Severe delayed complication after percutaneous endoscopic colostomy for chronic intestinal pseudo-obstruction： A case report and review of the literature

Percutaneous endoscopic colostomy （PEC） is increasingly proposed as an alternative to surgery to treat various disorders, including acute colonic pseudo-obstruction, chronic intestinal pseudo-obstruction and relapsing sigmoid volvulus. We report on a severe complication that occurred two months after PEC placement. A 74-year-old man with a history of chronic intestinal pseudo-obstruction evolving since 8 years was readmitted to our hospital and received PEC to provide long-standing relief. The procedure was uneventful and greatly improved the patient＇s quality of life. Two months later, the patient developed acute stercoral peritonitis. At laparotomy, the colostomy flange was embedded in the abdominal wall but no pressure necrosis was found at the level of the colonic wall. This complication was likely related to inadvertent traction of the colostomy tube. Subtotal colectomy with terminal ileostomy was performed. We review the major features of 60 cases of PEC reported to date, including indications and complications.     

Chronic pancreatitis： Maldigestion, intestinal ecology and intestinal inflammation

Exocrine pancreatic insufficiency caused by chronic pancreatitis results from various factors which regulate digestion and absorption of nutrients. Pancreatic function has been extensively studied over the last 40 years, even if some aspects of secretion and gastrointestinal adaptation are not completely understood. The main clinical manifestations of exocrine pancreatic insufficiency are fat malabsorption, known as steatorrhea, which consists of fecal excretion of more than 6 g of fat per day, weight loss, abdominal discomfort and abdominal swelling sensation. Fat malabsorption also results in a deficit of fat-soluble vitamins （A, D, E and K） with consequent clinical manifestations. The relationships between pancreatic maldigestion, intestinal ecology and intestinal inflammation have not received particular attention, even if in clinical practice these mechanisms may be responsible for the low efficacy of pancreatic extracts in abolishing steatorrhea in some patients. The best treatments for pancreatic maldigestion should be re-evaluated, taking into account not only the correction of pancreatic insufficiency using pancreatic extracts and the best duodenal pH to permit optimal efficacy of these extracts, but we also need to consider other therapeutic approaches including the decontamination of intestinal lumen, supplementation of bile acids and, probably, the use of probiotics which may attenuate intestinal inflammation in chronic pancreatitis patients.     

Gallstone ileus： Report of two cases and review of the literature

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.     

小肠钡灌对慢性特发性假性小肠梗阻的诊断：附3例病例

慢性特发性假性小肠梗阻是以慢性肠梗阻表现为特征的一种综合征，临床少见。本文报道了应用小肠钡剂灌肠发现的本病３例，并指出诊断慢性假性小肠梗阻应主要依靠小肠钡剂灌肠检查。     

Maintenance of radiation-induced intestinal fibrosis： Cellular and molecular features

Recent advances in cell and molecular radiobiology clearly showed that tissue response to radiation injury cannot be restricted to a simple cell-killing process, but depends upon continuous and integrated pathogenic processes, involving cell differentiation and crosstalk between the various cellular components of the tissue within the extracellular matrix. Thus, the prior concept of primary cell target in which a single-cell type (whatever it’s epithelial or endothelial cells) dictates the whole tissue response to radiation injury has to be replaced by the occurrence of coordinated multicellular response that may either lead to tissue recovery or to sequel development. In this context, the present review will focus on the maintenance of the radiation-induced wound healing and fi brogenic signals triggered by and through the microenvironment toward the mesenchymal cell compartment, and will highlight how sequential and sustained modifi cations in cell phenotypes will in cascade modify cell-to-cell interactions and tissue composition.     

Diagnosis and treatment of small intestinal bleeding： Retrospective analysis of 76 cases

INTRODUCTION Due to the lack of specific clinical symptoms and physical signs of small intestinal bleeding and the limitations in the present diagnostic methods for tumors inside the alimentary tract, early diagnosis of small intestinal bleeding is diffic…     

Primary early-stage intestinal and colonic non-Hodgkin＇s lymphoma： Clinical features, management, and outcome of 37 patients

AIM: To analyze the clinical features, management, and outcome of treatment of patients with primary intestinal and colonic non-Hodgkin's lymphoma (PICL). METHODS: A retrospective study was performed in 37 patients with early-stage PICL who were treated in our hospital from 1958 to 1998. Their clinical features, management, and outcome were assessed. Prognostic factors for survival were analyzed by univariate analysis using the Kaplan-Meier product-limit method and log-rank test. RESULTS: Twenty-five patients presented with Ann Arbor stage I PICL and 12 with Ann Arbor stage II PICL. Thirty-five patients underwent surgery (including 31 with complete resection), 22 received postoperative chemotherapy or radiotherapy or both. Two patients with rectal tumors underwent biopsy and chemotherapy with or without radiotherapy. The 5- and 10-year overall survival (OS) rates were 51.9% and 44.5%. The corresponding disease-free survival (DFS) rates were 42.4% and 37.7%. In univariate analysis, multiple-modality treatment was associated with a better DFS rate compared to single treatment (P=0.001). While age, tumor size, tumor site, stage, histology, or extent of surgery were not associated with OS and DFS, use of adjuvant chemotherapy significantly improved DFS (P=0.031) for the 31 patients who underwent complete resection. Additional radiotherapy combined with chemotherapy led to a longer survival than chemotherapy alone in six patients with gross residual disease after surgery or biopsy. CONCLUSION: Combined surgery and chemotherapy is recommended for treatment of patients with PICL. Additional radiotherapy is needed to improve the outcome of patients who have gross residual disease after surgery.     

Ischemic colitis associated with intestinal vasculitis： Histological proof in systemic lupus erythematosus

I schemic colitis is an uncommon complication in patients with systemic lupus erythematosus （SLE）. In previously reported cases of colitis caused by SLE, intestinal vasculitis is implicated as the causative process, but is rarely confirmed histologically. We described a case of a 32-year-old man with increased activity of SLE, who presented with hematochezia and abdominal pain due to ischemic colitis with small vessel vasculitis which was proven by sigmoidoscopic biopsy. The clinical course of the patient was improved after steroid and conservative management.     

Intestinal pseudo-obstruction：An uncommon condition with heterogeneous etiology and unpredictable outcome

Intestinal pseudo-obstruction （IPO） either acute or chronic is a condition including features of intestinal ileus in absence of mechanical obstruction. Our paper presents such a rare case of idiopathic IPO in a 53-year-old male patient with recurrent episodes of pseudo-obstruction, which were successfully resolved by anticholinesterase agents, motilin agonists or colonic decompression. However, the patient finally underwent total colectomy. Huge colonic dilatation was identified intraoperatorily, while histology showed a neuropathic variant of chronic intestinal pseudo-obstruction. Etiologic mechanisms and current therapeutic methods are reviewed in this paper, which concludes that IPO is a condition in which conservative treatment usually fails. Total colectomy with ileoanal pouch may be the only solution in these situations.     

Application of laparoscopy in diagnosis and treatment of massive small intestinal bleeding： Report of 22 cases

INTRODUCTION Massive small intestinal bleeding is rare, accounting for 0.4% of all cases of gastrointestinal bleeding. So far there has been no effective method for its definite diagnosis due to its nonspecific clinical symptoms and signs, thus its treatm…     

系统性红斑狼疮并发假性肠梗阻及输尿管肾盂积水的临床及实验室特点

目的通过分析系统性红斑狼疮(SLE)并发假性肠梗阻(IPO)及输尿管肾盂积水患者的临床及实验室特点,以提高临床医生对此并发症的认识。方法回顾性分析本院2000—2005年SLE并发IPO患者10例,收集临床及实验室资料,分析其发病情况、病情活动情况及受累脏器、病程、治疗及预后特点。结果以肠梗阻为首发者3例,同时伴输尿管肾盂积水者7例(7/9),膀胱壁增厚、毛糙5例(5/9),伴有胆囊壁增厚或壁毛糙者6例(6/8)。抗核抗体阳性10例,抗dsDNA抗体阳性6例,抗SSA抗体阳性6例,抗核糖核蛋白(RNP)抗体阳性5例,抗心磷脂抗体IgG阳性4例(4/7)。所有病例均有血清补体C3和C4的降低。肠梗阻症状均在大剂量糖皮质激素治疗1周左右缓解。结论IPO常与输尿管肾盂积水及胆囊壁增厚相伴发,提示由内脏平滑肌受累本身运动障碍所致,及时使用肾上腺糖皮质激素治疗对于控制病情、改善预后非常重要,应避免不必要的手术干预。     

An unusual case of intestinal pseudo-obstruction presenting in an adolescent with juvenile-onset systemic lupus erythematosus: A diagnostic challenge

Introduction

Systemic lupus erythematosus (SLE) is an autoimmune disease with multiple systemic manifestations. The disease itself typically causes only 2–30% of SLE-associated gastrointestinal conditions.

Intestinal pseudo-obstruction in patients with systemic lupus erythematosus: A real diagnostic challenge

Intestinal pseudo-obstruction secondary to systemic lupus erythematosus (SLE) is a rare syndrome described in recent decades. There are slightly over 30 published cases in the English language literature, primarily associated with renal and hematological disease activity. Its presentation and evolution are a diagnostic challenge for the clinician. We present four cases of intestinal pseudo-obstruction due to lupus in young Mexican females. One patient had a previous diagnosis of SLE and all presented with a urinary tract infection of varying degrees of severity during their evolution. We consider that recognition of the disease is of vital importance because it allows for establishing appropriate management, leading to a better prognosis and avoiding unnecessary surgery and complications.     

Chronic intestinal pseudo-obstruction in patients with systemic lupus erythematosus: report of four cases

Chronic intestinal pseudo-obstruction (CIPO), a recently recognized manifestation of systemic lupus erythematosus (SLE) with only 23 cases reported in the English literature, may appear as a complication or as the initial presentation of SLE and usually occurs during the setting of an active lupus. The pathogenic mechanism in SLE is unknown. We describe four additional cases with clinical, radiological, and manometric features of CIPO. As SLE-related CIPO usually responds to treatment with high doses of corticosteroids and/or immunosuppressive and prokinetic agents, a high level of awareness of this complication is needed to avoid unnecessary surgical intervention.     

Intestinal pseudo-obstruction in inactive systemic lupus erythematosus: An unusual finding

Chronic intestinal pseudo-obstruction (CIP) is an infrequent complication of an active systemic lupus erythematosus (SLE). We illustrate a case of SLE inactive-related CIP. A 51-year old female with inactive SLE (ECLAM score 2) was hospitalized with postprandial fullness, vomiting, abdominal bloating and abdominal pain. She had had no bowel movements for five days. Plain abdominal X-ray revealed multiple fluid levels and dilated small and large bowel loops with air-fluid levels. Intestinal contrast radiology detected dilated loops. CIP was diagnosed. The patient was treated with prokinetics, octreotide, claritromycin, rifaximin, azathioprine and tegaserod without any clinical improvement. Then methylprednisolone (500 mg iv daily) was started. After the first administration, the patient showed peristaltic movements. A bowel movement was reported after the second administration. A plain abdominal X-ray revealed no air-fluid levels. Steroid therapy was slowly reduced with complete resolution of the symptoms. The patient is still in a good clinical condition. SLE-related CIP is generally reported as a complication of an active disease. In our case, CIP was the only clinical demonstration of the SLE.     

Chronic intestinal pseudo-obstruction in systemic lupus erythematosus

Background/Aims—Chronicintestinal pseudo-obstruction (CIPO) reflects a dysfunction of thevisceral smooth muscle or the enteric nervous system. Gastrointestinalmanifestations are common in systemic lupus erythematosus (SLE)but CIPO has not been reported. Features of CIPO are reported in fivepatients with SLE.
Methods—From 1988 to1993, five patients with SLE or SLE-like syndrome were hospitalised forgastrointestinal manometric studies. CIPO was the onset feature in twocases. Antroduodenal manometry (three hours fasting, two hours fed) wasperformed in all patients, and oesophageal manometry in four.
Results—Intestinalhypomotility associated with reduced bladder capacity and bilateralureteral distension was found in four patients and aperistalsis of theoesophagus in three. Treatment, which consisted of high dosecorticosteroids, parenteral nutrition, promotility agents, andantibiotics, led to remission of both CIPO and urinary abnormalities inall cases. Antroduodenal manometry performed in two patients afterremission showed increased intestinal motility. One patient died, andpostmortem examination showed intestinal vasculitis.
Conclusions—CIPO inSLE is a life threatening situation that can be reversed by treatment.It may be: (a) a complication or onsetfeature of the disease; (b) secondary tosmooth muscle involvement; (c) associatedwith ureteral and vesical involvement; (d)the result of intestinal vasculitis.

Keywords:chronic intestinal pseudo-obstruction; systemiclupus erythematosus

     

系统性红斑狼疮并发的假性肠梗阻

目的 分析系统性红斑狼疮(SLE)罕见的临床并发症——假性肠梗阻(IPO)，以引起临床医师重视。方法 结合文献复习，回顾性分析北京协和医院6年来SLE合并IPO患者10例。结果 10例女性患者平均年龄29．4岁(14～50岁)，SLE诊断均符合1982年美国风湿病协会关于SLE的诊断标准，并无硬皮病和重叠综合征的临床表现，无腹部手术史。所有患者抗核抗体滴，度增高，其中4例为轻度增高，双链DNA阳性5例。6例IPO为SLE内脏病变的首发症状，并同时伴有肾盂积水、输尿管扩张，其中1例死于肠穿孑L。结论 IPO是SLE的一个罕见但严重的并发症，由内脏平滑肌受累运动障碍所致，自身抗体谱有其特点。及早诊断，联合肾上腺皮质激素和环磷酰胺治疗对于改善预后非常重要。     

系统性红斑狼疮合并肾盂输尿管积水患者的早期发现

目的 分析系统性红斑狼疮(SLE)相关肾盂输尿管积水的临床特点,提高早期发现SLE合并肾盂输尿管积水的能力.方法 回顾性分析本院2000-2008年SLE相关肾盂输尿管积水31例,总结其临床特点,对不同治疗时机下治疗效果进行比较,数据分析采用X2检验和t检验.结果 SLE相关肾盂输尿管积水占同期SLE住院病例1.26%(31/2468),同时合并慢性假性肠梗阻28例(90%);14例(45%)有膀胱刺激症状;双侧肾盂输尿管积水19例(61%),单侧肾盂输尿管积水8例(26%),动态观察由单侧发展至双侧肾盂输尿管积水4例(13%),双侧肾盂输尿管积水多合并膀胱壁增厚、膀胱容积变小;抗核抗体S型比例及抗SSA抗体阳性率高,均为14例(45%).31例患者均使用激素及免疫抑制剂治疗,11例完全恢复,3例无效,其中2例永久保留肾需造瘘术,1例行膀胱颈切开加输尿管膀胱再植术.结论 肾盂输尿管积水可以出现在膀胱刺激症状之前,常并发慢性假性肠梗阻,高S型ANA核型和抗SSA抗体阳性率可能是其重要免疫学特征,激素及免疫抑制剂治疗有效,早期发现、早期治疗可以改善预后.

Abstract：

Objective To improve the ability of rheumatologist to diagnose systemic lupus erythematosus (SLE) complicated with ureterohydronephrosis by analyzing the characteristics of clinical manifestations.Methods Patients with ureterohydronephrosis hospitalized in Peking Union Medical College Hospital between 2000 to 2008 were analyzed retrospectively. The clinical characteristics, serological findings, treatment and prognosis of these patients were reviewed. Comparisons between the groups were performed with X2 test and t-test. Results SLE patient with ureterohydronephrosis accounted for 1.26% of the SLE patients hospitalized in the same period. Twenty-eight patients presented with gastrointestinal symptoms, 14 patients suffered from bladder irritative symptoms. Nineteen patients were with bilateral ureterohydronephrosis, and 8 patients were with unilateral ureterohydronephrosis. Fourteen patients had stype positive ANA, 14 patients had positive antiSSA antibodies. All patients were treated with steroid and immune suppressive therapy, 11 patients were cured, while 3 patients had no improvement. Conclusion Ureterohydronephrosis isn't a very rare complication of SLE. SLE patients with ureterohydronephrosis often present with gastrointestinal symptoms and have high incidence of chronic intestinal pseudo obstruction. High ratio of stype ANA antibody and high positive rate of anti-SSA are most important characteristics in this subtype of SLE patients. The complications can be reversed if the patients are treated early and appropritaely.     

系统性红斑狼疮合并肠假性梗阻12例临床分析

目的 分析系统性红斑狼疮(SLE)合并肠假性梗阻病人的临床表现及实验室检查，提高对SLE合并肠梗阻的认识。方法对12例SLE合并肠梗阻的病人进行回顾性分析，收集整理其临床资料及有关实验室检查，分析其发病情况、临床累及脏器、实验室检查、病程、治疗及预后等特点。结果发病年龄2l～56岁，平均36岁，平均病程31个月。死亡5例。以肠梗阻为首发症状者2例。有肾脏累及者9例，血液系统累及者6例，中枢神经系统累及者2例，循环系统累及者8例。其他：胃肠出血4例，腹水4例。2例以肠梗阻为首发症状者入院前分别误诊为溃疡性结肠炎和肠炎。2例曾行剖腹探查并部分小肠切除术，病理报告均提示肠道血管炎。结论SLE合并肠梗阻患者病情较重，常伴有其他脏器累及，病死率较高。以肠梗阻为首发症状的SLE患者易被误诊。有肠梗阻症状并有其他脏器累及者应排除有无SLE可能。肠道血管炎是引起肠梗阻的主要原因。     

Abnormal galactosylation of serum IgG in patients with systemic lupus erythematosus and members of families with high frequency of autoimmune diseases

Summary Gas chromatographic carbohydrate analyses of IgG from 30 patients with idiopathic systemic lupus erythematosus (SLE) revealed lower content of galactose when compared to that in 36 controls of similar ages (mean ±SD, 3.18±0.66 vs 3.82±0.41 galactose residues/mole of IgG, P<0.001). Abnormal galactosylation was observed in 60% of SLE patients. Analyses of IgG from 58 members of five families, characterized by a high frequency of SLE and other autoimmune diseases and serological abnormalities, and 51 controls of similar age range revealed that IgG galactose deficiency was detecable not only in some members with clinical and serological abnormalities (P0.001), but also in those without evidence of autoimmune diseases or abnormal serologies (P0.001). These data indicate that abnormal galactosylation of IgG frequently occurs in asymptomatic members of families with a high frequency of SLE and other autoimmune diseases and suggests that this abnormality may be an indicator for the development of these diseases.