Proliferative enteropathy caused by Lawsonia intracellularis in rabbits in Southern Brazil / Enteropatia proliferativa por Lawsonia intracellularis em coelhos no Sul do Brasil

Proliferative enteropathy (PE), also known as ileitis, is a disease caused by the bacterium Lawsonia intracellularis. This disease is characterized by diarrhea and ill-thrift. The aim of this study is to describe a PE outbreak in rabbits that occurred in Southern Brazil. The farm had 700 rabbits at the time the outbreak occurred. The clinical signs were severe diarrhea, dehydration, and apathy. Necropsy was performed in 33 rabbits, and the most evident macroscopic findings were thickening of the intestinal wall, intestinal loops distended by large amounts of gas, and liquid feces. Histopathological examination demonstrated a marked proliferation of enterocytes in intestinal crypts, decrease number of goblet cells, and crypts microabscesses. Silver impregnation technique (Warthin-Starry) demonstrated in intestinal crypts inside of enterocytes cytoplasm, curved vibrioid bacteria compatible with L. intracellularis. Immunohistochemical staining with anti-L. intracellularis confirmed the agent presence. PCR was performed and L. intracellularis was confirmed as the etiological agent.

A enteropatia proliferativa (EP), também conhecida como ileíte, é uma doença causada pela bactéria Lawsonia intracellularis, que é caracterizada por diarreia com redução do ganho de peso. O objetivo deste trabalho é descrever um surto de EP em coelhos na região sul do Brasil. A propriedade possuía 700 coelhos, durante o período do surto. O quadro clínico caracterizava-se por diarreia severa, desidratação e apatia. Realizou-se o exame de necropsia em 33 coelhos, e as alterações macroscópicas mais evidentes eram: alças intestinais acentuadamente distendidas por gás e fezes líquidas, além de serosa rugosa e parede intestinal moderadamente espessada. Na análise histopatológica do intestino delgado visualizou se marcada hiperplasia de enterócitos de criptas, moderada diminuição do número de células caliciformes e microabscessos de criptas. A etiologia das lesões foi confirmada pela técnica de impregnação pela prata (Warthin-Starry), evidenciando bactérias vibrioides compatíveis com L. intracellularis no ápicede enterócitos das criptas intestinais. Ainda, foi obtida imunomarcação positiva de enterócitos de criptas na imuno-histoquímica com anticorpo anti-L. intracellularis e a PCR positiva em amostras de intestino.

Proliferative enteropathy caused by Lawsonia intracellularis in rabbits in Southern Brazil / Enteropatia proliferativa por Lawsonia intracellularis em coelhos no Sul do Brasil

Proliferative enteropathy (PE), also known as ileitis, is a disease caused by the bacterium Lawsonia intracellularis. This disease is characterized by diarrhea and ill-thrift. The aim of this study is to describe a PE outbreak in rabbits that occurred in Southern Brazil. The farm had 700 rabbits at the time the outbreak occurred. The clinical signs were severe diarrhea, dehydration, and apathy. Necropsy was performed in 33 rabbits, and the most evident macroscopic findings were thickening of the intestinal wall, intestinal loops distended by large amounts of gas, and liquid feces. Histopathological examination demonstrated a marked proliferation of enterocytes in intestinal crypts, decrease number of goblet cells, and crypts microabscesses. Silver impregnation technique (Warthin-Starry) demonstrated in intestinal crypts inside of enterocytes cytoplasm, curved vibrioid bacteria compatible with L. intracellularis. Immunohistochemical staining with anti-L. intracellularis confirmed the agent presence. PCR was performed and L. intracellularis was confirmed as the etiological agent.(AU)

A enteropatia proliferativa (EP), também conhecida como ileíte, é uma doença causada pela bactéria Lawsonia intracellularis, que é caracterizada por diarreia com redução do ganho de peso. O objetivo deste trabalho é descrever um surto de EP em coelhos na região sul do Brasil. A propriedade possuía 700 coelhos, durante o período do surto. O quadro clínico caracterizava-se por diarreia severa, desidratação e apatia. Realizou-se o exame de necropsia em 33 coelhos, e as alterações macroscópicas mais evidentes eram: alças intestinais acentuadamente distendidas por gás e fezes líquidas, além de serosa rugosa e parede intestinal moderadamente espessada. Na análise histopatológica do intestino delgado visualizou se marcada hiperplasia de enterócitos de criptas, moderada diminuição do número de células caliciformes e microabscessos de criptas. A etiologia das lesões foi confirmada pela técnica de impregnação pela prata (Warthin-Starry), evidenciando bactérias vibrioides compatíveis com L. intracellularis no ápicede enterócitos das criptas intestinais. Ainda, foi obtida imunomarcação positiva de enterócitos de criptas na imuno-histoquímica com anticorpo anti-L. intracellularis e a PCR positiva em amostras de intestino.(AU)

[Independent risk factors for severity and mortality in lower gastrointestinal bleeding]. / Hemorragia digestiva baja, factores predictores de severidad y mortalidad en un hospital p úblico de Lima.

In lower gastrointestinal bleeding (LGIB), it is very important to stratify the risk of LGIB for a proper management. OBJECTIVE: Identity the independent risk factors to mortality and severity (require critical care, prolonged hospitalization, reebleding, re hospitalization, politrasfusion, surgery for bleeding control) in LGIB. MATERIALS AND METHODS: It is an analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. Independent factors were determined using binomial logistic regression. RESULTS: A total of 98 patients were included, of which 13 patients (13,3%) died, and 56 (57,1%) met severity criteria. The independent risk factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg, albumin lower than 2,8 g/dL. CONCLUSIONS: The frequency of mortality and severe LGIB is high in our population, the principal risk factors were systolic blood pressure under than 100 mm Hg, Glasgow score lower than 15, albumin lower than 2,8 g/dL. Identifying these associated factors would improve the management of LGB in the emergency room.

Time trends in mortality from intestinal infectious diseases among children under five years old, in São Paulo State, Brazil, 2000-2012. / Tendência temporal da mortalidade por doenças infecciosas intestinais em crianças menores de cinco anos de idade, no estado de São Paulo, 2000-2012.

OBJECTIVE: to analyze time trends in mortality owing to intestinal infectious diseases (IID) among children under five years of age in São Paulo State and its Regional Health Care Networks (RRAS), from 2000 to 2012. METHODS: this was a time series study of deaths having IID as their underlying, antecedent or contributory cause, using Mortality Information System data. RESULTS: there were 2,886 deaths from IID in the state; the IID mortality rate went down by 10.5% per year (95%CI 4.8;15.8%); there was a significant decrease in the mortality rate in 13 of the 17 RRAS, with annual decrease in the range 16.6% - 8.3%. CONCLUSION: The IID mortality rate went down significantly in most RRAS, at different speeds, possibly reflecting inequalities in socio-economic conditions and health care network organization.

Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery: 20 Years of Experience.

OBJECTIVE: Bariatric surgery (BS) is currently the most effective treatment for severe obesity. However, these weight loss procedures may result in the development of gut failure (GF) with the need for total parenteral nutrition (TPN). This retrospective study is the first to address the anatomic and functional spectrum of BS-associated GF with innovative surgical modalities to restore gut function. METHODS: Over 2 decades, 1500 adults with GF were referred with history of BS in 142 (9%). Of these, 131 (92%) were evaluated and received multidisciplinary care. GF was due to catastrophic gut loss (Type-I, 42%), technical complications (Type-II, 33%), and dysfunctional syndromes (Type-III, 25%). Primary bariatric procedures were malabsorptive (5%), restrictive (19%), and combined (76%). TPN duration ranged from 2 to 252 months. RESULTS: Restorative surgery was performed in 116 (89%) patients with utilization of visceral transplantation as a rescue therapy in 23 (20%). With a total of 317 surgical procedures, 198 (62%) were autologous reconstructions; 88 (44%) foregut, 100 (51%) midgut, and 10 (5%) hindgut. An interposition alimentary conduit was used in 7 (6%) patients. Reversal of BS was indicated in 84 (72%) and intestinal lengthening was required in 10 (9%). Cumulative patient survival was 96% at 1 year, 84% at 5 years, and 72% at 15 years. Nutritional autonomy was restored in 83% of current survivors with persistence or relapse of obesity in 23%. CONCLUSIONS: GF is a rare but serious life-threatening complication after BS. Successful outcome is achievable with comprehensive management, including reconstructive surgery and visceral transplantation.

Race affects outcome among infants with intestinal failure.

OBJECTIVE: Intestinal failure (IF) is a rare, devastating condition associated with significant morbidity and mortality. We sought to determine whether ethnic and racial differences were associated with patient survival and likelihood of receiving an intestinal transplant in a contemporary cohort of children with IF. METHODS: This was an analysis of a multicenter cohort study with data collected from chart review conducted by the Pediatric Intestinal Failure Consortium. Entry criteria included infants ≤ 12 months receiving parenteral nutrition (PN) for ≥ 60 continuous days and studied for at least 2 years. Outcomes included death and intestinal transplantation (ITx). Race and ethnicity were recorded as they were in the medical record. For purposes of statistical comparisons and regression modeling, categories of race were consolidated into "white" and "nonwhite" children. RESULTS: Of 272 subjects enrolled, 204 white and 46 nonwhite children were available for analysis. The 48-month cumulative incidence probability of death without ITx was 0.40 for nonwhite and 0.16 for white children (P < 0.001); the cumulative incidence probability of ITx was 0.07 for nonwhite versus 0.31 for white children (P = 0.003). The associations between race and outcomes remained after accounting for low birth weight, diagnosis, and being seen at a transplant center. CONCLUSIONS: Race is associated with death and receiving an ITx in a large cohort of children with IF. This study highlights the need to investigate reasons for this apparent racial disparity in outcome among children with IF.

Natural history of pediatric intestinal failure: initial report from the Pediatric Intestinal Failure Consortium.

OBJECTIVE: To characterize the natural history of intestinal failure (IF) among 14 pediatric centers during the intestinal transplantation era. STUDY DESIGN: The Pediatric Intestinal Failure Consortium performed a retrospective analysis of clinical and outcome data for a multicenter cohort of infants with IF. Entry criteria included infants <12 months receiving parenteral nutrition (PN) for >60 continuous days. Enteral autonomy was defined as discontinuation of PN for >3 consecutive months. Values are presented as median (25th, 75th percentiles) or as number (%). RESULTS: 272 infants with a gestational age of 34 weeks (30, 36) and birth weight of 2.1 kg (1.2, 2.7) were followed for 25.7 months (11.2, 40.9). Residual small bowel length in 144 patients was 41 cm (25.0, 65.5). Diagnoses were necrotizing enterocolitis (71, 26%), gastroschisis (44, 16%), atresia (27, 10%), volvulus (24, 9%), combinations of these diagnoses (46, 17%), aganglionosis (11, 4%), and other single or multiple diagnoses (48, 18%). Prescribed medications included oral antibiotics (207, 76%), H2 blockers (187, 69%), and proton pump inhibitors (156, 57%). Enteral feeding approaches varied among centers; 19% of the cohort received human milk. The cohort experienced 8.9 new catheter-related blood stream infections per 1000 catheter days. The cumulative incidences for enteral autonomy, death, and intestinal transplantation were 47%, 27%, and 26%, respectively. Enteral autonomy continued into the fifth year after study entry. CONCLUSIONS: Children with IF endure significant mortality and morbidity. Enteral autonomy may require years to achieve. Improved medical, nutritional, and surgical management may reduce time on PN, mortality, and need for transplantation.

Intestinal transplantation outcomes.

Intestinal transplantation has evolved from being considered an experimental procedure into a clinically accepted therapy for patients with intestinal failure and parenteral nutrition life-threatening complications. Early referral, advances in immunosuppression therapy, standardization of surgical techniques, prophylactic therapy of infections, early diagnosis of rejection, and better posttransplant patient management are some of the changes that have allowed more patients to receive transplants, thus recovering intestinal sufficiency, and at the same time allowing the procedure to spread worldwide. Over the last 2 decades, transplant centers have focused on improving short-term patient survival, which has consequently increased by >20%. It is now clear that even though isolated intestinal-transplant recipients have lower mortality risk on the waiting list, they are at higher risk for long-term graft loss. Mortality is higher on the waiting list and early posttransplant in recipients whose intestinal transplants are associated with liver grafts; however, they have better long-term patient and graft survival. Nevertheless, 3-year actuarial patient survival has not changed over the same period of time, and therefore this is our challenge for the next decade.

Iatrogenic intestinal injury concomitant to iatrogenic bile duct injury: the second component.

OBJECTIVE: Bile duct injuries have a frequency of 0.1% to 0.3% even in the most experienced centers. Complex biliary lesions usually require a bilioenteric anastomosis, achieving good long-term results in 80% to 90% of the cases. Besides injuries to the abdominal contents during laparoscopy (by trocars or electrocautery), intestinal complications associated with reconstruction attempts can be observed. We analyzed the concomitant intestinal complications in 251 patients with iatrogenic biliary injuries reconstructed over this 12-year period. METHODS: A retrospective review of patients with biliary tract reconstruction after iatrogenic injury in a tertiary academic health-care center was done. All patients with concomitant intestinal injury were included; type of operation and postoperative outcome were analyzed. RESULTS: Among 251 patients, 35 cases had a concomitant intestinal injury. The most common site of fistulization was the duodenum (18 cases, 50%); 9 cases were associated with long-term subhepatic drains (more than three weeks), and the other 9 cases were associated with a dehiscent hepatoduodenostomy. Faulty Roux-en-Y reconstruction was observed in 5 cases. In 5 cases, fistulization of the jejunum and ileum, secondary to drain placement, was documented, as well as 3 cases with colonic injuries. Two patients had a dehisced Roux-en-Y anastomosis. One had a bilioenteric omega type ileal anastomosis, and 1 had a hepatoileal anastomosis without omega reconstruction. Primary repair of the duodenum with resection of the affected intestinal or colonic segment was done at the same time of biliary repair without related morbidity. CONCLUSIONS: Concomitant gastrointestinal injures were found with an incidence of 15% in our series. The most common site of fistulization is the duodenum. In half of the patients, it was secondary to a dehiscent hepatoduodenostomy, whereas in the other, it was caused by long-term subhepatic drains. Besides faulty Roux-en-Y reconstruction, fistulization was related with long-term drains. Primary repair and resection of the affected segment of jejunum, ileum, and colon can be done during the same operative stage of biliary reconstruction, without significant correlated mortality.

Mortality due to intestinal infectious diseases in Latin America and the Caribbean, 1965-1990.

PIP: Life expectancy has increased in Latin America and the nonLatin Caribbean (LA/CA) from 51.8-66.6 years and 56.4-72.4 years between 1950-1955 and 1985-1990 respectively. Reduction in mortality due to infectious and parasitic diseases had the most significant effect on this rise in life expectancy. Indeed since the actual number of intestinal infection related deaths did fall while the populations grew considerably, there was a true reduced risk of death from these infections. Improved nutrition, potable water and waste disposal availability, immunizations, and safer food handling directly impacted on this reduction while the downward trend of the birth rate, increased literacy (especially among women), and mass media indirectly prompted the decline. Nevertheless these improvements have not yet reached the levels of the US and Canada during 1965-1970 (.07/1000) and have not been equitably divided among the different population groups. Indeed the technology existed 2 decades earlier to achieve zero deaths from diarrhea, yet deaths rates in LA/CA continued to range from .17-9.83/1000 during 1985-1990. Costa Rica and Chile experienced more of a decline in mortality from intestinal infections than most other countries. For example, the number of deaths fell about 90% for about the entire population and 93% and 95% respectively for children 5 years old. Even though there was a 95% reduction in the number of deaths for 5 year old children in Chile, the 64% reduction in Mexico resulted in more lives saved (355 vs. 529). Further data analysis showed that the death rate for 5 old children was the most valid indicator to analyze changes in mortality from intestinal infections. Over the 25 year period the countries with the least reduction in death rates from diarrhea included Guatemala, Honduras, and Nicaragua.^ieng

Ganhos potenciais em anos de vida com a exclusäo dos óbitos por doenças infecciosas intestinais em Fortaleza, no período 1978-80 / Potencial gains in years of life with the exclusion of causes of death by intestinal infections diseases in Fortaleza, 1978-80

Analisa-se o impacto da mortalidade das Doenças Infecciosas Intestinais (D.I.I.) em Fortaleza, no período 1978-80, através das Tábuas de Vida de Múltiplo Decremento, observando-se os comportamentos das probabilidades de morte, de sobrevivência e nas esperanças de vida. Os resultados mostraram substancias ganhos potenciais de anos de vida, sobretudo em menores de cinco anos, e que a exclusäo das D.I.I. como causa de morte representaria uma progressäo de uma década em Saúde Pública. Tecem-se consideraçöes sobre o envolvimento dos possíveis fatores condicionantes das D.I.I. e destaca-se a importância desse método para o diagnóstico e planejamento em Saúde