Equine duodenitis-proximal jejunitis: A review.

Duodenitis-proximal jejunitis (DPJ) is an inflammatory process of the proximal part of the small intestine and occurs sporadically in horses. It is clinically characterized by an acute onset of ileus and nasogastric reflux leading to systemic signs of toxemia. This review discusses the definition of the disease, potential etiologic agents, clinical findings, epidemiological features, histopathologic and clinico-pathological findings, and medical management of this condition. Salmonella spp., mycotoxins, Clostridium perfringens, and Clostridium difficile have all been associated with the disease but there is limited supporting evidence for any agent other than C. difficile. Particular attention, however, was given to etiological investigations and the data available to support the proposed etiological agents. The potential role of C. difficile as the etiological agent of DPJ, possible pathogenesis, and recent efforts to support this hypothesis are highlighted, but it is recognized that there could be more than one agent that causes the disease.

L'entérite proximale chez le cheval: revision. L'entérite proximale est un processus inflammatoire de la portion proximale du petit intestin qui se présente sporadiquement chez le cheval. Cliniquement, elle est caractérisée par un début soudain d'iléus et de reflux nasogastrique menant à des signes systémiques d'endotoxémie. Cet article discute de la définition de la maladie, des agents étiologiques potentiels, des signes cliniques, des caractéristiques épidémiologiques, des trouvailles histopathologique et clinique et du traitement médical de cette condition. Salmonella spp., les mycotoxines, Clostridium perfringens et Clostridium difficile ont tous été associés avec la maladie, mais les preuves sont limitées pour tout autre agent que C. difficile. Une attention particulière a été mise sur l'étude étiologique et sur les données disponibles pour supporter les agents étiologiques proposés. Le rôle potentiel de C. difficile comme étant l'agent étiologique de l'entérite proximale, la possible pathogénèse et les efforts récents pour supporter cette hypothèse sont soulignés, mais il est reconnu qu'il pourrait y avoir plus d'un agent causatif de la maladie.(Traduit par Dr Marie-Soleil Dubois).

Utility of an immune cell function assay to differentiate rejection from infectious enteritis in pediatric intestinal transplant recipients.

The Cylex Immune Cell Function Assay measures cell-mediated immunity based on ATP production by stimulated CD4 + cells. We hypothesized that this test would discriminate acute cellular rejection (ACR) from infectious enteritis (IE) in pediatric intestinal transplant (ITx) recipients with allograft dysfunction. We retrospectively analyzed 224 Cylex assays drawn in 47 children who received 53 ITx. Samples were classified as stable, ACR, or IE based on clinical status. ATP values were analyzed using Kruskal-Wallis and t-tests. Overall, there was a statistically significant difference in ATP values based on clinical status (p = 0.03); however, overlap was observed between groups. The median ATP value during ACR was significantly greater than during stable periods (p = 0.02). No difference was seen in IE vs. stability (p = 0.8). The difference in median ATP value in ACR vs. IE approached significance (p = 0.1). Relative to previous levels, ACR episodes were associated with a median ATP increase of 101 ng/mL and IE episodes with a decrease of 3 ng/mL (p = 0.3). These data indicate that the Cylex assay has limited utility in differentiating ACR from IE, largely due to interpatient variability. Following longitudinal intrapatient trends may be an adjunctive tool in discriminating IE from ACR and guiding immunosuppression adjustments in select patients.

Disseminated Histoplasmosis Causing Temporally and Spatially Discrete Gastrointestinal Perforations in an HIV-Negative Patient.

Histoplasma capsulatum is a dimorphic fungi endemic to the Ohio and Mississippi River valleys. Immunocompetent persons who become infected are generally asymptomatic or present with mild symptoms. Symptomatic disease is seen primarily in immunocompromised patients with pulmonary manifestations being the most common presentation. We present a case of a young HIV-negative male who required 4 exploratory laparotomies over the course of 4 months during 2 hospitalizations due to discrete perforations of the ileum and jejunum caused by biopsy-proven gastrointestinal histoplasmosis despite maximal medical therapy as well as a gastric perforation.

Mouldy feed, mycotoxins and Shiga toxin - producing Escherichia coli colonization associated with Jejunal Hemorrhage Syndrome in beef cattle.

BACKGROUND: Both O157 and non-O157 Shiga toxin - producing Escherichia coli (STECs) cause serious human disease outbreaks through the consumption of contaminated foods. Cattle are considered the main reservoir but it is unclear how STECs affect mature animals. Neonatal calves are the susceptible age class for STEC infections causing severe enteritis. In an earlier study, we determined that mycotoxins and STECs were part of the disease complex for dairy cattle with Jejunal Hemorrhage Syndrome (JHS). For STECs to play a role in the development of JHS, we hypothesized that STEC colonization should also be evident in beef cattle with JHS. Aggressive medical and surgical therapies are effective for JHS, but rely on early recognition of clinical signs for optimal outcomes suggesting that novel approaches must be developed for managing this disease. The main objective of this study was to confirm that mouldy feeds, mycotoxins and STEC colonization were associated with the development of JHS in beef cattle. RESULTS: Beef cattle developed JHS after consuming feed containing several types of mycotoxigenic fungi including Fusarium poae, F. verticillioides, F. sporotrichioides, Penicillium roqueforti and Aspergillus fumigatus. Mixtures of STECs colonized the mucosa in the hemorrhaged tissues of the cattle and no other pathogen was identified. The STECs expressed Stx1 and Stx2, but more significantly, Stxs were also present in the blood collected from the lumen of the hemorrhaged jejunum. Feed extracts containing mycotoxins were toxic to enterocytes and 0.1% of a prebiotic, Celmanax Trademark, removed the cytotoxicity in vitro. The inclusion of a prebiotic in the care program for symptomatic beef calves was associated with 69% recovery. CONCLUSIONS: The current study confirmed that STECs and mycotoxins are part of the disease complex for JHS in beef cattle. Mycotoxigenic fungi are only relevant in that they produce the mycotoxins deposited in the feed. A prebiotic, Celmanax Trademark, acted as a mycotoxin binder in vitro and interfered with the progression of disease.

[Actinomycosis associated with perforation of jejunum in patient after cholecystectomy--a case report]. / Perforacja jelita cienkiego w przebiegu promienicy u chorego po cholecystektomii--opis przypadku.

Actinomyces is endogenic infection with rare abdominal manifestations. Diagnosis is very difficult and not always taken into account in differential diagnosis. Disease is recurrent and treatment is mostly pharmacologic and takes a long time. The aim of the paper was to present a case of patient operated on acute cholecystitis with intraabdominal actinomycosis. The 66 years old patient 28 days after cholecystectomy appeared to have jejunal perforation in the course of actinomycosis. Patient regarded two interventions due to intraabdominal abscesses. Since last discharge, a year ago, we do not observe recurrence. Intraabdominal actinomycosis is often recurrent and should be considered in patients with purulent complications after surgical procedures.

Jejunal stricture due to mucormycosis.

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.

[Jejunal mucormycosis in a patient with Hodgkin's lymphoma]. / Mucormicosis yeyunal en paciente con linfoma de Hodgkin.

We report a case of intestinal mucormycosis in a 46-year-old male diagnosed with classical Hodgkin's disease, IV-B stage. During the first phase of chemotherapy he had a massive digestive bleeding event secondary to a jejunal ulcer, and zygomicosis mucor-type was diagnosed by endoscopic biopsy. The patient was treated with antifungal drugs and surgical resection of the intestine involved. At surgery a double covered perforation of the jejunum was seen. Pathological examination confirmed the previous diagnosis. After one year of follow-up the patient is doing well, and his lymphoma is on remission. To our best knowledge this is the second case of intestinal mucormycosis in a patient with Hodgkin's lymphoma reported in the medical literature.

Extensive jejunal diverticulosis in a family, a matter of inheritance?

Diverticulosis of the jejunum is a rare finding (0.06 to 1.3%). Possible complications are bacterial overgrowth, malabsorption, bleeding, mechanical obstruction, volvulus and perforation. At present only one case report on familial jejunal diverticulosis has been published. We describe three patients with jejunal diverticulosis within one family, which might suggest inheritance.

Duodenitis-Proximal Jejunitis in Horses After Experimental Administration of Clostridium difficile Toxins.

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.

Ascites, elevated CA 125, and a large adnexal mass with an enteroovarian fistula.

BACKGROUND: Rectovaginal and vesicovaginal fistulae occur commonly in human immunodeficiency virus (HIV)-positive women and typically present with a characteristic vaginal discharge. CASE: We report a case of a jejunal-ovarian fistula presenting as suspected malignancy in a 38-year-old woman with HIV. The patient presented with ascites, moderately elevated CA 125, and a 12-cm adnexal mass. She was expedited to surgery secondary to a persistent pelvic mass and the patient's desire for definitive treatment. We believe the patient's immunocompromised state caused a microperforation in the small bowel, which subsequently formed a fistula to the ovary. The patient's left adnexa was removed, along with a 3-cm portion of small bowel. CONCLUSION: Uncommon entities should be included in the differential diagnosis of pelvic masses in immunocompromised women.

Potential role of Clostridium difficile as a cause of duodenitis-proximal jejunitis in horses.

Duodenitis-proximal jejunitis (DPJ) is an idiopathic condition in the horse characterized by inflammation and oedema of the duodenum and proximal jejunum. Clinical signs include colic, ileus, depression, fluid accumulation in the small intestine and stomach, and endotoxaemia. The objective of this study was to investigate prospectively the role of Clostridium difficile in this idiopathic disease. Nasogastric reflux from 10 consecutive cases with DPJ and 16 consecutive horses with other causes of nasogastric reflux was cultured for C. difficile, other Clostridium spp., and Salmonella. Toxigenic strains of C. difficile were isolated from 10/10 (100%) of horses with DPJ and 1/16 controls (P<0.0001). No other known pathogenic clostridia were isolated from either group. Results of this study suggest that C. difficile might be an important cause of this syndrome.

Salmonella enterica serovar Choleraesuis infection of the porcine jejunal Peyer's patch rapidly induces IL-1beta and IL-8 expression.

Salmonella enterica serovar Choleraesuis is an enteric pathogen of swine, producing septicemia, enterocolitis, pneumonia, and hepatitis. The initial molecular events at the site of Salmonella infection are hypothesized to be critical in the initiation of innate and adaptive immune responses; however, the acute immune response elicited by porcine intestinal tissues is not well understood. To address this need, we employed explants of jejunal Peyer's patch (JPP) mucosa from pigs to examine Salmonella-induced immune responses under controlled conditions as well as to overcome limitations of whole animal approaches. JPP explants mounted in Ussing chambers maintained normal histological structure for 2 h and stable short-circuit current and electrical conductance for 2.5 h. After ex vivo luminal exposure to Salmonella serovar Choleraesuis, JPP responded with an increase in mRNA expression of IL-1beta and IL-8, but not TNFalpha. Increased IL-1beta and IL-8 expression were dependent on efficient Salmonella adhesion and internalization, whereas mutant Salmonella did not induce inflammatory cytokine expression. Commensal enteric bacteria, present in some experiments, also did not induce inflammatory cytokine expression. These findings indicate that Salmonella uptake by Peyer's patch is important in the induction of an innate response involving expression of IL-1beta and IL-8, and that ex vivo intestinal immune tissue explants provide an intact tissue model that will facilitate investigation of mucosal immunity in swine.

New insights into environmental enteric dysfunction.

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.

Jejunal infection with Campylobacter.

A patient had common variable immunodeficiency, chronic malabsorption, and Campylobacter jejuni infection. Infection was diagnosed by jejunal aspiration. A follow-up jejunal aspirate was culture positive at the same time that a stool culture was negative. Infection resulted in worsening of chronic diarrhea, but it was not associated with clinical features of colitis or proctitis. The duration of infection was prolonged and initial antimicrobial therapy was ineffective. Single drug therapy with erythromycin ethylsuccinate and then chloramphenicol led to the emergence of resistant organisms. After five months of bacterial excretion, combination therapy with metronidazole and neomycin sulfate eliminated the organism. This case emphasizes that the clinical manifestations and response to therapy of C jejuni infection can be altered in immunodeficient patients.

Determination of the effect of single abomasal or jejunal inoculation of Clostridium perfringens type A in dairy cows.

A randomized study was conducted to determine if inoculation of the abomasum or jejunum with Clostridium perfringens Type A would induce jejunal hemorrhage syndrome in healthy cows. Twelve adult nonlactating dairy cows were inoculated with 10 mL of pure culture broth of C. perfringens type A (beta2 toxin positive) into the abomasum (n = 6) or jejunum (n = 6). On day 6, the cows were euthanized and samples for culture were taken from the abomasum, jejunum, and feces. No cows developed clinical signs of jejunal hemorrhage syndrome during the course of the study. Five of 6 abomasal samples and 1 of 6 jejunal samples were positive for C. perfringens Type A (beta2 negative) prior to inoculation. Eight of 12 abomasal samples, 11 of 12 fecal samples, and 10 of 12 jejunal samples were positive for C. perfringens Type A (beta2 negative) after inoculation. Intraluminal inoculation of C. perfringens Type A alone at this dose and under these conditions did not induce clinical signs of jejunal hemorrhage syndrome in adult dairy cows. The multifactorial nature of the disease likely contributed to our inability to reproduce the disease in this study.

Serum unconjugated bile acids: qualitative and quantitative profiles in ileal resection and bacterial overgrowth.

Qualitative and quantitative profiles of unconjugated bile acids in the serum obtained over a 24-h period from three patients with ileal resections and one with a bacterial overgrowth are described. Unconjugated serum bile acids were determined using the high sensitivity and resolution of capillary column gas liquid chromatography after their rapid extraction and isolation using reverse phase octadecylsilane bonded silica cartridges and the lipophilic gel Lipidex 1000. Unconjugated serum bile acid concentrations were elevated throughout the day in both ileum resected patients and in conditions involving bacterial overgrowth when compared to healthy subjects. Total conjugated cholic acid concentrations were expectedly low in both intestinal disorders and were without the postprandial increases generally observed in healthy subjects. Qualitative gas chromatographic profiles of serum unconjugated bile acids in bacterial overgrowth distinctly revealed a predominance of deoxycholic acid and other secondary bile acids in all samples, while, in conditions of an impaired enterohepatic circulation, deoxycholic acid was absent or present in only trace amounts. The potential significance of measuring serum unconjugated bile acids in intestinal disorders is discussed.

A comparison of Campylobacter jejuni enteritis incidence rates in high- and low-poultry-density counties: Michigan 1992-1999.

To compare the incidence of Campylobacter jejuni enteritis in high- and low-poultry-density counties in Michigan between the years 1992 and 1999, an ecological study was conducted in the state of Michigan. A log-linear model was used to compare yearly, seasonal, age, and gender-specific incidence rates between county groupings. Counties with a high poultry density had a higher overall incidence of C. jejuni enteritis, particularly among children and young adults, compared with counties with low poultry density. The findings suggest that living in high-poultry-density counties is associated with higher odds for C. jejuni enteritis. This may be due to occupational exposure among poultry workers in these counties, but the findings in children suggest that indirect or environmental exposures may also play a role. Future studies should be conducted to investigate these issues.

Disseminated aspergillosis inciting intestinal ischaemia and obstruction.

Invasive aspergillosis is an opportunistic infection that characteristically affects the immunocompromised host, resulting in a high degree of morbidity and mortality. Although the portal of entry is usually pulmonary, there are rare reports of invasive aspergillosis localized to the gastrointestinal tract. In addition, haematological spread may develop, with life threatening disseminated infection involving the vital organs and the gastrointestinal tract. Although disseminated infection is well recognized, the CT findings of gastrointestinal disease have not been reported to our knowledge. We describe the CT findings in a patient with invasive aspergillosis involving the gastrointestinal tract, which resulted in intestinal ischaemia complicated by small bowel obstruction.

Intestinal perforation secondary to Salmonella typhi: case report and review of the literature.

The case of a young woman presenting with fever, abdominal distention, and diarrhea is presented. While hospitalized, she developed peritonitis, and a laparotomy was performed emergently. Intraoperative and pathologic examinations are highly suggestive of Salmonella typhi as an etiology for her symptoms and eventual perforation. Salmonella enteritis can be a difficult diagnosis to make, but in most cases it is a self-limited disease process. In a minority of cases, multidrug antibiotic therapy may be required secondary to an increasing prevalence of resistant strains. Patients who perforate require prompt operation to limit morbidity and mortality. Outcome is significantly improved in those patients by directed resection of the affected segment of bowel and by aggressive perioperative care.