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Intussusception is defined as the invagination of a proximal segment of the bowel into the adjoining or distal segment. In most adults with intussusception, there is a demonstrable lead point with a definite pathologic abnormality. The clinical features of intussusception include chronic intermittent abdominal pain, nausea and vomiting, constipation, and a palpable abdominal mass. The present case report describes a 62-year-old woman with a 2-week history of abdominal pain and 9-day history of vomiting. Clinical, imaging, and histologic evaluations revealed a jejunojejunal intussusception with a gastrointestinal stromal tumor as the lead point. A gastrointestinal stromal tumor should be considered as a possible lead point in adult patients with intussusception. The implication of reducing the intussusception prior to tumor resection requires further evaluation in view of the risk of venous embolism, including direct spread of malignant cells, in cases involving a large polypoid mass with a necrotic surface that extends to the serosa as shown by intraoperative examination. Accordingly, the rationale for adjuvant therapy with imatinib also requires further evaluation., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

A well-functional intestinal mucosal barrier can be compromised as a result of various diseases, chemotherapy, radiation, and chemical exposures including surfactants. Currently, there are no approved drugs targeting a dysfunctional intestinal barrier, which emphasizes a significant medical need. One candidate drug reported to regulate intestinal mucosal permeability is melatonin. However, it is still unclear if its effect is primarily receptor mediated or antioxidative, and if it is associated with enteric neural pathways. The aim of this rat intestinal perfusion study was to investigate the mechanisms of melatonin and nicotinic acetylcholine receptors on the increase in intestinal mucosal clearance of 51 Cr-labeled ethylenediaminetetraacetate induced by 15 min luminal exposure to the anionic surfactant, sodium dodecyl sulfate. Our results show that melatonin abolished the surfactant-induced increase in intestinal permeability and that this effect was inhibited by luzindole, a melatonin receptor antagonist. In addition, mecamylamine, an antagonist of nicotinic acetylcholine receptors, reduced the surfactant-induced increase in mucosal permeability, using a signaling pathway not influenced by melatonin receptor activation. In conclusion, our results support melatonin as a potentially potent candidate for the oral treatment of a compromised intestinal mucosal barrier, and that its protective effect is primarily receptor-mediated.

Intestinal tissue is highly susceptible to ischemia/reperfusion injury in many hazardous health conditions. The anti-inflammatory and antioxidant glycoprotein fetuin-A showed efficacy in cerebral ischemic injury; however, its protective role against intestinal ischemia/reperfusion remains elusive. Therefore, this study investigated the protective role of fetuin-A supplementation against intestinal structural changes and dysfunction in a rat model of intestinal ischemia/reperfusion. We equally divided 72 male rats into control, sham, ischemia/reperfusion, and fetuin-A-pretreated ischemia/reperfusion (100 mg/kg/day fetuin-A intraperitoneally for three days prior to surgery and a third dose 1 h prior to the experiment) groups. After 2 h of reperfusion, the jejunum was dissected and examined for spontaneous contractility. A jejunal homogenate was used to assess inflammatory and oxidative stress enzymes. Staining of histological sections was carried out with hematoxylin, eosin and Masson's trichrome stain for evaluation. Immunohistochemistry was performed to detect autophagy proteins beclin-1, LC3, and p62. This study found that fetuin-A significantly improved ischemia/reperfusion-induced mucosal injury by reducing the percentage of areas of collagen deposition, increasing the amplitude of spontaneous contraction, decreasing inflammation and oxidative stress, and upregulating p62 expression, which was accompanied by beclin-1 and LC3 downregulation. Our findings suggest that fetuin-A treatment can prevent ischemia/reperfusion-induced jejunal structural and functional changes by increasing antioxidant activity and regulating autophagy disturbances observed in the ischemia/reperfusion rat model. Furthermore, fetuin-A may provide a protective influence against intestinal ischemia/reperfusion complications.

Ischemia/reperfusion (I/R)-induced rapid inflammation involving activation of leukocyte-endothelial adhesive interactions and leukocyte infiltration into tissues is a major contributor to postischemic tissue injury. However, the molecular mediators involved in this pathological process are not fully known. We have previously reported that caveolin-2 (Cav-2), a protein component of plasma membrane caveolae, regulated leukocyte infiltration in mouse lung carcinoma tumors. The goal of the current study was to examine if Cav-2 plays a role in I/R injury and associated acute leukocyte-mediated inflammation. Using a mouse small intestinal I/R model, we demonstrated that I/R downregulates Cav-2 protein levels in the small bowel. Further study using Cav-2-deficient mice revealed aggravated postischemic tissue injury determined by scoring of villi length in H&E-stained tissue sections, which correlated with increased numbers of MPO-positive tissue-infiltrating leukocytes determined by IHC staining. Intravital microscopic analysis of upstream events relative to leukocyte transmigration and tissue infiltration revealed that leukocyte-endothelial cell adhesive interactions in postcapillary venules, namely leukocyte rolling and adhesion were also enhanced in Cav-2-deficient mice. Mechanistically, Cav-2 deficiency increased plasminogen activator inhibitor-1 (PAI-1) protein levels in the intestinal tissue and a pharmacological inhibition of PAI-1 had overall greater inhibitory effect on both aggravated I/R tissue injury and enhanced leukocyte-endothelial interactions in postcapillary venules in Cav-2-deficient mice. In conclusion, our data suggest that Cav-2 protein alleviates tissue injury in response to I/R by dampening PAI-1 protein levels and thereby reducing leukocyte-endothelial adhesive interactions. NEW & NOTEWORTHY The role of caveolin-2 in regulating ischemia/reperfusion (I/R) tissue injury and the mechanisms underlying its effects are unknown. This study uses caveolin-2-deficient mouse and small intestinal I/R injury models to examine the role of caveolin-2 in the leukocyte-dependent reperfusion injury. We demonstrate for the first time that caveolin-2 plays a protective role from the I/R-induced leukocyte-dependent reperfusion injury by reducing PAI-1 protein levels in intestinal tissue and leukocyte-endothelial adhesive interactions in postcapillary venules.

Ischemic jejunal stricture due to mesenteric vein thrombosis (MVT) rarely occurs in patients with extrahepatic portal vein obstruction (EHPVO). This is because the thrombus often occludes only a short segment of superior mesenteric vein adjacent to splenoportal confluence, facilitating development of collateral veins that protect bowel from ischemia. However, ischemic strictures can develop when the thrombus involves jejunal veins, venous arcades or vasa recta. We report three patients with EHPVO, who developed jejunal strictures due to MVT. They presented with symptoms of proximal bowel obstruction. Two of these patients had evidence of recurrent deep vein thrombosis (DVT), suggesting possibility of an underlying prothrombotic state. One of them had completely occluded bilateral iliac veins and inferior vena cava following DVT, 10 years ago. At the same time, he was identified as having a portal cavernoma. Contrast-enhanced computed tomography showed portal cavernoma together with MVT in all the patients. The thrombus was identified in the jejunal veins in two patients and in the entire superior mesenteric vein up to splenic vein in one patient. All three patients were found to have a tight concentric stricture involving a long length of proximal jejunum. Two patients required urgent surgical intervention and one died.

Competing Interests: Competing interests: None declared.

Rationale: Intussusception is defined as the invagination or telescoping of a proximal portion of the intestine into the distal portion of the intestine. Intussusception can occur at any age but is more common among children. Most cases of intussusception in adults have a pathological lead point. Inflammatory fibroid polyp (IFP) is a rare benign tumor-like lesion arising from the submucosa of the gastrointestinal tract that can cause intussusception in adults. Here, we report a case of adult intussusception due to IFP. We also present a literature review of 31 reports including 34 cases between 2012 and December 2019, which shows a mean age of 45.4 ± 14.2 years and female dominance (23/34) of intussusception due to IFP., Patient Concerns: A 47-year-old man presented with a half-day history of epigastric abdominal pain. Physical examination revealed distension and tenderness of the upper abdomen. Computed tomography (CT) of the abdomen and pelvis demonstrated intussusception of the jejunum along with a suspicious jejunal mass associated with mesenteric lymphadenopathies., Diagnosis: Intussusception of the jejunum along with a suspicious jejunal mass, and histopathological examination of the resected specimen showed IFP., Interventions: The patient underwent emergency laparotomy. The intussusception was resected without attempts for reduction., Outcomes: The postoperative period was uneventful, and the patient was discharged on the fourth postoperative day., Lessons: Intussusception in adults is rare, especially that secondary to IFP. The most commonly used diagnostic tool for adult intussusception is abdominal CT, and the optimal management is resection of the involved bowel segment without reduction if malignancy cannot be ruled out.

Competing Interests: Declaration of Competing Interest None declared.

Rationale: Although percutaneous endoscopic gastrojejunostomy (PEG-J) tubes are believed to reduce the side effect of aspiration, cautious catheter management is required. Intussusception is a serious complication of these tubes., Patient Concerns: A 7-year-old boy bedridden with hypoxic encephalopathy owing to drowning at the age of 1 year was admitted our hospital with urinary retention for 1 month. At the age of 4 years, a PEG-J tube was inserted. Concomitant with hyperaldosteronemia, an intestinal intussusception from the duodenum to the jejunum was observed via computed tomography (CT). The patient's condition worsened dramatically; gastrointestinal perforation was suspected, and laparotomy was performed., Diagnosis: Jejuno-jejunal intussusception., Interventions: Open surgery was performed to release the intussusception. By assessing the reduced intestinal tract, the intussusception starting from a 50 cm portion from the Treitz ligament had been extended to 100 cm from the Treitz ligament. The oral side jejunum was dilated. No evidence of intestinal perforation or strangulated ileus was observed, and the intussusception was manually remediable., Outcomes: Preoperative CT examination showed intussusception from the duodenum to the jejunum. Laparotomy showed intussusception on the anal side of the Treitz ligament. With regard to the CT findings associated with the progression of intussusception to the duodenal site, as a result of the telescope phenomenon extending to the duodenum due to the relaxation of the Treitz ligament through repeated intussusception, it was considered that CT examination revealed intussusception extending from the jejunum to the duodenum of oral side. After 3 postoperative weeks, the patient was finally able to return home., Lessons: If the ileus is observed during the insertion of a PEG-J, clinicians should consider the possibility of intussusception even in the duodenum.

Competing Interests: Competing interests: None declared.

Mucormycosis is generally considered to be an acute, rapidly progressing, opportunistic fungal infection. Chronic manifestations are extremely rare. Mucormycosis affecting the jejunum is very rare and few cases have been reported. We report a case of mucormycosis causing jejunal stricture in an infant aged six months.

Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.

Jejunal diverticulosis is an underdiagnosed condition due to its relatively benign existence and uncharacteristic presentation. The complications can be very severe and, due to its often late diagnosis, patients may require urgent surgery. We present a woman who initially complained of non-specific abdominal symptoms but was diagnosed with a contained jejunal diverticular perforation relatively early. We managed her non-operatively with intravenous antibiotics from which she recovered well. She was discharged 2 days later and has remained completely well. Follow-up at 3 months showed no recurrence. Our case differs from most of the literature due to the early diagnosis and successful non-operative management of the patient. We conclude that, in cases of non-specific abdominal pain with diagnostic ambiguity, a diagnosis of small bowel diverticulosis should be considered. It should be managed non-operatively where possible., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Although erosions and ulcerations are the most common small-bowel abnormalities found on wireless capsule endoscopy (WCE), a computer-aided detection method has not been established. We aimed to develop an artificial intelligence system with deep learning to automatically detect erosions and ulcerations in WCE images., Methods: We trained a deep convolutional neural network (CNN) system based on a Single Shot Multibox Detector, using 5360 WCE images of erosions and ulcerations. We assessed its performance by calculating the area under the receiver operating characteristic curve and its sensitivity, specificity, and accuracy using an independent test set of 10,440 small-bowel images including 440 images of erosions and ulcerations., Results: The trained CNN required 233 seconds to evaluate 10,440 test images. The area under the curve for the detection of erosions and ulcerations was 0.958 (95% confidence interval [CI], 0.947-0.968). The sensitivity, specificity, and accuracy of the CNN were 88.2% (95% CI, 84.8%-91.0%), 90.9% (95% CI, 90.3%-91.4%), and 90.8% (95% CI, 90.2%-91.3%), respectively, at a cut-off value of 0.481 for the probability score., Conclusions: We developed and validated a new system based on CNN to automatically detect erosions and ulcerations in WCE images. This may be a crucial step in the development of daily-use diagnostic software for WCE images to help reduce oversights and the burden on physicians., (Copyright © 2019 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Heterotopic pancreas (HP) is localized pancreatic tissue that has no relation to orthotopic pancreas and has its own channel and vascular structures. Usually, the submucosa is located in the upper gastrointestinal tract; mesenteric placement is rarely reported. It is frequently asymptomatic and is detected incidentally in imaging, laparotomies, or autopsies. Rarely, pancreatitis may be the cause of small bowel obstruction, massive gastrointestinal bleeding, and malignant transformation. However, this has usually been reported in localized submucosal HP cases. The imaging findings are typical, and the diagnosis can be verified without the need for a histopathological diagnosis. In this case report, we aimed to present the imaging findings of asymptomatic HP located in the proximal jejunum mesentery of a 44-year-old woman. To avoid unnecessary surgical procedures, the characteristic imaging findings of HP are understood and should be considered in the differential diagnosis of masses seen in the mesentery.

Stenosis of the pancreaticodigestive anastomosis (pancreaticogastrostomy and pancreaticojejunostomy) is a very rare complication that usually develops several years after pancreaticoduodenectomy (PD). Only a few cases have been previously reported. We have reviewed the literature and present 2 more cases of pancreaticojejunostomy stenosis that started with episodes of recurrent acute pancreatitis 6 years and 1 year after PD, respectively. Diagnosis was based on symptoms of pancreatitis (12-15 episodes between 5 and 20 months after PD) and CT and MRI scans. Both patients were treated by resection of the pancreaticojejunostomy stenosis, including a 1-cm slice of pancreatic parenchyma in contact with the jejunum, followed by a new well-vascularized two-layer end-to-side PJ with external drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both cases, and after a follow-up period of 3 and 2.5 years, respectively, the patients remain asymptomatic but with endocrine and exocrine insufficiency. Resection of the PJ and construction of a new PJ with external stent drainage of the Wirsung duct is our preferred surgical option in the rare cases of PJ stenosis after a Whipple procedure., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Ectopic pancreas also known as heterotopic pancreas (HP) is a rare congenital anomaly, mainly found as incidental finding during autopsy or abdominal exploration for an other condition. Incidence rate is probably underestimated as patients are mostly asymptomatic; otherwise, it is capable of producing symptoms depending on its location, size, often appearing in the 4th-to-6th decades. Complications such as inflammation, obstruction, bleeding, and malignancy degeneration must be considered. Pediatrics cases are very rare, generally concerning HP within Meckel's diverticulum, manifesting by gastrointestinal bleeding and intussusception. We report a rare case of jejunum bleeding, due to an isolated HP in a 15-year-old adolescent. Endoscopic and computed tomographic scan were normal, in particular did not found Meckel's diverticulum. Diagnosis and treatment have been apprehended performing a laparoscopic exploration. It is a singular location for HP, predominantly found in upper gastrointestinal tractus. So far, there have been no case reports of jejunal bleeding from ectopic pancreas without Meckel's diverticulum in children.

Aim: To investigate the intra-observer and interobserver variability of quantitative apparent diffusion coefficient (ADC) measurements in children with inflammatory bowel disease., Materials and Methods: Nine readers were recruited. Six magnetic resonance imaging (MRI) enterography cases with known active disease in the jejunum, terminal ileum, or colon were analysed. Readers measured repeat ADC values from the known diseased site and an unaffected site, at two sittings., Results: Seven readers completed the study. The Lin concordance coefficient for intra-observer agreement was poor (0.844, 95% confidence interval [CI]: 0.77, 0.896). Bland-Altman limits of agreement for intra-observer agreement were 0.66×10 -3 mm 2 /s (95% CI: 0.46, 0.86), and -0.56×10 -3 mm 2 /s (95% CI: -0.36, -0.76). Therefore, a single measured value would be compatible with no disease, superficial ulceration, or deep ulceration according to published thresholds. Interobserver variability was poor to moderate across all observers (intraclass correlation coefficient [ICC]: 0.51, 95% CI: 0.27, 0.77). Between the two best-agreeing observers, agreement was good using the ICC (ICC 0.85, 95% CI: 0.43, 1.0), but poor using the Lin correlation coefficient (Lin 0.83, 95% CI: 0.65, 0.93), and Bland-Altman., Conclusion: The intra-observer and interobserver agreement is inadequate to allow accurate characterisation of disease activity using previously published thresholds. Qualitative ADC assessment may be preferable., (Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objective: To observe ulcer characteristics of Crohn's disease under double balloon enteroscopy, and to evaluate the correlation between endoscopic severity and clinical manifestations.
 Methods: A prospective, observational study from July 2015 to December 2016 in the Third Xiangya Hospital, Central South University, we selected 45 patients with positive double-balloon enteroscopy (DBE) and confirmed Crohn's disease. Two digestive internal physician observed the ulcer characteristics of Crohn's disease under double balloon enteroscopy, and gave a simple endoscopic score for CD (SES-CD). We analyzed the correlation between SES-CD and Crohn's disease activity index (CDAI).
 Results: DBE indicated 24 patient ulcers (53.33%) locating at the end of the ileum, 5 (11.11%) locating at ileocolon, 16 (35.56%) locating at upper gatrointestinal tract and they did not affect the end of the ileum. Among them, 8 cases (17.78%) affected only jejunum. Thirty-two patients with longitudinal ulcers in Crohn's disease, accounting for 71.11%. There was no correlation between SES-CD score and CDAI score (r=0.237, P=0.136).
 Conclusion: The ulcerative appearance in Crohn's disease were diverse under double balloon enteroscopy. Crohn's disease could only affect the upper gastrointestinal tract or jejunum. The unwounded ileum and ileocecal valve couldn't be a sign to exclude Crohn's disease. CDAI score couldn't fully assess the prognosis of Crohn's disease.

Somatostatins are proteins that are involved in gastrointestinal function. However, little is known with regard to somatostatin receptor subtype (SSTR) expression changes that occur in the jejunum during low-grade inflammation and during subsequent octreotide treatment. The aim of the present study was to investigate the expression of SSTRs in the jejunums of Cryptosporidium parvum (C. parvum)-infected rats by immunohistochemisty, reverse transcription (RT) PCR and quantitative real-time RT-PCR assays. Five-day-old suckling Sprague-Dawley rats (n = 15 for each group) were orally gavaged with 105 Nouzilly isolate (NoI) oocysts. Rats then received 50 μg/kg/day of octreotide by intraperitoneal injection from day 10 to day 17 post-infection. Animals were sacrificed on days 7 and 14 post-infection for immunohistochemical analysis and on days 14, 35 and 50 for mRNA expression analysis of SSTR subtypes. Histological analysis of jejunum tissues demonstrated infection of C. parvum along the villus brush border on day 7 post-infection and infection clearance by day 14 post-infection. Real-time PCR analysis indicated that in the inflamed jejunum, a significant increase in SSTR1 and SSTR2 expression was observed on day 14 post-infection. Octreotide therapy down-regulated the expression of SSTR2 on day 37 post-infection but significantly increased expression of SSTR1, SSTR2 and SSTR3 on day 50 post-infection. The results indicate that specific SSTRs may regulate the inflammatory pathway in the rat intestinal inflammation model.

Background/aims: Circular RNAs (circRNAs) make up a large class of non-coding RNAs and play important roles in a variety of diseases, including nervous system diseases and cancers. The intestinal epithelium is sensitive to ionizing radiation, radiotherapy of abdominal or pelvic tumors or nuclear accident exposure can lead to high radiation toxicity, which can result in radiation-induced intestinal injury. The goal of this present study was to analyze the potential roles of circRNAs in radiation-induced intestinal injury., Methods: Mice were divided into two groups: control group and irradiated group. Irradiated group was 3.5 days after 14Gy abdominal irradiation (ABI) group. We started with RNA-seq of circRNA changes in mouse jejuna after radiation and validated by RT-PCR in the following experimental. miRNAs targeted mRNAs were predicted using proprietary software based on target scan and Miranda. The network of circRNA-miRNA-mRNA was illustrated by cytoscape software., Results: 2751 circRNAs were detected in the two groups. At day 3.5 post-radiation, 42 and 48 circRNAs were found to be significantly upregulated and downregulated, respectively, compared to the control (p≤0.05, Fold Change ≥2). Further, the altered expression of 10 circRNAs (chr18: 35610871-35613502+, chr15: 95864225-95894541+, chr3: 96041338-96042928-, chr5: 64096979-64108263+, chr19: 16705875-16710941-, chr5: 134491893-134500149-, chr19: 42562552-42564341+, chr5: 32640331-32664400+, chr3: 72958113-72960367- and chr8: 79343654-79372364-) were verified by RT-PCR. Compared the miRNA-targeted mRNAs with our mRNAs sequencing data, we found 14 upregulated circRNA-targeted mRNAs were also unregulated and 22 downregulated circRNAs-targeted mRNAs were also downregulated. Gene ontology and KEGG pathway analyses indicated the predicted genes were mainly involved in the MAPK signaling pathway., Conclusions: This study reveals that expression of circRNAs was altered in the jejuna of mice post-irradiation and provides a resource for the study of circRNAs in radiation-induced intestinal injury and repair., (© 2018 The Author(s). Published by S. Karger AG, Basel.)

Background: Small bowel necrosis after enteral feeding through a jejunostomy tube (tube feed necrosis, TFN) is a rare, serious complication of major abdominal surgery. However, strategies to reduce the incidence and morbidity of TFN are not well established. Here, in the largest series of TFN presented to date, we report our institutional experience and a comprehensive review of the literature., Methods: Eight patients who experienced TFN from 2000 to 2014 after major abdominal surgery for oncologic indications at the University of Cincinnati were reviewed. Characteristics of post-operative courses and outcomes were reviewed prior to and after a change in tube-feeding protocol. The existing literature addressing TFN over the last three decades was also reviewed., Results: Patients with TFN ranged from 50 to 74 years old and presented with upper gastrointestinal tract malignancies amenable to surgical resection. Six and two cases of TFN occurred following pancreatectomy and esophagectomy, respectively. Prior to TF protocol changes, which included initiation at a low rate, titrating up more slowly and starting at one-half strength TF, three of six cases of TFN (50%) resulted in mortality. With the new TF protocol, there were no deaths, goal TF rate was achieved 3 days later, symptoms of TFN were recognized 3 days earlier, and re-operation was conducted 1 day earlier., Conclusion: This case series describes a change in clinical practice that is associated with decreased morbidity and mortality of TFN. Wider implementation and further refinement of this tube-feeding protocol may reduce TFN incidence at other institutions and in patients with other conditions requiring enteral nutrition.

Purpose: The jejunum is a relatively uncommon localization of Crohn's disease (CD) compared to the terminal ileum or the large bowel. The type of surgery and the short and long-term results after surgery have not been extensively investigated. A review of patients who underwent surgery for jejunal CD in our center was examined., Methods: Between 1986 and 2011, 110 patients underwent surgery for jejunal CD. Thirty patients (27.3 %) were surgically treated with resection, 29 patients (26.4 %) with one or more strictureplasties, and 51 patients (46.3 %) with both a resection and one or more strictureplasties., Results: There was no statistical difference in terms of short-term postoperative complications between patients operated with three different options (p = 0.72). Patients were followed up for a period ranging from 2 to 18 years (mean 11 years). During this period, 42 patients had no CD recurrence, 11 patients had medical recurrences only, while 57 patients had surgical recurrences, too. There was no statistical difference in terms of medical and surgical recurrence between the three types of surgical procedures employed (p = 0.24) and between smokers and non-smokers. The recurrent CD was prevalently treated with strictureplasty., Conclusions: The most frequently employed surgery for the treatment of jejunal CD is a combined type of treatment, i.e., resection of the most affected tract and strictureplasty of the residual strictures. This approach does not imply an increased risk of postoperative complications and recurrence and can reduce the risk of the short bowel syndrome.

Rationale: The objective of this autopsy study was to determine whether gastrointestinal angiodysplasia develops during continuous-flow left ventricular assist device (LVAD) support., Objective: LVAD support causes pathologic degradation of von Willebrand factor (vWF) and bleeding from gastrointestinal angiodysplasia at an alarming rate. It has been speculated that LVAD support itself may cause angiodysplasia. The relationship to abnormal vWF metabolism is unknown. We tested the hypothesis that abnormal gastrointestinal vascularity develops during continuous-flow LVAD support., Methods and Results: Small bowel was obtained from deceased humans, cows, and sheep supported with a continuous-flow LVAD (n=9 LVAD, n=11 control). Transmural sections of jejunum were stained with fluorescein isothiocyanate-conjugated isolectin-B4 for endothelium to demarcate vascular structures and quantify intestinal vascularity. Paired plasma samples were obtained from humans before LVAD implantation and during LVAD support (n=41). vWF multimers and degradation fragments were quantified with agarose and polyacrylamide gel electrophoresis and immunoblotting. Abnormal vascular architecture was observed in the submucosa of the jejunum of human patients, cows, and sheep supported with a continuous-flow LVAD. Intestinal vascularity was significantly higher after LVAD support versus controls (5.2±1.0% versus 2.1±0.4%, P =0.004). LVAD support caused significant degradation of high-molecular-weight vWF multimers (-9±1%, P <0.0001) and accumulation of low-molecular-weight vWF multimers (+40±5%, P <0.0001) and vWF degradation fragments (+53±6%, P <0.0001)., Conclusions: Abnormal intestinal vascular architecture and LVAD-associated vWF degradation were consistent findings in multiple species supported with a continuous-flow LVAD. These are the first direct evidence that LVAD support causes gastrointestinal angiodysplasia. Pathologic vWF metabolism may be a mechanistic link between LVAD support, abnormal angiogenesis, gastrointestinal angiodysplasia, and bleeding., (© 2017 American Heart Association, Inc.)

The global incidence of Fusarium head blight and attendant cereal grains multi-contamination by the trichothecene mycotoxins deoxynivalenol (DON) and nivalenol (NIV) are increasing as a possible result of climate change and inadequate agricultural practices. At the molecular level, these mycotoxins bind to the ribosome, activate the mitogen-activated protein kinase and induce a local and systemic inflammation. DON is of public health concern owing to the narrow margin between exposure and tolerable daily intake. The intestinal inflammatory response to DON, NIV and their mixture was analyzed to determine thresholds for their intestinal pro-inflammatory effects and characterize the type and magnitude of their interaction. Fully differentiated three-dimensional porcine jejunal explants were exposed to increasing doses of DON and NIV alone or in combination; the expression levels of IL-1α, IL-1β, IL-8, IL-17A and IL-22 were measured by RT-PCR. Doses as low as 0.16 µM DON or 0.73 µM NIV significantly increase the intestinal expression levels of the tested inflammation-related genes. These doses are lower than those previously reported for other intestinal toxicity endpoints. The combined pro-inflammatory activity of DON and NIV was synergistic for all the tested genes with combination index value range of 0.23-0.8. Our results indicate that (1) inflammation is a very sensitive endpoint for the intestinal toxicity of the trichothecenes and (2) co-exposure to DON and NIV has a greater inflammatory effect than induced by mycotoxins alone. This synergy should be taken into account considering the frequent co-occurrence of DON and NIV in the diet.

A jejunal nodular mass was identified in an aging rat. Histologically, the boundaries between the lesion and surrounding normal tissue as well as between the inner circular muscle and outer longitudinal muscle were indistinct. The lesion consisted of abundant eosinophilic matrix and cells with a large round to oval nucleus and indistinct cytoplasm. There was no characteristic proliferating pattern, nuclear polymorphism and a low mitotic figure count. Masson's trichrome stain revealed that the intestinal smooth muscles were replaced by the abundant collagen fiber. Immunohistochemistry revealed that the cells with a large round to oval nucleus were labeled with anti-vimentin antibody and not with anti-α smooth muscle actin antibody, suggesting that these cells were fibroblasts. The mass was diagnosed as jejunal fibroplasia.

Small bowel diverticulosis of the jejunum and ileum is an uncommon finding with a prevalence rate of 0.2% to 1.3% at autopsy and 0.3% to 1.9% on small bowel studies. Diagnosis can be difficult because there are no pathognomonic features or clinical symptoms that are specific for small bowel diverticulosis. Though rare, it is critical to keep the possibility of small bowel diverticulosis in mind when evaluating cases of malabsorption, chronic abdominal pain, haemorrhage, perforation and intestinal obstruction, especially in patients with connective tissue disorders, a family history of diverticula and a personal history of colonic diverticulosis. Guidelines for the treatment of complicated small bowel diverticulosis are not clearly defined. However, the consensus in treatment is to do a small bowel resection with primary anastomosis. We report three interesting cases of jejunoileal diverticula that presented in an occult manner and later progressed to more emergent manifestations., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Rationale: Gastrointestinal Mucormycosis (GIM) is a kind of opportunistic fungal infection with poor prognosis. It usually occurs in patients with immune deficiency. We reported a case of immunocompetent male patient., Patient Concerns: This patient was presented as abdominal distension and gastrointestinal bleeding., Diagnoses: A variety of hemostatic methods was ineffective to stop the bleeding. The patient finally received laparotomy, and the jejunum lesions were found., Interventions: Pathological examination confirmed it to be gastrointestinal mucormycosis in jejunum., Outcomes: However, after systemic anti-fungi therapy, the patient died of septic shock., Lessons: The diagnosis mainly relies on pathological examination. Early diagnosis and early application of systemic amphotericin B liposome were fundamental for improving the prognosis.

Background: Duodenitis-proximal jejunitis (DPJ) is an acute sporadic gastrointestinal disorder of horses of unknown cause., Hypothesis/objectives: We hypothesize that Clostridium difficile toxins are involved in the pathogenesis of DPJ in horses. The objective of this study was to determine whether experimentally delivered C. difficile toxins cause clinical signs and histologic lesions similar to those of naturally occurring DPJ., Animals: Six healthy mature mixed breed horses., Methods: Experimental study: animal model of animal disease. Fasted horses were administered crude C. difficile toxins via gastroscopy and monitored for up to 48 hour. Blood was collected for complete blood cell count, biochemistry profile, and plasma fibrinogen assay, and abdominal fluid was collected for cytologic analysis and total solids before and after toxin administration. Physical examination and abdominal ultrasonography were performed throughout the study period. Tissues were collected from the gastrointestinal tract and processed for routine histologic analysis, and lesions were scored., Results: Clinical signs were observed in 2 of 6 horses that are typical although not specific for horses with naturally occurring DPJ. Histopathologic lesions were observed in 6 of 6 horses and were similar to those reported in horses with naturally occurring DPJ. Two horses were severely affected., Conclusions and Clinical Importance: Duodenitis-proximal jejunitis is likely a syndrome with multiple causes that result in the same clinical and pathologic findings, and our data suggest that the toxins of C. difficile represent one cause of this syndrome. Toxin dose and variation in individual animal susceptibility might affect the clinical signs and lesions after administration of C. difficile toxins., (Copyright © 2016 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Small gut volvulus with multiple Jejuno-ileal diverticulosis is an unusual pathology of the small intestine with a scarce number of cases reported so far. It usually goes unnoticed because it is often asymptomatic but complications like diverticulitis, perforation, bleeding or intestinal obstruction can occur in 10-30% of the cases. Mechanical obstruction, if it occurs, can be caused by adhesions or stenosis due to diverticulitis, intussusception at the site of the diverticulum and volvulus of the segment containing the diverticula. Acute volvulus of the small bowel is a serious abdominal emergency that poses a difficulty in diagnosis and delayed operative intervention can lead to dire consequences. We herein report the case of a 42-yearold man presented at the emergency department with acute abdominal pain, absolute constipation and vomiting. Preoperative investigations followed by laparotomy revealed small gut volvulus and multiple giant jejunal and ileal diverticula.

The pacemaker function of interstitial cells of Cajal (ICC) is impaired during intestinal inflammation. The aim of this study is to clarify the pathophysiological mechanisms of ICC dysfunction during inflammatory condition by using intestinal cell clusters. Cell clusters were prepared from smooth muscle layer of murine jejunum and treated with interferon-gamma and lipopolysaccharide (IFN-γ+LPS) for 24h to induce inflammation. Pacemaker function of ICC was monitored by measuring cytosolic Ca(2+) oscillation in the presence of nifedipine. Treatment with IFN-γ+LPS impaired the pacemaker activity of ICC with increasing mRNA level of interleukin-1 beta, tumor necrosis factor-alpha and interleukin-6 in cell clusters; however, treatment with these cytokines individually had little effect on pacemaker activity of ICC. Treatment with IFN-γ+LPS also induced the expression of inducible nitric oxide synthase (iNOS) in smooth muscle cells and resident macrophages, but not in ICC. Pretreatment with NOS inhibitor, L-NAME or iNOS inhibitor, 1400W ameliorated IFN-γ+LPS-induced pacemaker dysfunction of ICC. Pretreatment with guanylate cyclase inhibitor, ODQ did not, but antioxidant, apocynin, to suppress NO-induced oxidative stress, significantly suppressed the impairment of ICC function induced by IFN-γ+LPS. Treatment with IFN-γ+LPS also decreased c-Kit-positive ICC, which was prevented by pretreatment with L-NAME. However, apoptotic ICC were not detected in IFN-γ+LPS-treated clusters, suggesting IFN-γ+LPS stimulation just changed the phenotype of ICC but not induced cell death. Moreover, ultrastructure of ICC was not disturbed by IFN-γ+LPS. In conclusion, ICC dysfunction during inflammation is induced by NO-induced oxidative stress rather than NO/cGMP signaling. NO-induced oxidative stress might be the main factor to induce phenotypic changes of ICC., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Environmental enteric dysfunction (EED) has been recognised as an important contributing factor to physical and cognitive stunting, poor response to oral vaccines, limited resilience to acute infections and ultimately global childhood mortality. The aetiology of EED remains poorly defined but the epidemiology suggests a multifactorial combination of prenatal and early-life undernutrition and repeated infectious and/or toxic environmental insults due to unsanitary and unhygienic environments. Previous attempts at medical interventions to ameliorate EED have been unsatisfying. However, a new generation of imaging and '-omics' technologies hold promise for developing a new understanding of the pathophysiology of EED. A series of trials designed to decrease EED and stunting are taking novel approaches, including improvements in sanitation, hygiene and nutritional interventions. Although many challenges remain in defeating EED, the global child health community must redouble their efforts to reduce EED in order to make substantive improvements in morbidity and mortality worldwide., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)