Enterocutaneous Fistula: Open Repair after Unsuccessful Stenting-A Case Report.

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin; by some estimates, it represents 88.2% of all fistulae. It can either develop spontaneously due to underlying malignancy, inflammatory bowel disease, radiation exposure, or, more commonly, as a complication of gastrointestinal surgery. A 75-year-old woman was treated for a small bowel enterocutaneous fistula that developed after laparoscopic cholecystectomy using a HANAROSTENT self-expanding metal stent (SEMS) to cover the fistula. Seven months later, the patient was discharged. For the following 2 years, the patient refused the reconstructive surgery until stent obstruction occurred. After optimizing the patient's nutritional status, laparotomy and small bowel resection were performed successfully. The use of SEMS in fistulas of the lower gastrointestinal tract is a heavily debated and fairly under-researched topic, especially in the context of enterocutaneous fistulas. No international guidelines officially recommend using SEMS in the small bowel ECF.

Small bowel stricture is associated with abnormal motility on the cine MRI sequence in patients with Crohn's disease.

PURPOSE: A multiphasic cine sequence performed during magnetic resonance enterography (MRE) has been shown to increase diagnostic accuracy of MRE demonstrating limited movement in inflamed intestine in patients with Crohn's disease (CD). Our aim was to confirm in our study population that intestinal inflammation was associated with decreased motility and determine if factors suggestive of complicated disease such as the presence of a stricture or fistula were associated with decreased motility on the MRE cine sequence. METHODS: This was a retrospective study of 59 patients (mean age 40.8 ±â€¯16.1) with Crohn's disease who had a small bowel lesion on MRE. Two gastrointestinal radiologists independently scored MRE findings using a qualitative, subjective scoring system. Univariate and multivariable ordered logistic regression models were used to evaluate the associations between cine sequence score, radiologic image findings, and clinical data. RESULTS: On univariate analysis, radiologic findings reflecting active inflammation, the presence of a stricture, and penetrating disease were associated with decreased motility. On multivariable analysis, hyper-enhancement, the presence of a comb sign, and global evidence of active inflammation remained associated with decreased motility. Of the factors suggesting complicated disease, the presence of stricture (Odds Ratio 0.40, 95% Confidence Interval 0.17-0.95, p-value 0.038) was associated with decreased motility. CONCLUSIONS: As previously shown, well-established radiologic findings of bowel inflammation were associated with decreased small bowel motility. In this study, we have added that the radiologic finding of a fixed stricture is also associated with decreased motility.

Aortoenteric fistula: a rare but critical cause of small bowel bleeding discovered on capsule endoscopy.

A 78-year-old man attended for outpatient capsule endoscopy, to investigate a recent history of unexplained small bowel bleeding. His previous medical history included an abdominal aortic aneurysm repair 6 years ago. Soon after capsule ingestion, he experienced sudden onset abdominal pain and collapsed on hospital grounds. He was rapidly transferred to the emergency department as he was haemodynamically unstable, and a significant per rectum (PR) bleed was found on examination. The patient was quickly stabilised following fluid resuscitation. CT angiography was performed which did not show active bleeding. However, use of the real-time capsule viewer indicated a profuse active jejunal bleed originating from the aortic graft, suggestive of an aortoenteric fistula. The patient underwent emergency endovascular cuff placement, and subsequent endovascular abdominal aortic stent grafting, to good effect.

Massive upper gastrointestinal bleeding: a rare complication of cholecystoduodenal fistula.

A biliary fistula which may occur spontaneously or after surgery, is an abnormal communication from the biliary system to an organ, cavity or free surface. Spontaneous biliary-enteric fistula is a rare complication of gallbladder pathology, with over 90% of them secondary to cholelithiasis. Approximately 6% are due to perforating peptic ulcers. Symptoms of biliary-enteric fistula varies widely and usually non-specific, mimicking any chronic biliary disease. Cholecystoduodenal fistula causing severe upper gastrointestinal (UGI) bleed is very rare. Bleeding cholecystoduodenal fistula commonly requires surgical resection of the fistula and repair of the duodenal perforation. We describe the case of a previously healthy older patient who initially presented with symptoms suggestive of UGI bleeding. Bleeding could not be controlled endoscopically. When a laparotomy was performed, a cholecystoduodenal fistula was discovered and bleeding was noted to originate from the superficial branch of cystic artery.

Congenital fistulisation of Meckel's diverticulum in omphalocele sac: case report.

Fistulisation of Meckel's diverticulum in the top of an omphalocele sac is very rare. To our Knowledge, three cases were reported in the literature. We presente in this report a new case of this uncommon presentation.

Small bowel and abdominal wall transplantation: A novel technique for synchronous revascularization.

Abdominal wall transplantation (AWT) was introduced in 1999 in the context of reconstruction of complex abdominal wall defects in conjunction with visceral organ transplantation. As of recently, 38 cases of total AWT have been performed worldwide, about half of which were performed in the United States. While AWT is technically feasible, one of the major challenges presenting to the reconstructive surgeon is time to revascularization of the donor abdominal wall (AW), given the immediate proximity of the visceral organ and AWT. The authors report a novel AW revascularization technique during a synchronous small bowel and AWT in a 37-year-old man.

Role of Epithelial-to-Mesenchymal Transition in Inflammatory Bowel Disease.

Intestinal fibrosis is an inevitable complication in patients with inflammatory bowel disease [IBD], occurring in its two major clinical manifestations: ulcerative colitis and Crohn's disease. Fibrosis represents the final outcome of the host reaction to persistent inflammation, which triggers a prolonged wound healing response resulting in the excessive deposition of extracellular matrix, eventually leading to intestinal dysfunction. The process of epithelial-to-mesenchymal transition [EMT] represents an embryonic program relaunched during wound healing, fibrosis and cancer. Here we discuss the initial observations and the most recent findings highlighting the role of EMT in IBD-associated intestinal fibrosis and fistulae formation. In addition, we briefly review knowledge on the cognate process of endothelial-to-mesenchymal transition [EndMT]. Understanding EMT functionality and the molecular mechanisms underlying the activation of this mesenchymal programme will permit designing new therapeutic strategies to halt the fibrogenic response in the intestine.

Transplantation of Human Intestine Into the Mouse: A Novel Platform for Study of Inflammatory Enterocutaneous Fistulas.

BACKGROUND AND AIMS: Enteric fistulas represent a severe and medically challenging comorbidity commonly affecting Crohn's disease [CD] patients. Gut fistulas do not develop in animal models of the disease. We have used transplantation of the human fetal gut into mice as a novel platform for studying inflammatory enterocutaneous fistulas. METHODS: Human fetal gut segments were transplanted subcutaneously into mature SCID mice, where they grew and fully developed over the course of several months. We first analysed the resident immune cells and inflammatory response elicited by systemic lipopolysaccharide [LPS] in normal, fully developed human gut xenografts. Thereafter, we used immunostaining to analyse fully developed xenografts that spontaneously developed enterocutaneous fistulas. RESULTS: Resident human innate and adaptive immune cells were demonstrated in gut xenografts during steady state and inflammation. The expression of human IL-8, IL-1ß, IL-6, TNF-α, A20, and IkBα was significantly elevated in response to LPS, with no change in IL-10 gene expression. Approximately 17% [19/110] of fully developed subcutaneous human gut xenografts spontaneously developed enterocutaneous fistulas, revealing striking histopathological similarities with CD fistula specimens. Immunohistochemical analyses of fistulating xenografts revealed transmural lymphocytic enteritis associated with massive expansion of resident human CD4+ lymphocytes and their migration into the intraepithelial compartment. Regionally, mucosal epithelial cells assumed spindle-shaped mesenchymal morphology and formed fistulous tracts towards chronic non-healing wounds in the host mouse skin overlying the transplants. CONCLUSIONS: Inflammation and fistulas developed in human gut xenografts lacking IL-10 gene response. This novel model system will enable systematic studies of the inflamed and fistulating human gut in live animals.

Pyeloduodenal Fistula in Xanthogranulomatous Pyelonephritis: A Series of Two Cases.

Xanthogranulomatous inflammation, characterized by destruction and replacement of tissues with chronic inflammatory cells, including foamy histiocytes and hemosiderin-laden macrophages, is uncommon. In patients with xanthogranulomatous pyelonephritis, inflammation may extend from the kidney to the overlying duodenum, creating a pyeloduodenal fistula that further complicates medical and surgical management. We present two cases with recurrent kidney infections who each ultimately received a nephrectomy and repair of their duodenal fistula.

Human mesenchymal stem cell therapy in the management of luminal and perianal fistulizing Crohn's disease - review of pathomechanism and existing clinical data.

INTRODUCTION: Crohn's disease (CD) is a chronic, recurring, idiopathic disease which is associated with imbalanced mucosal immune response, manifesting as a chronic inflammation of any location throughout the gastrointestinal tract. The purpose of currently available therapy is to suppress the heightened immune response. However, these treatments have no direct influence on the healing process of damaged tissues. The mesenchymal stem cell (MSC) therapy may represent a new alternative solution in both luminal and fistulizing CD, as it is able to inhibit the inflammation and promote the regeneration process at the same time. AREAS COVERED: Aim of this review is to summarize the existing clinical data about the clinical impact of MSC therapy in luminal and perianal fistulizing CD. EXPERT OPINION: Clinical trials demonstrated that MSC transplantation has an outstanding, durable efficacy with low fistula recurrence in biological therapy-refractory fistulizing CD; however, further clinical trials are required to confirm its effectiveness in luminal CD. Unlike to biological therapy, MSCs are able to promote the regeneration process of damaged tissues as well. This additional benefit besides their sustained immunosuppressive effect with no decrease of efficiency over time makes MSCs a new, highly potential therapeutic approach in the management of inflammatory bowel disease.

Pyeloduodenal fistula diagnosed with technetium-99m scintigraphy and managed with a conservative strategy.

We present a case of pyeloduodenal fistula in an 89-year-old woman with history of nephrolithiasis and recurrent urinary tract infection (UTI) who presented to the emergency department with back pain. CT revealed a malrotated right kidney with a large renal stone and possible fistulous connection between the second portion of the duodenum and the right renal collecting system. Technetium-99m scintigraphy confirmed presence of the fistula. The patient declined intervention and was discharged from the hospital with oral antibiotic suppressive therapy. The patient remained clinically stable at time of follow-up 3 months later. Spontaneous pyeloduodenal fistula is an aetiology of recurrent upper or lower UTIs or persistent bacteriuria though uncommonly recognised. Diagnosis may be achieved using several modalities, including technetium-99m scintigraphy. Nephrectomy and primary fistula closure has traditionally been the treatment of choice for this condition; however, conservative management is an option for patients with intact renal function.