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PubMed1976

Abnormal micelle formation in various malabsorption syndromes.

In order to clarify the abnormal micelle formation in various malabsorption syndromes, the analysis of upper intestinal contents after administering a test meal of Borgström et al. was performed. It was demonstrated that the percentage of micellar fat to total fat and lipase concentrations decreased markedly from the normal controls despite of normal concentrations of bile salts and pH in cases of pancreatitis and pancreatectomy. In contrast, it was shown that the percentage of micellar fat was markedly low and the concentrations of conjugated bile salts were reduced in cases of ileal diseases. Unconjugated bile salts were detected although the concentrations of total bile salts were normal in blind-loop syndrome. The correlation between the percentage of micellar fat and lipase concentrations or bile salts concentrations in normal controls and various malabsorption syndromes was also reported.

Bile Acids and Salts↗

PubMedDate not supplied

Duodenal atresia and stenosis: reassessment of treatment and outcome based on antenatal diagnosis, pathologic variance, and long-term follow-up.

Duodenal atresia and stenosis was observed in 103 infants and children from 1972 to 1991. There were 59 girls and 44 boys. Atresia was noted in 79 instances and stenosis in 24. Maternal hydramnios was detected in 33 cases, 46 babies were premature, and 31 had Down's syndrome. Fifty-four infants had significant associated anomalies including 35 with cardiac defects. Diagnosis was achieved by prenatal ultrasound examination in 14 cases, observation of a double-bubble sign on abdominal radiograph in 73, and contrast studies in 30 infants including 24 with stenosis. At operation annular pancreas was noted in 37 cases, malrotation in 37 cases, anterior portal vein in 4, and a second web in 3. Surgical treatment included duodenoduodenostomy in 85, duodenotomy and web excision in 8, and duodenojejunostomy in 10. Operative survival was 95%. Deaths were related to complex cardiac defects. Despite antenatal diagnosis, prompt intervention, and apparent early surgical success (95% survival), late deaths (5%) and late complications including motility disorders, megaduodenum, gastroesophageal reflux, duodenal-gastric reflux, gastritis, peptic ulcer disease, blind loop syndrome, and biliary-pancreatic conditions may be observed months to years after management during the neonatal period. Modifications in surgical technique including early tapering duodenoplasty may be useful, and close long-term follow-up is an essential component of patient care.

Anastomosis, Surgical↗

PubMed1998

Long-term outcome after neonatal meconium obstruction.

OBJECTIVE: It is unclear whether children with cystic fibrosis (CF) who present with neonatal meconium ileus have a different long-term outcome from those presenting later in childhood with pulmonary complications or failure to thrive. We examined a cohort of patients with meconium ileus, and compared their long-term outcome with children who had CF without meconium ileus and neonates who had meconium obstruction without CF (meconium plug syndrome). STUDY DESIGN: Comparative study using retrospective and follow-up interview data. PATIENTS: Group 1 consisted of 35 surviving CF patients who presented with meconium ileus between 1966 and 1992. Two control groups were also studied: 35 age- and sex-matched CF patients without meconium ileus (group 2), and 12 infants presenting with meconium plug syndrome during the same time period (group 3). OUTCOME MEASURES: Pulmonary, gastrointestinal, nutritional, and functional status were reviewed, and surgical complications were recorded. RESULTS: Mean follow-up was 12.6 +/- 6, 12.6 +/- 6, and 9. 3 +/- 4 years in groups 1, 2, and 3, respectively. Patients without CF (group 3) demonstrated better growth and functional status, and had a lower incidence of pulmonary and gastrointestinal problems. Although the presence of meconium ileus among CF patients was associated with an earlier diagnosis, there were no significant differences between groups 1 and 2 with respect to hepatobiliary, nutritional, functional, or respiratory status. Meconium ileus was associated with a higher risk of meconium ileus equivalent (20% vs 6%), although this difference was not statistically significant. Long-term surgical complications (adhesive small bowel obstruction and blind loop syndrome) were seen in 27% of children with meconium ileus; there were no long-term surgical complications in groups 2 or 3, because these infants did not have any neonatal surgical procedures. Children presenting with complicated meconium ileus had a higher rate of long-term surgical complications than those with uncomplicated meconium ileus (36% vs 17%), and those managed with resection or enterostomy had more complications than those treated by enterotomy and lavage (33% vs 0%). CONCLUSIONS: Long-term outcome is similar in CF patients who present with meconium ileus and those who do not, except for a slightly higher incidence of meconium ileus equivalent, and a significantly higher rate of surgical complications. The risk of surgical complications is highest in those presenting with complicated meconium ileus and those undergoing resection or enterostomy. Patients with meconium obstruction who do not have CF have an excellent long-term prognosis. This information will be useful in counseling the families of infants presenting with neonatal meconium obstruction.

Cystic Fibrosis↗

PubMed1983

Surgical management of small-bowel radiation enteritis.

We treated 17 patients with severe small-bowel radiation enteritis surgically. Fourteen patients were female. Gynecologic malignant lesions (cervical, ovarian, and endometrial) were the most frequent sites of the primary tumors for which radiation was given. Thirteen patients had bowel obstruction, and the remainder had enterovaginal fistulae. Intestinal bypass, rather than resection, was the preferred approach in the treatment of these patients, and was used in 11 cases. Successful palliation was provided in nine patients, with minimal morbidity and no operative deaths. Follow-up at eight to 60 months has shown no further sequelae of radiation injury or of blind loop syndrome. This supports the relative safety of intestinal bypass for the surgical management of small-bowel radiation enteritis.

Adult↗

PubMed1977

[The regulation of serum albumin in physiological and pathological conditions (author's transl)].

12 g of albumin are synthesized daily by the bound polyribosomes of all human liver cells together, corresponding to 10% of the intravascular albumin mass. The cell is producing a precursor albumin. During secretion albumin is liberated by splitting of a small peptide. Only 40% of the total body albumin is located intravascularly. 12g of albumin are degraded or excreted daily, 30% of it by the liver, the kidneys and the gastrointestinal tract. The main site of albumin catabolism is unknown. Albumin with a half-life of about 20 days is degraded at a constant fractional catabolic rate. The absolute rate of degradation varies depending on the plasma content. This mechanism allows an effective regulation of the serum albumin level. The fractional catabolic rate, however, is not completely fixed. It is slowly reduced if the serum albumin content is markedly reduced as in protein deficiency, the blind loop syndrome, cirrhosis, nephrosis, and diseases of the gastrointestinal tract. Infusion of albumin increases the fractional catabolic rate slowly. This must be taken in consideration substitution albumin in chronic diseases. The shift from the extravascular to the intravascular compartment is a short-term regulatory mechanism. The regulation of synthesis and degradation are independent from each other. The molecular mechanism of regulation of synthesis and degradation are unknown, partially due to inadequate methods.

Amino Acids↗

PubMed2000

[20 years small intestinal bypass surgery. What is left?].

The jejunoileostomy was a frequently used surgical procedure to treat morbid obese patients (obesity grade III) from 1970 to 1980. The observed weight loss was very good, 50-60 kg during the first 18 months after operation (n = 288). Even obesity-induced side effects were improved significantly. However, negative consequences and complications were seen all too often: chronic loss of electrolytes, protein and vitamins and diarrhea with perianal skin problems. Reoperations were often necessary due to renal stone formation, cholecystolithiasis or blind loop syndrome. Therefore this procedure was abandoned in favor of operations such as vertical banded gastroplasty or the adjustable gastric band. However, in special cases similar operations may be helpful if gastric restriction has failed.

Adult↗

PubMed2005

Segmental dilatation of ileum: an unusual cause of severe malnutrition.

Segmental dilatation of the ileum causing blind loop syndrome was seen in a 6-year-old boy presenting with nonspecific symptoms and severe malnutrition. Barium meal was characteristic. Resection of the affected segment and an end-to-end anastomosis was curative and restored normal bowel function. Clinicians' awareness of this entity would help in appropriately managing such cases.

Child↗

PubMed2003

Pancreatic Enzyme Supplementation Therapy.

Effective treatment of malabsorption due to severe pancreatic exocrine insufficiency requires delivery of sufficient enzymatic activity into the duodenal lumen simultaneously with meal nutrients. To achieve this, modern therapeutic concepts recommend administration of 25,000 to 40,000 units of lipase per meal using pH-sensitive pancreatin microspheres. In case of treatment failure, dosage should be increased two to three times. If this still is not successful, compliance may be checked by measurement of fecal chymotrypsin, although this is not a standardized procedure. In the compliant patient, diagnosis of pancreatic exocrine insufficiency needs to be reviewed, particularly cases of celiac disease, (concomitant) bacterial overgrowth, and blind loop syndrome, as well as giardiasis, which need to be excluded or otherwise be treated specifically. Finally, additional acid suppression with application of unprotected pancreatin and/or reduced fat intake may help to control malabsorption. Still, in most patients, lipid digestion cannot be completely normalized by current standard therapy. On the one hand, this leads to loss of energy that may only partly be compensated for by increased nutrient intake. On the other hand, increased nutrient exposition of distal intestinal sites may release excessive amounts of mostly inhibitory distal intestinal neurohumoral mediators, and thereby disturb gastrointestinal secretory and motor functions. Consequently, future developments are needed for optimizing treatment.

Journal Article↗

PubMed1988

Primary hypothyroidism in an adult patient with protein-calorie malnutrition: a study of its mechanism and the effect of amino acid deficiency.

A man with diabetes mellitus, chronic hepatitis, chronic pancreatitis, and blind loop syndrome but without any previous thyroid disease developed three episodes of transient primary hypothyroidism associated with protein-calorie malnutrition (PCM). Clinical examinations suggested that this primary hypothyroidism was not caused by chronic thyroiditis, iodine deficiency, or iodine excess. Since the three times association of primary hypothyroidism with PCM suggested the possibility that the primary hypothyroidism was caused by PCM, we have tried to clarify its mechanism. For this purpose we have investigated the change of thyroid functions during protein-calorie repletion and the effect of amino acid deficiency. Total parenteral nutrition with full supplementation of amino acids resulted in a rapid increase in serum thyroxine (T4), triiodothyronine (T3), free T4, and reverse T3, and subsequently, a rapid decrease in TSH in several days after the nutrition was begun. When amino acid solution was changed to that depleted of phenylalanine and tyrosine after the restoration of thyroid functions, serum T4 and T3 showed a gradual decrease, but serum free T4 and TSH remained within normal range. However, resupplementation of phenylalanine and tyrosine after 8 weeks of depletion gave a rapid increase in serum T4, T3, free T4, and reverse T3. These results suggested that the primary hypothyroidism was caused by an impaired T4 production and that the deficiency of amino acids in PCM partly contributed to the impairment of T4 production.

Aged↗

PubMed2003

Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop.

BACKGROUND: The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed. METHODS: Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying. RESULTS: Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups. CONCLUSIONS: The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.

Anastomosis, Roux-en-Y↗

PubMed2001

A new biliodigestive anastomosis technique to prevent reflux and stasis.

BACKGROUND: The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications. METHODS: This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days. RESULTS: Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals. CONCLUSIONS: Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.

Anastomosis, Roux-en-Y↗

PubMed1998

Subtotal duodenectomy with jejunal patch for megaduodenum secondary to congenital duodenal malformation.

BACKGROUND/PURPOSE: This report describes a technique devised for two children with megaduodenum consisting of subtotal duodenal resection with the proximal jejunum used as an onlay patch. METHODS: A 2-year-old boy presented after unsuccessful surgical repairs for duodenal stenosis with web. Another 8-year-old boy returned from the United States after several surgical procedures for complicated congenital left diaphragmatic hernia with gastric outlet obstruction. Both boys manifested postprandial right upper abdominal fullness, occasional vomiting, abdominal pain, and failure to thrive. Upper gastrointestinal contrast study findings showed massively dilated duodenums in both patients that were larger than the stomach. During the operative procedures, about 95% of the duodenal wall was resected, leaving the basal portion that was unified with the pancreatic head and the ampulla of Vater as linguiform flap, which was covered with the proximal jejunum as an onlay patch so as to form the anterior wall of the duodenal bulb. RESULTS: The patients showed markedly improved quality of life and catch-up growth after the operations. The duodenal bulbs were of adequate size in follow-up gastrointestinal series. CONCLUSION: This technique will be useful in cases of functional duodenal obstruction with megaduodenum secondary to congenital duodenal malformations leading to blind loop syndrome.

Child↗

PubMed2002

Intestinal obstruction due to tuberculosis.

OBJECTIVES: Intestinal obstruction due to tuberculosis is a rare form of mechanical bowel obstruction. The objectives of this study were to determine the clinical features, to evaluate the role of surgery and to choose procedures in management of this disease. METHODS: In this 7-year retrospective study (from 1992 to 1998), 23 patients (20 males, three females) were included, accounting for 4.5% of all mechanical intestinal obstructions. More than 80% of the patients had a clinical picture of lower small bowel obstruction, while 90.5% of patients had advanced pulmonary tuberculosis. RESULTS: In 54.6% of cases, obstruction occurred in the ileocaecal region. The main lesion causing obstruction was intestinal tuberculosis in the hypertrophic form (86.4%). Diagnosis of intestinal tuberculosis as a cause of obstruction was not easy because it has no specific symptoms and signs. CONCLUSION: In terms of management, ileocolostomy was often used (68.2%) but long-term results were not very good. Blind loop syndrome was one of its disadvantages. Resection may be the safe and effective procedure.

Adult↗

PubMed1992

Lactic acidosis from thiamine deficiency during parenteral nutrition in a two-year-old boy.

This is a case report of a two-year-old boy who was operated electively for a blind-loop syndrome of the proximal jejunum. Because of the appearance of chylous ascites, parenteral nutrition was carried out postoperatively. The boy developed a severe uncompensated acidosis and paralytic ileus. Relaparotomy on suspicion of ischemic bowel did not explain the cause of the acidosis and ileus. Postoperatively, the child's condition worsened, requiring intensive care. The drastically elevated lactate levels corroborated the eventually suspected diagnosis of a vitamin B1 deficiency syndrome. The administration of thiamine within two hours produced correction of the acidosis without further bicarbonate therapy. In 24 hours circulation was stabilized. Two months post-operatively the boy had completely recovered from the sequelae of his shock event.

Acidosis, Lactic↗

PubMed1980

Clinical settings in pseudomembranous colitis.

Renewed interest in pseudomembranous colitis (PMC) has occurred in recent years due to an increased incidence following the introduction of the antibiotics clindamycin and lincomycin. However, the disease was well known before the antibiotic era. In this paper the histopathological features are reemphasised and the similarity to early amoebic colitis is stressed. From a background of 32 patients, some unusual clinical settings are described. These consist of an association with renal transplantation; the demonstration of the lesion on the mucosal surface of rectal polypi and metaplastic bladder mucosa; its occurrence in an area of isolated ileum presenting as a "blind loop syndrome"; and examples suggesting that this disease can exist for quite long periods of time or may recur several times in the same patient.

Adolescent↗

PubMed2000

Two surgical procedures for strictures at Finney strictureplasty for small bowel Crohn's disease.

In patients with Crohn's disease, long small bowel strictures are sometimes treated by a Finney strictureplasty. Strictures at an entrance and exit of a previous Finney strictureplasty are associated with severe obstructive symptoms and sometimes blind loop syndrome. Those strictures are difficult to manage. We herein introduce two different surgical procedures: one is a continuous T-shaped strictureplasty and the other is anastomosis between the Finney pouch and the divided small bowel. Both procedures immediately relieved obstructive symptoms and required no major resection of the bowel. After a 2-year follow-up, there has been no recurrence at the previous Finney strictureplasty.

Anastomosis, Surgical↗

PubMed2002

Jejunoileal bypass in the treatment of morbid obesity: a 25-year follow-up study of 36 patients.

BACKGROUND: Induction of intestinal malabsorption by jejunoileal (JI) bypass was a widely performed procedure for morbid obesity in the 1970's. The purpose of this study was to evaluate the long-term results. METHODS: A total of 36 patients underwent JI bypass from November 1971 to September 1976. At operation the median age was 33 years and median BMI 42 kg/m2. Shunt lengths varied between 45 and 60 cm. The present check-up of the 28 patients still alive included clinical examination, biochemical tests, bone density measurement and measurement of fecal fat excretion. RESULTS: 10 patients (28%) had had their shunt reversed. With one exception these patients quickly regained weight, and 5 (50%) of them were dead. 23 patients with an intact JI shunt are alive, but 5 of them have had the shunt shortened due to weight gain. Their median age today is 56 years, and median BMI is 30. None of these patients were known to have coronary heart disease or diabetes mellitus at follow-up. Malabsorption of fat is still present. Blind loop syndrome, flatulence, foul fecal smell and diarrhea are the most troublesome long-term sequelae. Vitamin and mineral deficiencies are common. 2 of 21 patients (age 80 and 57 years) have osteoporosis. CONCLUSION: When the optimal shunt length for the individual patient is found, JI bypass maintains a substantially reduced weight for 25 years. Vitamin and mineral deficiencies are common, but no serious clinical deficiency states are seen.

Adult↗

PubMed1998

Do arthralgias occur after bilio-intestinal bypass for morbid obesity.

BACKGROUND: Intestinal bypass operations are used occasionally for treating morbid obesity if other methods are unsuitable. Jejuno-ileal bypass (JIB) operations are considered to be a cause of occasional joint pain related disorders. However, bilio-intestinal bypass (BIB) is intended to avoid the blind loop syndrome. This study compared joint pain disorders in an operated BIB group, an obese nonoperated control group, and a lean reference group. METHODS: Using a questionnaire in a cross-sectional study, pain disorders were investigated in age-, sex- and weight-matched groups of operated, obese and lean subjects. The operated group had previously had a BIB and was matched using the preoperative BMI (body mass index, kg/m2). RESULTS: Mean time since operation was 12.4 years (SD 3.4) and the BIB group had lost 15.2 kg/m2 compared with the obese control group. These two groups had a high frequency of pain disorders of similar distribution, differing significantly from the lean reference group. No evidence of major differences in the type of pain disorders could be seen in the two groups. CONCLUSION: Pain disorder was an integral part of an obese syndrome, and was not affected significantly by weight reduction after BIB. The study appears to support the view that approximately 4% of patients develop arthritis vasculitis syndrome after BIB.

Adult↗