivered from the proximal arcade of the superior mesenteric artery, significant muscular fibrosis occurred.

Conclusion: Superselective arterial embolization for lower gastrointestinal hemorrhage can be safely performed by minimizing the amount of embolic materials and delivering them as distally as possible.

Outcome and Safety of Anterograde and Retrograde Single-Balloon Enteroscopy: Clinical Experience at a Tertiary Medical Center in Taiwan

Single-balloon enteroscopy (SBE) is designed for identifying possible small bowel lesions with balloon-assisted enteroscopy that allows deep intubation of the intestine. However, data regarding the outcome and safety of SBE remain limited. We conducted this study to evaluate the outcome and safety of anterograde and retrograde SBE approaches. This retrospective review from a tertiary medical center in Taiwan included endoscopic reports and chart data from 128 patients with 200 anterograde and retrograde procedures from September 2009 to November 2014. In this study, the most common indication for both anterograde and retrograde SBE was obscure gastrointestinal bleeding (64.4% vs. 60.6%). There were no significant differences between anterograde and retrograde approaches in terms of the diagnostic yield (69.3% vs. 52.5%) and intervention rate (23.8% vs. 17.2%). The procedure time was shorter for anterograde SBE than for retrograde SBE (68.1 ± 23.9 vs. 76.8 ± 27.7 min, P = 0.018). In addition, among the subgroup of patients with obscure gastrointestinal bleeding, the most common etiologies for those in different age-groups were angiodysplasia (≥ 65 years), non-specific ulcers (30–64 years), and Meckel’s diverticulum (< 30 years). The major complication rate during the study was 1.5%; the rate of asymptomatic hyperamylasemia was higher for patients who underwent anterograde SBE than for those who underwent retrograde SBE (13.9% vs. 2%, P = 0.005). The outcome and safety of anterograde and retrograde SBE are similar. However, anterograde SBE has a shorter procedural time and a higher rate of asymptomatic hyperamylasemia.

Study on the small intestine absorptive kinetics characters of tanshinol and protocatechualdehyde of Salvia miltiorrhiza extracts in rats in vivo

In order to provide scientific basis for clinical selection of drugs, to compare and analyze the effective constitutes and the intestinal absorption in vivo in rats of the compound salvia tablets and compound salvia dropping pills (taken as the representatives). Determine the contents of tanshinol, protocatechuic aldehyde, salvianolic acid B and tanshinone II A, cryptotanshinone, ginseng saponin Rg1 and Rb1 in the compound salvia tablets and compound salvia dropping pills by High Performance Liquid Chromatography (HPLC). The intestinal absorption condition of the tanshinol, protocatechuic aldehyde, salvianolic acid B of the compound salvia tablets and compound salvia dropping pills in rats were detected by intestinal perfusion experiment. Only the intake of protocatechuic aldehyde in the compound salvia tablets was higher than in the compound dropping pills, the intake of the other 6 effective constitutes were all lower than in the compound dropping pills. The intestinal absorption of protocatechuic aldehyde was rather complete, while the intestinal absorption of tanshinol and salvianolic acid B were not significant. The duodenum was the main absorption region of these three components. The absorption of protocatechuic aldehyde was different in different regions of the intestines. Each intake of the effective constitutes in the tablets and dropping pills were significantly different, and the rat intestinal absorption of part of the components were different.

Strangulating Closed-Loop Obstruction: Sonographic Signs

PURPOSE

To evaluate different sonographic signs of strangulating closed-loop obstruction retrospectively.

MATERIALS AND METHODS

Over a period of approximately 10 years all documents, US scans and video clips of patients with strangulating intestinal obstruction were reviewed. The following sonographic signs were evaluated: akinetic bowel loops; echo-free luminal content; hyperechoic congestion of the mesentery; free peritoneal fluid; bowel wall thickening; signs of ischemia on color Doppler or contrast-enhanced US. Moreover, we looked for signs of bowel obstruction proximal to the closed loop and for the width of the strangulated segment.

RESULTS

The most often documented features of strangulating closed-loop obstruction were an akinetic bowel loop (94 %), a hyperechoic and thickened mesentery (82 %) and free peritoneal fluid (100 %). In 54 % of cases the luminal content was almost anechoic. In 76 % of patients bowel wall thickening and in 50 % signs of ischemia on color Doppler or contrast-enhanced US were documented. In 67 % small bowel dilatation proximal to the strangulated bowel segment was present. The width of the strangulated bowel loops was 2.86 cm on average.

CONCLUSION

The akinetic bowel loops, hyperechoic thickening of the attached mesentery and free peritoneal fluid are typical for strangulating closed-loop obstruction. An anechoic luminal content is only visible in about half of the patients, but this eye-catcher can lead the investigator to the correct diagnosis. In about one third of patients no signs of bowel obstruction proximal to the strangulated loops are present. Dilatation of the strangulated loop may be absent or mild.

Diagnostic value of intestinal fatty acid-binding protein for pneumatosis intestinalis

BACKGROUND

Pneumatosis intestinalis (PI) is known as a sign of a life-threatening bowel ischemia. We aimed to evaluate the utility of intestinal fatty acid-binding protein (I-FABP) in the diagnosis of pathologic PI.

METHODS

All consecutive patients who presented to our emergency department with PI were prospectively enrolled. The diagnostic performance of I-FABP for pathologic PI was compared with that of other traditional biomarkers and various parameters.

RESULTS

Seventy patients with PI were enrolled. Pathologic PI was diagnosed in 27 patients (39%). The levels of most biomarkers were significantly higher in patients with pathologic PI than those with nonpathologic PI (P < .05). Receiver operator characteristic analysis revealed that the area under the curve (AUC) was highest for I-FABP (area under the curve = .82) in the diagnosis of pathologic PI.

CONCLUSIONS

High I-FABP value, in combination with other parameters, might be clinically useful for pathologic PI.