Relationship between Morphological Findings and Function of the Small Intestine in Familial Amyloidosis with Polyneuropathy

Twenty-seven patients with familial amyloidosis with polyneuropathy were studied with regard to the morphology of the small intestine, and this was correlated to symptoms and malabsorption features. The mucosa was normal in all cases investigated by the dissecting microscope, the light microscope, and the scanning electron microscope. Amyloid was demonstrated in 83% of the cases by the presence of green birefringent material in the biopsy specimens stained with alkaline Congo red and examined in polarized light. Nineteen patients had steatorrhea, and 12 had pathological D-xylose test results. The degree of amyloid infiltration did not correlate with these data, nor did the symptomatic state correlate with the amount of amyloid in the biopsy specimens. The surface ultrastructure was normal when investigated by means of the scanning electron microscope in all patients except five in whom the glycocalyx was altered. As a group, however, those five did not differ in any respect from the rest of the patients. Rod-shaped microorganisms were shown to adhere to the surface in one patient. The results suggest that mechanisms other than bowel-wall deposition of amyloid cause the dysfunction of the gastrointestinal tract in familial amyloid polyneuropathy.     

REVIEW: Small Bowel Review: Diseases of the Small Intestine

In the past year there have been many advances in the area of small bowel physiology and pathology and therapy. In preparation for this review, over 1500 papers were assessed. The focus is on presenting clinically useful information for the practicing gastroenterologist. Selected important clinical learning points include the following: (1) glutamine may restore the AIDs-associated increased intestinal permeability to normal; (2) substance P is a major mediator of diarrhea caused by Costridium difficile toxin A, acting by binding to a G-protein-coupled receptor, and represents a possible 2therapeutic target; (3) the serological diagnosis of celiac disease has been greatly enhanced with the use of anti-endomysial antibody testing, and the recent antitransglutaminase; (4) a quarter of patients with celiac disease may have secondary pancreatic insufficiency and require enzyme replacement therapy; (5) in the patient with unexplained elevation in the serum transaminase concentration, consider celiac disease as an obscure possibility; (6) bosentan and endothelin receptor agonist may prove to be useful in reducing gut ischemia in patients with septic shock; and (7) the administration of recombinant human fibroblast growth factor-2 may prove to be useful to prevent radiation damage to the gastrointestinal tract.     

双气囊小肠镜诊断小肠克罗恩病的作用

目的 探讨双气囊小肠镜在小肠克罗恩病诊断中的作用.方法 对28例疑有小肠疾病者行双气囊小肠镜检查,分析双气囊小肠镜检查对小肠疾病,尤其是小肠克罗恩病的检出率、诊断准确性、患者依从性和不良反应发生率等.结果 28例中,小肠病变总检出率为71.43%(20/28),小肠克罗恩病检出率为21.43%(6/28),占所有检出病变的30%(6/20).6例双气囊小肠镜检查判断为克罗恩病者中,结合病理、治疗效果和临床随访,6例均确诊为克罗恩病,诊断准确率为100%(6/6).结论 双气囊小肠镜检查是一项针对小肠疾病安全、有效的检查方法 ,是诊断小肠克罗恩病较为理想的方法 .     

An Unusual Case of Malignant Melanoma of the Small Intestine

A 42-year-old woman presented with abdominal pain and diarrhea. Small bowel x-rays and endoscopy revealed a diffuse, infiltrating lesion of the small intestine, which on biopsy proved to be melanoma diffusely infiltrating the lamina propria. Because of marked hypoalbuminemia, protein-losing enteropathy was suspected. This is an unusual case, because melanoma of the small intestine usually does not produce diffuse involvement.     

Capsule Endoscopy Versus Push Enteroscopy for Evaluation of Obscure Gastrointestinal Bleeding with 1-Year Outcomes

Because of the low diagnostic yield of standard radiologic tests for identifying sources of obscure gastrointestinal bleeding in the small intestine, we compared wireless video capsule endoscopy with push enteroscopy and small-bowel follow-through. Patients referred to Mayo Clinic, Scottsdale, Arizona, between August and December 2001 for evaluation of obscure gastrointestinal bleeding were potential candidates. Eligible patients had previously inconclusive endoscopy, colonoscopy, small-bowel follow-through, and other radiologic studies. Participants underwent capsule endoscopy and enteroscopy (within 24 hr). The primary end point was localization of any bleeding source, with 1-year telephone follow-up. Capsule endoscopy yielded positive findings in 10 of 20 patients (11 men; mean age, 69 years), 6 of whom had negative enteroscopy and small-bowel follow-through. No patient with negative findings on capsule endoscopy had positive findings on enteroscopy and small-bowel follow-through. At follow-up, 19 patients reported fewer transfusions, gastrointestinal procedures, and hospitalizations. Capsule endoscopy identified more lesions and improved outcomes.Published as an abstract at Digestive Disease Week, San Francisco, California, May 19–22, 2002.     

Iron Excretion from the Goblet Cells of the Small Intestine in Man

Iron-excreting goblet cells were observed by chance in a patient with myelogenic leukaemia. Duodenal and jejunal biopsies from patients with a wide spectrum of disorders have therefore been examined retrospectively after staining with Perl's iron method. Thirty-seven of the patients had iron-excreting goblet cells. The presence of iron has been confirmed by X-ray microanalysis and by electron microscopic histochemistry. In addition to iron-excreting goblet cells, most of these patients had iron-containing macrophages in lamina propria. This may indicate that the two types of cells co-operate in the excretion process. It is suggested that iron excretion may be part of the common iron balance mechanism.     

Plasmablastic Lymphoma of the Small Intestine in an HIV- and EBV-negative Patient

Plasmablastic lymphoma (PBL) is a rare aggressive B-cell lymphoproliferative disorder that is strongly associated with immunodeficiency, most often with human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) infection, and that mainly occurs in the oral cavity. Although some clinical features can lead to a diagnosis, PBL in an extraoral site is difficult to suspect clinically in a patient who is HIV negative. The small intestine as a site of PBL has also been described very rarely. We herein present a rare case of PBL of the small intestine in an 85-year-old HIV- and EBV-negative male.     

Structural and Morphometric Analysis of Murine Small Intestine after Indomethacin Administration

Ettarh RR, Carr KE. Structural and morphometric analysis of murine small intestine after indomethacin administration. Scand J Gastroenterol 1993;28:795-802.

Indomethacin, a nonsteroidal anti-inflammatory drug, induces the formation of gastrointestinal ulceration both in experimental animals and in humans. A study of indomethacin-induced ulcers in the mouse showed that two doses of indomethacin, each administered subcutaneously at 85 mg/kg body weight, induced well-defined gastrointestinal ulcers in C57 mice, accompanied by inflammatory and vascular changes in the stomach and small intestine. Maximal damage was observed 20 h after the second dose of indomethacin. Morphometric analysis identified changes in all compartments of the small intestine. There was a marked reduction in the length of the small intestine, intestinal dilatation, a significant decrease in villous height, with the formation of subepithelial blisters or blebs within villi, and submucosal vascular dilatation. There was no change in the number of villi or of submucosal arterioles or in the total amount of muscle present in the wall of the intestine. The tissue changes identified in this study may have implications for gut function at specific periods during indomethacin treatment.     

A Case of Ileal Malignant Lymphoma Presenting with Intussusception

Abstract: A-66-year-old male presented with a chief complaint of intermittent abdominal pain. Colonoscopy and barium enema indicated intussusception of a submucosal tumor of the ileum into the ascending colon. Surgery was thus carried out. The tumor was located 25 cm from the ileocecal junction, measured 4.1 × 3.2×2.3 cm, and showed intraluminal growth. Histopathologic examination of the resected specimen revealed a diffuse mixed cell type malignant lymphoma, and the tumor had invaded the subserosal layer. Intussusception due to malignant lymphoma is relatively rare in adults. We reviewed 43 cases of ileal lymphoma involving intussusception, reported in Japan over the preceding 12 years, and these cases are discussed along with the present case.     

Detection of Neuroendocrine Tumors of the Small Bowel by Double Balloon Enteroscopy

Background Neuroendocrine tumors (NET) account for one-third of all small bowel neoplasms. The search for the primary tumor in NET is important, even though it is difficult to localize, as its surgical excision leads to a better prognosis, even in metastasized stages of the disease. The objective of this study was to evaluate the use of double balloon enteroscopy (DBE) for the detection of the primary tumor in patients with NET. Methods Twelve consecutive patients (eight women, four men) with suspected carcinoid syndrome, either metastatic to the liver (n = 5), symptoms of a neuroendocrine tumor with elevated tumor markers (n = 5), or obscure gastrointestinal bleeding (n = 2) underwent DBE for the search of the primary tumor or the source of bleeding. All patients underwent abdominal sonography and a computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), ileocolonoscopy, and octreotide scintigraphy prior to DBE. Capsule endoscopy was performed in four patients. Results A total of 17 DBE were performed in the 12 patients. The CT scan and sonography of the abdomen as well as EGD and ileocolonoscopy were unable to detect the primary tumor in any patient. A submucosal tumor of the ileum or the jejunum could be detected by DBE was detected in seven patients (58%) (anal route, n = 4; oral route, n = 3). In four of these patients (33%) this finding could be confirmed by the surgical resection of a NET. In two patients (17%) with a submucosal ileum protrusion suspicious for NET, laparotomy and intraoperative endoscopy did not confirm the tumor. Conclusions In this study, the diagnostic yield of DBE for primary tumor search in patients with metastatic or suspected NET was 33%. Although endoscopic small bowel investigation by DBE seems to enrich the diagnostic possibilities for the diagnosis of small bowel-NET, at the present time DBE should only be performed in selected cases, possibly based on a positive previous work-up. Michael Bellutti and Lucia C. Fry contributed equally to this paper.     

Impairment of Host Resistance to Helminthes with Age in Murine Small Intestine

Age‐associated alterations of Th2 immune responses against nematode parasites are largely unknown. We investigated primary and memory responses against two types of gastrointestinal nematode parasites, Heligmosomoides polygyrus (Hp) and Nippostrongylus brasiliensis (Nb), in aged mice. The small intestinal gene expression of Th2 cytokines was almost unchanged after primary (Nb and Hp) and secondary infection (Hp) in aged mice in contrast to strongly increased small intestinal gene expression of Th2 cytokines in young (3‐month‐old) mice. Mucus production decreased (Nb), and worm expulsion was impaired (Nb and Hp) compared with the young mice. Immunofluorescent staining revealed that after Hp infection, the number of alternatively activated macrophages, which are induced by Th2 cytokines, was lower in the aged mice. On the other hand, the number of CD4⁺ T cells recruited to the worm cysts was normal compared with the young mice. These results suggest that migration of CD4⁺ T cells to the host–parasite interface is not affected by ageing. Alterations in Th2 immune responses in aged mice might be due to inappropriate or insufficient activation of CD4⁺ T cells in the submucosa.     

Disseminated Bone Marrow Carcinomatosis Due to Malignant Melanoma of Unknown Primary Origin

An 80-year-old woman was admitted to our hospital due to appetite loss and vomiting. A blood examination showed liver disorder with disseminated intravascular coagulation. All tumor markers and hepatitis virus markers were negative. Contrast-enhanced computed tomography did not show tumor lesions, bone lesions, lymphadenopathies, or thrombosis. A bone marrow biopsy revealed large, atypical cells with brown pigmentation and positive immunostaining for HMB-45, S100 proteins, and CD79a without myeloid or lymphoid markers. We experienced a case of disseminated carcinomatosis of the bone marrow due to malignant melanoma of unknown primary origin.     

Bacterial Flora of the Small Intestine and Bile Acid Metabolism in Patients with Hepatico-Jejunostomy Roux-en-Y

Duodenal and jejunal bacterial flora and bile acid metabolism were investigated in 14 patients with hepatico-jejunostomy Roux-en-Y. Anaerobic culture procedures were based on the use of a glove-box with an oxygen-free atmosphere and pre-reduced, anaerobically sterilized media. Anaerobic transport was based on evacuation of atmospheric air from transport-tubes and transport-time less than 30 minutes. Bile acid metabolism was evaluated from concentrations of total bile acids and deconjugated bile acids, glycine/taurine ratio and breath test. In 92 per cent of the patients an abnormal flora containing anaerobic and/or aerobic bacteria was found in the most proximal part of the jejunum at the site of the entero-entero anastomosis (cf. Fig. 1 and Table I). Total bile acid concentrations were low in half of the patients, whereas deconjugated bile acids or elevated glycine/taurine ratio was found in one patient only (cf. Table II). An abnormal breath test was found in 5 patients, but without any clear correlation between the breath test and the bacterial flora.     

Cyclosporine A Inhibits Partially Spermine-Induced Differentiation But Not Cell Loss of Suckling Rat Small Intestine

The polyamines are of great importance in several biological processes, such as cell proliferation, and differentiation. The ingestion of spermine by suckling rats induces the precocious maturation of their small intestine. This phenomenon is preceded by a cell elimination at the villus tip. We hypothesize that these two phenomena could be mediated by the immune system and thus inhibited by an immunosuppressive agent such as cyclosporine A. Cyclosporine A inhibits, at least partially, the spermine-induced increase of the maltase- and sucrase-specific activities in the small intestine but failed to inhibit lactase-specific activity decrease and cell loss. Spermine does not act by the same mechanism in differentiation and in cell loss. Moreover, spermine acts in a different way on lactase-specific activity compared to maltase- or sucrase-specific activity. We hypothesize that spermine acts on differentiation by a T-cell/IL-2-dependent mechanism.