HLA-DQA1*05 Associates with Extensive Ulcerative Colitis at Diagnosis: An Observational Study in Children

The human leukocyte antigen (HLA) allele group HLA-DQA1*05 predisposes to ulcerative colitis (UC) and is associated with the development of antibodies against infliximab in patients with inflammatory bowel disease (IBD). Therefore, we hypothesized that the presence of HLA-DQA1*05 correlates with characteristics of pediatric IBD. Within a multi-center cohort in Poland, the phenotype at diagnosis and worst flare was established and HLA-DQA1*05 status was assessed enabling genotype-phenotype analyses. HLA-DQA1*05 was present in 221 (55.1%) out of 401 children with IBD (UC n = 188, Crohn’s disease n = 213). In UC, the presence of HLA-DQA1*05 was moderately associated with a large extent of colonic inflammation at diagnosis (E4 55% more frequent in HLA-DQA1*05-positive patients, p = 0.012). PUCAI at diagnosis (p = 0.078) and the time from UC diagnosis to the first administration of biologic treatment (p = 0.054) did not differ depending on HLA-DQA1*05 status. The number of days of hospitalization for exacerbation was analyzed in 98 patients for whom sufficient follow-up was available and did not differ depending on HLA-DQA1*05 carriership (p = 0.066). HLA-DQA1*05 carriers with CD were less likely to present with both stenosing and penetrating disease (B2B3, p = 0.048) and to have active disease proximal to the ligament of Treitz (L4a) at the worst flare (p = 0.046). Future research focusing on explaining and preventing anti-TNF immunogenicity should take into account that ADA may develop not only as an isolated reaction to anti-TNF exposure but also as a consequence of intrinsic differences in the early course of UC.

Causes and Management of Lower Gastro-Intestinal Bleeding

Gastrointestinal (GI) bleeding from the colon is a communal reason for hospitalization and is being more frequent in older patients. Gastrointestinal bleeding is known as any bleeding that takes place in the GIT from mouth to anus. Lower GI bleeding is defined as bleeding distal to the ligament of Treitz. Lower GI bleed is typically presented as hematochezia which is the passing of bright red blood clots or burgundy stools through the rectum. The causes of lower GI bleeding are changing over the past several decades from diverticulosis (which is the protrusion of the colon wall at the site of penetrating vessels), infectious colitis, ischemic colitis, angiodysplasia, inflammatory bowel disease, colon cancer, hemorrhoids, anal fissures, rectal varices, dieulafoy lesion, radiation-induced damage following cancer treatment to post-surgical. Management of lower GI bleeding is done through assessing the severity of symptoms and the condition of the overall case.

META-ANALYSIS ON ETIOPATHOGENESIS OF SMALL BOWEL OBSTRUCTION IN THE DEPARTMENT OF GEN. SURGERY P.M.C.H. & K.M.C.H., BIHAR

Background:The small intestine is the longest and convoluted portion in the digestive tract. It starts from pylorus and ends at ileocaecal valve. The small bowel consists of three parts measuring about 5 to 6 meters. The rst 25cm is the duodenum. Out of the rest part of small gut, jejunum th th. constitute the proximal 2/5 and ileum distal 3/5 The jejunum and ileum extend from the peritoneal fold that supports the duodeno-jejunal junction (Ligament of Treitz) down to ileocaecal valve. Material and Methods:All the patients admitted to PMCH, Patna and KMC, Katihar as intestinal obstruction was included for the study. The time period of study was from October 2014 to November 2016 in PMCH and December 2016 to January 2019 in KMC, Katihar. Out of all Intestinal obstruction 59 cases only of adult small gut obstruction were recorded for comparison and conclusive study.Conclusion: Small bowel obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding delayed operation, whatever surgery is indicated, not every patient is always best served by immediate operation

Classification of the colonic splenic flexure based on three-dimensional CT analysis

Background Mobilization of the splenic flexure can be a challenging surgical step in colorectal surgery. This study aimed to classify the splenic flexure based on the three-dimensional (3D) coordinates of the splenic hilum and left renal hilum. This classification was used to compare splenic flexure mobilization during colorectal resection. Methods CT images of patients with colorectal cancer treated between April 2018 and December 2019 were analysed retrospectively. 3D mutual positioning of the splenic flexure from the ligament of Treitz to the splenic hilum or the left renal hilum was used to classify patients into three groups using cluster analysis. The difference in the procedure time between groups was also analysed in a subset of patients undergoing laparoscopic colectomy with complete splenic flexure mobilization. Results Of 515 patients reviewed, 319 with colorectal cancers were included in the study and categorized based on the 3D coordinates of the splenic hilum and left renal hilum as caudal (100 patients), cranial (118) and lateral (101) positions. Male sex (P < 0.001), older age (P = 0.004) and increased bodyweight (P = 0.043) were independent characteristics of the lateral group in multiple logistic regression analysis. Thirty-four patients underwent complete splenic flexure mobilization during the study period; this took significantly longer (mean 78.7 min) in the lateral group than in the caudal and cranial groups (41.8 and 43.2 min respectively; P = 0.006). Conclusion Locating the splenic flexure using 3D coordinates could be helpful in predicting a longer duration for mobilization of the splenic flexure.

Operative approach to intestinal malrotation encountered during laparoscopic gastric bypass

Congenital anomalies of midgut rotation are uncommon with a 0.2–0.5% incidence. Intestinal malrotation (IM) presents a unique challenge in bariatric surgery during laparoscopic gastric bypass (LRYGB), and familiarity with alternatives allows for safe laparoscopic intervention. IM was encountered in 5 of 1183 (0.4%) patients undergoing surgery. Once IM was suspected, a standardized approach was applied: rightward shift of ports, confirmation of IM by the absence of the ligament of Treitz, identification of the duodenojejunal junction, lysis of Ladd’s bands, mirror-image construction of the Roux limb and construction of the gastrojejunal anastomosis. Forty percent were male, age 33 ± 8 years, with body mass index 50 kg/m2 (37–75 kg/m2). IM was identified preoperatively in two patients (40%). All operations were completed laparoscopically. Despite the finding of IM, successful laparoscopic completion of gastric bypass can be anticipated if the surgeon has an understanding of the anatomic alterations and a strategy for intraoperative management.

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references