Gastrointestinal autonomic nerve tumour presenting as small bowel volvulus: a rare disease with a rare presentation

A 78-year-old Chinese woman presented with recurrent postprandial abdominal pain. Computerised tomography revealed a small bowel tumour causing volvulus of a segment of the small bowel. Laparotomy confirmed an extraluminal ileal tumour with partial volvulus of the involved small bowel segment. Small bowel resection was done. Histological and ultrastructural studies confirmed a gastrointestinal autonomic nerve tumour. We review the medical literature on this rare tumour.     

Presurgical angiographic localization of small bowel bleeding site with methylene blue injection

The source of gastrointestinal hemorrhage is found in 94-95% of patients who undergo radiologic and/or endoscopic examinations of the upper or lower bowel. However, the exact presurgical localization of small bowel bleeding sites, which account for the other 5-6%, remains diagnostically difficult. We describe a previously reported and uncommon but useful angiographic technique used in conjunction with surgery which assists in this localization.     

Intussusception of the small bowel due to Peutz-Jeghers syndrome: a case report

We report the case of a 45-year-old woman with an intussusception of the small bowel due to Peutz-Jeghers syndrome. Immediate laparotomy was performed, and approximately 5 cm of the small bowel had to be removed because of ischemic areas. Six other polyps were removed through buttonhole enterotomies. The Peutz-Jeghers syndrome is rare. Treatment is either surgery or a combination of surgery and intraoperative enteroscopy. Bowel resections must be kept to a minimum.     

The small bowel enema: experience with 150 examination

Clinical application of the small bowel enema has received waxing and waning enthusiasm since it was first described in 1929. Our experiences with 150 small bowel enema studies is presented. The Sellink method was used for patients without ileostomy, (140), and retrograde studies for those with ileostomy. The merits of the small bowel enema compared to the conventional technique are discussed. The small bowel enema is the preferred method for radiologic assessment of the small bowel in patients whose clinical picture suggests small bowel disease.     

Eccentric polyposis of the small bowel. A possible radiologic sign of plexiform neurofibromatosis of the small bowel and its mesentery

Eccentric polyposis was demonstrated on the small bowel series in a patient with Von Recklinghausen's disease. This proved to represent plexiform neurofibromatosis of the small bowel and its mesentery. This unique radiographic appearance may be a radiologic sign of plexiform neurofibromatosis.     

Peritoneal band containing talc: rare cause of small bowel obstruction in a previously unoperated child

The authors report on a 10-year-old boy who was operated on for small bowel obstruction. The obstruction was caused by a peritoneal band that was found to contain talc of an unknown source. The possible explanation for this rare pathology is discussed.     

Granulocytic sarcoma of the jejunum: a rare cause of small bowel obstruction

We report the case of a 40-yr-old man presenting with symptoms of small bowel obstruction. Small bowel x-rays revealed a stricture of the mid-jejunum. Push enteroscopy found a polypoid mass at 1 meter of the ligament of Treitz. Histopathological examination of the biopsy and surgical specimens showed a diffuse infiltrate of the mucosa made of medium to large cells, which were stained on immunohistochemistry by the leucocyte marker CD45 and the histiocyte/monocyte marker CD68 but were negative for the B and T cell markers. Cytological examination of the ascitic fluid revealed many myelobasts with cytoplasmic Auer rods and positive myeloperoxidase staining. There was no evidence of blood or bone marrow involvement suggestive of acute leukemia or myeloproliferative disorders. These findings were consistent with the diagnosis of preleukemic granulocytic sarcoma (or chloroma). Chemotherapy led to complete remission, but 21 months later the patient developed an acute myeloid leukemia. He died from aspergillus pneumonitis, 10 months after bone marrow allograft. Preleukemic granulocytic sarcoma of the small bowel is a rare condition and its diagnosis is usually not easy, requiring histochemical or immunohistochemical studies. Most cases have progressed to acute myeloid leukemia.     

Myoelectric activity during small bowel allograft rejection

The effect of rejection on myoelectric activity of an orthotopically transplanted small intestinal segment (group I, N = 14) was studied. Electrodes were placed on grafts and recipient small bowel. Isografts (group II, N = 5) and native bowel (group III, N = 5) served as controls. The first morphological signs of rejection were seen on day 6 and steadily progressed until day 11, when the cellular infiltrate involved all layers of the bowel wall. Slow-wave frequencies remained unchanged throughout the observation period. No difference was detectable between grafts (group I: 31.9 +/- 1.65; group II: 31.36 +/- 0.7) and native bowel after transection (group I: 32.16 +/- 1.78; group II: 31.50 +/- 1.01), which was different (P = 0.0001) from intact bowel of group III animals (38.4 +/- 0.81). Irregular MMCs were detectable in grafts from day 5 on and replaced after food intake by random spiking activities. At day 8, spiking activities disappeared in allografts, which showed a still preserved mucosal architecture, while slow-wave activities continued. These findings demonstrate that intestinal allografts during rejection develop paralysis before mucosal destruction is established, which might be of clinical relevance.     

Nitric oxide-producing neurons remain intact after small bowel transplantation

This study documents the fate of nitric oxide neurons following small bowel transplantation. Heterotopic, syngeneic small bowel transplants were performed in five male Lewis rats. The grafts were harvested 7, 36, 55, 60, and 65 days postoperatively, together with the native bowel for comparison. NADPH diaphorase staining of cryostat sections was used to identify the nitric oxide-producing neurons. NADPH diaphorase activity was concentrated in the myenteric plexus, deep muscular, and submucous plexus. No differences were detected between the transplanted and native bowel at any time after transplantation. This suggests that nitric-oxide-producing neurons are well preserved after transplantation and that posttransplant dysmotility is probably not related to interrupted nitric oxide innervation.     

Ophthalmologic effects of bowel disease

Ocular findings in diseases affecting primarily the digestive tract are relatively rare; however, it is important for the physician to recognize these relationships, appropriately uncover symptoms related to the eye disease, and have the patient evaluated by an ophthalmologist if indicated. In addition, ocular inflammation may be the first indication of bowel disease (e.g., uveitis in Crohn's disease). This article describes the associations between ocular diseases and gastrointestinal diseases and their causes, signs, symptoms, prognosis, and treatment.     

Constipation, diarrhea, and irritable bowel syndrome

Constipation, diarrhea, and irritable bowel syndrome are commonly encountered in the primary care practice. Most episodes of constipation and diarrhea are benign and self-limited. Patients with chronic constipation should undergo a screening evaluation to exclude organic disease, after which most can be managed successfully with dietary modification and fiber supplementation. The cause of chronic diarrhea usually can be discerned clinically, with irritable bowel syndrome, inflammatory bowel disease, and lactose intolerance being diagnosed most frequently. Irritable bowel syndrome is a functional gastrointestinal disorder characterized by abdominal pain and disordered defecation, which is successfully managed with a strong physician-patient relationship and periodic pharmacologic intervention.     

Intestinal motility after massive small bowel resection

To evaluate intestinal motility after 80% massive distal small bowel resection (MSBR), we continuously monitored interdigestive and postprandial bowel motility using bipolar electrodes and/or contractile strain gage force transducers in conscious beagle dogs before, and at 0-4 weeks and 8-13 months after the surgery. Fasting duodenal migrating myoelectric (or motor) complexes (MMCs) occurred at longer intervals in the short-term after 80% MSBR than in controls, and were simulated in long-term that in controls. MMCs arising from the duodenum were often migrated to the proximal jejunum, the jejunum above the anastomosis, and to the terminal ileum beyond the anastomosis. The velocity of duodenal MMC propagation was slowed in every intestinal segment in the short-term, and had not recovered even long after the operation. The duration of the postprandial period without duodenal MMCs was prolonged significantly in the short-term, and still remained longer in the long-term than in controls. These findings suggest that changes in gut motility after MSBR tend to compensate for the shorter intestine and maintain small bowel absorption early postoperatively, and adaptations of motility would occur over the long-term to increased intestinal absorption.     

A new method of intestinal salvage for severe small bowel ischemia

The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.     

Community experience with small bowel bypass for morbid obesity

A comparison of small bowel bypass performed at university centers and by private practitioners in a large metropolitan area demonstrates definite stmilarities in terms of patient selection, mortality and morbidity, and weight loss results. The only aspect of small bowel bypass in the private sector that could be criticized would be the adequacy of follow-up. An operation with as many known and probably other unknown long-term complications as jejunoileal bypass necessitates prolonged careful patient follow-up. We belive the person most qualified to provide such follow-up is the surgeon who performed by bypass procedure.     

Quality of life issues: parenteral nutrition to small bowel transplantation--a review

Parenteral nutrition (PN) has given life to patients with chronic intestinal failure who would otherwise have died. Home parenteral nutrition has improved the quality of life for many children. However, morbidity from this therapy remains significant with complications of line sepsis, lack of venous access, hepatic dysfunction, and pulmonary embolism. These complications are common in younger children. Detailed discussion must take place with the family regarding risks and benefits of PN. In those children developing complications of PN, intestinal transplantation is a logical extension of treatment. Early referral of patients for assessment is vital because significant mortality occurs when liver disease is established. Time is needed to counsel families on the potential benefits and risks of this treatment, including the physical and emotional demands made on the child and family. Overall worldwide survival for isolated small bowel transplantation is currently 50% and for combined small bowel and liver transplantation 40%. Significant complications are rejection, sepsis, and lymphoproliferative disease. Postoperative management can be complex and prolonged; child and parents require a great deal of physical and emotional support. The burden of care for parents decreases significantly after the first year. Small bowel transplantation offers a realistic alternative to PN. The choice of treatments is influenced by expected quality of life, which is just beginning to be evaluated.     

Laparoscopic intervention to relieve small bowel obstruction following laparoscopic herniorrhaphy

In this report, we present two cases of small bowel obstruction after laparoscopic herniorrhaphy (LH). One case involved incarceration of the small intestine into the port site, resulting in obstruction in an 80-year-old man on the third day after LH. The other case involved a 78-year-old man with bilateral inguinal hernia and a recurrent type on one side. In this case, a small bowel obstruction occurred due to intestinal herniation through the repaired peritoneum in the pelvic floor. In both cases, the location of the obstruction was diagnosed by means of a computed tomography scan. Subsequently, the trocar incision was extended to relieve obstruction with laparotomy in the first case, and the herniated intestinal loop was extracted followed by reclosure of the defective peritoneum under laparoscopic intervention in the second case. After the second operation, the clinical course of each patient was uneventful, and they were discharged from hospital at 10 days after the second surgery. In conclusion, (a) although patients can greatly benefit from LH, it must be kept in mind that problems can occur and (b) laparoscopic surgery to relieve small bowel obstruction following LH is the preferred procedure.     

Small bowel causes of per rectum haemorrhage

The majority of cases of per rectal haemorrhage (PRH) are due to colorectal causes within the diagnostic reach of the colonoscope. However a few cases are from the small bowel which may pose difficulty and delay in diagnosis. We reviewed 1489 patients with PRH from 1989 to 1993 and identified 10 cases of bleeding originating from the small bowel (0.7%). These were diagnosed when both the colonoscopy and upper gastrointestinal endoscopy were negative or by observing blood coming through the ileo-caecal valve. The causes were Meckel's diverticulum (4), leiomyoma (1), intussusception (1), lymphoma (1), carcinoma (1), Crohn's disease (1) and vasculitis (1). Six cases presented with active bleeding and haemodynamic instability; 4 had chronic bleeding associated with anaemia. Bleeding from Meckel's diverticulum could be differentiated by age, mid-20s or younger compared with mid-40s or older of non-Meckel's cases. Small bowel causes need to be considered in PR bleeding unexplained on colonoscopy and oesophagogastroduodenoscopy findings. A 99mtechnetium isotope scan is most likely to be of help in the young adult but from mid-life onwards, however, other techniques such as small bowel barium studies are required.     

Diagnosis of small intestinal bacterial overgrowth in clinical praxis: a comparison of the culture of small bowel aspirate, duodenal biopsies and gastric aspirate

BACKGROUND/AIMS: This study was undertaken to validate the usefulness of the culture of duodenal biopsy specimens and gastric aspirate compared to the culture of small bowel aspirate for diagnosing small intestinal bacterial overgrowth. We also investigated the occurrence of predisposing conditions in these patients. METHODOLOGY: Seventy five consecutive patients, admitted because of symptoms which caused us to suspect small intestinal bacterial overgrowth, were studied. For all patients, specimens for the culture of small bowel aspirate, duodenal biopsies and gastric aspirate were obtained during upper endoscopy. RESULTS: Eighteen patients showed growth of gram negative bacteria, 22 growth of gram positive bacteria and 35 showed no significant growth in cultures of small bowel aspirate. Cultures of duodenal biopsies revealed gram negative bacteria in 11 patients, gram positive bacteria in 9 and no growth in 55. Cultures of gastric aspirate revealed gram negative bacteria in 7 patients, gram positive bacteria in 12 and no growth in 51. Ten of the 18 patients with gram negative overgrowth and 13 of the 22 patients with gram positive overgrowth had a predisposing condition. In contrast, only 4 of the 35 without overgrowth had a predisposing condition. CONCLUSIONS: The culture of duodenal biopsy specimens or gastric aspirate is a less sensitive method than the culture of small bowel aspirate. Most patients with culture-proven small intestinal bacterial overgrowth had at least one predisposing condition.     

The menstrual cycle and its effect on inflammatory bowel disease and irritable bowel syndrome: a prevalence study

OBJECTIVE: Female patients with bowel disease commonly report worsening symptoms in relation to the menstrual cycle. Our aim was to determine the nature of gastrointestinal symptoms correlating with the menstrual cycle in women with inflammatory and irritable bowel disease. METHODS: This was a retrospective study involving 49 women with ulcerative colitis (UC), 49 women with Crohn's disease (CD), 46 women with irritable bowel syndrome (IBS), and 90 healthy community controls. Participants were interviewed using a questionnaire including information regarding general health, medication history, pregnancy, as well as premenstrual and menstrual symptoms. Chi2 testing and logistic regression modeling were used to test for differences in frequencies between groups and for risk analysis. RESULTS: Premenstrual symptoms were reported by 93% of all women but statistically more often by patients with CD (p < 0.01). CD patients were also more likely to report increased gastrointestinal symptoms during menstruation ( < 0.01), diarrhea being the symptom reported most often. All disease groups had a cyclical pattern to their bowel habits significantly more than controls (p=0.01). Cyclical symptoms included diarrhea, abdominal pain, and constipation. Logistic regression revealed an odds ratio (OR) of 1.1 (95% CI 0.9-1.2) for experiencing bowel symptoms during the premenstrual and menstrual phases and an OR of 2.0 (95% CI 1.2-3.2) for experiencing a cyclical pattern in bowel habit changes in women with bowel disease. CONCLUSION: The prevalence of menstrually related symptoms is high, and appears to affect bowel patterns. The physiological and clinical effects of the menstrual cycle should be taken into consideration when assessing for disease activity.     

Aflatoxin B1-adduct formation in rat and human small bowel enterocytes

BACKGROUND/AIMS: Hepatic CYP3A enzymes have been implicated in the bioactivation of aflatoxin B1 (AFB1) to DNA binding metabolites. CYP3A enzymes are also abundant in the small bowel, and we therefore examined the ability of this tissue to form intracellular AFB1 adducts. METHODS: Immunohistochemistry using a antibody to the stable AFB1-DNA adduct was performed on small bowel sections obtained from rats orally gavaged with AFB1 and on human small bowel biopsy specimens maintained in explant culture. 3H-AFB1 was instilled into a loop of small bowel of untreated rats and rats pretreated with the CYP3A inducer dexamethasone during vivisection. DNA was isolated from the loop 2 hours later and assayed for specific activity. RESULTS: In both rats and humans, AFB1-adducts were detected exclusively in mature enterocytes in a pattern similar to the distribution of CYP3A enzymes. Induction of enterocyte CYP3A in rats resulted in an increase in enterocyte immunoreactive AFB1 adducts and in a 1.8-fold increase in 3H-AFB1-nucleic acid adducts (P = 0.01). CONCLUSIONS: Intracellular AFB1 adducts are formed in the small intestine, and this reflects, at least in part, the catalytic activity of CYP3A enzymes. Because these AFB1 adducts should ultimately pass in stool, enterocyte CYP3A may represent a regulatable barrier to dietary aflatoxins.