Ulcerated Stenosis of the Small Intestine Associated With Hepatic Portal Venous Gas After Treatment for Cytomegalovirus Enteritis: A Case Report.

Due to its rarity, cytomegalovirus (CMV) enteritis remains poorly described with regard to its endoscopic and radiological findings. A 75-year-old woman was admitted to our hospital with abdominal pain and was treated with an antiviral agent for CMV enteritis. She was readmitted to our hospital 10 days after discharge due to a recurrence of abdominal pain. Emergency computed tomography revealed hepatic portal venous gas (HPVG) and ileal dilatation involving focal stenosis of the ileum. The patient underwent laparoscopic partial resection of the small intestine and was finally diagnosed with ulcered stenosis of the small intestine after treatment for CMV enteritis. This report represents a valuable addition to the literature describing a rare case of ulcerated stenosis of the small intestine associated with HPVG after treatment for CMV enteritis.

Expression and Possible Role of Silent Mating Type Information Regulation 2 Homolog 1 in Post-necrotizing Enterocolitis Stricture in vivo and in vitro.

Purpose: To investigate the expression and possible role of Sirtuin1 or Silent mating-type information regulation 2 homolog-1 (SIRT1) in post-necrotizing enterocolitis stricture. Materials and Methods: The expression characteristics of SIRT1 and TGF-ß1 in post-necrotizing enterocolitis stricture were detected by immunohistochemistry. The siRNA-SIRT1 was used to inhibit the expression of SIRT1 in intestinal epithelial cells-6 (IEC-6), and qRT-PCR, WB, and ELISA were utilized to detect the changes of Transforming growth factor-ß1 (TGF-ß1), nuclear factor (NF)-κB, tumor necrosis factor-α (TNF-α), tight junction protein-1 (ZO-1), and vascular endothelial growth factor (VEGF) expressions. The IEC-6 cell proliferation and migration ability were tested via CCK8 kit and Transwell test. The expression of E-cadherin and Vimentin in cells was detected by immunofluorescence. Results: The CRP, IL-6, IL-10, and IFN-γ in the serum of Necrotizing enterocolitis (NEC) intestinal stenosis patients were significantly higher than the reference values. The SIRT1 protein was under-expressed and the TGF-ß1 protein was overexpressed in NEC intestinal stenosis tissue. And the expression of SIRT1 was negatively correlated with TGF-ß1. At the time of diagnosis of NEC, the expression of SIRT1 decreased in children with respiratory distress syndrome and CRP level increased. After inhibiting the expression of SIRT1 in IEC6 cells, the expression levels of TGF-ß1, Smad3, and NF-κB were decreased, and the expression of ZO-1 was also decreased. The proliferation and migration ability of IEC6 cells was decreased significantly, and the expression of E-cadherin and Vimentin proteins in IEC6 cells did not change significantly. Conclusion: Promotion of intestinal fibrosis by inflammation may be the mechanism of post-necrotizing enterocolitis stricture. SIRT1 may be a protective protein of NEC. The probable mechanism is that SIRT1 can regulate intestinal fibrosis and can protect the intestinal mucosal barrier function to participate in the process of post-necrotizing enterocolitis stricture.

Experimental Intestinal Stenosis Alters Crohn's Disease-Like Intestinal Inflammation in Ileitis-Prone Mice.

BACKGROUND: Clinical observations indicate that mechanical factors contribute to the expression or recurrence of Crohn's disease. We investigated whether the creation of an intestinal stenosis could alter the severity of the expected Crohn-like ileitis, in a Crohn's disease animal model, the TNFΔare/+ mouse. METHODS: Thirty-six, 6-weeks-old TNFΔare/+ mice, were divided into 3 intervention groups: triple suture, single suture and sham. In the terminal ileum, in the first group, a triple suture stenosis was created, whereas, in the second, a loose suture was placed. Same triple-suture stenosis was performed on twelve wild type mice. All animals were sacrificed at 6 weeks post-operatively and the ileum parts were evaluated histopathologically. A summative total ileitis score was applied in each sample using a bespoke semiquantitative histological scoring system for the Crohn-like changes. RESULTS: The triple suture stenosis induced significant muscular hypertrophy proximal to interventional site which was more prominent in TNFΔare/+ than wild type mice. In triple suture group, the total ileitis score was significantly increased proximal to the intervention as compared to the single suture (P: 0.004) and the sham groups (P: 0.013). The total ileitis score distally, was unaffected, regardless of the experimental intervention. Intestinal stenosis did not induce intestinal inflammation in wild type mice. CONCLUSION: The creation of a stenosis in the terminal ileum of TNFΔare/+ mice alters Crohn-like inflammation. We assume that mechanical forces, such as intraluminal pressure, may contribute as important co-factors to the pathophysiology of Crohn's disease in genetically predisposed subjects.

A case report of intestinal obstruction caused by cryptogenic multifocal ulcerous stenosing enteritis.

BACKGROUND: Cryptogenic multifocal ulcer stenosing enteritis (CMUSE) is a rare disease characterized by multiple superficial ulcers, stenosis, and obstruction of the small intestine of unknown origin, and the course can recur. CASE PRESENTATION: We encountered a 62-year-old male patient with intestinal obstruction. The patient was admitted to the hospital for surgical treatment due to intestinal obstruction, and was diagnosed with cryptogenic multifocal ulcer stenosis enteritis due to comprehensive surgery and postoperative pathological considerations. CONCLUSION: In the future, we will continue to follow up the patient. The present study aims to remind clinicians of this disease, and reduce the incidence of misdiagnosis.

Intraoperative ultrasonography in patients undergoing surgery for Crohn's disease. Prospective evaluation of an innovative approach to optimize staging and treatment planning.

Percutaneous ultrasonography (perc-US) and magnetic resonance enterography (e-MR) are the present standards for staging patients with Crohn's disease (CD). However, intraoperative data still have some discrepancies with preoperative ones. The contribution of intraoperative ultrasonography (IOUS) has never been evaluated. Sixty-five consecutive patients scheduled for ileal/colonic resection for CD between 2010 and 2014 were prospectively enrolled. All patients had perc-US, e-MR and IOUS. Data from different imaging modalities were compared. The reference standard was the final pathology. Surgery was scheduled because of intestinal obstruction (n = 31 patients), inflammatory mass (n = 21), fistula (n = 10), or abdominal pain/sepsis (n = 3). Fourteen (21.5%) patients had a major discrepancy between preoperative and intraoperative data that required a modification of the surgical planning (five additional ileal lesions, three unknown ileo-sigmoid fistulas, and six not confirmed CD sites). IOUS correctly staged CD in all but one patients (missed ileo-colonic fistula). Pathology data differed from Perc-US data in 13 (20%) patients, from e-MR data in 14 (21.5%), and from IOUS data in one (1.5%). The sensitivity of Perc-US, e-MR and IOUS was: for the identification of CD sites 84.2%, 86.1%, and 100%; for the identification of stenoses 86.8%, 86.8%, and 100%; for the identification of fistulas 75.0%, 81.3%, and 93.8%, respectively. IOUS contributed to the surgical planning in 8 (12.3%) patients. IOUS is a safe, feasible and easy-to-perform procedure that optimizes staging of CD and, in some patients, helps to better define the treatment strategy. It could be helpful to face complex disease presentations on the basis of objective and reproducible data.

Congenital intestinal stenosis and Hirschsprung's disease: two extremely rare pathologies in a newborn puppy.

BACKGROUND: Hirschsprung's disease (HSCR) is a common congenital malformation of the enteric nervous system (ENS). During fetal development, ganglion cells of the ENS are derived from neural crest cells that migrate to the bowel. These cells reside principally in two ganglionated plexus: 1) The myenteric plexus, extending from the esophagus to the anus, and 2) submucous plexus, extending from the duodenum to the anus. In large animal species, there is a third plexus called Henle's or Schabadasch's plexus. ENS ganglion cells play a key role in normal gastrointestinal motility, respond to sensory stimuli and regulate blood flow. Both plexus show a high degree of independence from the central nervous system. Alterations in the embryonic development of the ENS can induce multiple pathologies in animal models and humans. CASE PRESENTATION: The present case was a female the fifth born in a litter of 5 puppies. At about 2-3 weeks of age, she suffered from abdominal distension, pain, and constipation. At approximately 8-10 weeks of age, the puppy started to vomit abundantly, and the regurgitated food appeared undigested. Progressive abdominal distention was observed, with quite visible peristaltic movements and more frequent vomiting episodes. The abdominal radiographs, based on AP and side projections, revealed an enlargement of the abdominal diameter and an increased width in the epigastric region. At 12 weeks of age, exploratory surgery revealed a stenotic segment in the jejunum, followed by a small transition zone and then a significantly reduced diameter. Immunohistochemical examinations were performed using antibodies against calretinin, S-100 protein, CD56, neuron specific enolase (NSE) and synaptophysin, which are the biological markers for diagnosing HSCR. CONCLUSION: A reduced number of ganglion cells (1-3 cells per ganglion) were found. There was no specific staining pattern for many of these; while for others, the pattern was compatible with HSCR. Surgical intervention to remove the stenotic section prolonged the life of the puppy for 13 years. Extremely rare pathologies such as that discussed herein should be studied to understand the pathophysiology and be able to diagnose small species in veterinary medicine in a timely fashion. To our knowledge, this is the first report of congenital intestinal stenosis and Hirschprung's disease in a newborn puppy.

A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism.

BACKGROUND: Cholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis. CASE PRESENTATION: A 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake. Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE. CONCLUSION: This appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.

Combined laparoscopic resection of intestinal stenosis of Garré and open preperitoneal mesh repair for irreducible femoral hernia.

Intestinal stenosis of Garré is a rare condition caused by a benign fibrous bowel stricture due to complicated strangulated hernia. We present a case of intestinal stenosis of Garré associated with right femoral hernia in an 85-year-old woman. The patient visited our hospital with a 2-day history of vomiting. Her abdomen was slightly distended. A mass was palpated in the right groin region. CT showed prolapse of the small intestine in the right groin region. An incarcerated right femoral hernia was diagnosed and manually reduced. Thirteen days later, the patient complained of abdominal pain. CT revealed dilatation and caliber change in part of the small bowel, indicating a small bowel obstruction due to intestinal stenosis of Garré. Laparoscopic release of the bowel obstruction and femoral hernia repair via an anterior approach were performed simultaneously. No recurrence of femoral hernia or bowel obstruction was noted at the 15-month follow-up.

Case series of Cryptogenic Multifocal Ulcerating Stenosing Enteritis (CMUSE).

BACKGROUND AND STUDY AIMS: Small bowel ulceration poses a limited, but difficult differential diagnosis. The most common causes are Crohn's disease (CD), NSAID-associated enteritis, lymphoma, cytomegaly virus infection and tuberculosis. A less known and relatively novel differential diagnosis is cryptogenic multifocal ulcerative stenosing enteritis (CMUSE). PATIENTS AND METHODS: ive patients referred for balloon-assisted enteroscopy for various reasons showed endoscopic features of CMUSE. These findings and, when available, medical imaging were reviewed in order to increase general knowledge on CMUSE. RESULTS: Five patients, 3 males and 2 females, with a mean age of 39±5 years, underwent balloon-assisted enteroscopy. Typical short, circular, ulcerative stenoses were detected in the jejunum in 2 and in the ileum in 3 patients. The number of stenoses ranged from 1 to 7 per patient. Histopathology revealed nonspecific granulocyte inflammation without specific CD findings. Stenoses were often missed on pre-enteroscopy CT or MRI enteroclysis due to their short length. Treatment consisted of endoscopic balloon dilation in 3, corticosteroids in 3, azathioprine in 1 and anti-TNFα biologicals in 3 patients. 3 patients needed additional surgery because of ongoing symptomatic small bowel stenosis or retained wireless videocapsule. CONCLUSION: In patients with short, ulcerative small intestinal stenoses CMUSE is an important but often neglected differential diagnosis. The pathophysiology and relationship to CD are subject of ongoing debate, but specific endoscopic characteristics, different histopathological findings and lack of clear abnormalities on CT or MRI enterography suggest that CMUSE is a distinct albeit rare chronic inflammatory bowel disease.

Clinical features of ten cases of cryptogenic multifocal ulcerous stenosing enteritis / 中华消化杂志

Objective To investigate the clinical features of cryptogenic multifocal ulcerous stenosing enteritis(CMUSE),and to improve the diagnosis of this rare disease.Methods From 2010 to 2015,clinical data of 10 patients with CMUSE were retrospectively analyzed,including clinical features,laboratory examination,imaging examination,appearance under endoscopy,pathologic characteristics,location of lesions,treatment and prognosis.Results Among the 10 patients with CMUSE (male six,female four),the mean age was (35.1±14.8) years.The predominant clinical manifestation was melena (eight cases),abdominal pain (eight cases) and anemia (nine cases).The results of laboratory examination showed normal in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).Among seven patients,hypersensitive C reactive protein (hsCRP) of two patients increased.Imaging examination showed intestinal stricture and appearance under endoscopic examination was intestinal ulcers and stenosis.Pathologic finding was superficial ulcers at mucosal and submucosal layers.Lesions mostly involved small intestine,and one case involving ileocecal valves and rectum.Among the 10 patients,seven patients received combination of surgical resection and prednisone treatment,and three patients were only administrated with medications.After treatment,seven patients remainedremission and three patients relapsed after remission.Immunosuppressors and enteral nutrition was effective in two of them and glucocorticoid resistance happened in one patient.Conclusions The diagnosis of CMUSE should he considered in patients with unexplained recurrent bowel obstruction,melena,anemia and concomitant intestinal ulcer and stricture.Endoscopy plays an important role in the diagnosis.Glueocorticoid is effective but easy to relapse.Immunomodulators and enteral nutrition may be considered as second-line therapy.

Retention of the cellophane wall of a patency capsule by intestinal stenosis: a report of three cases.

Here we report three cases in which the cellophane wall of the PillCam® patency capsule (tag-less PC), lacking a radio frequency identification tag, was retained. Case 1 A 33-year-old man with Crohn's disease (CD) who was administered the tag-less PC, subsequently underwent resection for perforated colon. We recovered the cellophane wall that could perforate the intestine and cause peritonitis. Case 2 A 34-year-old man with a recurring intestinal obstruction of unknown cause was administered the tag-less PC test. Computed tomography (CT) detected the cellophane wall at the oral side of an ileal stenosis. He was subsequently diagnosed with CD. Case 3 A 60-year-old woman with recurrent diarrhea was examined using CT, which revealed a thickened ileal wall. She was administered the tag-less PC test. CT detected the cellophane wall at the oral side of an ileal stenosis. Double-balloon enteroscopy revealed that the stenosis was caused by a malignant lymphoma, and the cellophane wall was simultaneously removed. Although there are numerous studies that report the usefulness and safety of tag-less PCs, few studies mention entrapment of the cellophane wall. Our present report indicated that tag-less PCs may cause such adverse effects and illustrated the usefulness of CT for detecting the trapped cellophane wall.

A 5-fluorouracil-loaded polydioxanone weft-knitted stent for the treatment of colorectal cancer.

In-stents restenosis caused by tumour ingrowth is a major problem for patients undergoing stent displacement because the conventional stents often lack a sustained anti-tumour capability. The aim of this paper was to develop a weft-knitted polydioxanone stent which can slow release 5-fluorouracil (5-FU). In order to determine the most suitable drug concentration, the 5-FU safe concentration in vivo and appropriate loading percentage in the membranes were investigated, and then 5-FU-loaded poly-l-lactide membranes at concentration of 3.2%, 6.4% and 12.8% were coated onto the stent using electro-spinning method, respectively. The morphology, chemical structure and in vitro drug release property of the coating membranes were subsequently examined. Their anti-tumour activity and mechanism were assessed in vitro and in vivo using a human colorectal cancer cell line HCT-116 and tumour-bearing BALB/c nude mice. The half maximal inhibitory concentration (IC50) and the median lethal dose (LD50) demonstrated that the 6.4% and 12.8% membranes had better anti-tumour effects than pure 5-FU due to the sustainable drug releasing property of the coated membranes on the stent. The membranes possessing appropriate drug loading doses, such as 6.4% or 12.8% also provided better anti-in-stents restenosis effects than other groups tested. Therefore, it is concluded that the drug-loaded stents have great potential for the use in the treatment of intestinal cancers in the future.

Atypical small bowel obstruction following repair of inguinal hernia: a case of intestinal stenosis of Garre.

We report an atypical case of small bowel obstruction 10 days after the repair of an inguinal hernia that had been recurrently reduced. A preoperative diagnosis of the rare intestinal stenosis of Garre is difficult, and was based on the clinical, operative and pathological findings. Forced reduction of a hernia is not recommended because of the risk of rendering its contents ischaemic with subsequent fibrotic stenosis, or reducing a strangulated bowel into the abdominal cavity with subsequent perforation and peritonitis.

Atypical Small Bowel Obstruction Following Repair of Inguinal Hernia: A Case of Intestinal Stenosis of Garré

We here report an atypical case of small bowel obstruction ten days following repair of an inguinal hernia that had been recurrently reduced. A preoperative diagnosis of this rare intestinal stenosis of Garré is difficult, and was based on the clinical, operative and pathological findings. Forced reduction of a hernia is not recommended because of the risk of rendering its contents ischaemic with subsequent fibrotic stenosis, or reducing a strangulated bowel into the abdominal cavity with subsequent perforation and peritonitis.

Role of Magnetic Resonance Enterography in Differentiating between Fibrotic and Active Inflammatory Small Bowel Stenosis in Patients with Crohn's Disease.

OBJECTIVE: To assess the diagnostic accuracy of magnetic resonance imaging (MRI) in prospectively differentiating between fibrotic and active inflammatory small bowel stenosis in patients with Crohn's disease (CD). MATERIALS AND METHODS: A total of 111 patients with histologically proven CD presenting with clinical and plain radiographic signs of small bowel obstruction underwent coronal and axial MRI scans after oral administration of polyethylene glycol solution. A stenosis was judged present if a small bowel segment had >80% lumen reduction as compared to an adjacent normal loop and mural thickening of >3 mm. At the level of the stenosis, both T2 signal intensity and post-gadolinium T1 enhancement were quantified using a 5-point scale (0: very low; 1: low; 2: moderate; 3: high; and 4: very high). A stenosis was considered fibrotic if the sum of the two values (activity score: AS) did not exceed 1. RESULTS: A small bowel stenosis was identified in 48 out of 111 patients. Fibrosis was confirmed at histology in all of the 23 patients with AS of 0 or 1, who underwent surgery within 3 days of the MRI examination. In the remaining 25 patients (AS: 2-8), an active inflammatory stenosis was suspected and remission of the obstructive symptoms was obtained by means of medical treatment. One of these patients (AS: 2), however, underwent surgery after 14 days, due to recurrence. MRI had 95.8% sensitivity, 100% specificity, and 97.9% accuracy in the diagnosis of fibrotic stenosis. CONCLUSION: MRI is reliable in differentiating fibrotic from inflammatory small bowel stenosis in CD.

Estenosis congénita de íleon en un lactante de 5 meses de edad con síndrome de obstrucción intestinal / Congenital stenosis of the ileum in a 5-month-old infant with intestinal obstruction syndrome

Introducción. La atresia intestinal se refiere a la obstrucción completa de la luz del intestino y la estenosis al bloqueo parcial de ésta. Ocurre un caso por cada 4,000 a 5,000 nacimientos y no existen diferencias de presentación en cuanto al sexo. Cuando la obstrucción es incompleta los signos como vómito, la distensión abdominal y el estreñimiento pueden aparecer poco tiempo después del nacimiento o retrasarse de forma indeterminada. No se presentan grandes dificultades para diagnosticar la atresia intestinal; en cambio es más complicado diagnosticar la estenosis. El síndrome obstructivo del lactante obliga a descartar la estenosis congénita intestinal. Se han presentado casos en edades más avanzadas aunque esto es raro. Caso clínico. Se presenta el caso de un paciente femenino de 5 meses de edad con un cuadro clínico de obstrucción intestinal que fue manejado quirúrgicamente; se encontró una estenosis congénita de íleon. La paciente evolucionó sin complicaciones. Conclusiones. El síndrome obstructivo del lactante por estenosis intestinal es una entidad rara que no suele sospecharse de primera instancia; sin embargo, debe descartarse al realizar el protocolo de estudio para obstrucción intestinal.

Background. Intestinal atresia refers to complete obstruction or partial stenosis of the intestinal lumen. The prevalence is 1/4000-5000 births, without gender predilection. When the blockage is incomplete, signs such as vomiting, abdominal distension, and constipation may occur shortly after birth or delayed in an unspecifed manner. In intestinal atresia, the challenge may not be significant; however, stenosis may pose considerable diffculties. Obstructive syndrome must be ruled out in infant congenital intestinal stenosis. Even more rare cases have occurred during later ages. Case Report. We report on a 5-month-old female infant with clinical symptoms of intestinal obstruction, which was managed surgically. Surgical finding was a congenital stricture of the ileum. The patient recovered without complications. Conclusions. Obstructive syndrome in infant intestinal stenosis is a rare entity, which is usually not first suspected, but it should be ruled out as a study protocol for intestinal obstruction.

Posttraumatic Intestinal Stenosis

We report a case of posttraumatic intestinal stenosis (PIS), an uncommon sequela of blunt abdominal trauma, in which injury to the mesentery and bowel wall results in later focal ischemic stricture of that segment. We present CT images at the time of trauma and 3 weeks later when clinical signs of intestinal obstruction occurred. At surgery, a stenotic small bowel loop was found adjacent to a healed defect in the mesentery. Histologic examination of the resected segment showed mucosal and submucosal ischemia with mucosal ulceration, mural inflammation, and fibrosis. PIS subsequent to a mesenteric tear should be included in the differential diagnosis for a patient with a history of blunt abdominal trauma and signs of intestinal obstruction.

A Clinical Study of Congenital Intestinal Atresia and Stenosis

Seventy neonates with congenital intestinal atresia and stenosis who were treated at pediatric surgical service, Hanyang University Hospital from September 1979 to December 1996 were analyzed retrospectively. The lesion occurred in 27 cases at the duodenum, in 26 cases at the jejunum, in 13 cases at the ileum, and in 2 cases at the pylorus and colon each. The atresia predominated over the stenosis by the ratio of 4 : 1. Male to female ratio was 1.3 : 1. The average gestational age was 38 weeks, and the average birth weight was 2,754 grams. Though 22.9% were borne prematurely and 34.3% had low birth weight, 92.3% of them had a weight appropriate for gestational age. The clinical manifestations were bile-stained vomiting (70%), abdominal distention (35.7%), jaundice (37.1%), and delayed passage of meconium (51.4%). Polyhydramnios (40%) was more frequently observed in duodenal and jejunal atresia while microcolon in ileal atresia (58.3%). Weight loss and electrolyte imbalance occurred more frequently in the duodenal stenosis cases because of delayed diagnosis. Twenty (55.6%) of 37 jejunoileal atresia cases had evidence of intrauterine vascular accident : 4 intrauterine intussusception, 3 intrauterine volvulus and 3 strangulated intestine in gastroschisis, and 10 cases of intrauterine peritonitis. There were one or more associated anomalies in 45 patients (64.3%). Preoperatively proximal loop volvulus developed in 3 cases and proximal loop perforation in 5 cases and one case each of distal loop perforation, duodenal perforation and midgut volvulus occurred in the jejunoileal atresia. There were 10 multiple atresia cases and 14 short bowel cases. Overall mortality rate was 20%.