Severe acute ischemic colitis: What is the place of endoscopy in the management strategy?

Background and study aims Ischemic colitis (IC) is potentially lethal. Clinical and biology information and results of computed tomography (CT) scan and/or colonoscopy are used to assess its severity. However, decision-making about therapy remains a challenge. Patients and methods This was a retrospective, single-center study between 2006 and 2015. Patients with severe IC who underwent endoscopic evaluation were included. The aims were to determine outcomes depending on endoscopic findings and assess the role of endoscopy in the management. Results A total of 71 patients were included (men = 48 (68%), mean age = 71 ± 13 years). There was hemodynamic instability in 29 patients (41 %) and severity signs on CT scan in 18 (38 %). Twenty-nine patients (41 %) underwent surgery and 24 (34 %) died. The endoscopic grades were: 15 grade 1 (21 %), 32 grade 2 (45 %), and 24 grade 3 (34%). Regarding patients with grade 3 IC, 55 % had hemodynamic instability, 58 % had severity signs on CT scan, 68 % underwent surgery, and 55 % died. The decision to perform surgery was based on hemodynamic status in 62 % of cases, CT scan data in 14 %, endoscopic findings in 10 %, and other in 14 %. Colectomy was more frequent in patients with grade 3 IC (P < 0.05). A mismatch between mucosal aspect (necrosis) and serous (normal) was observed in 13 patients (46 %). Risk factors for colectomy in univariate analysis were aortic aneurysm surgery, hemodynamic instability, no colic enhancement on CT scan, and endoscopic grade 3. Risk factors for mortality in multivariate analysis were hemodynamic instability, colectomy, and Charlson score > 5 (P < 0.05). Conclusions This study suggests a low impact of endoscopy on surgical decision making. Hemodynamic instability was the first indication for colectomy. A discrepancy between endoscopic mucosal (necrosis) and surgical serous (normal) aspects was frequently noted.

Spontaneous outbreak of Yersinia enterocolitica infection and co-infection with Escherichia coli in black-tufted marmosets (Callithrix penicillata)

Yersiniosis is a zoonotic bacterial disease that affects humans and animals, including primates. The aim of the study was to report one case of fatal Yersinia enterocolitica infection and two cases of co-infection with Escherichia coli in captive black tufted marmosets (Callithrix penicillata) in Apucarana, Paraná, south Brazil. The affected animals presented severe diarrhea and progressed to death. Gross examination showed multifocal to coalescing necrosis in the liver, mild diffuse hepatomegaly, mild diffuse necrotizing enteritis, moderate splenomegaly and focally extensive hyperemia of the leptomeninges. Microscopically, the liver lesions comprised multifocal areas of lytic necrosis with intralesional colonies of gram-negative coccobacilli, characterizing a severe, random, multifocal to coalescing necrotizing hepatitis. A moderate multifocal lymphocytic cholangiohepatitis, severe focally extensive mucosal necrosis in the small intestine, and mild multifocal lymphoplasmacytic leptomeningitis in the brain were observed. Two cases of co-infection by Y. enterocolitica and E. coli, and one case by Y. enterocolitica were confirmed through bacterial culture, biochemical characteristics and 16S rRNA. To the best of the author’s knowledge, it is the first report of an infection of Y. enterocolitica and co-infection with E. coli in black-tufted marmosets resulting in diarrhea, septicemia and death.

Histopathology of human intestinal anastomosis

The faultless seal of the anastomosis is an important aspect of abdominal surgery but opportunities to make a histological evaluation of human intestinal anastomosis sites are rare. This retrospective study examined 30 anastomoses that had been resected following complications or postmortem; the aim was to describe the histological changes at various stages of healing ranging from 4 days to 3.5 years post-surgery. Anastomosis dehiscence showed features of extensive mucosal necrosis and bad submucosal apposition. Old healed anastomoses continued to have chronic inflammatory cells and muscular discontinuity with areas of intervening fibrosis. It would be useful to underst and more about how the intraluminal contents are propelled through this scarred area

Mucosal necrosis of the palate after embolization for labial arterioveinous malformation

Objective: Cervico-facial arteriovenous malformations (AVMs) are complex and rare vascular lesions, and present in 0.1% of the population. Of traumatic or congenital origin, they are characterized by variable growth, and their complications can be disfiguring and potentially fatal. The treatment of choice is embolization followed by surgery if necessary. The main complications are recurrence and postoperative bleeding. Case report: We report the rare case of a 59-year-old female patient who underwent embolization of a right upper labial and jugal AVM, followed by complete necrosis of the right hemi-palatal mucosa associated with dental mobility and pain. Follow-up at 6 months showed complete reepithelialisation of the palate. Conclusions: Soft tissue necrosis after AVM embolization is a rare event and is more commonly described after embolization for epistaxis. The evolution is generally favourable within a few weeks.

A case of esophageal rupture caused by long-term exposure to vinegar and resolved by damage control strategies

A 75-year-old woman had the habit of drinking vinegar. She had emergent transport to our hospital because of vomiting and unconsciousness. The patient underwent emergency surgery for esophageal rupture and septic shock. Intraoperatively, a 25 mm perforated area was found, and the visible esophageal mucosa was black. Because the suture closure or anastomosis was difficult and the shock was prolonged, she was placed in the intensive care unit after undergoing resection of the thoracic esophagus and thoracic drainage. Fifteen hours after the first surgery, we performed external esophagostomy and enterostomy. The third surgery was a retrothoracic cervical esophagogastric anastomosis, and reconstructive surgery was performed 60 days after the first surgery. Prolonged exposure to vinegar may have resulted in esophageal mucosal necrosis. This is a valuable case in which the esophageal mucosa was necrotic, and we performed esophagectomy and reconstruction as a damage control strategy to save her life.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett’s oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.