ABSTRACT
Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.
ABSTRACT
Introduction: IgA vasculitis is more commonly seen in the pediatric population than in adults. Rarely IgA vasculitis is associated with malignancy, most commonly solid tumor malignancies, although there are case reports of association with hematologic malignancies. We report a case of large B-cell lymphoma mimicking IgA vasculitis in a 33-year-old immunosuppressed male with a prior history of IgA vasculitis. Case Description/Methods: A 33-year-old Caucasian male post renal transplant from reflux nephropathy on chronic immunosuppression was hospitalized for postprandial epigastric abdominal pain, nausea, vomiting and diarrhea. Two years prior, he was admitted for the same symptoms, palpable purpura of the lower extremities and elevated serum IgA. Enteroscopy had shown duodenal and jejunal ulceration with biopsies staining positive for IgA, confirming IgA vasculitis. He had complete resolution with a steroid taper. His current presentation had resulted in multiple hospital admissions, but empiric trial of steroids failed to alleviate symptoms. Vitals were normal and exam was notable for epigastric tenderness. Labs were notable for WBC 19.00 x103/cmm with normal differential, hemoglobin 9.2 gm/dL (prior 11.0 gm/dL), CRP 20.7 mg/L, serum creatinine 2.7 mg/dL (prior 1.5 mg/dL), and urinalysis with proteinuria, sterile pyuria, and hematuria. CTA abdomen/pelvis revealed thickening of the duodenum with shotty mesenteric lymph nodes without ischemia. Enteroscopy revealed an erythematous duodenum and jejunum (figure A). Jejunal biopsy (figure B) revealed CD20 positive cells consistent with DLCBL (figure C). He was seen by oncology and treated with R-CHOP but later unfortunately expired due to COVID-19 complications. Discussion(s): Non small cell lung cancer and renal cell carcinoma are most commonly associated with IgA vasculitis. It may also be seen in both Hodgkin and Non-Hodgkin lymphomas in adult patients. If IgA vasculitis occurs after a malignancy is diagnosed, it may indicate that metastasis has occurred. Malignancy associated IgA vasculitis is more likely to have an incomplete response to steroids and requires treatment of the underlying malignancy to achieve remission. Our case illustrates posterior probability error and premature closure cognitive biases. We should consider alternative diagnoses rather than anchor on prior diagnoses even when presentations are similar. Our case also highlights the importance of considering occult malignancy in adults with diagnosis of IgA vasculitis.
ABSTRACT
A 63-year-old man was admitted to our hospital with sore throat and fever. He was diagnosed with Coronavirus Disease 2019(COVID-19), and on the 3rd day after diagnosis, he started on ventilatory management. On the 25th day, the patient presented with over 3 L of watery diarrhea, which continued daily. When the diarrhea did not improve with various treatments, on the 98th day, a double-balloon endoscopy of the small intestine was performed, and diffuse loss of villi structure in the jejunum was noted. Due to massive pleural effusion, the patient succumbed to circulatory and respiratory failure 111 days after admission to the hospital. The pathological autopsy revealed that the mucosal epithelium had been exfoliated from the entire small intestine. As this case shows, some COVID-19 cases are associated with severe diarrhea;further investigation is needed to elucidate the pathogenesis of COVID-19-associated diarrhea.Copyright © 2023 Authors. All rights reserved.
ABSTRACT
Livestock products supply about 13 percent of energy and 28 percent of protein in diets consumed worldwide. Diarrhea is a leading cause of sickness and death of beef and dairy calves in their first month of life and also affecting adult cattle, resulting in large economic losses and a negative impact on animal welfare. Despite the usual multifactorial origin, viruses are generally involved, being among the most important causes of diarrhea. There are several viruses that have been confirmed as etiological agents (i.e., rotavirus and coronavirus), and some viruses that are not yet confirmed as etiological agents. This review summarizes the viruses that have been detected in the enteric tract of cattle and tries to deepen and gather knowledge about them.Copyright © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
ABSTRACT
Aim is to discuss diagnostic and therapeutic difficulties in COVID-19 related postoperative outcomes. A 5-year-old boy operated for jejunal atresia in neonatal period admitted with recurrent bilious vomiting. The upper GI series revealed dilated jejunum and absence of mechanical obstruction. The dilated jejunal segment was excised and anastomosis was performed. Later, he developed peritonitis without signs of anastomotic leaks. The second surgical exploration revealed diffuse peritonitis causing thickened and fibrous bowel loops causing hardly lysable adhesions. Then, his grandmother was learned to be COVID-PCR positive. Therefore, patients with atypical postoperative course should be investigated for possible COVID-19 during pandemics. Copyright © 2022 Ankara Pediatric Hematology Oncology Training and Research Hospital. All rights reserved.
ABSTRACT
Jejunal Dieulafoy's lesion is difficult to diagnose due to its rarity, intermittent hemorrhage, and lesion site, which is largely inaccessible to conventional endoscopes. A 39-year-old man, who had no underlying disease, presented to the emergency department (ED) with weakness, dizziness, and dry cough with a history of several rectal bleeding episodes in the last few years. Endoscopy was normal, and the colon was full of clots on colonoscopy, and no gross pathology was found. On computed tomography (CT) angiography, a hyperdensity was seen in the middle of the jejunum, possibly suggesting contrast extravasation. Due to decreased hemoglobin of the patient, and hemodynamic instability, the patient became a candidate for surgery. A palpable lesion in the Jejunum was touched that opened longitudinally, which revealed active arterial bleeding from the nipple-like lesion. This segment was resected, and an anastomosis was performed. Histopathological examination of the small intestine confirmed a Dieulafoy's lesion. It seems that, when upper endoscopy and colonoscopy fail to identify the cause of gastrointestinal bleeding, a Dieulafoy's lesion should be included in the differential diagnoses.
ABSTRACT
Small bowel injury in a sports setting is a rare occurrence with a paucity of reported cases. A 30-year old male patient consulted for generalized abdominal pain subsequent to secondary blunt abdominal trauma during kick-boxing practice. A computed tomography scan of the abdomen and pelvis revealed a moderate amount of free fluid in both the parietocolic space and the rectovesical pouch, with perihepatic pneumoperitoneum. Emergency laparoscopy was indicated and a closure of small bowel defect was performed. Diagnosis of small bowel injuries is difficult, resulting in delayed treatment and increased mortality and morbidity.
ABSTRACT
AIM: Enteroscopy is an endoscopic procedure to approach the small intestine in order to diagnose and treat various pathologies. The aim of this study is to share the experience of our center with this modality and highlight the main indications and diagnostic yield pf the procedure. METHODS: This is a single center retrospective study at Aga Khan University Hospital Karachi, Pakistan in which we included all the enteroscopies done in last five years. RESULTS: A total of 37 enteroscopies were done in past five years, the numbers has reduced significantly in the Covid-19 era. The mean age was 50.4 ± 16.5 years with 19 (51.4%) females and 18 (48.6%) males. The most common indications were jejunal thickening on CT scan 17 (45.9%) followed by obscure gastrointestinal bleeding 7 (18.9%) and chronic diarrhea 5 (13.5%). Most of the enteroscopies showed no gross pathology 17 (45.9%). However, jejunal ulcers 6 (16.2%), arteriovenous malformations 4 (10.8%), jejunal polyps 3 (8.1%), erythematous mucosa 2 (5.4%), pale mucosa 2 (5.4%), jejunal mass 2 (5.4%) and gastric polyp 1 (2.7%) are the findings noticed in rest of the enteroscopies performed. In 18 (48.6%) no biopsies were taken due to normal findings. 12 (32.4%) had nonspecific chronic inflammation in the jejunum. The remaining seven patient's histopathology showed giardiasis, MALTOMA, high grade B cell lymphoma, moderately differentiated adenocarcinoma, inflammatory polyp, hamartomatous polyp and adenomatous polyp. CONCLUSIONS: We shared the five year experience of enteroscopies done in our center which belongs to a low income country. The number of enteroscopies has greatly affected by the cost, low socioeconomic status of patients. Covid-19 has further reduced the number of diagnostic procedures in general. Most of the enteroscopies didn't reveal significant findings however there are cases where lymphoma and adenocarcinoma has been diagnosed.
ABSTRACT
Purpose/Background: Although GI melanoma is commonly a metastatic disease, it is very unusual to see the mesenteric mass of the cecum and terminal ileum as the primary origin of melanoma. Hypothesis/Aim: This is a case report and presentation showing a rare occasion of primary melanoma in the cecum and the terminal ileum mesentery along the ileocolic pedicle causing cecal complete bowel obstruction. Methods/Interventions: The reported case is a rare occasion of large bowel obstruction near the cecum resulted from primary mesenteric melanoma invading into the wall of the descending colon. Primary melanoma of the GI tract is still controversial and only a limited of cases have been reported in the literature. We added a review of the other published case reports to this case report using Endnote. Results/Outcome(s): This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt this was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient service and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/ mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. She had also intraoperative liver biopsy that demonstrated metastasis of the melanoma to the liver. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. Limitations: Case report study with reported cases reviewed. Conclusions/Discussion: Large bowel obstruction could be related to unusual diagnoses like melanoma of the bowel mesentery. Although, primary GI melanoma is rare this showed the possibility of such diagnosis. (Figure Presented).
ABSTRACT
DDW 2022 Author Disclosures: Ryosuke Kobayashi: NO financial relationship with a commercial interest ;Natalia C. Calo: NO financial relationship with a commercial interest ;Bong Sik Kim: NO financial relationship with a commercial interest ;Christopher Teshima: NO financial relationship with a commercial interest Aims: Push enteroscopy (PE) is commonly used in patients with obscure GI bleeding after a negative esophagogastroduodenoscopy and colonoscopy to investigate for a bleeding source within the proximal small bowel. However, there is almost no literature that has measured the anticipated proportion of the small intestine that can be evaluated by using the PE technique. The primary aim of this study was to quantify the percentage of small bowel examined by PE by using capsule endoscopy (CE). Methods: Prospective patients referred for small bowel investigation of obscure GI bleeding were offered single session PE followed by CE. PE was performed using a pediatric colonoscope fitted with a distal attachment cap that was advanced as far as possible into the small intestine using a water immersion method and aided by multiple reduction maneuvers. Two endoscopic clips were placed to denote the maximal insertion point reached by PE. Potential bleeding sources identified during PE were treated during careful endoscope withdrawal. CE was then performed with direct endoscopic placement of the capsule into the duodenum by use of a gastroscope fitted with a capsule delivery device. CE was then performed as per usual standard-of-care. The clips were identified during CE and the small bowel insertion depth of PE was quantified by the percentage of small bowel transit time (SBTT) and of small bowel progress (SBP) from the CE examination. The study was approved by our center’s IRB. Results: Fifty-six patients were enrolled between August 2019 and November 2021;mean age 62 years;59% male. Study recruitment was hindered by our institution’s pausing of clinical research recruitment in the first year of the Covid-19 pandemic. Five cases were excluded due to incomplete small bowel examination by CE and 1 case in which PE could not be performed;leaving 50 cases for the analysis. The median CE SBTT was 4h 55m. The median SBP and SBTT percentage as determined by the location of the endoscopic clips placed during PE were 14% (IQR 5-26) and 11% (IQR 4-21), respectively. Bleeding lesions were detected by PE in the stomach in 10 cases and in the duodenum/jejunum in 20 cases. CE identified potential bleeding lesions within the segments of small bowel examined by PE in 12 cases and distal to the clips in 22 cases. CE detected only 69% of angioectasias that had been treated by PE and did not visualize 2 cases of submucosal tumor that were discovered during PE. Conclusions: PE achieves an average examination of the proximal 14% of the small bowel. This should inform appropriate selection of PE vs. DBE when a bleeding lesion is detected by CE. However, notable lesions may be missed by both PE and CE examinations.
ABSTRACT
Background: Although SARS-CoV-2 has mainly respiratory manifestations, gastrointestinal symptoms are observed in 30% of cases. The ACE-2 receptor used by SARS-CoV-2 to infect cells is highly expressed in the brush border of enterocytes. However, studying the small intestine in live patients is a challenge in the field of clinical research. A minimally invasive alternative for studying the small intestine is the use of capsule endoscopy, which could be useful in the context of COVID-19. Here, we describe endoscopic changes in the mucosa of the small intestine secondary to severe SARS-CoV-2 infection in hospitalized patients. Methods: We performed a prospective observational study in hospitalized patients with a severe COVID-19 according to NIH guidelines. Participants with a positive COVID-19 PCR from nasopharyngeal swab, hemodynamically stable, able to swallow, and without additional respiratory co-infections, were enrolled between January 27th and May 17th, 2021 at the largest tertiary COVID-19 referral center in Mexico City. Demographic and clinical characteristics were collected for each participant from clinical files. A PillCam capsule from Medtronic® was used for Capsule Endoscopy (CE). Each capsule study was reviewed separately by two trained endoscopists. Detection of SARS-CoV-2 RNA in stool samples was performed according to CDC guidelines for all participants. Results: Twenty volunteers were enrolled in the study. Diarrhea was the most common gastrointestinal symptom (78%). CE study was normal in 6 participants, while the rest showed at least one intestinal finding. The most frequent finding was shortening or atrophy of villi and hyperemia (45%);followed by red spots (40%), and ulcers (15%). Two participants with shortening or atrophy of villi also presented denuded mucosa. CE findings were observed mainly in duodenum and jejunum. Participants showing changes in villi also presented positive SARS-CoV-2 RNA in stool. Conclusion: We observed that macroscopic changes in the small intestine mucosa, specifically in villi, occurred frequently in severe COVID-19 patients. These changes were accompanied by the presence of SARS-CoV-2 RNA in stool. We proposed the term COVID-19 Enteropathy to encompass these findings. Further studies are warranted to establish mechanisms of SARS-CoV-2-associated gastrointestinal disease.
ABSTRACT
This experiment was conducted to investigate the effects of recombinant porcine Lactobacillus reuteri secreting bovine lactoferrin peptide (LFCA) on growth performance of newborn piglets and the protective effect on porcine transmissible gastroenteritis virus (TGEV)infection which caused piglet diarrhea. Experiment 1:thirty-six one-day-old newborn piglets with an average body weight of about 1.5 kg were randomly divided into 3 groups, which were pPG-LFCA/LR-CO21 group, pPG/LR-CO21 group and control group, each group with 12 piglets. Piglets in each group were orally administered recombinant porcine Lactobacillus reuteri expressing LFCA pPG-LFCA/LR-CO21, containing empty vector plasmid PPG/LR-CO21 and equal volume phosphate buffer (PBS);oral administration continued for 3 days, and the observation time after oral administration was 14 d. During the period, piglets were fed freely, and the changes of body weight and diarrhea were recorded. Experiment 2:thirty one-day-old newborn piglets with an average body weight of about 1.5 kg were randomly divided into 5 groups and given TGEV with a half tissue culture infection dose (TCID50) of 10-7.50/mL by oral administration of 1, 3, 6, 9 and 12 mL, respectively. The observation period of 7 d was set to analyze the conditions of half lethal dose. Experiment 3:another thirty-two newborn piglets with an average body weight of about 1.5 kg were selected as experimental animals and randomly divided into 4 groups, with 8 piglets in each group. The groups were pPG-LFCA/LR-CO21 group, pPG/LR-CO21 group, control group and TGEV infect group. There were 8 replicates in each group and 1 piglet in each replicate. Each head of the experimental group was orally fed ppG-LFCA/LR-CO21, pPG/LR-CO21 and equal volume of PBS at a dose of 2..1010 CFU per day for 1 consecutive week. At 8 days of age, TGEV was infected by oral administration at half lethal dose, and samples were collected after 7 days of infection. The weight change and diarrhea of each group of piglets were recorded;hematoxylin-eosin staining was used to detect the length of intestinal villi and the depth of crypts;enzyme linked immunosorbent assay (ELISA) was used to determine total serum total immunoglobulin G (IgG) and total secretory immunoglobulin A (sIgA) antibody contents. RT-qPCR was used to detect the mRNA relative expression levels of Claudin-1, Occludin, tight junction protein-1 (ZO-1), inflammatory cytokines interleukin-6 (IL-6), interleukin-8 (IL-8), interferon-P (IFN-P), tumor necrosis factor-a (TNF-a) and Toll-like receptor 2 (TLR2). The flora structure of the contents of the piglet's cecum was analyzed. After oral recombinant porcine Lactobacillusreuteri, compared with the control group, the average daily gain of newborn piglets in the pPG-LFCA/LR-CO21 group was significantly increased (P < 0.01), while the diarrhea rate was significantly decreased (P < 0.01). Compared with TGEV infection group, the average daily gain of piglets in pPG-LFCA/LR-CO21 group was increased and diarrhea rate was decreased, and the differences were significant (P < 0.05). Villus height and the ratio of villus height to crypt depth in jejunum and ileum were significantly increased (P < 0.05). The contents of total IgG and intestinal mucosal total sIgA antibody in serum of piglets were significantly increased (P < 0.05);the mRNA relative expression levels of tight junction protein-related genes Claudin-1, Occludin and ZO-1 in intestinal mucosal tissue were extremely significantly increased (P < 0.01), and the serum TNF-a content was extremely significantly decreased (P < 0.01). Serum IFN-P, IL-6, IL-8 and TLR2 contents were significantly increased (P < 0.01), and the survival rate of piglets was improved. The analysis of the bacterial diversity in the contents of the piglets' cecum showed that the proportion of normal intestinal flora of piglets decreased after TGEV infection. Compared with the TGEV infect group, the proportion of pathogenic bacteria Bacteroides in piglet's intestinal flora decreased by o
ABSTRACT
Several case reports have suggested that COVID-19 may increase the risk of gastrointestinal perforation. We report a case of a gastrointestinal perforation developing in a COVID-19 patient who presented due to injuries from a motor vehicle accident. On admission, the patient had elevated white blood cells, with neutrophilia and lymphopenia. Histological examination of tissue surrounding the perforation revealed extensive infiltration of lymphocytes and plasma cells into the intestinal mucosa. These findings are consistent with SARS-CoV-2 infection. However, further pathophysiological studies are needed to assess the mechanisms by which COVID-19 may damage the gastrointestinal mucosa leading to gastrointestinal perforation.