A Study of Histopathological Findings in Neonatal Necrotizing Enterocolitis in Early and Late Term Infants

BACKGROUND Neonatal necrotising enterocolitis (NNEC) is very common among premature infants. However, its incidence in term babies has also been on the rise. It is a potentially devastating condition with variable mortality. The diagnosis and management of NNEC is clinically supported by modified Bell’s grading. In cases where surgical resection of bowel is performed, histological findings are rarely given much importance. In this study, we have studied the histopathology of resected bowel in NNEC in term babies and correlated these findings with the age of the neonate and also with modified Bell’s grading. METHODS 25 cases of small bowel specimens of term infants received at the pathology department of a tertiary paediatric referral hospital were studied in detail for gross and microscopic features. The histological parameters considered were transmural coagulative necrosis, granulation tissue, crypt distortion, pseudomembrane formation, villous atrophy and pneumatosis intestinalis. These findings were compared with the age of the neonates and also correlated with the modified Bell’s grading. The clinical presentation and histology were also compared in early presenting term neonates less than a week in age and term infants of more than a week. RESULTS We found early neonates of age less than a week to have higher Bell’s grading and more severe histology. CONCLUSIONS Term neonates also present with severe NNEC, requiring surgical resection of the bowel. Early presentation and higher Bell’s grading are associated with more severe histopathological changes. KEYWORDS NNEC, Term Neonates, Bell’s Grading, Histopathology

Resected bowel syndrome: clinical course and treatment options

The current concepts of the short bowel syndrome and malabsorption after intestinal surgery are generally accepted, but do not fully reflect the patients condition, making it difficult to diagnose and treat it. Aim.The purpose of the study is to analyze the clinical course of the patients after bowel resection, to create a classification based on the variants identified to allow for a differentiated treatment and to introduce the concept of the resected bowel syndrome. Materials and methods.We observed 239 patients (96 men and 143 women) aged 18 to 80 who underwent intestinal resection for 1 month to 16 years (from 2002 to 2018). The 1st group included 96 patients with small bowel resection (40 men and 56 women). The 2nd group included 39 men and 58 women with small bowel resection, including the resection of the ileocecal valve and the right-hand side of the colon (n=97). The 3rd group included 17 men and 29 women with the resection of the right-hand side of the colon or colectomy (n=46). The survey included the NRS-2002 (Nutritional Risk Screening 2002) screening test to identify nutritional risk, a clinical assessment of the symptoms that occurred after the surgery, instrumental methods (esophagogastroduodenoscopy, colonoscopy with biopsy, ultrasound of the abdominal cavity organs and the kidneys, a plain radiography of the abdominal cavity organs, an X-ray examination of the small intestine and the intestinal passage), serum citrulline and short-chain fatty acids in faeces. Results.Based on the analysis of the clinical symptoms and the nutritional status of the patients, a new concept is proposed the resected bowel syndrome with two variants of its progression: either with or without the development of nutritional insufficiency of three types: the dehydration type, the protein-energy insufficiency type and a mixed type. Type 1 requires the use of antimicrobials with the control of SCFA concentrations in faeces. Type 2 requires the introduction of an optimal amount of easily digestible protein to correct protein-energy deficit. The 3rd (most severe) mixed type requires prescription of a parenteral nutrition component with the control of citrulline concentration in the blood serum. Conclusion.The proposed concept the resected bowel syndrome makes it possible to improve its diagnosis, take into account the variants of its progression and allow for a differentiated treatment.

Rare cause of right iliac fossa pain in a UK patient

A 62-year-old Asian man presented with a 3-month history of right iliac fossa pain which had progressively worsened over the last 3 weeks. All blood parameters were found to be unremarkable except for mildly elevated erythrocyte sedimentation rate. CT imaging demonstrated thickening of the ascending colon and caecum. Colonoscopic biopsies showed submucosal granulomas with features suggestive of schistosomiasis and parasite serology was positive for Schistosoma antibodies. He was treated with praziquantel and showed subsequent symptomatic and radiological improvement. However, he represented nearly 2 years later and underwent a right hemicolectomy for small bowel obstruction. The resected bowel showed an inflammatory caecal mass and a terminal ileal adenocarcinoma.

P105 PREDICTIVE FACTORS FOR DEVELOPING SMALL BOWEL OBSTRUCTIONS AFTER ILEAL RESECTION IN PATIENTS WITH CROHN’S DISEASE

Background and Aims Patients with Crohn’s disease (CD) may require small bowel resections. Unfortunately, some of these patients may develop post-operative small bowel obstructions (SBO). Many clinicians perceive ileal resections dramatically increase the risk of developing SBO in the future, but the incidence and risk factors to developing SBO are poorly described. The primary aim of this study is to document the incidence and factors associated with the development of SBO not related to recurrence of disease in CD patients that undergo ileal resection. We also sought to assess long-term outcomes of this complication. Methods We performed a retrospective cohort study including patients aged 18 years or older with CD, who have had ileocecal resection with ileocolonic anastomosis or segmental small bowel resection. Data abstracted included demographics, phenotype and therapies of CD, disease recurrence post-ileal resection and multiple surgical variables. The primary outcome was the development of SBO within 5 years post-surgery not including obstructions secondary to recurrence of CD. Results 92 total patients were included in the analysis. All had a colonoscopy within a year of the surgery. The mean Rutgeerts score was 0 (interquartile range [IQR] 0 to 2) and the mean short endoscopic score was 0 (IQR 0 to 4). The remainder of baseline characteristics are shown in Table 1. At 6 months, 1 year, and 5 years, the rate of SBO was 4/92 (4%), 6/92 (6.5%), and 15/92 (16%), respectively. Throughout follow-up, only 5 patients had an SBO attributed to intra-abdominal adhesions and only 2 patients required surgical lysis of adhesions. Patients that were found to have histologic inflammation in the margins of the resected bowel specimen had a significantly higher chance of developing an SBO within 5 years of the initial surgery (OR: 4.5 [95%CI: 1.3–15.3], p=0.02 - Table 2). Conversely, patients with either active endoscopic and/or radiologic inflammation on post surgical surveillance colonoscopy did not have a higher risk of developing an SBO within 5 years of the initial surgery (p=0.37). Finally the length of bowel resected at the index surgery was not associated with the development of an SBO (AUC: 0.62, p=0.18). Conclusions The incidence of SBO after ileal resection in CD is low and resolves with medical management on most cases. Inflammation in the margins of the resected bowel and previous bowel resections were associated with new SBO within 5 years. These results must take into account the study population were monitored and cannot be extrapolated to those patients that lost follow-up.

Still time to perform intestinal revascularization in patients with acute mesenteric ischemia with peritonitis: An analysis of bowel viability in resections

Objective: Acute mesenteric ischemia is often fatal, and many survivors develop short bowel syndrome. To avoid massive bowel resection, revascularization is recommended for acute mesenteric ischemia patients. However, whether acute mesenteric ischemia patients with clinical peritonitis can be revascularized remains uncertain. Therefore, this study aimed to evaluate the histopathological potential reversibility of resected bowel in acute mesenteric ischemia patients with peritonitis. Methods: We retrospectively reviewed the medical records of acute mesenteric ischemia patients treated at the Kameda Medical Center between January 2001 and March 2015. Pathological evaluation regarding bowel resection was performed. Patients with and without peritonitis were compared. The primary outcome was the proportion of patients with reversible or irreversible ischemia. Patients with reversible and irreversible ischemia were characterized. Results: Of 41 patients, 17 underwent laparotomy, 6 endovascular surgery, and 18 palliative care. Among 23 patients receiving curative treatment, 7 had peritonitis and 13 did not. Seven patients of each group received bowel resection, but 85.7% of those with peritonitis had reversible ischemia. We categorized patients with ischemia into reversible and irreversible groups. The median time between symptom onset and diagnosis in the reversible group was >27 h. Systemic inflammatory response syndrome was found in 72.2% and 66.7% of the reversible and irreversible groups, respectively. Conclusion: Acute mesenteric ischemia patients with clinical peritoneal signs may have potentially reversible ischemia. As a result, revascularization should be considered, even in the case of peritonitis.

Massive Lipomatosis of the Small Intestine Causing Intussusception

Lipomatosis is a rare condition characterized by diffuse, unencapsulted adipose tissue deposition. Intestinal involvement is rare, and presentation as intussusception is rarer still. We report a 40-year-old man who presented with abdominal pain and fecal urgency. Abdominal CT scan showed a protuberant ileo-cecal valve, with intussusception of the ileum into the cecum. The mucosal surface of the resected bowel was bulbous and protuberant, showing loss of mucosal folds, and there was an 8 × 5 × 5 cm mass prolapsing into the ileo-cecal valve. Microscopically there was abundant adipose tissue in the submucosa with an unremarkable mucosa. The patient recovered uneventfully with only occasional cramping in the left abdomen.

The Influence of Microscopic Inflammation at Resection Margins on Early Postoperative Endoscopic Recurrence After Ileocaecal Resection for Crohn’s Disease

Background and Aims The pathogenesis and risk factors for early postoperative endoscopic recurrence of Crohn’s disease [CD] remain unclear. Thus, this study aimed to identify whether histological inflammation at the resection margins after an ileocaecal resection influences endoscopic recurrence. Methods We have prospectively followed up patients with CD who underwent ileocaecal resection at our hospital between January 2012 and January 2018. The specimens were histologically analysed for inflammation at both of the resection margins [ileal and colonic]. We evaluated whether histological results of the resection margins are correlated with endoscopic recurrence of CD based on colonoscopy 6 months after ileocaecal resection. Second, we assessed the influence of known risk factors and preoperative therapy on endoscopic recurrence of CD. Results A total of 107 patients were included in our study. Six months after ileocaecal resection, 23 patients [21.5%] had an endoscopic recurrence of CD. The histological signs of CD at the resection margins were associated with a higher endoscopic recurrence [56.5% versus 4.8%, p < 0.001]. Disease duration from diagnosis to surgery [p = 0.006] and the length of the resected bowel [p = 0.019] were significantly longer in patients with endoscopic recurrence. Smoking was also proved to be a risk factor for endoscopic recurrence [p = 0.028]. Conclusions Histological inflammation at the resection margins was significantly associated with a higher risk of early postoperative endoscopic recurrence after an ileocaecal resection for CD.

Hemophagocytic lymphohistiocytosis associated with Epstein–Barr virus infection: case report and literature review

Hemophagocytic lymphohistiocytosis (HLH) is rare and life threatening syndrome. There are only a few reported cases of HLH with GI symptoms. We describe the case of an 18 months old boy who presented with a history of fever for 40 days, abdominal distention and hepatosplenomegaly. Abdominal x-ray showed a pneumoperitoneum. Urgent laparotomy was done which revealed an isolated cecal perforation. The histopathological findings in the subsequent resected bowel was HLH with evidence of positive EBV Barr infection.

Peutz-Jeghers syndrome: need for early screening

Peutz-Jeghers syndrome (PJS) is an autosomal dominant cancer-predisposing condition characterised by intestinal hamartomatous polyps and distinct melanin depositions in skin and mucosa. Small intestinal cancer in patients with PJS usually presents by the third decade. A 7-year-old-PJS boy presented with recurrent episodes of colicky abdominal pain and melena requiring repeated blood transfusions. Abdominal CT scan revealed multiple jejunal polyps with jejunoileal intussusception. On exploration, the intussuscepted bowel was resected along with its mesentery and anastomosed. Simultaneously, multiple enterotomies with resection of palpable polyps were performed. The resected bowel showed well-differentiated stage 2A adenocarcinoma with clear resected margins. Postoperatively, the complaints were relieved. On follow-up, he was asymptomatic and is now on yearly cancer surveillance. This is probably the youngest reported case of small bowel cancer in PJS.