Assessment of plasma microRNAs in congenital intestinal malrotation.

Intestinal malrotation in newborns often requires urgent surgical treatment, especially in the presence of volvulus. Therefore, early­stage diagnosis is critical. In the present study, differentially expressed plasma microRNAs (miRNAs) were screened for in patients with intestinal malrotation using high­throughput Illumina sequencing, and validated using reverse transcription­quantitative PCR. Receiver operating characteristic curve (ROC) analysis was conducted to evaluate their specificity, sensitivity and assess their diagnostic value for intestinal malrotation. Bioinformatics analysis was performed to investigate the functions associated with the dysregulated miRNAs. A profile consisting of 28 differentially expressed plasma miRNAs was obtained, of which nine were verified to exhibit significantly altered expression. According to a ROC analysis, four of these could represent novel early­stage, non­invasive biomarkers for intestinal malrotation. Bioinformatics analysis demonstrated that the differentially expressed miRNAs were predominantly involved in 'metal ion transmembrane transporter activity' and 'calcium­dependent protein binding', which may be related to the 'endocytosis' pathway. In conclusion, significantly differentially expressed plasma miRNAs were identified in congenital intestinal malrotation and their potential roles were described. These differentially expressed miRNAs may serve as biomarkers of intestinal malrotation and improve early diagnosis for this condition.

Preliminary heritability of complete rotation large colon volvulus in Thoroughbred broodmares.

Large colon volvulus (LCV) is a life-threatening form of colic that occurs when the large colon rotates 360° or more on its axis, resulting in colonic distention and ischaemia. Any horse can suffer from LCV, but the risk is greatest for periparturient Thoroughbred broodmares; the objective of this study was to estimate the heritability of LCV in these horses. The criteria for classification as an LCV case were being a Thoroughbred broodmare from one of three farms in central Kentucky and having had surgical correction for LCV. Controls were identified as Thoroughbred broodmares present on the same farms with no history of surgical colic. Thirty-nine cases and 191 controls were identified. Age of the LCV cases at the time of incident was significantly younger than that of the controls at the time of the study (P<0.0001). A total of 2223 horses were present when the five-generation pedigrees of the 230 study horses were combined. Heritability of LCV was estimated at 0.311±0.383 from the fit of a logit sire model with binomial data including year of birth and farm as fixed effects. Further data on broodmares from these and other farms will help to improve this estimate, which suggests the LCV is moderately heritable.

Rare copy number variants contribute pathogenic alleles in patients with intestinal malrotation.

BACKGROUND: Intestinal malrotation is a potentially life-threatening congenital anomaly due to the risk of developing midgut volvulus. The reported incidence is 0.2%-1% and both apparently hereditary and sporadic cases have been reported. Intestinal malrotation is associated with a few syndromes with known genotype but the genetic contribution in isolated intestinal malrotation has not yet been reported. Rare copy number variants (CNVs) have been implicated in many congenital anomalies, and hence we sought to investigate the potential contribution of rare CNVs in intestinal malrotation. METHODS: Analysis of array comparative genomic hybridization (aCGH) data from 47 patients with symptomatic intestinal malrotation was performed. RESULTS: We identified six rare CNVs in five patients. Five CNVs involved syndrome loci: 7q11.23 microduplication, 16p13.11 microduplication, 18q terminal deletion, HDAC8 (Cornelia de Lange syndrome type 5 and FOXF1) as well as one intragenic deletion in GALNT14, not previously implicated in human disease. CONCLUSION: In the present study, we identified rare CNVs contributing pathogenic or potentially pathogenic alleles in five patients with syndromic intestinal malrotation, suggesting that CNV screening is indicated in intestinal malrotation with associated malformations or neurological involvements. In addition, we identified intestinal malrotation in two known syndromes (Cornelia de Lange type 5 and 18q terminal deletion syndrome) that has not previously been associated with gastrointestinal malformations.

Two new mutations of the CLMP gene identified in a newborn presenting congenital short-bowel syndrome.

Congenital short-bowel syndrome (CSBS) is a rare neonatal pathology associated with poor prognosis and high mortality rate. We describe a newborn presenting CSBS intestinal malrotation and chronic intestinal pseudo-obstruction syndrome (CIPS), compound heterozygous for two previously unreported heterozygous mutations in Coxsackie and adenovirus receptor-like membrane protein (CLMP) gene, one in intron 1 (c.28+1G>C), the other on exon 4 (c502C>T, p.R168X). Both mutations are predicted to be pathogenic, leading to impaired splicing and the appearance of a premature stop codon, respectively. Our case is remarkable in that it concerns two heterozygous truncating mutations associated with a good clinical prognosis with a favorable cerebral and gastrointestinal outcome and a substantial enteral input at 8 months of age, despite a small intestine measuring only 35cm.

Control of stomach smooth muscle development and intestinal rotation by transcription factor BARX1.

Diverse functions of the homeodomain transcription factor BARX1 include Wnt-dependent, non-cell autonomous specification of the stomach epithelium, tracheo-bronchial septation, and Wnt-independent expansion of the spleen primordium. Tight spatio-temporal regulation of Barx1 levels in the mesentery and stomach mesenchyme suggests additional roles. To determine these functions, we forced constitutive BARX1 expression in the Bapx1 expression domain, which includes the mesentery and intestinal mesenchyme, and also examined Barx1(-/)(-) embryos in further detail. Transgenic embryos invariably showed intestinal truncation and malrotation, in part reflecting abnormal left-right patterning. Ectopic BARX1 expression did not affect intestinal epithelium, but intestinal smooth muscle developed with features typical of the stomach wall. BARX1, which is normally restricted to the developing stomach, drives robust smooth muscle expansion in this organ by promoting proliferation of myogenic progenitors at the expense of other sub-epithelial cells. Undifferentiated embryonic stomach and intestinal mesenchyme showed modest differences in mRNA expression and BARX1 was sufficient to induce much of the stomach profile in intestinal cells. However, limited binding at cis-regulatory sites implies that BARX1 may act principally through other transcription factors. Genes expressed ectopically in BARX1(+) intestinal mesenchyme and reduced in Barx1(-/-) stomach mesenchyme include Isl1, Pitx1, Six2 and Pitx2, transcription factors known to control left-right patterning and influence smooth muscle development. The sum of evidence suggests that potent BARX1 functions in intestinal rotation and stomach myogenesis occur through this small group of intermediary transcription factors.

46,XY disorders of sex development and congenital diaphragmatic hernia: a case with dysmorphic facies, truncus arteriosus, bifid thymus, gut malrotation, rhizomelia, and adactyly.

The association of 46,XY disorder of sex development (DSD) with congenital diaphragmatic hernia (CDH) is rare, but has been previously described with and without other congenital anomalies. Literature review identified five cases of 46,XY DSD associated with CDH and other congenital anomalies. These five cases share characteristics including CDH, 46,XY karyotype with external female appearing or ambiguous genitalia, cardiac anomalies, and decreased life span. The present case had novel features including truncus arteriosus, bifid thymus, gut malrotation, and limb anomalies consisting of rhizomelia and adactyly. With this case report, we present a review of the literature of cases of 46,XY DSD and CDH in association with multiple congenital abnormalities. This case may represent a unique syndrome of 46,XY DSD and diaphragmatic hernia or a more severe presentation of a syndrome represented in the previously reported cases.

Severe acute abdomen caused by symptomatic Meckel's diverticulum in three children with trisomy 18.

Meckel's diverticulum (MD) is the most prevalent congenital anomaly of the gastrointestinal tract and often presents a diagnostic challenge. Patients with trisomy 18 frequently have MD, but the poor prognosis and lack of consensus regarding management for neonates has meant that precise information on the clinical manifestations in infants and children with MD is lacking. We describe the cases of three children with trisomy 18 who developed symptomatic MD. Intussusception was diagnosed in Patient 1, intestinal volvulus in Patient 2, and gastrointestinal bleeding in Patient 3. All three patients underwent surgical treatment and only the Patient 1 died due to pulmonary hypertensive crisis. The other two patients experienced no further episodes of abdominal symptoms. In patients with trisomy 18, although consideration of postoperative complications and prognosis after surgical treatment is necessary, symptomatic MD should carry a high index of suspicion in patients presenting with acute abdomen.

ACTA2 mutation with childhood cardiovascular, autonomic and brain anomalies and severe outcome.

Thoracic aortic aneurysm and dissection (TAAD) are associated with connective tissue disorders like Marfan syndrome and Loeys-Dietz syndrome, caused by mutations in the fibrillin-1, the TGFß-receptor 1- and -2 genes, the SMAD3 and TGFß2 genes, but have also been ascribed to ACTA2 gene mutations in adults, spread throughout the gene. We report on a novel de novo c.535C>T in exon 6 leading to p.R179C aminoacid substitution in ACTA2 in a toddler girl with primary pulmonary hypertension, persistent ductus arteriosus, extensive cerebral white matter lesions, fixed dilated pupils, intestinal malrotation, and hypotonic bladder. Recently, de novo ACTA2 R179H substitutions have been associated with a similar phenotype and additional cerebral developmental defects including underdeveloped corpus callosum and vermis hypoplasia in a single patient. The patient here shows previously undescribed abnormal lobulation of the frontal lobes and position of the gyrus cinguli and rostral dysplasis of the corpus callosum; she died at the age of 3 years during surgery due to vascular fragility and rupture of the ductus arteriosus. Altogether these observations support a role of ACTA2 in brain development, especially related to the arginine at position 179. Although all previously reported patients with R179H substitution successfully underwent the same surgery at younger ages, the severe outcome of our patient warns against the devastating effects of the R179C substitution on vasculature.

Recent advances in the molecular and genetic understanding of congenital gastrointestinal malformations.

Major developmental paradigms are highly conserved among vertebrates. The contribution of developmental biology to the understanding of human disease and regeneration has soared recently. We review advances in the molecular and genetic understanding of gastrointestinal development using evidence from both mammalian and nonmammalian models. When appropriate, we highlight relevance and applicability to human disease.

A novel mutation in FOXF1 gene associated with alveolar capillary dysplasia with misalignment of pulmonary veins, intestinal malrotation and annular pancreas.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, fatal, neonatal developmental lung disorder, which usually presents as persistent pulmonary hypertension unresponsive to treatment. The authors report the case of a neonate with persistent pulmonary hypertension, associated with duodenal stenosis secondary to annular pancreas and intestinal malrotation. Support treatment, inhaled nitric oxide, oral sildenafil and nebulized iloprost were used with no clinical improvement. The neonate presented an overwhelming course, with hypoxemia refractory to treatment. At autopsy lung histology showed the characteristic features of ACD/MPV. DNA sequence analysis revealed a heterozygous nonsense mutation c.539C>A;p.S180X, in the first exon of FOXF1. FOXF1 has been identified as one of the genes responsible for ACD/MPV associated with multiple congenital malformations. This clinical case is the first report of a heterozygous nonsense mutation c.539C>A;p.S180X in the first exon of FOXF1, in a patient with ACD/MPV associated with annular pancreas and intestinal malrotation.

Delayed presentation of familial intestinal malrotation with volvulus in two adult siblings.

Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Familial cases of malrotation are extremely rare in the absence of other congenital malformations. We present the case of a 22-year-old woman with undiagnosed chronic abdominal pain and her previously well 16-year-old brother who presented within 18 months of each other with acute midgut volvulus secondary to intestinal malrotation. Clinicians should be aware of this rare but serious cause of abdominal pain.

An adult case of midgut volvulus in familial visceral myopathy.

We report an adult case of midgut volvulus in familial visceral myopathy (FVM) that had affected family members over three generations. The patient was a Japanese woman in her fifties, who had chronic intestinal pseudo-obstruction (CIPO) since the age of about 40 years and had been treated chronically with conservative therapies. Her abdominal symptoms suddenly worsened and surgery became necessary. Surgery revealed a midgut volvulus secondary to intestinal malrotation and the twisted intestine was resected. Histology revealed diffuse damage of myocytes confined to the muscularis propria throughout the resected intestine. The myocytes were irregulary arranged, contained cytoplasmic inclusions, and had mild and focal vacuolar changes. The mucsularis propria showed hypertrophy with delicate interstitial fibrosis. A diagnosis of FVM was made on the basis of this characteristic myopathy. Intestinal malrotation is known to be a complication of CIPO in children, but is rare in adults. Although midgut volvulus appears to be extremely rare, it can occur after a relatively stable chronic phase in adult CIPO patients, who should be monitored carefully to assess the risk of such complications.

Iris transillumination defects associated with pallister-killian syndrome.

This report describes a new finding of iris transillumination defects in Pallister-Killian syndrome, a rare multi-system disorder resulting from mosaic tetrasomy of the short arm of chromosome 12.

Mosaic trisomy 22 associated with total colonic aganglionosis and malrotation.

AIMS: Abnormalities of chromosome 22 karyotype have been reported to be associated with both malrotation and aganglionosis. However, although malrotation has been reported to occur in the rare mosaic trisomy 22, Hirschsprung's disease has not. We present a case of mosaic trisomy 22 that presented during the neonatal period with malrotation and total colonic aganglionosis, and we discuss the possible pathogenesis of both conditions in the light of this rare genetic abnormality. The association of total colonic aganglionosis and mosaic trisomy 22 has not previously been reported. RESULTS: A male neonate with an antenatal diagnosis of de novo mosaic trisomy 22 underwent a laparotomy with correction of malrotation and midgut volvulus on day 3 of life. Rectal biopsy was performed because he had not passed meconium. This revealed Hirschsprung's disease; an ileostomy was formed, and histology confirmed aganglionosis as far as the terminal ileum. At 6 months, a modified Lester Martin Duhamel pull-through was performed. He is showing normal development at follow-up. CONCLUSIONS: We recommend an increased index of suspicion of Hirschsprung's disease and malrotation in patients with mosaic trisomy 22 until further evidence can establish or exclude a meaningful relationship.

Pallister-Killian syndrome: a report of 2 cases and review of its surgical aspects.

Pallister-Killian syndrome (PKS) is a rare mosaic genetic disorder defined by the presence of isochromosome for the short arm of chromosome 12. The authors report 2 new cases of PKS with prenatal diagnosis of tetrasomy 12p made by cytogenetic study of amniocytes. Typical dysmorphic craniofacial features were noted postnatally. Both newborns were referred to a surgical department because of congenital anomalies requiring operative management. One had an imperforate anus with an anocutaneous fistula and underwent minor anorectoplasty on day 2 of life. The second newborn required emergency laparotomy because of malrotation with midgut volvulus. This is the first report of clinical manifestation of malrotation in a patient with PKS. The authors undertook a detailed review of reported to date cases of PKS with special emphasis on its surgical aspects.

Growth factor and receptor mRNA expression in the intestine of horses with large colon volvulus: a pilot study.

REASONS FOR PERFORMING STUDY: Growth factors (GF) are important for maintenance and repair of intestinal mucosal structure and function, but there have been no studies investigating growth factor (GF) or growth factor receptor (GF-R) mRNA expression in the intestine of horses with large colon volvulus (LCV). OBJECTIVES: (1) To determine mRNA expression for epidermal growth factor (EGF), EGF receptor (EGF-R), insulin-like growth factor-I (IGF), IGF receptor (IGF-R), vascular endothelial growth factor (VEGF) and VEGF receptor (VEGF-R) in the intestine of horses with an LCV compared to normal intestine. (2) To measure the correlation between histological intestinal injury and mRNA expression. METHODS: In 5 horses, samples were collected from the mid-jejunum (small intestine, SI), pelvic flexure (PF) and right dorsal colon (RDC) prior to creation of the LCV (NORM), 1 h following creation of the LCV (ISCH) and 1 h following correction of the LCV (REPER). In 2 clinical cases of LCV, samples were collected from the PF and RDC. Samples were assessed histologically for the amount of intestinal injury. The mRNA expressions of growth factors and receptors were determined using qRT-PCR. RESULTS: VEGF and VEGF-R mRNA expression was greater in horses with an LCV compared to NORM. Expression of IGF-R mRNA increased in the SI during ISCH and REPER. CONCLUSION AND POTENTIAL RELEVANCE: The increase compared to NORM in VEGF and VEGF-R mRNA expression in horses with LCV may be important in early intestinal healing and may also explain, in part, the increase in vascular permeability in horses with a LCV. Expression of IGF and IGF-R in the SI warrants further investigation and may be important for understanding post operative complications in horses with SI lesions.

Familial malrotation: report of three affected siblings.

We herein report the case of three siblings presenting with intestinal malrotation. Their medical history and circumstances of diagnosis are described. Barium meal demonstrated a minor duodenal anomaly in the mother. As far as we can ascertain, this is the third report of isolated familial malrotation in more than one generation, raising questions about its developmental mechanism. We thus highlight in what circumstances familial investigations should be undertaken in case of malrotation.