Disseminated aspergillosis causing intestinal failure following colectomy for perforated colitis.

Disseminated aspergillosis is a rare, invasive, opportunistic, fungal infection associated with a high mortality. We report a non-fatal case diagnosed following extensive enterectomy for intestinal infarction in a patient recovering from emergency abdominal colectomy for perforated ulcerative colitis. This resulted in intestinal failure necessitating life-long parenteral nutrition and prolonged antifungal therapy.

Management of acute intestinal failure.

Intestinal failure (IF) occurs when intestinal absorptive function is inadequate to maintain hydration and nutrition without enteral or parenteral supplements. It has been classified into three types depending on duration of nutrition support and reversibility. Type 1 IF is commonly seen in the peri-operative period as ileus and usually spontaneously resolves within 14 d. Type 2 IF is uncommon and is often associated with an intra-abdominal catastrophe, intestinal resection, sepsis, metabolic disturbances and undernutrition. Type 3 IF is a chronic condition in a metabolically stable patient, which usually requires long-term parenteral nutrition. This paper focuses on Types 1 and 2 IF (or acute IF) that are usually found in surgical wards. The objectives of this paper are to review the incidence, aetiology, prevention, management principles and outcome of acute IF. The paper discusses the resources necessary to manage acute IF, the indications for inter-hospital transfer and the practicalities of how to transfer and receive a patient with acute IF.

Successful endovascular treatment of multiple mesenteric arterial aneurysms associated with alpha-1-antitrypsin deficiency.

We present a rare case of a patient who presented with acute abdominal pain with a previous history of alpha-1-antitrypsin deficiency (alpha1-antitrypsin deficiency). Further clinical deterioration necessitated computed tomography (CT) imaging, which demonstrated a hemoperitoneum. Angiography confirmed the rupture of multiple aneurysms originating from the mesenteric arterial arcade, which were treated successfully with endovascular embolization. The association between mesenteric arterial aneurysm rupture and alpha-1-antitrypsin deficiency is explored.

Operative management of small bowel Crohn's disease.

Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.

Plasma concentrations of glucagon-like peptide-2 in adult patients with treated and untreated coeliac disease.

BACKGROUND: Coeliac disease is a common chronic inflammatory enteropathy characterized by villous atrophy and crypt hyperplasia in the small intestine. The mechanism of the intestinal damage in coeliac disease remains unclear. Glucagon-like peptide (GLP)-2 is an enterotrophic peptide that causes crypt hyperplasia and intestinal cell proliferation. We postulate that GLP-2 may be involved in the mucosal changes found in coeliac disease. OBJECTIVES: To study plasma concentrations of GLP-2 in untreated patients with coeliac disease and determine the response to a gluten-free diet (GFD). METHODS: A 440 kcal gluten-free test meal was given to seven controls and 12 coeliac patients at three time intervals: (1) before commencing a GFD; (2) 3 months after a GFD; and (3) 9 months after a GFD. Serial blood sampling was performed over a 2-h period. Each sample was analysed using radioimmunoassay for GLP-2, GLP-1, N-terminal glucagon (N-glucagon) and C-terminal glucagon (C-glucagon). RESULTS: Untreated coeliac patients had significantly higher basal and peak GLP-2 and N-glucagon plasma concentrations compared with controls. After 3 months on a GFD, there was a significant decrease in basal GLP-2 plasma concentrations. There was no significant difference between GLP-1 or C-glucagon in untreated coeliac patients compared with controls. CONCLUSION: This is the first reported study of GLP-2 in coeliac disease. After a GFD there is recovery of the intestine and a reduction in the GLP-2 trophic response. Our findings support the theory that GLP-2 may be part of the mucosal healing and maintenance mechanisms in coeliac disease.

Role of adenosine in immunomodulation: review of the literature.

OBJECTIVE: Advances in the understanding of sepsis have failed to deliver satisfactory new treatments aimed at attenuating inflammatory-mediated organ dysfunction. Phagocytic cells play a pivotal role in driving the inflammatory response and causing direct tissue injury. Adenoreceptor stimulation may attenuate such inflammatory-mediated damage by down-regulating phagocytic activity and preventing excessive respiratory burst activation. DATA: A Medline database was used to perform a literature search for all articles relating to the use of adenosine as an immunomodulatory agent. CONCLUSION: There is convincing evidence to suggest that adenoreceptor modulation can prevent tissue injury through a variety of pathways. The use of adenosine modulation in ischemia/reperfusion injury has been the subject of considerable investigation, although experience with its use in sepsis is limited.

Phagocyte priming as a prognostic indicator in the intensive care unit.

BACKGROUND: The purpose of this study was to study the temporal changes in circulating phagocyte respiratory burst activity and its relationship to mortality in intensive care unit (ICU) patients. METHODS: Thirty-seven consecutive patients over a 3-week period were studied on their first, third, and seventh day of admission to the regional ICU in Northern Ireland. Blood samples were assayed for respiratory burst activity using luminol-enhanced whole blood chemiluminescence. RESULTS: Compared with survivors, nonsurvivors exhibited significantly higher Acute Physiology and Chronic Health Evaluation II scores, a base deficit, and reduced phagocyte activity (median [interquartile range]) (24.00% [18.00%, 56.00%] vs. 38.00% [30.00%, 63.50%], p = 0.047, Mann-Whitney U test) on day 3 of admission to the ICU. CONCLUSION: Temporal changes in phagocyte activation dependent on the underlying insult were seen in ICU patients. Furthermore, the degree of phagocyte activation was able to distinguish between survivors and nonsurvivors on day 3 of admission to the ICU. Nonsurvivors exhibited reduced phagocyte activation, suggesting patients at risk of mortality exhibit systemic anergy.