Clinical Case Summary

Introduction: With an incidence of 0.5-1%, jejunal diverticulosis is a rare gastrointestinal pathology, which remains mostly asymptomatic. However 18% of patients present with life-threatening complications like bleeding or perforation.
Case report: We present the case of a 75-year-old patient admitted to the intensive care unit (ICU) with suspected middle gastrointestinal bleeding. The patient presented to the emergency unit with symptoms including recurrent syncope, hematemesis and hematochezia. Additionally, vital signs such as arterial hypotonia and tachycardia were noted, along with the initial hemoglobin value of 5.5 g/dl, which indicated significant blood loss.Because of the unstable hemodynamic situation the patient was transferred to the ICU. For airway protection endotracheal intubation was performed. An enteroscopy detected blood in the stomach, duodenum and jejunum and revealed multiple jejunal diverticula, however without active bleeding. After transfusion of multiple erythrocyte concentrates and administration of cathecolamines, the patient could be stabilized. Despite initial interventions, a recurrence of decreased hemoglobin levels was observed. Computed tomography failed to localize the bleeding. Emergency laparotomy revealed jejunal diverticulosis, necessitating resection of 40 cm of the jejunum. Intraoperative, resection borders could be endoscopically guided. Postoperatively, the patient was successfully extubated and discharged days later.
Conclusion: Localization of small bowel diverticula bleeding can be endoscopically or radiologically achieved, however is often difficult and problematic. Jejunal diverticular bleeding must be suspected in cases of obscure bleeding and therapeutic strategies must be interdisciplinary discussed. Surgical laparotomy represents ultima ratio in these pathology. A precise surgical resection can be achieved using intraoperative endoscopy in such cases.

Introduction

Obesity and metabolic dysfunction-associated steatotic liver disease (MASLD) have been linked to gut dysbiosis.

Aims & Methods

This study aimed to investigate the relationship between gut microbiota composition, hepatic fat content and stiffness, and body mass index (BMI) status. This cross-sectional study enrolled adolescents aged 12 to 18. Transient elastography with controlled attenuation parameter (CAP) was employed to diagnose hepatic fibrosis and steatosis. Fecal samples were analyzed by 16S rRNA sequencing. Relative abundance, as well as alpha- and beta-diversity of the microbiota, were compared across participants with different nutrition statuses and the presence of hepatic steatosis and fibrosis.

Results

A total of 76 participants (51 males) were recruited for this study, including 43 with normal weight, 19 overweight, and 14 obese. The clinical characteristics of the participants are presented in Table 1. Hepatic steatosis was present in 8 out of 14 obese participants (57.2%) and 2 out of 19 overweight (10.5%) participants. Hepatic fibrosis was detected in 4 out of 14 obese participants (28.6%) but none in the normal weight or overweight groups. There were no significant differences in alpha- or beta-diversity between the normal weight, overweight, and obese groups. The Firmicutes to Bacteroidetes (F/B) ratio was 1.2 across all three groups. Several genera, including Eubacterium_halli_group and Ruminococcus_gauvreauii_group were present in higher abundances in the gut microbiome of the obese group compared to the normal-weight group, with p values of 0.025 and 0.036, respectively. In contrast, Bifidobacterium was more abundant in the normal-weight participants (p=0.012). Obese individuals with hepatic fibrosis exhibited a significantly higher F/B ratio compared to those without hepatic fibrosis (p=0.04). There were significant differences in the relative abundance of specific genera between the fibrosis and non-fibrosis groups: Phascolarctobacterium (p=0.020), Dorea (p=0.040), and Ruminococcus_gauvreauii_group (p=0.045) were present in higher abundances in the fibrosis group, whereas Senegalimassilia was more abundant in the non-fibrosis group (p=0.037).

Conclusion

Hepatic steatosis and fibrosis are common among obese adolescents. The gut microbiota abundance in obese individuals with hepatic fibrosis differ from those without it. Further studies are crucial to explore the role of gut microbiota modification in the progression of hepatic steatosis and fibrosis.

Clinical Case Summary

A 2-week-old full-term female infant presented to the pediatric emergency department with five days of vomiting, loss of appetite, and bloody stools. Initially fed a cow milk-based formula, she did not gain weight. On admission, she appeared lethargic, with vital signs indicating low blood pressure, elevated heart rate, increased respiratory rate, and a body temperature of 36.6°C. Cold extremities, delayed capillary refill time, and marbled skin were noted. Abdominal examination revealed distension without peritonitis or skin discoloration, and no hepatosplenomegaly was present. Laboratory tests showed metabolic acidosis with an elevated anion gap and high lactate levels. The patient vomited stomach contents and fecal material, prompting the use of a nasogastric tube, which drained extensively. An abdominal x-ray revealed diffuse pneumatosis in the intestinalis without bowel perforation. Managed in the pediatric intensive care unit with nil per os, total parenteral nutrition, and empirical parenteral antibiotics. Blood and urine cultures, as well as stool PCR testing for common viral and bacterial pathogens, were negative. The infant showed improvement after two weeks of conservative treatment, including abdominal X-rays, which revealed normal gas patterns without signs of pneumatosis intestinalis. Introduction of an amino acid-based formula was well-tolerated without recurrence of symptoms.

Pneumatosis intestinalis mainly occurs during the neonatal period and is more common among preterm neonates. The main etiology is necrotizing enterocolitis (NEC). However, it can present among term neonates, infants, children, and even adults. The differential diagnosis is wide, including cow’s milk protein allergy, infectious diseases, trauma, ischemia, child abuse, and intestinal failure.
The working diagnosis of this case was pneumatosis intestinalis secondary to milk protein allergy, which was managed successfully and conservatively without any invasive procedure.

References

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