Difference between revisions of "Talk:Gastrointestinal Tract - Abnormalities"

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===Gastroschisis: one year outcomes from national cohort study===
BMJ 2011; 343 doi: 10.1136/bmj.d6749 (Published 15 November 2011)
Cite this as: BMJ 2011;343:bmj.d6749
Australian  ABC story on Cluster  statistics
Australian  ABC story on Cluster  statistics

Revision as of 14:58, 18 November 2011

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Cite this page: Hill, M.A. (2021, May 7) Embryology Gastrointestinal Tract - Abnormalities. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Talk:Gastrointestinal_Tract_-_Abnormalities


Gastroschisis: one year outcomes from national cohort study

BMJ 2011; 343 doi: 10.1136/bmj.d6749 (Published 15 November 2011)

Cite this as: BMJ 2011;343:bmj.d6749


Australian ABC story on Cluster statistics http://www.abc.net.au/news/stories/2011/05/14/3216786.htm

Hedgehog/Notch-induced premature gliogenesis represents a new disease mechanism for Hirschsprung disease in mice and humans

Clin Invest. 2011 Sep 1;121(9):3467-78. doi: 10.1172/JCI43737. Epub 2011 Aug 15.

Ngan ES, Garcia-Barceló MM, Yip BH, Poon HC, Lau ST, Kwok CK, Sat E, Sham MH, Wong KK, Wainwright BJ, Cherny SS, Hui CC, Sham PC, Lui VC, Tam PK.


Hirschsprung (HSCR) disease is a complex genetic disorder attributed to a failure of the enteric neural crest cells (ENCCs) to form ganglia in the hindgut. Hedgehog and Notch are implicated in mediating proliferation and differentiation of ENCCs. Nevertheless, how these signaling molecules may interact to mediate gut colonization by ENCCs and contribute to a primary etiology for HSCR are not known. Here, we report our pathway-based epistasis analysis of data generated by a genome-wide association study on HSCR disease, which indicates that specific genotype constellations of Patched (PTCH1) (which encodes a receptor for Hedgehog) and delta-like 3 (DLL3) (which encodes a receptor for Notch) SNPs confer higher risk to HSCR. Importantly, deletion of Ptch1 in mouse ENCCs induced robust Dll1 expression and activation of the Notch pathway, leading to premature gliogenesis and reduction of ENCC progenitors in mutant bowels. Dll1 integrated Hedgehog and Notch pathways to coordinate neuronal and glial cell differentiation during enteric nervous system development. In addition, Hedgehog-mediated gliogenesis was found to be highly conserved, such that Hedgehog was consistently able to promote gliogenesis of human neural crest-related precursors. Collectively, we defined PTCH1 and DLL3 as HSCR susceptibility genes and suggest that Hedgehog/Notch-induced premature gliogenesis may represent a new disease mechanism for HSCR.

PMID 21841314

Gastrointestinal system malformations in children are associated with congenital heart defects

Anadolu Kardiyol Derg. 2011;11(2):146-9. doi: 10.5152/akd.2011.034. Epub 2011 Feb 23. Orün UA, Bilici M, Demirçeken FG, Tosun M, Ocal B, Cavuşoğlu YH, Erdoğan D, Senocak F, Karademir S. Source Clinic of Pediatric Cardiology, Department of Pediatric Cardiology, Faculty of Medicine, Fatih University, Ankara, Turkey. Abstract OBJECTIVE: To determine the frequency of congenital heart defects (CHD) in children with gastrointestinal malformations (GISM) and mortality rates in patients with GISM.

METHODS: Two hundred and forty two consecutive children patients with GISM followed up in Pediatric Surgery Clinics of our hospital were examined for cardiovascular anomaly by the Department of Pediatric Cardiology, and the CHD incidence was investigated by examining the records of the patients retrospectively. Chi-square test was used for the statistical analysis of data.

RESULTS: Two hundred and forty two patients with gastrointestinal system malformations were included in the study. Of 242 patients, 135 (55.8%) were male and 107 (44.2%) were female, and their age range was 0-15 years. The most frequent GISM were anorectal malformations (43.2%), atresia involving stomach, ileum or colon (21%) and esophageal atresia/tracheoesophageal fistula (18.3%). Congenital heart defects were observed in 28.5% of the participants. The most frequent defects were as follows; atrial septal defect (31 patients, 44.9%) a, ventricular septal defect (17 patients, 24.6%) and patent ductus arteriosus (5 patients, 7.2%). There was no significant difference (p>0.05) in mortality rate in patients with CHD (16.7%) and without CHD (13.3%) undergoing operations for GISM.

CONCLUSION: We would like to emphasize the importance of the earliest possible cardiological evaluation of all patients with gastrointestinal system malformations.

PMID: 21342865 http://www.ncbi.nlm.nih.gov/pubmed/21342865

A case of congenital duodenal web causing duodenal stenosis in a down syndrome child: endoscopic resection with an insulated-tip knife

Gut Liver. 2011 Mar;5(1):105-9. Epub 2011 Mar 16.

Lee SS, Hwang ST, Jang NG, Tchah H, Choi DY, Kim HY, Ryoo E. Source Department of Pediatrics, Gachon University of Medicine and Science Graduate School of Medicine, Incheon, Korea.

Abstract A 35-month-old girl visited our hospital with repetitive vomiting and abdominal distention; this was especially aggravated after the introduction of solid and semisolid foods. At 5 months of age, the patient, who had Down's syndrome, had undergone surgery for ventricular septal defect, atrial septal defect, and patent ductus arteriosus, and had subsequently been frequently hospitalized for respiratory infections and other viral infectious diseases. After her admission, the abdominal distension improved with fasting and intravenous fl uid therapy. Radiograph from a small-bowel series revealed a thin fi lling defect with a dilated duodenal bulb in the distal region of the second portion of the duodenum, suggesting a duodenal web, and endoscopy revealed duodenal stenosis. We therefore performed endoscopic resection with an insulated-tip knife because of the history of prior operations, fasting problems after operations, and respiratory infections. Seven days later, scar formation was noted on the second portion of the duodenum, the scope passed well at the excision site, and no retained food material was noted on the follow-up endoscopy. After the procedure, the patient's abdominal distention and repetitive vomiting subsided, and she was discharged with the ability to eat eat an age-appropriate normal diet. There were no specifi c symptoms or other complications for 1 year after the procedure.

PMID: 21461083 http://www.ncbi.nlm.nih.gov/pubmed/21461083


Fig. 1 The findings of the gastrointestinal barium study. (A) A beak-like narrowing of the distal esophagus up to the gastroesophageal junction with mild passage disturbance, and a thin filling defect are noted on the distal region of the second portion of the duodenum. (B) Contrast is retained on the dilated stomach and duodenal bulb.

Fig. 3 Initial endoscopic findings. (A) A mucosal diaphragm is seen on the second portion of the duodenum, suggesting a duodenal web. (B) A mucosal diaphragm in the second portion of the duodenum shows a stenotic lumen.


Review of genetic factors in intestinal malrotation

Pediatr Surg Int. 2010 Aug;26(8):769-81. Epub 2010 Jun 13.

Martin V, Shaw-Smith C. Source Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK.


Intestinal malrotation is well covered in the surgical literature from the point of view of operative management, but few reviews to date have attempted to provide a comprehensive examination of the topic from the point of view of aetiology, in particular genetic aetiology. Following a brief overview of molecular embryology of midgut rotation, we present in this article instances of and case reports and case series of intestinal malrotation in which a genetic aetiology is likely. Autosomal dominant, autosomal recessive, X-linked and chromosomal forms of the disorder are represented. Most occur in syndromic form, that is to say, in association with other malformations. In many instances, recognition of a specific syndrome is possible, one of several examples discussed being the recently described association of intestinal malrotation with alveolar capillary dysplasia, due to mutations in the forkhead box transcription factor FOXF1. New advances in sequencing technology mean that the identification of the genes mutated in these disorders is more accessible than ever, and paediatric surgeons are encouraged to refer to their colleagues in clinical genetics where a genetic aetiology seems likely.

PMID: 20549505 http://www.ncbi.nlm.nih.gov/pubmed/20549505

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.


Management of jejunoileal atresias: an experience at eastern Nepal

BMC Surg. 2010 Nov 26;10:35.

Shakya VC, Agrawal CS, Shrestha P, Poudel P, Khaniya S, Adhikary S. Source Department of Surgery, B, P, Koirala Institute of Health Sciences, Dharan, Nepal. vikalcsh@yahoo.com


BACKGROUND: Intestinal atresia is a common cause of neonatal intestinal obstruction, and management of this disease in limited setup of a developing country is very difficult.

METHODS: This study is a retrospective study of patients with jejunoileal atresias and their postoperative outcome in a teaching hospital in eastern Nepal over a 5-year period.

RESULTS: There were 28 children (19 boys and 9 girls). 11 children (39.28%) had jejunal atresia and 17 (60.71%) had ileal atresia. Eight (28.5%) patients died, 6 were jejunal atresia (54.5%) and 2 were ileal atresia (11.7%). The most common cause of death was sepsis which occurred in 7 out of 8 cases (87.5%). The risk factors for mortality identified were leucopenia, neutropenia, delay in surgery, location of atresia and type of atresia. Jejunal atresia tended to have a higher mortality than ileal atresia, and severe types of atresia (type IIIb and IV) were more often associated with mortality than other types of atresia. The significant differences between jejunal and ileal atresia were the increased duration between presentation and surgery, longer postoperative and total hospital stay, presence of more severe atresias and an increased risk of mortality in case of jejunal atresias.

CONCLUSION: The prognosis for this disease have definitely changed in the last few decades in developed countries but in our environment, problems like late presentation and diagnosis, lack of availability of good neonatal intensive care units and parenteral nutritional support still prevail.

PMID: 21108847 http://www.ncbi.nlm.nih.gov/pubmed/21108847


Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

BMC Gastroenterol. 2007 Jul 5;7:26.

Disibeyaz S, Parlak E, Cicek B, Cengiz C, Kuran SO, Oguz D, Güzel H, Sahin B. Source Department of Gastroenterology, Turkiye Yüksek Ihtisas Hospital, Sihhiye, Ankara, Turkey. selcukdisibeyaz@yahoo.com Abstract BACKGROUND: Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.

METHODS: The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.

RESULTS: A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty-seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).

CONCLUSION: The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

PMID: 17610747 http://www.ncbi.nlm.nih.gov/pubmed/17610747



Duodenal stenosis, a new finding on congenital rubella syndrome: case description and literature review

J Infect. 2006 Nov;53(5):e207-10. Epub 2006 Mar 20.

Diamanti A, Pietrobattista A, Bevivino E, De Angelis P, Calce A, Dall'Oglio L, Gambarara M. Source Children's Hospital, Gastroenterology and Nutrition Unit, Piazza S. Onofrio 4, Rome, Italy. diamanti@opbg.net

Abstract Congenital rubella syndrome (CRS) continues to represent a public healthcare problem although an effective vaccination program. Gastrointestinal involvement is rather infrequent and the association of CRS with duodenal stenosis has been never reported. In this study a case of CRS with duodenal diaphragm is reported and the gastrointestinal diseases described in association with CRS are reviewed. A 10-month-old child affected by CRS with congenital hearth disease, perceptive deafness and microcephaly, was admitted because of vomiting and failure to thrive. An upper endoscopy demonstrated dilated proximal duodenum and a perforated diaphragm in the second segment of the duodenum. Endoscopic membranectomy was therefore performed. Two months later the patient was submitted to a further endoscopic evaluation that showed a partial diaphragm persistence and a second excision was performed. Follow-up one year after the first treatment showed good clinical conditions, reasonable physical growth and disappearance of vomiting. In conclusion we report the first case of CRS in association with duodenal stenosis. Duodenal stenosis in the absence of other intestinal localizations may be due to rubella capacity of infecting only small numbers of fetal cells but we cannot exclude that the duodenal stenosis in our patient be only a casual association.

PMID: 16546260 http://www.ncbi.nlm.nih.gov/pubmed/16546260

Cassart M, Massez A, Lingier P, Absil AS, Donner C, Avni F. Sonographic prenatal diagnosis of malpositioned stomach as a feature of uncomplicated intestinal malrotation. Pediatr Radiol. 2006 Feb 8;:1-3

Strouse PJ. Animal models of implantation. Reproduction. 2004 Dec;128(6):679-95. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol. 2004 Nov;34(11):837-51.


Occlusion and subsequent re-canalization in early duodenal development of human embryos: integrated organogenesis and histogenesis through a possible epithelial-mesenchymal interaction

Anat Embryol (Berl). 2002 Jan;205(1):53-65.

Matsumoto A, Hashimoto K, Yoshioka T, Otani H. Source Departments of Anatomy and Surgery, Shimane Medical University, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan.


Histogenesis of the duodenum, especially changes in the epithelium in relation to temporal occlusion and re-canalization of the lumen, was investigated by light microscopy together with morphometric analysis, as well as by scanning and transmission electron microscopy of 133 externally normal human embryos ranging from Carnegie stage 12 to 23. A series of morphogenetic events passed the duodenum in a cranio-caudal (proximo-distal) wave like fashion during the period examined. They included: (1) a decrease in the caliber and area of the lumen, (2) 'occlusion' of the lumen, (3) vacuole formation, (4) 're-canalization' and villi formation. The only exemption to this rule was that, in the upper part of the duodenum, the lumen was not obliterated in the embryos examined. Morphometric analyses revealed that both the area of the epithelium and the number of epithelial cells decreased during the 'occlusion' phase. This result suggests that, unlike the classical view, epithelial cell proliferation does not play an important role in occluding the lumen, but the predominant morphogenetic event during this phase is convergence of the epithelial cells to elongate the duodenum. Apoptosis, contrary to some classical views, decreased during the 're-canalization' phase, and it appeared to be involved in the formation of the small lumens in the epithelial 'plug' and in villi formation, but not in enlarging the secondary lumens. The secondary small lumens in the occluded lumen were frequently formed near the border between the central 'plug' and peripheral basal cells on the basement membrane. This and other findings of concentric differentiation in both the epithelial and mesenchymal layers suggested a possible control mechanism by the epithelium-mesenchymal interaction on human duodenal morphogenesis and histogenesis. The present electron microscopic observations also provided details on the mechanisms involved in the enlargement of the secondary lumen and differentiation of villi. The implications of these findings to duodenal anomalies are also discussed.

PMID: 11875666



Intestinal atresia and stenosis: a 25-year experience with 277 cases

Arch Surg. 1998 May;133(5):490-6; discussion 496-7.

Dalla Vecchia LK, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, Engum SA. Source Department of Pediatric Surgery, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis 46202, USA. Abstract OBJECTIVE: To evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care, and outcome in infants with intestinal atresia.

DESIGN: Retrospective case series.

SETTING: Pediatric tertiary care teaching hospital.

PATIENTS: A population-based sample of 277 neonates with intestinal atresia and stenosis treated from July 1, 1972, through April 30, 1997. The level of obstruction was duodenal in 138 infants, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction in more than 1 site. Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%). Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%).

INTERVENTIONS: Patients with duodenal obstruction were treated by duodenoduodenostomy in 119 (86%), of 138 patients duodenotomy with web excision in 9 (7%), and duodenojejunostomy in 7 (5%) A duodenostomy tube was placed in 3 critically ill neonates. Patients with jejunoileal atresia were treated with resection in 97 (76%) of 128 patients (anastomosis, 45 [46%]; tapering enteroplasty, 23 [24%]; or temporary ostomy, 29 [30%]), ostomy alone in 25 (20%), web excision in 5 (4%), and the Bianchi procedure in 1 (0.8%). Patients with colon atresia were managed with initial ostomy and delayed anastomosis in 18 (86%) of 21 patients and resection with primary anastomosis in 3 (14%). Short-bowel syndrome was noted in 32 neonates.

MAIN OUTCOME MEASURES: Morbidity and early and late mortality.

RESULTS: Operative mortality for neonates with duodenal atresia was 4%, with jejunoileal atresia, 0.8%, and with colonic atresia, 0%. The long-term survival rate for children with duodenal atresia was 86%; with jejunoileal atresia, 84%; and with colon atresia, 100%. The Bianchi procedure (1 patient, 0.8%) and growth hormone, glutamine, and modified diet (4 patients, 1%) reduced total parenteral nutrition dependence.

CONCLUSIONS: Cardiac anomalies (with duodenal atresia) and ultrashort-bowel syndrome (<40 cm) requiring long-term total parenteral nutrition, which can be complicated by liver disease (with jejunoileal atresia), are the major causes of morbidity and mortality in these patients. Use of growth factors to enhance adaptation and advances in small bowel transplantation may improve long-term outcomes.

Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%).

Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%).


Classification of jejunoileal atresia (Gray and Skandalakis)

type I atresia - mucosal web

type II atresia - fibrous cord

type III atresia - complete separation type IIIa (mesenteric gap defect), type IIIb ("apple peel")

type IV atresia - multiple atresias


Initial classification

Gray SW, Skandalakis JE. Embryology for Surgeons. Philadelphia, Pa: WB Saunders Co; 1972:147-148. Modified

Martin LW, Zerella JT. Jejunoileal atresia: a proposed classification. J Pediatr Surg. 1976;11:399-403. http://www.ncbi.nlm.nih.gov/pubmed/957064

Grosfeld JL, Ballantine TVN, Shoemaker R. Operative management of intestinal atresia and stenosis based on pathologic findings. J Pediatr Surg. 1979;14:368-375. http://www.ncbi.nlm.nih.gov/pubmed/480102

The 2 major theories regarding the etiology of intestinal atresia are Tandler's concept (Tandler J. Zur Entwicklungsgeschichte des Menschlichen Duodenum in Fruhen Embryonalstadien. Morphol Jahrb. 1900;29:187-216) of a lack of revacuolization of the solid cord stage of intestinal development and the classic study by Louw and Barnard (Louw JH, Barnard CN. Congenital intestinal atresia: observations on its origin. Lancet. 1955;2:1065-1067) suggesting that a late intrauterine mesenteric vascular accident is the cause of most jejunoileal and colonic atresias.

duodenal atresia revacuolization is the probable cause for most cases

jejunoileal atresias occur as a result of intestinal volvulus, intussusception, internal hernia, or strangulation in a tight gastroschisis or omphalocele defect.

PMID: 9605910 http://www.ncbi.nlm.nih.gov/pubmed/9605910


Duplications of the alimentary tract. Clinical characteristics, preferred treatment, and associated malformations

Ann Surg. 1988 Aug;208(2):184-9.

Ildstad ST, Tollerud DJ, Weiss RG, Ryan DP, McGowan MA, Martin LW. Source Department of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, OH 45229. Abstract Duplications of the alimentary tract are unusual congenital anomalies that frequently present a diagnostic as well as therapeutic challenge to the surgeon. Because these lesions occur so infrequently, they are often not suspected until encountered intraoperatively. Due to the complicated anatomy and common blood supply shared between the duplication and associated native bowel, appropriate management requires a familiarity with the anatomy and clinical characteristics of this entity. To better define the range of patient characteristics, clinical presentation, and preferred therapy, 20 enteric duplications were reviewed in 17 patients treated at the Children's Hospital Medical Center from 1956 to 1986. Ages of patients ranged from 1 day to 11 years; 60% were less than 2 years of age at initial presentation. Seven duplications in six patients involved alimentary tract structures of foregut derivation (esophagus, stomach, and Parts I and II of duodenum), with a predominance of girls (4 of 6). Most of these patients (67%) presented with moderate to severe acute respiratory distress and a mass present on chest radiograph. In 67% of the patients, the correct diagnosis was established before operation. None required emergency operative intervention. By contrast, 13 duplications in 11 patients were of midgut or hindgut derivation (Parts III and IV of the duodenum, jejunum, ileum, and colon). In this group of patients, 62% of the duplications involved the cecum, 23% involved the ileum, and 16%, the jejunum. Seventy-eight per cent of the patients were boys. The most common symptoms were nausea and vomiting, and the most common sign was a palpable abdominal mass. Emergency operative intervention was required of eight of 11 patients with duplications involving the small bowel and colon. Three patients presented with an intussusception, four with signs and symptoms consistent with acute appendicitis, one with a small bowel obstruction, and two with gastrointestinal hemorrhage due to the presence of ectopic gastric mucosa within the duplication. It was found that two important points must be considered in regard to the management of enteric duplications: (1) the common blood supply shared between the duplication and native bowel must be carefully protected to avoid undue sacrifice of normal bowel, and (2) the presence of heterotopic gastric mucosa in 35% of patients negates internal drainage.(ABSTRACT TRUNCATED AT 400 WORDS)

PMID: 3401062 http://www.ncbi.nlm.nih.gov/pubmed/3401062


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1493602/figure/F5/ small intestine duplication image

Anorectal malformations

Classification of non-syndromic anorectal malformations (ARM)

Recto-perineal fistula

Recto-urethral-bulbar fistula

Recto-urethral-prostatic fistula

Recto-bladderneck fistula

Imperforated anus without fistula

Complex and unusual defects

Recto-perineal fistula

Recto-vestibular fistula

Cloaca with short common channel (< 3 cm)

Cloaca with long common channel (> 3 cm)

Imperforated anus without fistula

Complex and unusual defects
Cloacal extrophy, covered cloacal extra

Posterior cloaca

Associated to presacral mass

Rectal atresia

Levitt and Peña Orphanet Journal of Rare Diseases 2007 2:33 doi:10.1186/1750-1172-2-33