Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum.Small bowel tuberculosis,characterized by predominant involvement of the small intestine,is an extremely rare condition with highly atypical clinical presentations,making diagnosis even more challenging.CASE SUMMARY We report three cases of small intestinal tuberculosis,two of the patients pre-sented primarily with abdominal pain,and one presented with gastrointestinal bleeding.All patients underwent blood tests and imaging examinations.Small bowel endoscopy(SBE)revealed that the main lesions in these patients were in-testinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers.One patient ultimately underwent surgical treatment.Following a complex diagnostic process and comprehensive analysis,all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment,leading to an improvement in their condition.CONCLUSION Patients with SBTs present with nonspecific symptoms such as abdominal pain,weight loss,and occasional gastrointestinal bleeding.Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagno-sis and complications.

Immune signature of small bowel adenocarcinoma and the role of tumor microenvironment

In this editorial we comment on the article published“Clinical significance of programmed cell death-ligand expression in small bowel adenocarcinoma is determined by the tumor microenvironment”.Small bowel adenocarcinoma(SBA)is a rare gastrointestinal neoplasm and despite the small intestine's significant surface area,SBA accounts for less than 3%of such tumors.Early detection is challenging and the reason arises from its asymptomatic nature,often leading to late-stage discovery and poor prognosis.Treatment involves platinum-based chemotherapy with a 5-fluorouracil combination,but the lack of effective chemotherapy contributes to a generally poor prognosis.SBAs are linked to genetic disorders and risk factors,including chronic inflammatory conditions.The unique characteristics of the small bowel,such as rapid cell renewal and an active immune system,contributes to the rarity of these tumors as well as the high intratumoral infiltration of immune cells is associated with a favorable prognosis.Programmed cell death-ligand 1(PD-L1)expression varies across different cancers,with potential discrepancies in its prognostic value.Microsatellite instability(MSI)in SBA is associated with a high tumor mutational burden,affecting the prognosis and response to immunotherapy.The presence of PD-L1 and programmed cell death 1,along with tumor-infiltrating lymphocytes,plays a crucial role in the complex microenvironment of SBA and contributes to a more favorable prognosis,especially in the context of high MSI tumors.Stromal tumor-infiltrating lymphocytes are identified as independent prognostic indicators and the association between MSI status and a favorable prognosis,emphasizes the importance of evaluating the immune status of tumors for treatment decisions.

Precision medicine in inflammatory bowel disease:Individualizing the use of biologics and small molecule therapies

The advent of biologics and small molecules in inflammatory bowel disease(IBD)has marked a significant turning point in the prognosis of IBD,decreasing the rates of corticosteroid dependence,hospitalizations and improving overall quality of life.The introduction of biosimilars has also increased affordability and enhanced access to these otherwise costly targeted therapies.Biologics do not yet represent a complete panacea:A subset of patients do not respond to first-line anti-tumor necrosis factor(TNF)-alpha agents or may subsequently demonstrate a secondary loss of response.Patients who fail to respond to anti-TNF agents typically have a poorer response rate to second-line biologics.It is uncertain which patient would benefit from a different sequencing of biologics or even a combination of biologic agents.The introduction of newer classes of biologics and small molecules may provide alternative therapeutic targets for patients with refractory disease.This review examines the therapeutic ceiling in current treatment strategies of IBD and the potential paradigm shifts in the future.

Clinical significance of programmed cell death-ligand expression in small bowel adenocarcinoma is determined by the tumor microenvironment

BACKGROUND Comprehensive genomic analysis has shown that small bowel adenocarcinoma(SBA)has different genomic profiles from gastric and colorectal cancers.Hence,it is essential to establish chemotherapeutic regimens based on SBA characteristics.The expression of programmed cell death-ligand 1(PD-L1)and programmed cell death-ligand 2(PD-L2)in SBA is not fully understood.Anti-PD-L1/PD-1 therapy uses tumor-infiltrating lymphocytes(TILs);therefore,the status of TILs in the tumor microenvironment(TME)may influence their efficacy.The ratio of FoxP3+to CD8+T cells has been reported to be useful in predicting the prognosis of digestive system cancers.AIM To investigate the clinicopathological significance of PD-L1/2 expression according to the status of TILs in SBA tissues.METHODS We performed immunohistochemical analysis for PD-L1,PD-L2,CD8,FoxP3,and DNA mismatch repair(MMR)proteins using formalin-fixed,paraffin-embedded tissues from 50 patients diagnosed with primary SBA.The immunoreactivities of PD-L1 and PD-L2 were determined separately in tumor cells and tumor-infiltrating immune cells throughout the tumor center and invasive margins,and finally evaluated using the combined positive score(CPS).We assessed CD8+and FoxP3+T cells in the intratumoral and tumor-surrounding stroma.Subsequently,we calculated and summed the ratio of FoxP3 to CD8+T cell counts.Immune-related cell densities were graded as low or high.Immunohistochemical results were compared with clinicopathological factors and patient prognosis.The distribution of cancer-specific survival(CSS)was estimated using the Kaplan–Meier method,and the log-rank test was used to test for significant differences in CSS.A Cox proportional hazard model was also used to assess the effect of tumor variables on CSS.RESULTS PD-L1 expression was positive in 34%in tumor cells(T-PD-L1)and 54%in tumor-infiltrating immune cells(I-PDL1)of the cases examined.T-PD-L2 was positive in 34%and I-PD-L2 was positive in 42%of the cases.PD-L1 CPS≥10 and PD-L2 CPS≥10 were observed in 50%and 56%of the cases,respectively.Deficient MMR(dMMR)was 14%of the cases.T-PD-L1,I-PD-L1 and PD-L1 CPS≥10 were all significantly associated with dMMR(P=0.037,P=0.009,and P=0.005,respectively).T-PD-L1,I-PD-L1,and PD-L1 CPS≥10 were all associated with deeper depth of invasion(P=0.001,P=0.024,and P=0.002,respectively).I-PD-L2 expression and PD-L2 CPS≥10 were significantly higher in the differentiated histological type(P=0.015 and P=0.030,respectively).The I-PD-L1 and IPD-L2 levels were significantly associated with better CSS(P=0.037 and P=0.015,respectively).CD8-high was significantly associated with less lymph node metastasis(P=0.047),less distant metastasis(P=0.024),less peritoneal dissemination(P=0.034),and earlier TNM stage(P=0.047).The CD8-high group had better prognosis than the CD8-low group(P=0.018).FoxP3 expression was not associated with any clinicopathological factors or prognosis.We found that patients with PD-L2 CPS≥10 tended to have worse prognosis in the FoxP3/CD8-low group(P=0.088).CONCLUSION The clinicopathological significance of PD-L1/2 expression may differ depending on the TME status.Immune checkpoint inhibitors may improve the prognosis of SBA patients with low FoxP3/CD8 ratio and PD-L2 expression.

Idiopathic sclerosing mesenteritis presenting with small bowel volvulus in a patient with antiphospholipid syndrome:A case report

BACKGROUND Sclerosing mesenteritis is a rare disorder involving inflammation of the mesentery.Its etiology remains unclear,but it is believed to be associated with previous abdominal surgery,trauma,autoimmune disorders,infection,or malignancy.Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain,bloating,diarrhea,weight loss,formation of an intra-abdominal mass,bowel obstruction,and chylous ascites.Here,we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome.CASE SUMMARY A 68-year-old female presented with recurrent small bowel obstruction.Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus.Computed tomography scans also revealed pulmonary embolism,and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants.The patient subsequently improved clinically and was discharged.The patient was also diagnosed with antiphospholipid syndrome after a hematological workup.CONCLUSION Sclerosing mesenteritis is a rare condition,and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Comprehensively evaluate the short outcome of small bowel obstruction:A novel medical-economic score system

BACKGROUND Small bowel obstruction(SBO)still imposes a substantial burden on the health care system.Traditional evaluation systems for SBO outcomes only focus on a single element.The comprehensive evaluation of outcomes for patients with SBO remains poorly studied.Early intensive clinical care would effectively improve the short-term outcomes for SBO,however,the full spectrum of the potential risk status regarding the high complication-cost burden is undetermined.AIM We aim to construct a novel system for the evaluation of SBO outcomes and the identification of potential risk status.METHODS Patients who were diagnosed with SBO were enrolled and stratified into the simple SBO(SiBO)group and the strangulated SBO(StBO)group.A principal component(PC)analysis was applied for data simplification and the extraction of patient characteristics,followed by separation of the high PC score group and the low PC score group.We identified independent risk status on admission via a binary logistic regression and then constructed predictive models for worsened management outcomes.Receiver operating characteristic curves were drawn,and the areas under the curve(AUCs)were calculated to assess the effectiveness of the predictive models.RESULTS Of the 281 patients,45 patients(16.0%)were found to have StBO,whereas 236 patients(84.0%)had SiBO.Regarding standardized length of stay(LOS),total hospital cost and the presence of severe adverse events(SAEs),a novel principal component was extracted(PC score=0.429×LOS+0.444×total hospital cost+0.291×SAE).In the multivariate analysis,risk statuses related to poor results for SiBO patients,including a low lymphocyte to monocyte ratio(OR=0.656),radiological features of a lack of small bowel feces signs(OR=0.316)and mural thickening(OR=1.338),were identified as risk factors.For the StBO group,higher BUN levels(OR=1.478)and lower lymphocytes levels(OR=0.071)were observed.The AUCs of the predictive models for poor outcomes were 0.715(95%CI:0.635-0.795)and 0.874(95%CI:0.762-0.986)for SiBO and StBO stratification,respectively.CONCLUSION The novel PC indicator provided a comprehensive scoring system for evaluating SBO outcomes on the foundation of complication-cost burden.According to the relative risk factors,early tailored intervention would improve the short-term outcomes.

Small bowel adenocarcinoma in neoterminal ileum in setting of stricturing Crohn’s disease:A case report and review of literature

BACKGROUND Small bowel adenocarcinomas(SBA) are rare malignancies with exceedingly low survival rates, with different presentation in Crohn’s disease(CD). CD-induced SBA poses diagnostic challenges given overlapping presentation with stricturing CD and lack of diagnostics for early detection. Moreover, guidance is lacking on the impact of recently approved therapeutics in CD on SBA management. Here, we aim to highlight the future of CD-induced SBA management and discuss the potential merit of balloon enteroscopy and genetic testing for earlier detection.CASE SUMMARY We report the case of a 60-year-old female with longstanding Crohn’s ileitis, presenting with acute obstructive symptoms attributed to stricturing phenotype. Her obstructive symptoms were refractory to intravenous(Ⅳ) steroids, with further investigation via computed tomography enterography not providing additional diagnostic yield. Ultimately, surgical resection revealed SBA in the neoterminal ileum, with oncologic therapy plan created. However, this therapy plan could not be initiated due to continued obstructive symptoms attributed to active CD. Ultimately, infused biologic therapy was initiated, but her obstructive symptoms continued to remain dependent on Ⅳ corticosteroids. Review of diagnostics by a multidisciplinary care team suggested metastatic disease in the peritoneum, lending to a shift in the goals of care to comfort.CONCLUSION With the diagnostic and therapeutic challenges of concurrent SBA and CD, multidisciplinary care and algorithmic management can optimize outcomes.

Predictors for success of non-operative management of adhesive small bowel obstruction

BACKGROUND Majority of adhesive small bowel obstruction(SBO)cases can be managed nonoperatively.However,a proportion of patients failed non-operative management.AIM To evaluate the predictors of successful non-operative management in adhesive SBO.METHODS A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018.Data collated included basic demographics,clinical presentation,biochemistry and imaging results and management outcomes.The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes.The patients were divided into group A operative(including those that failed initial non-operative management)and group B non-operative for analysis.RESULTS Of 252 patients were included in the final analysis;group A(n=90)(35.7%)and group B(n=162)(64.3%).There were no differences in the clinical features between both groups.Laboratory tests of inflammatory markers and lactate levels were similar in both groups.From the imaging findings,the presence of a definitive transition point[odds ratio(OR)=2.67,95%confidence interval(CI):0.98-7.32,P=0.048],presence of free fluid(OR=2.11,95%CI:1.15-3.89,P=0.015)and absence of small bowel faecal signs(OR=1.70,95%CI:1.01-2.88,P=0.047)were predictive of the need of surgical intervention.In patients that received water soluble contrast medium,the evidence of contrast in colon was 3.83 times predictive of successful non-operative management(95%CI:1.79-8.21,P=0.001).CONCLUSION The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.

Small bowel diverticulum with enterolith causing intestinal obstruction: A case report

BACKGROUND Small bowel diverticula are rare in clinics,and small intestinal obstruction caused by coprolites is rarer and difficult to diagnose early.The true incidence of these diverticula may be underestimated due to their clinical symptoms not differing from those of small bowel obstruction resulting from other causes.It is common in the elderly,although it can occur at any age.CASE SUMMARY This is a case report of a 78-year-old man with epigastric pain for 5 d.Conservative treatment does not effectively relieve pain,inflammatory indicators are elevated,and computed tomography suggests jejunal intussusception and mild ischemic changes in the intestinal wall.Laparoscopic exploration showed that the left upper abdominal loop was slightly edematous,the jejunum mass at the near Flex ligament was palpable,the size was about 7 cm×8 cm,the local movement was slight,and the diverticulum was seen 10 cm downward,and the local small intestine was dilated and edema.Segmentectomy was performed.After the short parenteral nutrition after surgery,the fluid and enteral nutrition solution were pumped through the jejunostomy tube,and the patient was discharged after the treatment was stable,and the jejunostomy tube was removed in an outpatient clinic one month after the operation.Postoperative pathology:Jejunectomy specimen:(1)Small intestinal diverticulum with chronic inflammation,ulcer with full-thickness activity,and necrosis of the intestinal wall in some areas;(2)also see that the hard object is consistent with stone changes;and(3)the incision margin on both sides shows chronic inflammation of mucosal tissue.CONCLUSION Clinically,the diagnosis of small bowel diverticulum is difficult to distinguish from jejunal intussusception.Combined with the patient’s condition,rule out other possibilities after a timely disease diagnosis.According to the patient’s body tolerance adopt personalized surgical methods to achieve better recovery after surgery.

Mucocutaneous ulcer positive for Epstein–Barr virus,misdiagnosed as a small bowel adenocarcinoma:A case report

BACKGROUND Epstein–Barr virus(EBV)-positive mucocutaneous ulcers(MCUs)are an uncommon disorder characterized by ulcerative lesions in the skin,oral cavity or gastrointestinal tract in patients with iatrogenic or aging-induced immunosuppression.The nonspecific lesions are difficult to differentiate from small bowel adenocarcinomas.We present the case of a 69-year-old woman who was initially misdiagnosed with a small bowel adenocarcinoma but was later surgically diagnosed with and treated for EBV-MCU.Through this case,we aim to emphasize the importance of accurately distinguishing between the two conditions.CASE SUMMARY The patient presented with an incidental finding of a small bowel tumor during computed tomography(CT)examination performed for hematuria.The CT scan showed irregular thickening of the distal ileum,which was suggestive of a malignant small bowel tumor.An exploratory laparotomy revealed an 8-cm mass in the distal ileum;thus,a segment of the small intestine,including the mass,was resected.Histopathological analysis revealed an ulceroinfiltrative mass-like lesion with luminal narrowing,marked inflammatory cell infiltration,and large atypical lymphoid cells(positive for EBV-encoded small RNA).A final diagnosis of an EBV-MCU was established.The postoperative course was uneventful,and the patient was discharged on postoperative day 7.The patient remained recurrencefree until 12 mo after surgery.CONCLUSION This case highlights the diagnostic challenges for EBV-MCUs and emphasizes the importance of comprehensive evaluation and accurate histopathological analysis.

Prediction models for recurrence in patients with small bowel bleeding

Obscure gastrointestinal bleeding(OGIB)has traditionally been defined as gastrointestinal bleeding whose source remains unidentified after bidirectional endoscopy.OGIB can present as overt bleeding or occult bleeding,and small bowel lesions are the most common causes.The small bowel can be evaluated using capsule endoscopy,device-assisted enteroscopy,computed tomography enterography,or magnetic resonance enterography.Once the cause of smallbowel bleeding is identified and targeted therapeutic intervention is completed,the patient can be managed with routine visits.However,diagnostic tests may produce negative results,and some patients with small bowel bleeding,regardless of diagnostic findings,may experience rebleeding.Predicting those at risk of rebleeding can help clinicians form individualized surveillance plans.Several studies have identified different factors associated with rebleeding,and a limited number of studies have attempted to create prediction models for recurrence.This article describes prediction models developed so far for identifying patients with OGIB who are at greater risk of rebleeding.These models may aid clinicians in forming tailored patient management and surveillance.

A Far-Out Case of Ascariasis Causing Small Bowel Obstruction in Mauritius

Ascaris lumbricoides (A. lumbricoides), the soil-transmitted helminth is the most prevalent parasitic infection of the gastrointestinal tract in developing countries. Heavy worm loads mainly due to untreated worm infestations are often associated with increased risk of severe sequelae. We report the first complicated case of A. lumbricoides causing small bowel obstruction in a 9-year-old boy that necessitated surgical intervention on a tropical island in the Indian Ocean, where cases of Ascariasis are rarely encountered.

Stage Ⅳ non-small cell lung cancer with multiple metastases to the small intestine leading to intussusception: A case report

BACKGROUND Gastrointestinal tract metastasis from lung cancer is rare and compared to small cell lung cancer(SCLC),non-SCLC(NSCLC)is even less likely to metastasize in this manner.Additionally,small intestinal tumors can also present with diverse complications,some of which require urgent intervention.CASE SUMMARY In this report,we detail a unique case of stage IV lung cancer,where the presence of small intestine tumors led to intussusception.Subsequent to a small intestine resection,pathology confirmed that all three tumors within the small intestine were metastases from adenocarcinoma of the lung.The postoperative follow-up period extended beyond 14 mo.CONCLUSION In patients with stage IV NSCLC,local tumor control can be achieved with various treatments.However,if small intestinal metastasis occurs,surgical intervention remains necessary,as it may improve survival.

Bezoar-induced small bowel obstruction: Clinical characteristics and diagnostic value of multi-slice spiral computed tomography

AIM: To determine the possible predisposing factors of bezoar-induced small bowel obstruction(b I-Sb O) and to discuss the diagnostic value of multi-slice spiral computed tomography,particularly contrast-enhanced scanning,in this condition.METHODS: A total of 35 b I-Sb O cases treated at our hospital from January 2007 to December 2013 were retrospectively analysed.Complete clinical and computed tomography(CT) data of the patients were available and confirmed by surgery.SbO was clinically diagnosed on the basis of clinical manifestations.Of the 35 patients,18 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT and 17 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT combined with contrastenhanced examination.Original images were processed using a GE ADW4.3 workstation to obtain MPR,CPR,MIP and CTA images.The images of all patients were evaluated by two abdominal imaging experts.The main analytical contents of planar scanning included intestinal bezoar conditions,changes in the intestinal wall and changes in peri-intestinal conditions.Vascular hyperaemia and arterial blood supply conditions at a specific obstruction site and the distal end of the obstruction site were evaluated through contrastenhanced examination.RESULTS: The proportion of males to females among the 35 cases was 1:1.69(13:22); median age was 63.3 years.The following cases were observed: 29(82.8%) cases occurred in autumn and winter and showed a history of consuming high amounts of persimmon and hawthorn; 19(54.3%) cases revealed a history of gastrointestinal surgery; 19 exhibited incomplete dentition,with missing partial or whole posterior teeth; 26 suffered from obstruction at the ileum.A total of 51 bezoars were found in these patients,of whom 16(45.7%) had multiple bezoars.CT planar scanning of bezoars showed lumps with mottled gas inside the intestinal cavity.Furthermore,9 cases of bezoars had envelopes and 11 cases were accompanied with thickening of the distal wall of the obstructed bowel.Scanning of 17 cases was enhanced; the results revealed that the mesenteric blood vessels at the obstruction site and the proximal site were dilated,and a total of 7 cases were accompanied with distal vascular dilation and intestinal wall thickening.CONCLUSION: b I-Sb O exhibits regional and seasonal characteristics.CT planar and contrast-enhanced scanning can be applied to diagnose and observe vascular conditions in obstructed zones.

Oral purgative and simethicone before small bowel capsule endoscopy

AIM:To evaluate small bowel cleansing quality,diagnostic yield and transit time,comparing three cleansing protocols prior to capsule endoscopy.METHODS:Sixty patients were prospectively enrolled and randomized to one of the following cleansing protocols:patients in Group A underwent a 24 h liquid diet and overnight fasting;patients in Group B followed protocol A and subsequently were administered 2 L of polyethylene glycol(PEG) the evening before the procedure;patients in Group C followed protocol B and were additionally administered 100 mg of simethicone 30 min prior to capsule ingestion.Small bowel cleansing was independently assessed by two experienced endoscopists and classified as poor,fair,good or excellent according to the proportion of small bowel mucosa under perfect conditions for visualization.When there was no agreement between the two endoscopists,the images were reviewed and discussed until a consensus was reached.The preparation was considered acceptable if > 50% or adequate if > 75% of the mucosa was in perfect cleansing condition.The amount of bubbles was assessed independently and it was considered significant if it prevented a correct interpretation of the images.Positive endoscopic findings,gastric emptying time(GET) and small bowel transit time(SBTT) were recorded for each examination.RESULTS:There was a trend favoring Group B in achieving an acceptable(including fair,good or excellent) level of cleansing(Group A:65%;Group B:83.3%;Group C:68.4%) [P = not significant(NS)] and favoring Group C in attaining an excellent level of cleansing(Group A:10%;Group B:16.7%;Group C:21.1%)(P = NS).The number of patients with an adequate cleansing of the small bowel,corresponding to an excellent or good classification,was 5(25%) in Group A,5(27.8%) in Group B and 4(21.1%) in Group C(P = 0.892).Conversely,7 patients(35%) in Group A,3 patients(16.7%) in Group B and 6 patients(31.6%) in Group C were considered to have poor small bowel cleansing(P = 0.417),with significant fluid or debris such that the examination was unreliable.The proportion of patients with a significant amount of bubbles was 50% in Group A,27.8% in Group B and 15.8% in Group C(P = 0.065).This was significantly lower in Group C when compared to Group A(P = 0.026).The mean GET was 27.8 min for Group A,27.2 min for Group B and 40.7 min for Group C(P = 0.381).The mean SBTT was 256.4 min for Group A,256.1 min for Group B and 258.1 min for Group C(P = 0.998).Regarding to the rate of complete examinations,the capsule reached the cecum in 20 patients(100%) in Group A,16 patients(88.9%) in Group B and 17 patients(89.5%) in Group C(P = 0.312).A definite diagnosis based on relevant small bowel endoscopic lesions was established in 60% of the patients in Group A(12 patients),44.4% in Group B(8 patients) and 57.8% in Group C(11 patients)(P = 0.587).CONCLUSION:Preparation with 2 L of PEG before small bowel capsule endoscopy(SBCE) may improve small bowel cleansing and the quality of visualization.Simethicone may further reduce intraluminal bubbles.No significant differences were found regarding GET,SBTT and the proportion of complete exploration or diagnostic yield among the three different cleansing protocols.

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia(IDA)is common and often under recognized problem in the elderly.It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract.Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel(SB).Capsule endoscopy(CE)provides direct visualization of entire SB mucosa,which was not possible before.It is superior to push enteroscopy,enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA.Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA.The diagnostic yield of CE for IDA progressively increases with advancing age,and is highest among patients over 85 years of age.Balloon assisted enteroscopy is used to treat the lesions seen on CE.CE has some limitations mainly lack of therapeutic capability,inability to provide precise location of the lesion and false positive results.Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.

Double-balloon enteroscopy in small bowel tumors: A Chinese single-center study

AIM: To analyze the clinical characteristics of small bowel tumors detected by double-balloon enteroscopy (DBE) and to evaluate the diagnostic value of DBE in tumors. METHODS: Four hundred and forty consecutive DBE examinations were performed in 400 patients (250 males and 150 females, mean age 46.9 ± 16.3 years, range 14-86 years) between January 2007 and April 2012. Of these, 252 patients underwent the antegrade approach, and 188 patients underwent the retrograde approach. All the patients enrolled in our study were suspected of having small bowel diseases with a negative etiological diagnosis following other routine examinations, such as upper and lower gastrointestinal endoscopy and radiography tests. Data on tumors, such as clinical information, endoscopic findings and opera-tion results, were retrospectively collected. RESULTS: Small bowel tumors were diagnosed in 78 patients, of whom 67 were diagnosed using DBE, resulting in a diagnostic yield of 16.8% (67/400); the other 11 patients had negative DBE findings and were diagnosed through surgery or capsule endoscopy. Adenocarcinoma (29.5%, 23/78), gastrointestinal stromal tumor (24.4%, 19/78) and lymphoma (15.4%, 12/78) were the most common tumors. Among the 78 tumors, 60.3% (47/78) were located in the jejunum, and the overall number of malignant tumors was 74.4% (58/78). DBE examinations were frequently performed in patients with obscure gastrointestinal bleeding (47.4%) and abdominal pain (24.4%). The positive detection rate for DBE in the 78 patients with small bowel tumors was 85.9% (67/78), which was higher than that of a computed tomography scan (72.9%, 51/70). Based on the operation results, the accuracy rates of DBE for locating small bowel neoplasms, such as adenocarcinoma, gastrointestinal stromal tumor and lymphoma, were 94.4%, 100% and 100%, respectively. The positive biopsy rates for adenocarcinoma and lymphoma were 71.4% and 60%, respectively. CONCLUSION: DBE is a useful diagnostic tool with high clinical practice value and should be considered the gold standard for the investigation of small bowel tumors.

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

Double-balloon enteroscopy for mesenchymal tumors of small bowel:Nine years' experience

AIM:To assess the value of double-balloon enteroscopy(DBE) for the diagnosis of gastrointestinal mesenchymal tumors(GIMTs) in the small bowel and clarify their clinical and endoscopic characteristics.METHODS:A retrospective review in a total of 783 patients who underwent a DBE procedure from January 2003 to December 2011 was conducted.Data from patients with pathologically confirmed GIMTs were analyzed at a single tertiary center with nine years' experience.The primary outcomes assessed included characteristics of patients with GIMTs,indications for DBE,overall diagnostic yield of GIMTs,endoscopic morphology,positive biopsy,comparison of diagnosis with capsule endoscopy,and subsequent interventional management.RESULTS:GIMTs were identified and analyzed in 77 patients.The mean age was 47.74 ± 14.14 years(range:20-77 years),with 63.6% being males.The majority of individuals presented with gastrointestinal bleeding,accounting for 81.8%,followed by abdominal pain,accounting for 10.4%.Small bowel pathologies were found in 71 patients,the detection rate was 92.2%.The diagnostic yield of DBE for GIMTs was 88.3%.DBE was superior to capsule endoscopy in the diagnosis of GIMTs(P = 0.006;McNemar's χ2 test).Gastrointestinal stromal tumor was the most frequent and leiomyoma was the second frequent GIMT.Single and focal lesions were typical of GIMTs,and masses with smooth or unsmooth surface were the most common in the small bowel.GIMTs were removed from all the patients surgically except one patient treated with endoscopic resection.CONCLUSION:DBE is a safe and valuable procedure for patients with suspected GIMTs,and it provides an accurate position for subsequent surgical intervention.

Surgically treated primary malignant tumor of small bowel:A clinical analysis

AIM:To evaluate the clinical presentation,treatment and survival of patients with primary malignant tumor of small bowel(PMTSB).METHODS:Clinicopathologic data about 141 surgically treated PMTSB patients(91 males and 50 females) at the median age of 53.5 years(range 23-79 years) were retrospectively analyzed.RESULTS:The most common initial clinical features of the patients were intermittent abdominal discomfort or vague abdominal pain(67.4%),abdominal mass(31.2%),bowel obstruction(24.1%),hemotochezia(21.3%),jaundice(16.3%),fever(14.2%),coexistence of bowel perforation and peritonitis(5.7%),coexistence of gastrointestinal bleeding and shock(5.0%),and intraabdominal bleeding(1.4%).Ileum was the most common site of tumor(44.7%),followed by jejunum(30.5%)and duodenum(24.8%).PMTSB had a nonspecific clinical presentation.Segmental bowel resection(n=81)was the most common surgical procedure,followed by right hemicolectomy(n=15),pancreaticoduodenectomy(n=10),and others(n=19).Twenty-seven adenocarcinoma patients and 13 malignant lymphoma patients received adjuvant chemotherapy with 5-fluorouracil and cyclophosphamide,adriamycin,vincristine and prednisone,respectively.Information about 120 patients was obtained during the follow-up.The median survival time of PMTSB patients was 20.3 mo.The 1-,3-and 5-year survival rate was 75.0%(90/120),40.0%(48/120)and 20.8%(25/120),respectively.Adenocarcinoma was found in 73.7%(42/57),21.1%(12/57)and 15.8%(9/57)of the patients,respec-tively.Gastrointestinal stromal tumor was observed in 80.0%(20/25),72.0%(18/25)and 36.0%(9/25)of the patients,respectively.Carcinoid was detected in 100.0%(15/15),80.0%(12/15)and 46.7%(7/15)of the patients,respectively.Malignant lymphoma was demonstrated in 69.2%(9/13),30.8%(4/13)and 0%(0/13)of the patients,respectively.CONCLUSION:En bloc resection is the principal therapy for most PMTSB and chemotherapy is the important treatment modality for malignant lymphoma and other malignant tumors of small bowel which cannot be radically removed.