Electroacupuncture ameliorates corticotrophin-releasing factor-induced jejunal dysmotility in a rat model of stress.

BACKGROUND: Central injection of corticotrophin-releasing factor (CRF) mimics the effect of stress on gastrointestinal (GI) responses, including inhibition of GI motility. This study was designed to explore the effects of electroacupuncture (EA) on disordered jejunal motility in a rat model of stress induced by intracisternal (IC) injection of CRF. METHODS: A stress model was established by IC injection of CRF in Sprague-Dawley rats. GI motility was evaluated by assessing gastric emptying (GE), gastrointestinal transit (GIT) and jejunal motility in vivo. EA was performed at ST36. The functional roles of CRF receptor subtype 1 and subtype 2 (CRFr1 and CRFr2) were examined by IC administration of the corresponding selective CRF antagonists. Protein expression of CRFr1 and CRFr2 in the hypothalamus and jejunum was detected by Western blotting. RESULTS: IC injection of CRF significantly inhibited GE, GIT and jejunal motility. EA treatment remarkably improved the disturbed GI motility. Intriguingly, the disordered jejunal motility induced by central CRF was abolished by IC injection of a selective CRFr2 antagonist, indicating the essential role of central CRFr2 in mediating the stress-induced jejunal motor disorder. EA at ST36 decreased central and peripheral expression of CRFr2, which might be one of the potential mechanisms underlying the beneficial effect of EA on jejunal dysmotility in this rat model of stress. CONCLUSION: This study suggested that EA at ST36 could ameliorate disordered jejunal motility induced by stress, and that this might be associated with the down-regulation of CRFr2.

Rare aetiology of abdominal pain: contained abscess secondary to perforated jejunal diverticulitis.

A patient with a history of multiple jejunal diverticulosis (JD) presented with a non-peritonitic abdominal pain and leucocytosis. CT scan showed a thick-walled interloop collection within the left mid-abdomen with dilated bowels and mild diffuse air-fluid levels. Exploratory laparotomy revealed multiple diverticular outpouchings in the mid-jejunum, one of which was perforated, contained within the mesentery. Resection of the contained abscess and primary anastomosis were performed subsequently.

Diagnosis and management of jejunoileal diverticular haemorrhage: An update on the experience in a single centre.

INTRODUCTION: Jejunoileal diverticular haemorrhage is a rare disease that is difficult to diagnose and treat. Despite advances in endoscopic technology, recommendations on diagnosis and management for jejunoileal diverticular haemorrhage have remained unchanged and these new options have not been compared against traditional surgical management. MATERIALS AND METHODS: We retrospectively reviewed the diagnosis, management, and outcome for jejunoileal diverticular haemorrhage cases at our institution over the past 20 years. Data were organized and analysed by chi-square test, student t-test and Kaplan-Meier survival analysis. RESULTS: The most utilised diagnostic procedure was computed tomography, followed by enteroscopy, angiography, small bowel flow-through and surgery. Primary treatments included, in a decreasing order, medical therapy, surgery, endoscopy and radiology. Surgical treatment was not associated with rebleeding, but it did result in longer hospital stays and larger blood transfusions than non-surgical treatments. The bleeding-related mortality rate was very low. Notably, there was also little change in the diagnosis and treatment between decades. CONCLUSION: We presented our experience with the diagnosis and management of jejunoileal diverticular haemorrhage, as well as long-term follow-up after treatments that have not been reported previously. Surgical treatment continues to dominate management for jejunoileal diverticular haemorrhage, but we support increasing the role of endoscopy for select patient groups.

Juvenile dermatomyositis resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination of cyclophosphamide and rituximab: case-based review.

Dermatomyositis (DM) is a multi-system disease that results in chronic inflammation principally of the skin and striated muscle. Small blood vessel injury in the GI tract has been described in dermatomyositis, manifesting as bleeding, ulceration, pneumatosis intestinalis, and ultimately perforation. Recent histopathological studies have shown deposits in the capillaries of the skin, gastrointestinal tract, and brain of patients with dermatomyositis similar to that found in patients with Degos disease, suggesting these disease processes are closely related or represent varying degrees of severity on the same pathologic spectrum. We report a case of juvenile dermatomyositis (JDM) resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination rituximab and cyclophosphamide therapy. We systematically reviewed the literature detailing the medical and surgical treatments for gastrointestinal perforation in dermatomyositis, Degos-like dermatomyositis, and Degos disease. In addition to our case, as of October 2019, we identified 36 cases describing gastrointestinal perforation in patients with underlying dermatomyositis, 5 cases of Degos-like dermatomyositis and 17 cases of idiopathic Degos disease. Corticosteroid therapy was used widely for dermatomyositis and Degos-like dermatomyositis, while antiplatelet and anticoagulant medications were chiefly used for patients with idiopathic Degos disease. However, there were no cases that detailed the successful treatment of dermatomyositis or Degos disease with gastrointestinal perforation with rituximab alone or combined with cyclophosphamide. We report that rituximab, in combination with cyclophosphamide, can be used as a novel adjunctive therapy to successfully treat dermatomyositis with Degos-like gastrointestinal perforation.

Jejunal Diverticulitis: A Single-Center Experience and Proposed Management Algorithm.

Background: Jejunal diverticulitis is rare and usually an incidental diagnosis found on imaging. Its symptoms are non-specific. Hence, the diagnosis often is delayed, and a high mortality rate has been reported. The aim of this study was to review our experience in the management of jejunal diverticulitis and to propose a management algorithm. Methods: A retrospective review of all cases of jejunal diverticulitis seen from November 2015 to November 2018 was performed. Data collected included demographics, history of diverticulitis, risk factors, clinical presentation, biochemistry and imaging results, and management outcome. Results: Eight patients were identified during the study period, five females and three males with a median age of 71 years (range 61-85 years). One patient was on steroid treatment, and one patient had a history of jejunal diverticulitis. Abdominal pain was present in all patients, but other symptoms were variable. Two patients were initially believed to have constipation and were discharged home. All patients underwent a computed tomography (CT) scan for the diagnosis, showing that three had uncomplicated jejunal diverticulitis and five had localized perforation. Five patients were managed conservatively initially; two failed this treatment because of small bowel obstruction and persistent abdominal pain with rising inflammatory markers. Three underwent emergency laparotomy (two because of sepsis; one was thought to have a foreign body). There were no deaths. A proposed management algorithm is discussed. Conclusions: A CT scan is the mainstay for the accurate diagnosis of jejunal diverticulitis. The proposed algorithm can aid in selection of patients suitable for conservative management.

Sarcoidosis Involving the Gastrointestinal Tract: Diagnostic and Therapeutic Management.

Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.

Not all diverticulites are colonic: small bowel diverticulitis - A systematic review.

INTRODUCTION: Small bowel non-Meckelian diverticulitis (SBNMD) is not so an uncommon cause of admission in departments of emergency surgery. Our aim is to highlight signs and symptoms for early diagnosis and report proper surgical treatments. EVIDENCE ACQUISITION: The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P). EVIDENCE SYNTHESIS: Twelve studies met our inclusion criteria. A total of 527 patients diagnosed with SBNMD were analyzed: there were 159 (30%) cases of diverticular bleeding, 125 (23%) cases of perforated SBNMD, 91 (17.26%) cases of intestinal obstruction, 79 (14.9%) cases of non-complicated diverticulitis, and 36 (6.8%) cases of ileal diverticulosis. Among bleeding patients, endoscopy procedures were performed in 51 (32%) cases. Surgery was necessary in 77/159 (48.4%) cases. Medical treatment was sufficient in 15/159 (9.4%) cases. In case of perforation, 93/125 (74.4%) patients were submitted to surgery, with open technique in 78/93 (83.8%) patients, by laparoscopy in 2/93 (2.1%) with conversion rate of 1.07%. Eight of 125 (6.4%) cases received medical treatment. In case of obstruction, non-operative management was effective in 3/91 (3.2%) cases. Surgery was performed in 74/91 (78%) cases, with open technique in 64/91 (86.4%) cases, by laparoscopy in 3/74 (4%), with one patient converted in laparotomy. CONCLUSIONS: Diagnosis of SBNMD is often made at emergency surgical exploration with high morbidity and mortality rate. SBNMD must be considered in elderly patients presenting with abdominal pain. A multidisciplinary approach to the patient (involving a radiologist, a surgeon, and a gastroenterologist) is necessary to make an early diagnosis. In case of complicated SBNMD, the emergency surgeon must choose the right surgical treatment.

Short article: Outcome of medical and surgical management for perforated jejunal diverticulitis.

OBJECTIVES: Perforated jejunal diverticulitis (PJD) is rare, but it has high mortality rates. The role of nonsurgical management is debated. The aim of this study is to assess the outcomes of medical and surgical management of PJD. PATIENTS AND METHODS: A single-centre study on a series of emergency patients diagnosed with PJD between 2010 and 2016 was conducted. RESULTS: Eleven patients with PJD were treated (seven women). Nine out of 11 were diagnosed by a computed tomography scan, and two were diagnosed at laparotomy. The initial approach was medical treatment in five patients, based on clinical and imaging findings. Four (80%) of these five patients were discharged without the need for surgical intervention. The median hospital stay was 7.5 days. Seven patients required surgery overall with a median length of hospital stay of 10.8 days. Surgical procedures consisted of segmental bowel resection and primary anastomosis in six patients and simple closure in one. There was no perioperative deaths. One patient required percutaneous drainage because of anastomotic leak, and one required reoperation owing to evisceration. DISCUSSION: Selected patients with PJD can be successfully managed with conservative approach, based on clinical and computed tomography findings.

Jejunal diverticulitis in a healthy 91-year-old man.

A 91-year-old African American man was admitted with sudden onset diffuse abdominal pain which radiated to the right flank. CT of the abdomen with contrast showed diverticula in the jejunum with adjacent inflammation and microperforation that was contained. Conservative therapy similar to colonic diverticulitis was effective. Although rare, our case highlights the importance of having an early and high suspicion for jejunal diverticulitis when patients present with non-specific abdominal symptoms in order to avoid perforation.

[Management of jejunal diverticulitis. Experience in our center]. / Manejo de la diverticulitis yeyunal. Experiencia en nuestro centro.

Jejunal diverticular disease is a very uncommon pathology often asymptomatic. Associated complications appear in less than 30% of patients and they can present as diverticulitis, refractary inflammation, obstruction, hemorrhage, perforation or intraabdominal abscess formation. Clinical manifestations are usually unspecific and high suspicion index is required to reach the diagnosis. Treatment of complications includes volume replacement, transfusions, antibiotic therapy, percutaneous drainage or surgical intervention. We present a retrospective observational study of the cases treated in our hospital between 2007 and 2016.

La enfermedad diverticular yeyunal es una condición clínica muy poco frecuente y habitualmente asintomática. Las complicaciones asociadas aparecen en menos del 30% de los pacientes y pueden manifestarse como inflamación de los divertículos, obstrucción intestinal, hemorragia digestiva, malabsorción intestinal, formación de abscesos intraabdominales y perforación. La clínica de los pacientes es muchas veces inespecífica, requiriendo un alto grado de sospecha para llegar al diagnóstico. El tratamiento de las complicaciones de la enfermedad diverticular es variado, incluyendo reposición de volumen o transfusiones, antibioticoterapia, drenaje percutáneo o intervención quirúrgica. Presentamos un estudio observacional retrospectivo de los casos tratados en nuestro hospital entre 2007 y 2016.

Neonatal Intestinal Obstruction Syndrome.

Neonatal intestinal obstruction is caused by an anatomical abnormality that produces bowel movement failure. Intestinal obstruction presents with three classic clinical signs: vomiting, abdominal distention, and failure to pass meconium. Intestinal obstruction is one of the most common causes for admitting a pediatric patient to the pediatric surgery unit in his or her first weeks of postnatal life. Congenital obstruction of the digestive tract in neonates is a common problem, with the most frequent cause being anorectal malformations (41%), followed by esophageal obstruction (24%), and duodenal obstruction (20%). [Pediatr Ann. 2018;47(5):e220-e225.].

Acute Jejunoileal Diverticulitis: Multicenter Descriptive Study of 33 Patients.

OBJECTIVE: Acute jejunoileal diverticulitis is a very rare and potentially serious disease affecting mostly elderly patients. The diagnosis is based on imaging but remains underrecognized. The purpose of this study is to describe the clinical and CT features and the outcomes of patients with acute jejunoileal diverticulitis. MATERIALS AND METHODS: Cases of acute jejunoileal diverticulitis managed at three French hospitals November 2005 through January 2015 were identified retrospectively. The final diagnosis relied either on a clinical and radiologic data review by a panel of experts or on surgical findings. Demographic, clinical, laboratory, and 18-month outcome data were collected. CT scans were reviewed by two radiologists who reached a consensus about the presence of an inflammatory diverticulum, evidence of complications, and presence of other bowel diverticula. RESULTS: We identified 33 cases of acute jejunoileal diverticulitis in 33 patients with a median age of 78 years, including 30 (91%) patients in whom an inflammatory diverticulum was identified at the jejunum (n = 26, 87%) or ileum (n = 4, 13%). Extraintestinal gas was seen in 10 (30%) patients and extraintestinal fluid in 11 (33%) patients. Other small-bowel diverticula were visible in all 33 patients. The diverticulitis was mild and resolved with nonoperative treatment in 22 (67%) patients and was severe in the remaining 11 (33%) patients, eight of whom required emergent surgery. CONCLUSION: Acute jejunoileal diverticulitis is a rare and usually nonserious condition that chiefly involves the jejunum. A detailed CT assessment may allow nonoperative treatment.

Perinatal hemorrhage from ulceration of the umbilical cord: A potentially catastrophic association with duodenal and jejunal obstruction.

PURPOSE: The purpose of this study is to review published reports and contribute new cases of umbilical cord ulceration (UCU) with perinatal hemorrhage into the amniotic cavity in the setting of duodenal or jejunal obstruction because knowledge of this sequence is poorly disseminated and could be lifesaving. METHODS: Published reports of UCU with hemorrhage associated with congenital duodenal or jejunal obstruction were reviewed. Chart review was conducted for the cases encountered at our institutions between January 2008 and March 2017. We noted perinatal complications, method of delivery, gestational age, birth weight, gender, number, location, and pathologic description of umbilical cord ulcers, and outcome. RESULTS: Thirty-one reports and 7 new cases were studied. Perinatal complications included: preterm labor or preterm premature rupture of membranes: 63%; fetal distress: 95%; mean gestational age: 33weeks; premature gestation: 95%; bloody amniotic fluid: 90%. Pathological analysis of UCUs revealed solitary, multifocal, helical and punched-out lesions. There were 12 neonatal deaths (32%), and 12 intrauterine deaths (32%). Survival rate was 37%. CONCLUSIONS: UCU with perinatal hemorrhage is associated with duodenal and jejunal obstruction. Knowing the typical clinical signs of this potential catastrophic complication could prompt lifesaving delivery. TYPE OF STUDY: Prognostic LEVEL OF EVIDENCE: IV.

A novel finding of Rapunzel syndrome.

Rapunzel syndrome is a rare form of gastric trichobezoar (hair ball) involving extension of a tail of the hair into the small bowel. A 13-year-old girl was admitted with a 4-day history of epigastric pain and nausea which worsened after meals. Abdominal ultrasound showed duodenal wall thickening and lymphadenopathy. Esophagogastroduodenoscopy identified a gastric trichobezoar with a tail extending into the duodenum. In addition, multiple longitudinal duodenal and jejunal ulcers were noted. The ulcers appeared to be a result of direct pressure by the tail itself against the intestinal mucosa. The trichobezoar was successfully retrieved endoscopically under general anesthesia. Her symptoms resolved completely after retrieval. Psychiatric follow-up was carried out to help reduce the risk of recurrence. Here, we describe a novel complication of Rapunzel syndrome, i.e., multiple longitudinal ulcers of the small intestine. This novel finding suggests that the mucosal damage caused by the trichobezoar of Rapunzel syndrome can occur in an earlier stage than previously thought. In addition, we also strongly recommend using general anesthesia with intubation when removing a gastric trichobezoar to ensure protection of the airway.