Efficacy of a comprehensive binary classification model using a deep convolutional neural network for wireless capsule endoscopy.

The manual reading of capsule endoscopy (CE) videos in small bowel disease diagnosis is time-intensive. Algorithms introduced to automate this process are premature for real clinical applications, and multi-diagnosis using these methods has not been sufficiently validated. Therefore, we developed a practical binary classification model, which selectively identifies clinically meaningful images including inflamed mucosa, atypical vascularity or bleeding, and tested it with unseen cases. Four hundred thousand CE images were randomly selected from 84 cases in which 240,000 images were used to train the algorithm to categorize images binarily. The remaining images were utilized for validation and internal testing. The algorithm was externally tested with 256,591 unseen images. The diagnostic accuracy of the trained model applied to the validation set was 98.067%. In contrast, the accuracy of the model when applied to a dataset provided by an independent hospital that did not participate during training was 85.470%. The area under the curve (AUC) was 0.922. Our model showed excellent internal test results, and the misreadings were slightly increased when the model was tested in unseen external cases while the classified 'insignificant' images contain ambiguous substances. Once this limitation is solved, the proposed CNN-based binary classification will be a promising candidate for developing clinically-ready computer-aided reading methods.

The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function.

BACKGROUND: This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. METHODS: Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018. KEY RECOMMENDATIONS: The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia. CONCLUSIONS AND INFERENCES: This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.

Intestinal failure functional classification type associated with an extended length of stay at the intestinal failure unit, Central Hospital in Chihuahua, Mexico.

BACKGROUND: Intestinal failure (IF) was first defined as "a reduction in the functioning gut mass below the minimal amount necessary for adequate digestion and absorption." In our environment, there are no statistical data for IF in adult patients' extended length of stay (LOS), nor the economic impact that it implies. OBJECTIVE: The objective of the study was to describe the association between the IF type and extended LOS. METHODS: Patients admitted to our IF Unit between March 2016 and March 2018 were enrolled. We conducted a 2-year retrospective cross-sectional study. RESULTS: From the total of 53 patients, 35% corresponded to type I IF, 58.5% to type II IF, and 7.5% to type III IF. The mean LOS, according to the type of functional IF was 51 days for type I, 77.48 days for type II, and 68.25 days for type III. The mean LOS for the three IF types was 67.79 days. CONCLUSION: Extended LOS occurs in an important proportion of patients with IF, resulting in increased morbidity and mortality, as well as in costs and associated side effects. Future research should focus on economic studies, to know the economic impact that this subject entails for our health systems.

ANTECEDENTES: En nuestro entorno no existen datos estadísticos sobre la falla intestinal en adultos, su estancia hospitalaria prolongada (EHP) ni el impacto económico que implica. OBJETIVO: Describir la asociación entre el tipo de falla intestinal y la estancia hospitalaria prolongada en pacientes de la unidad de falla intestinal del Hospital Central del Estado Chihuahua, México. MÉTODO: Se realizó un estudio transversal retrospectivo con un total de 53 participantes durante el periodo de marzo de 2016 a marzo de 2018. RESULTADOS: De los 53 pacientes, el 35% tuvieron falla intestinal tipo I, el 58.5% tipo II y el 7.5% tipo III. La media de estancia fue de 51 días para la falla intestinal tipo I, 77,48 días para la tipo II y 68,25 días para la tipo III. La media de estancia hospitalaria para los tres tipos de insuficiencia intestinal fue de 67,79 días. CONCLUSIONES: La estancia hospitalaria prolongada ocurre en una proporción importante de pacientes con falla intestinal, lo que resulta en un aumento de la morbilidad, la mortalidad y los costos. Investigaciones futuras deberían centrarse en la realización de estudios económicos para conocer el impacto que esta cuestión tiene para nuestros sistemas de salud.

Advances in Evaluation of Chronic Diarrhea in Infants.

Diarrhea is common in infants (children less than 2 years of age), usually acute, and, if chronic, commonly caused by allergies and occasionally by infectious agents. Congenital diarrheas and enteropathies (CODEs) are rare causes of devastating chronic diarrhea in infants. Evaluation of CODEs is a lengthy process and infrequently leads to a clear diagnosis. However, genomic analyses and the development of model systems have increased our understanding of CODE pathogenesis. With these advances, a new diagnostic approach is needed. We propose a revised approach to determine causes of diarrhea in infants, including CODEs, based on stool analysis, histologic features, responses to dietary modifications, and genetic tests. After exclusion of common causes of diarrhea in infants, the evaluation proceeds through analyses of stool characteristics (watery, fatty, or bloody) and histologic features, such as the villus to crypt ratio in intestinal biopsies. Infants with CODEs resulting from defects in digestion, absorption, transport of nutrients and electrolytes, or enteroendocrine cell development or function have normal villi to crypt ratios; defects in enterocyte structure or immune-mediated conditions result in an abnormal villus to crypt ratios and morphology. Whole-exome and genome sequencing in the early stages of evaluation can reduce the time required for a definitive diagnosis of CODEs, or lead to identification of new variants associated with these enteropathies. The functional effects of gene mutations can be analyzed in model systems such as enteroids or induced pluripotent stem cells and are facilitated by recent advances in gene editing procedures. Characterization and investigation of new CODE disorders will improve management of patients and advance our understanding of epithelial cells and other cells in the intestinal mucosa.

In vitro intestinal permeability studies, pharmacokinetics and tissue distribution of 6-methylcoumarin after oral and intraperitoneal administration in Wistar rats

ABSTRACT 6-Methylcoumarin (6MC) is a semisynthetic coumarin with important in vitro and in vivo anti-inflammatory activity. In order to continue the pre-clinical characterization of this molecule, in vitro intestinal permeability, plasma profile and tissue distribution after oral administration in rats were studied. The permeability of 6MC was evaluated by the Caco-2 cellular model in both the apical-basal (A-B) and basal-apical (B-A) directions. The pharmacokinetics and biodistribution were evaluated in rats after oral and intraperitoneal administration at doses of 200 mg/kg. Transport experiments with Caco-2 cells showed that 6MC presented high permeability at all concentrations evaluated. This finding suggested that 6MC could be transported across the gut wall by passive diffusion. The plasma concentration-time curve showed that the maximum concentration (Cmax) was 17.13 ± 2.90 µg/mL at maximum time (Tmax) of 30 min for the oral route and Cmax 26.18 ± 2.47 µg/mL at 6.0 min for the intraperitoneal administration, with elimination constant of (Ke ) 0.0070 min-1 and a short life half time of (T1/2 ) lower that 120 min. The distribution study showed that 6MC has high accumulation in the liver, and widespread distribution in all the organs evaluated.

[Malabsorption is a leading clinical sign of small bowel disease]. / Narushenie vsasyvaniya - vedushchii klinicheskii priznak bolezni tonkoi kishki.

The paper presents a variety of clinical manifestations of malabsorption syndrome (MAS) in celiac disease, collagenous sprue, Whipple's disease, Crohn's disease, intestinal lymphangiectasia, amyloidosis, common variable immune deficiency, and treatment of short bowel syndrome. It shows the specific features of the pathophysiology, diagnosis, and treatment of MAS in small bowel diseases.

[Interintestinal anastomoses formation using permanent magnet in surgical treatment of children with intestinal stomas].

It was analyzed the results of treatment of 48 children aged from 1 month to 14 years. In these observations by the 6th - 7th days after doubleintestinalstoma formation magnetic dies with inductance from 300 to 360 mTl and energy force at least 255 kJ/m3 were introduced into lumen of afferent and efferent intestinal loops. Attractive or compression force between dies was 600 g, i.e. force per 1 cm2 was 200 g according to dies' surface 1.12.83.0 cm. Magnets are not only surgical instruments but also physiotherapeutic devices improving microcirculation and stimulating regeneration in the area of anastomosis. Interintestinal anastomosis has been completely formed for 5-7 days. Thereafter magnetic dies have been removed. Stool was normalized in 45 of 48 observations after surgery (1-3 times daily). Intestinal discharge from ileostomy reduced to minimal amount. In 2 patients irregular bowel movements was observed due to adhesive stenosis of interintestinal anastomosis. Magnetic dies can't be established in 1 case due to adhesive process. Hospital stay was from 10 to 25 days in 41 children. 7 patients were discharged for outpatient treatment later. All children were under observation for the period 2-4 months after discharge. Signs of hypotrophy including body weight deficit within 10% of age norm were diagnosed only in 3 children with prematurity degree I-II. Hereafter children were repeatedly hospitalized; intestinal stomas were surgically removed using conventional technique. Thus complete convalescence was obtained.

Identification of new cases of severe enteropathy has recently increased the spectrum of intestinal non-celiac villous atrophy.

From olmesartan-induced enteropathy to small CD4(+) T-cell intestinal lymphoproliferation, the spectrum of non-celiac villous atrophy has recently been largely extended. Precise characterization of the different types of non-celiac enteropathy with villous atrophy is necessary to avoid misdiagnosis, to identify a causal mechanism and propound appropriate therapeutic strategies. This paper discusses how to use the different diagnostic tools to address diagnostic criteria, citing the examples of recent new cases of non-celiac enteropathy with intestinal villous atrophy.

[Histological classification and quality of life in women with endometriosis]. / Classificação histológica e qualidade de vida em mulheres portadoras de endometriose.

PURPOSE: To assess the relationship between the histological classification and the quality of life of patients operated for endometriosis. METHODS: A cross-sectional observational study, with assessment of 32 biopsies of the intestine, peritoneum and uterosacral ligament from 40 women with deep endometriosis. The quality of life (QOL) was determined by applying the SF-36 questionnaire pre-operatively and at 6 and 12 months postoperatively. Biopsies were histologically classified into pure stromal (EP), glandular differentiated (GD), glandular undifferentiated (GI) and mixed (GM), remaining in the sample only GI and GM, which are related to eight domains of the SF-36. RESULTS: According to the histologic type, the following distribution was observed: peritoneum 63% GI and 35% GM; intestine 19% GI and 24% GM; uterosacral ligament with 41% GI and 35% GM. Regarding the QOL and the histological classification, in the intestine only GM was associated with improvement of social and emotional aspects from 0 to 6 months; the domains general health status (p=0.01) and social aspect (p=0.04) were significantly related to improvement of the QOL from 0 to 6 months, and the general health status tended to improve from 0 to 12 months. Regarding pain (p=0.06) and the emotional aspect (p=0.05), the QOL tended to improve from 0 to 6 months and the vital capacity (p=0.1) improved from 0 to 6 months and from 0 to 12 months. Regarding the emotional aspect, evolution of the two histological types was not favorable for improvement in MG from 0 to 6 months. No significant relationships between histologic type and QOL were evident in the uterosacral ligament samples. CONCLUSION: Improvement in the QOL of women undergoing laparoscopic surgery for deep endometriosis is associated with the histologic grade. The peritoneal biopsy of GI revealed improved QOL after surgery.

A novel bowel necrosis classification system and examination of patient outcomes in incarcerated groin hernia patients.

The objective of this study was to determine a classification system for BN in incarcerated groin hernia patients and to explore the possible relationship between BN staging and patient outcomes. Incarcerated groin hernia patients treated with emergency bowel resection from January 2008 to December 2013 were screened for inclusion in a prospective study. A novel three-stage classification system was proposed for BN (BN stages I-III) and correlations between adverse events (AEs) and mortality with BN stage were determined. A total of 108 patients were included, with 71, 26, and 11 patients in BN stages I, II, and III, respectively. AEs, which included wound and intra-abdominal infections and other systemic complications, increased with higher BN stage (all P < 0.05). Mortality increased with BN stage, with 2.8%, 7.7%, and 27.3% at BN stages I, II, and III, respectively (P < 0.05). The proposed BN staging system can objectively reflect the degree of bowel damage and its corresponding adverse outcomes.

ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults.

BACKGROUND & AIMS: Intestinal failure (IF) is not included in the list of PubMed Mesh terms, as failure is the term describing a state of non functioning of other organs, and as such is not well recognized. No scientific society has yet devised a formal definition and classification of IF. The European Society for Clinical Nutrition and Metabolism guideline committee endorsed its "home artificial nutrition and chronic IF" and "acute IF" special interest groups to write recommendations on these issues. METHODS: After a Medline Search, in December 2013, for "intestinal failure" and "review"[Publication Type], the project was developed using the Delphi round methodology. The final consensus was reached on March 2014, after 5 Delphi rounds and two live meetings. RESULTS: The recommendations comprise the definition of IF, a functional and a pathophysiological classification for both acute and chronic IF and a clinical classification of chronic IF. IF was defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". CONCLUSIONS: This formal definition and classification of IF, will facilitate communication and cooperation among professionals in clinical practice, organization and management, and research.

Increased prevalence of bladder and intestinal dysfunction in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is predominantly characterized by a progressive loss of motor function. While autonomic dysfunction has been described in ALS, little is known about the prevalence of lower urinary tract symptoms (LUTS) and intestinal dysfunction. We investigated disease severity, LUTS and intestinal dysfunction in 43 patients with ALS attending our outpatient department applying the ALS functional rating scale, the International Consultation on Incontinence Modular Questionnaire, the Urinary Distress Inventory and the Cleveland Clinic Incontinence Score. Results were compared to the German population of a cross-sectional study assessing LUTS in the healthy population, the EPIC study. Results showed that urinary incontinence was increased in patients with ALS aged ≥ 60 years compared to the EPIC cohort (female: 50%/19% (ALS/EPIC), p = 0.026; male: 36%/11% (ALS/EPIC), p = 0.002). No difference was seen at 40-59 years of age. Urge incontinence was the predominant presentation (73% of symptoms). A high symptom burden was stated (ICIQ-SF quality of life subscore 5.5/10). Intake of muscle relaxants and anticholinergics was associated with both urinary incontinence and severity of symptoms. Furthermore, a high prevalence of constipation (46%), but not stool incontinence (9%), was noted. In conclusion, the increased prevalence of urge incontinence and high symptom burden imply that in patients with ALS, LUTS should be increasingly investigated for.

Portal hypertensive enteropathy diagnosed by capsule endoscopy in cirrhotic patients: a nationwide multicenter study.

BACKGROUND AND AIM: Due to the limited data on portal hypertensive enteropathy (PHE), the prevalence of and clinical factors related to PHE remain unclear. This study determined the prevalence of PHE using capsule endoscopy (CE) and PHE-related clinical factors. METHODS: This was a retrospective multicenter study using the Capsule Endoscopy Nationwide Database Registry. From 2,879 cases that underwent CE, 45 cirrhosis patients with portal hypertension (PH) were enrolled and divided into PHE (n = 18) and non-PHE (n = 27) groups. From computed tomography (CT) images, six secondary changes due to PH were scored to give a total CT score of 0-6. The main outcome variable was the prevalence of PHE and PHE-related clinical factors. RESULTS: The prevalence of PHE was 40 %. Comparing the PHE and non-PHE groups, the most common findings were angiodysplasias in 55.7 % (vs. 7.4 %, p = 0.001) and varices in 38.9 % (vs. 0 %, p = 0.001). Active bleeding was observed in 16.6 and 3.7 %, respectively, but this difference was not significant. In the univariate analysis, Child-Turcotte-Pugh class C (p = 0.002) and a high CT score (≥3 vs. <3, p = 0.004) were significantly associated with PHE. However, only a high CT score was significant in the multivariate analysis (odds ratio 11.19; 95 % confidence interval, 1.59-infinity; p = 0.040). CONCLUSIONS: The prevalence of PHE was 40 %, and it might be more prevalent in cirrhosis patients with PH who have a high CT score. CE is a useful diagnostic tool for evaluating PHE in cirrhosis patients with PH.

[Second-generation colon capsule in small bowel and colon disorders in pediatrics].

BACKGROUND: Aim of the study was to assess the diagnostic yield of second-generation colon capsule in pediatric gastrointestinal diseases. PATIENTS AND METHODS: Five patients with different symptoms of gastrointestinal diseases were included in the study. Among them were: suspicion on diffuse polyposis, intestinal bleeding, lymphangiectasia and inflammatory bowel disease. Image interpretation was made by experienced capsule users, previously trained on small bowel capsule and first generation colon capsule. Lesions or abnormal changes of the mucosa identified on capsule endoscopy served as indications for colonoscopy or esophagogastroduodenoscopy with biopsy or polypectomy if needed. RESULTS: Standard white light endoscopy was made in all children without any adverse events. Second-generation colon capsule allows diagnosing Crohn's disease in small intestine and colon, limphangiectasia of the ileum, single rectosigmoid polyp and diffuse polyposis of the colon. CONCLUSION: Second-generation colon capsule can be used as non-invasive screening method in children without serious complications, thus allowing to differentiate indications for traditional white light endoscopy, which is usually made under general anesthesia in pediatrics.

[Prevention of incompetence of sutures of intestinal anastomoses by the method of permanent intramesenteric blockade and lymphotropic therapy].

The author considers results of inestigation for studying an efficiency of permanent intramesenteric (retroperitoneal) blockade and applying lymphotropic therapy for prevention of incompetence of sutures of intestinal anastomosis against the background of diffuse peritonitis and acute intestinal obstruction. An infusion was carried out 4-6 times a day with a special solution (novocain 0.5% (7 ml/kg/day); heparin (150 units/kg/days); proserin (0.03 mg/kg/day) and seftriakson (15 mg/kg/days)) in order to obtain the effect of permanent intramesenteric blockade and lymphotropic therapy. The solution is administered by droplet injection with the rate 100-120 drops a minute (80-120 ml per each infusion). Due to the application of the given method the frequency of cases of the incompetent sutures of intestinal anastomoses in patients of the main group decreased from 15.5% to 3.4% (X2 = 16.2; p < 0.001) as compared with the other patients.