Rare cause of small bowel obstruction: diaphragm disease.

Diaphragm disease is a rare cause of small bowel obstruction, caused by circular fibrotic membranes resulting in a narrowed intestinal lumen. It is associated with prolonged non-steroidal anti-inflammatory drug use, and often requires surgical resection. We report the case of a man in his 50s presenting with recurrent anaemia and intermittent small bowel obstruction. Exploratory laparoscopy identified three distinct areas of congested, thickened and narrowed ileum. Symptoms resolved following small bowel resection. Histological examination found elongated mucosal folds with ulceration and submucosal fibrosis consistent with diaphragm disease. Common radiological findings include small bowel strictures and thickening, mucosal hyperenhancement, and small bowel dilatation. In this case, on retrospective review of the initial CT scan, it is possible to appreciate circumferential mural thickening correlating with the histological findings. This case highlights the importance of rigorous examination of CT imaging and the utility of exploratory laparoscopy in diagnosing diaphragm disease.

Tonsillar Extraintestinal Enteropathy-Associated T-Cell Lymphoma in a Patient With Celiac Disease.

Enteropathy-associated T-cell lymphoma (EATL) is a rare but serious complication of celiac disease. Diagnosis is challenging. Patients can present with weight loss, abdominal pain, and diarrhea or acutely with bowel perforation or obstruction. Patients often present with advanced disease. Malnutrition further limits treatment options. Early diagnosis is important to start aggressive treatment strategies. However, even with prompt diagnosis, prognosis remains poor with a high mortality rate. We report the first documented case of sole tonsillar involvement, a rare extraintestinal and extranodal site of disease, leading to EATL diagnosis. We also highlight some of the challenges in diagnosing EATL.

Refractory primary intestinal lymphangiectasia effectively managed with subcutaneous octreotide.

This case report describes a young man with a history of lymphoedema and long-standing gastrointestinal symptoms since childhood. After undergoing extensive investigations, he was diagnosed with primary intestinal lymphangiectasia (IL). The patient's condition was refractory to conventional medium-chain triglyceride diet but responded well to treatment with subcutaneous octreotide. We have shown octreotide to be effective in improving the pathological effects of primary IL, associated with improved clinical well-being and serology, but it is not a curative therapy.

Simulator training improves practical skills in therapeutic GI endoscopy: results from a randomized, blinded, controlled study.

BACKGROUND: Therapeutic endoscopic procedures are technically challenging and have higher complication rates than diagnostic procedures. Less-experienced practitioners are significantly more likely to have a complication, yet there is very limited evidence of the efficacy of training in such procedures. OBJECTIVE: To evaluate the effect of knowledge-based teaching and hands-on, simulation-based skills training in 4 therapeutic endoscopic procedures: control of nonvariceal upper GI bleeding, polypectomy, stricture dilation, and percutaneous endoscopic gastrostomy (PEG) tube insertion. DESIGN: Single-blind, randomized, controlled trial. SETTING: Nationally accredited therapeutic endoscopy course. PARTICIPANTS AND INTERVENTION: Participants were randomized into groups to assess the effect of knowledge-based teaching and into subjects or controls to assess skills-based training. All delegates had an initial knowledge and skills assessment by blinded experts. Subjects received one-half day of hands-on skills training, whereas the controls did not. All delegates were retested on their procedural skills. MAIN OUTCOME MEASUREMENTS: Knowledge was assessed by using a multiple-choice questionnaire. Practical skills were assessed using station-specific checklists and a global score. RESULTS: Twenty-eight participants were randomized. There was no significant effect of knowledge-based teaching on the participants' practical skills or initial multiple-choice questionnaire score, although there was a trend toward improvement. There was a significant improvement in the subjects compared with the controls in the performance of polypectomy, control of upper GI bleeding, and esophageal dilation. There were no significant differences for PEG tube insertion. LIMITATIONS: The 2-person nature of PEG tube insertion may have resulted in performance improvement despite a lack of training. CONCLUSION: Hands-on skills training significantly improved performance in 3 therapeutic modalities. Knowledge-based teaching alone did not have a measurable effect. These results strongly support the benefit of intensive hands-on, simulation-based courses for endoscopic skills training.

Purine, kynurenine, neopterin and lipid peroxidation levels in inflammatory bowel disease.

The kynurenine metabolites of tryptophan may be involved in the regulation of neuronal activity and thus gut motility and secretion. We have now performed a pilot study to measure serum concentrations of purines and kynurenines in patients with mild inflammatory bowel disease, as well as in sex- and age-matched control subjects. For some analyses, the patients were subdivided into subgroups of those with Crohn's disease and those with ulcerative colitis. The analyses indicated an increased activity in one branch of the kynurenine pathway. While there was no demonstrable difference in neopterin levels in either of the patient groups compared with controls, indicating that the disorders were in an inactive quiescent phase, both groups showed significantly higher levels of lipid peroxidation products. This suggests the presence of increased oxidative stress even during relative disease inactivity. The increased level of kynurenic acid may represent either a compensatory response to elevated activation of enteric neurones or a primary abnormality which induces a compensatory increase in gut activity. In either case, the data may indicate a role for kynurenine modulation of glutamate receptors in the symptoms of inflammatory bowel disease.