Background: Hepatic artery aneurysms (HAAs) constitute 14% to 20% of visceral artery aneurysms. Most HAAs are asymptomatic. Although rare, obstructive jaundice due to external bile duct compression or rupture of the HAA into the biliary tree with occlusion of the lumen from blood clots has been reported. Case presentation: A 56-year-old white man presented to an outside hospital with symptoms of obstructive jaundice, including abdominal pain and yellowing of the skin. Imaging showed a large HAA. Patient was transferred to our hospital where an endoscopic retrograde cholangiopancreatography with biliary stenting was performed. This was followed by coil embolization of the HAA with improvement in symptoms and liver chemistries. Conclusions: Most clinicians agree that management of HAA is highly variable and depends on clinical presentation and anatomic location. Biliary stenting provides temporary relief for patients with obstructive jaundice. Definitive options include open aneurysmal repair versus endovascular therapy. Hepatic artery aneurysms represent a significant risk for hemorrhage and therefore must be addressed promptly once discovered.

BACKGROUND:Biological therapy targeting tumor necrosis factor-alfa has revolutionized the treatment of Crohn's disease (CD). Our study retrospectively reviewed clinical outcomes of 60 patients administratively substituted from Infliximab or Adalimumab to Certolizumab. Maintenance of disease and failure rates after substitution of anti-tumor necrosis factor-alfa agents in CD patients were monitored over 1 year, and this is the first outcomes study of patients maintained on Infliximab or Adalimumab substituted to Certolizumab.METHODS:A hospital pharmacy directive required all patients on biological therapy to be administratively substituted to Certolizumab therapy. This single-center retrospective analysis initially included 68 CD patients presenting at Louisiana State University Health Sciences Center-Shreveport. Clinical, endoscopic, and serologic data were compared at baseline and at 4 intervals over 1 year.RESULTS:Of 60 enrolled CD patients, 45 (75%) successfully transitioned to Certolizumab and had stable disease at 1 year. Of the 15 (25%) patients who "failed" substitution at 1 year, 5 were returned to Adalimumab and 7 to Infliximab; 3 were maintained on steroids awaiting subsequent therapy. Importantly, when patients were segregated on the basis of initial disease control, it was found that 3 (12.5%) previously well-controlled patients failed therapy, whereas 12 (33.3%) who initially had active disease failed Certolizumab substitution.CONCLUSIONS:Our study found that 25% of CD patients substituted to Cimzia failed substitution, whereas 75% still exhibited a good clinical response with stable disease at 1 year. Our findings indicate that disease status and behavior at the time of biological substitution may predict therapeutic responsiveness.

Inflammatory bowel diseases (IBD) are chronic idiopathic inflammatory conditions characterized by relapsing and remitting episodes of inflammation which can affect several different regions of the gastrointestinal tract, but also shows extra-intestinal manifestations. IBD is most frequently diagnosed during peak female reproductive years, with 25% of women with IBD conceiving after their diagnosis. While IBD therapy has improved dramatically with enhanced surveillance and more abundant and powerful treatment options, IBD disease can have important effects on pregnancy and presents several challenges for maintaining optimal outcomes for mothers with IBD and the developing fetus/neonate. Women with IBD, the medical team treating them (both gastroenterologists and obstetricians/gynecologists) must often make highly complicated choices regarding conception, pregnancy, and post-natal care (particularly breastfeeding) related to their choice of treatment options at different phases of pregnancy as well as post-partum. This current review discusses current concerns and recommendations for pregnancy during IBD and is intended for gastroenterologists, general practitioners and IBD patients intending to become, (or already) pregnant, and their families. We have addressed patterns of IBD inheritance, effects of IBD on fertility and conception (in both men and women), the effects of IBD disease activity on maintenance of pregnancy and outcomes, risks of diagnostic procedures during pregnancy and potential risks and complications associated with different classes of IBD therapeutics. We also have evaluated the clinical experience using "top-down" care with biologics, which is currently the standard care at our institution. Post-partum care and breastfeeding recommendations are also addressed.

Lower gastrointestinal bleeding (LGIB) can arise from many causes, with acute bleeding from the appendix being extremely rare and difficult to identify. Various etiologies of appendiceal hemorrhage have been reported in the English literature including appendiceal intussusception, diverticulitis, Crohn's Disease, tumors, ulcers and erosions. We present a unique case of large volume LGIB secondary to an appendiceal tubulovillous adenoma. A 70 year white woman with a past medical history of polycythemia vera, dyslipidemia, and sigmoidectomy for recurrent diverticulitis presented to the hospital for evaluation of maroon colored blood in the stool for the past 10 days. Admission vital signs were stable, and physical exam was unremarkable other than maroon blood on rectal exam. Hemoglobin was 12.9 g/dL (baseline 16.4 g/dL), Hematocrit 37.6 %, and other labs were within normal limits. Colonoscopy revealed a normal terminal ileum with yellow bile and fresh blood pooling at the appendiceal orifice. On initial examination, the appendiceal orifice appeared normal (Image 1) other than active oozing. With careful examination and manipulation of the cecum and appendiceal orifice, a bleeding polypoid mass was seen slowly emerging through the orifice into the cecum (Image 2). The mass was not amenable to endoscopic resection and the bleeding continued despite attempting hemostasis using epinephrine injection. Due to persistent bleeding and suspected malignancy a right hemicolectomy was performed the same day. Surgical pathology showed a 1.3 cm by 1 cm polypoid mass protruding from the appendiceal orifice extending 1.7 cm into the appendix with the lumen containing blood clots. Histologically the mass was consistent with tubulovillous adenoma. Appendiceal neoplasms are commonly found incidentally during an appendectomy performed for an unrelated condition. LGIB from an appendiceal neoplasm as a presenting symptom is uncommon. In general, patients with LGIB originating from the appendix are treated with an appendectomy and for malignant lesions a right hemicolectomy is the current standard treatment. Our case highlights the importance of a close, repetitive and careful appendiceal examination in a patient with obscure or recurrent LGIB to rule out an appendiceal etiology.Figure 1Figure 2

Scleroderma is an autoimmune disease characterized by excessive deposition of collagen and other connective tissue macromolecules in skin and multiple internal organs.It is called systemic Sclerosis(SS),when it involves internal organs.SS involves GI tract in 90% of the patients.Esophageal motility is the most frequently affected function in GI tract. It classically manifests as reduced LES pressure and loss of distal esophageal body peristalsis.In comparison Achalasia is a primary esophageal motor disorder characterized by insufficient relaxation of the LES and loss of esophageal peristalsis.While Sclerdoerma leads to low LESP, Achalasia causes insufficient LES relaxation.Coexistence of the two is rare.We report a case of a Scleroderma patient presenting with Achalasia. A 62 years old African American woman with history of Scleroderma and Systemic Lupus Erythematosus overlap syndrome was evaluated by gastroenterology for dysphagia. She had worsening dysphagia to both solids and liquids for three to four years.She underwent EGD which showed dilated, sigmoid shaped esophagus with retained liquid and solid food. LES was found to be hypertensive and resistance was felt while entering stomach.Barium esophagram showed dilated esophagus with narrowing at LES with bird beak appearance.So both studies were suggestive of Achalasia. Patient refused esophageal manometry at multiple occasions.Scleroderma occurs worldwide and affects all races but has higher general and age-specific rates in blacks with more severe disease and poorer outcomes than whites.GI tract involvement is very common and occurs early in the course of the disease. Esophagus is the most frequently involved internal organ causing symptoms of dysphagia, odynophagia,heartburn and regurgitation.Esophageal motility gets affected and is characterized by aperistalsis or low amplitude contractions, decreased or absent resting LES tone and lack of coordination between esophageal contractions and LES relaxations.Esophageal dysmotility in association with delayed gastric emptying results in impaired esophageal clearance of refluxed gastric contents and the development of reflux disease. In comparison Achalasia is characterized by absence of peristalsis in the distal two-thirds and elevated resting pressure in LES, typically above 45 mmhg along with failed LES relaxation with swallowing. LESP stays above 8 mmhg above gastric pressure.When the manometric characteristics of LES are compared, Achalasia is characterized by hypertensive LES and Scleroderma by hypotensive LES.Due to opposite changes in LESP, coexistence of Achalasia and scleroderma is extremely rare and so far only few cases have been reported. This case reports shows the rare coexistence of the two conditions making Achalasia one of differentials of dysphagia in Scleroderma patients.Figure 1Figure 2Figure 3

AIM:To investigate whether regional geography influences ethnic and gender trends for the development of gastric cancer (GC).METHODS:This retrospective analysis of the INVISION patient database at Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S), a southern United States regional hospital, was performed from 2005-2011. Using the international statistical classification of diseases 9 (ICD-9), inpatient, day surgery outpatient, and emergency outpatient diagnosis codes entered into medical records were used to identify GC patients. For each study year, the patients were evaluated for age, ethnicity, and gender, and each patient was counted only once throughout the study. Subsequent patient encounters were counted as visits and separated by inpatient and clinic visits. Complex or severe disease may require more frequent and intensive clinical management; therefore, we evaluated annual clinic visits as "surrogate markers" of disease severity. Finally, we studied the primary diagnosis for Helicobacter pylori (H. pylori) infection (ICD-9 code 41.86) as an additional factor that might increase the risk of GC.RESULTS:A total of 285 patients were diagnosed with GC at LSUHSC-S between 2005 and 2011. African Americans (181 patients, 89 males and 92 females, 63.5% of total patients) had significantly higher frequencies of GC diagnosis compared with non-Hispanic whites (104 patients, 54 males and 50 females, 36.5% of total patients), at a ratio of 1.74 (P = 0.002). Within each ethnic group, men and women were diagnosed at approximately equal annual rates. Our findings differed significantly from United States national trends, which found that African American females and white females had lower risks for GC than their corresponding male counterparts. The United States national trend between 2005 and 2011 showed that African Americans males had a higher incidence of GC, with an annual mean (per 100000) of 16.31 ± 0.76 compared with white males (9 ± 0.1, P < 0.001), African American females (8.7 ± 0.34, P < 0.001) and white females (4.05 ± 0.07, P < 0.001). Among the GC patients, the number of clinic visits was highest among African American males (195.1 ± 28.1), who had significantly more clinic visits than African Americans females (123 ± 13.02, P < 0.05), white males (41.57 ± 4.74, P < 0.001) and white females (35 ± 8.9, P < 0.001). Similar trends were found for inpatient visits, with an annual mean of 11.43 ± 1.5 for African American males, followed by African American females (7.29 ± 1.36), white males (2.57 ± 0.69) and white females (1.57 ± 0.612). African American males had significantly more inpatient visits than white males (P < 0.001), and African American females had more inpatient visits than white females (P < 0.01). African American patients showed the highest frequency of H. pylori positive status, with approximately 72% vs 28% for the white patients.CONCLUSION:Increase in GC diagnoses among women at LSUHSC-S is significantly higher than United States national averages, suggesting local geographic and socioeconomic influences may alter GC disease course.

and the mRNA expression of TNF-α, IL-1β, and iNOS was determined using real-time RT-PCR 6 h later.Results: Intrarectal injection of TNBS produced severe colitis accompanied by body weight loss and diarrhea as well as increased MPO activity and ROS production in WT mice.The severity of colitis, body weight loss, diarrhea, increased MPO activity and ROS production were significantly reduced in NOX1KO mice.The expression of iNOS, TNF-[alpha], IL-1[beta], KC, MIP-2, and MCP-1 expressions was markedly upregulated after the injection of TNBS in WT mice, but all these responses were significantly lower in NOX1KO mice.On the other hand, the apparent expression NOX1 mRNA in addition to NOX2 mRNA was detected in both lamina propria and peritoneal macrophages isolated from WT mice.The exposure of LPS to peritoneal macrophages isolated from WT mice caused marked upregulation of iNOS, TNF-[alpha], and IL-1[beta] mRNAs, but these increases were significantly mitigated in peritoneal macrophages isolated from NOX1KO mice.Conclusion: These findings suggest that NOX1 plays an important role in the pathogenesis of TNBSinduced colitis by upregulating inflammatory mediators, including iNOS, cytokines, and chemokines.It is likely that the NOX1 expressed in colonic macrophages may play an important role in these responses.Therefore, NOX1 expressed in colonic macrophages may be a novel target for the treatment and prevention of inflammatory bowel diseases.

Diabetic ketoacidosis (DKA)-induced hypertriglyceridemia causing pancreatitis is an interesting phenomenon that has rarely been reported in literature. Plasmapharesis is a well known treatment modality for hypertriglyceridemia-induced pancreatitis. We report a patient with DKA-induced hypertriglyceridemic acute pancreatitis treated successfully with plasmapharesis.

Purpose: Colorectal cancer (CRC) rates vary depending on regional geographics, socioeconomic status, race, and gender. Historically, African Americans (AA) have been reported to have higher rates of CRC compared to Caucasian (W) men (62/100,000 vs. 51.5/100,000, respectively). AA women are also reportedly likely to be diagnosed with CRC compared to W women (47/100,000 vs. 38.5/100,000; CDC, 2007). These findings may reflect sampling of populations which lack equal representation of AA and W patients. Methods: To investigate whether these trends would differ in a population with an equal contribution of AA and W patients, we performed a retrospective analysis (2005-2011) of CRC at LSU Health Shreveport, a public health facility with an approximately equal W and AA patient base. We evaluated total number of annual cases of CRC; the proportion of W males, AA males, W females, and AA females per total annual cases; the number of clinic visits as a surrogate marker of disease severity; and the number of hospital admissions over this period. Results: We found that W males, W females, AA males, and AA females had similar annual cases per year (not significantly different among groups, W males = 56±6.8; W females = 52.9±6.7; AA males 48±3.8, AA females 60.9±9.8; Average ± standard error of mean). However, when these data were compared as a fraction of total annual CRC cases we found that AA males represented the lowest proportion of annual cases, which was significantly lower than AA females (22.6±1% vs. 27.3±1.5%; p<0.05). We also considered clinic visits as a surrogate marker of disease activity in these populations. Among patients presenting with CRC, AA females had the highest number of annual clinic visits, followed by AA males, W females, and W males. By comparison, when we considered the proportion of hospital visits as a proportion by race and gender, W females were found to be the group with the lowest annual hospitalizations. Conclusion: Historically, the incidence of CRC is thought to vary depending on region, race, gender, and SES. The proportion between W and AA population representation in each region area may influence the apparent incidence of CRC. The patient base of LSU Health parallels the local demographic, which has roughly equal contributions of W and AA individuals. Surprisingly, in our analysis we found the annual cases of CRC in W males, W females, AA males, AA females were equivalent when compared over 2005-2011 (based on their annual cases per year). However, AA females sought medical attention more frequently, reporting more clinic visits compare to AA males or W patients. This may represent a ‘surrogate' marker of severe/more advanced disease in AA females. W females had the lowest percent of hospitalizations. Additional, longer and larger studies are needed to also consider the location and the staging of CRC at the time of diagnosis.

Inappropriate responses to normal commensal bacteria trigger immune activation in both inflammatory bowel disease and experimental colitis.How gut flora contribute to the pathogenesis of inflammatory bowel disease is unclear, but may involve entrapment of leukocytes and remodeling of the vascular system.Here we evaluated how the progression and tissue remodeling in experimental colitis differ in a germfree model of mouse colitis.Four treatment groups were used: control, antibiotic-treated (ABX), dextran sulfate colitis (DSS) and DSS pre-and co-treated with antibiotics (DSS + ABX).In days 0-3 of the study, germ-free mice received antibiotics (vancomycin, neomycin, and metronidazole).During the next 11 days, antibiotics were continued and DSS (3%) added to "colitis" groups.Disease activity, weight, stool form and blood were monitored daily.Mice were sacrificed and tissue samples harvested.Histopathological scores in controls (0.00) and in ABX (1.0 +/-0.81) were significantly (p < 0.001) lower than DSS (12 +/-0).Extents of injury, inflammation and crypt damage were all improved in DSS + ABX.The Disease Activity Index score (day 11) was significantly worse in the DSS group compared to the DSS + ABX group.Stool blood and form scores were also significantly improved among these groups.Importantly, myeloperoxidase was significantly reduced in DSS + ABX, indicating that neutrophil infiltration was blocked.Colitis was associated with an increase in blood and lymphatic vessels; both of these events were also significantly reduced by gut sterilization.Our experiment shows that clinical and histopathological severity of colitis was significantly worse in the DSS colitis group compared to the DSS + ABX group, supporting the hypothesis that development of IBD is likely to be less severe with appropriate antibiotic treatment.In particular, gut sterilization effectively reduces leukocyte-dependent (PMN) injury to improve outcomes and may be an important target for therapy.

Purpose: It has been suggested that male gender represents a significant risk factor for development of stomach cancer in the United States. Also, it has been reported that African Americans develop stomach cancer at twice the rate of Caucasians. To determine if there was a geographic or socioeconomic influence on the development of gastric cancer, we studied the patient base at LSU Health Shreveport, a Southern regional medical center serving a predominantly indigent patient population with an equal representation of black and white patients. Methods: We performed a retrospective analysis of gastric cancer (using CPT code 151.9) from 2005 to 2011 at LSU Health, a public health institution. Results: Interestingly, we found that white men and women developed approximately equal rates of stomach cancer (white males=7.7±1.36; white females=7.14±1.1) compared with African Americans (black males=12.7±1.2; black females=13.1±1). (Average ± is standard error of mean.) Surprisingly, black females showed the highest patient numbers among the four groups and were not significantly different from black males. We also considered clinic visits as a “surrogate marker” of disease activity in these different populations. Among patients presenting with a diagnosis of gastric cancer, the number of clinic visits was highest among black males. Black males had significantly more clinic visits than black females (**-p<0.01) and were more numerous than clinic visits for white females or black females (***-both p<0.001.). Similar trends were found for inpatient visits for patients with this diagnosis. Conclusion: The incidence of gastric cancer in black females was higher than the numbers anticipated from historically reported national averages. Black males appeared also to require more clinic visits compared to other groups. In our population, socioeconomic and geographical condition may lead to higher than average rates of gastric cancer in black women (compared with national trends). Larger studies should be performed to determine the risk factors contributing to these findings. These findings also suggest that greater surveillance in this group may be warranted particularly when low socioeconomic status or regional geographic influences may exist.

Purpose: Anti-tumor necrosis factor-alpha (anti-TNF-α) agents are a milestone in the medical therapy of Inflammatory Bowel Disease (IBD). They are effective in both achieving and maintaining remission in IBD. Anti-TNF-α agents are commonly associated with opportunistic infections, allergic reactions, lymphoma, heart failure, and lupus-like reactions. Sarcoidosis as a side effect has been reported in several patients on anti-TNF-α agents predominantly in Rheumatologic and Dermatologic conditions but rarely has it been reported in a patient with IBD. A 39-year-old African American male with a history of Crohn's colitis diagnosed at age sixteen, treated with multiple regimens in the past including azathioprine, budesonide, and infliximab, a history of proctocolectomy and Ileoanal J-pouch anastomosis four years prior for suspected colonic mass, presented for evaluation of several month onset of progressively worsening non-productive cough and dyspnea on exertion. He denied fever, chills, night sweats, weight loss, fatigue, PND, orthopnea, edema, skin nodules or rashes. He received infliximab for at least two years, which was eventually discontinued due to a loss of response, and then switched to adalimumab, approximately ten months prior to the onset of symptoms. Physical exam revealed a medium built male, with no lymphadenopathy, normal cardiovascular, respiratory, abdominal and skin exams, without evidence of lower extremity edema. Labs revealed normal CBC, BMP, LFT, and BNP. Chest x-ray showed a new right hilar mass when compared to an x-ray taken prior to the initiation of adalimumab. CT Thorax showed mediastinal and right hilar adenopathy vs mass. He had a negative PPD, angiotensin converting enzyme level was normal at 36, and PFT showed a mild obstructive pattern. Video-assisted thoracoscopic surgery revealed a 2.5 × 3 cm collection of right hilar lymph nodes, biopsy of which showed non-caseating granulomatous inflammation consistent with sarcoidosis. His dyspnea on exertion and cough continue to improve gradually and adalimumab has been continued. As with all new treatment modalities, it is difficult to ascertain all potential side effects of a drug during its initial phases. Our case demonstrates the possible induction of pulmonary sarcoidosis several months after the initiation of adalimumab. Therefore, it is important to be cognizant of this rare paradoxical induction of sarcoidosis even in IBD patients treated with anti-TNF-α agents.

Purpose: Collagenous gastroenteritidies are relatively uncommon entity. Collagenous colitis is the most common and was first described in 1976 by Lindström. Collagenous gastritis is a rather rare disorder with less than 50 cases being reported in the English literature and was first described in 1989 by Colletti and Trainer. Association of collagenous gastroduodenitis, ileitis and colitis is extremely rare. Clinical presentation depends on the area involved of the gastrointestinal tract. The etiology and prognosis are poorly understood. Three hypotheses have been proposed for the etiology, 1) clinical inflammation and autoimmunity, 2) abnormality of the pericryptal fibroblast sheath and 3) Leakage of plasma protein and fibrinogen, causing subsequent replacement with collagen. The histopathology findings are characterized with subepithelial collagen deposition, dense eosinophils and mucosal inflammatory cells in the lamina propria. We present a 64-year-old woman with 5 months history of nausea, vomiting, watery diarrhea, abdominal pain, weight loss, and anemia. Endoscopy revealed villous atrophy and mosaic patern of the duodenal mucosa, otherwise normal (Figure 1). Multiple biopsies from stomach, duodenum, ileum, colon and rectum were taken. Histopathology revealed collagenous gastroduodenitis, ileitis and colitis (Figure 2). Celiac panel and DLQ2, DLQ8 genetic testing both were negative. The patient was initiated on Prednisone with subsequent improvement of clinical symptoms, subepithelial collagen deposition and inflammatory cells on repeat endoscopy after 3 months. To our best knowledge this is the first reported case in English literature of collagenous gastroduodenitis, ileitis and colitis.Figure: [1354] Endoscopy picture of the duodenum with mosaic pattern and villous atrophy.Figure: [1354] Trichrome staining of gastric antrum revealing subepithelial collagen deposition.

Purpose: Infectious agents account for 18% of all cancers worldwide. Helicobacter pylori (HP) prevalence varies from 33-90% depending on geographic variation. Evidence has shown HP infection is associated with gastric ulcers and gastric cancer, but HPs roles in development of colorectal cancer remains controversial. Helicobacter species can colonize extragastric locations, but its significance is unclear. Here, gender and race associations with HP in several GI tumors are reviewed at our institution. Methods: A retrospective analysis of medical records at LSUHSC-Shreveport between 1999-2011 was performed using ICD 9 codes (151, 152, 153, 154, 211) for benign and malignant tumors of stomach, intestine and rectum. ICD 9 code 041.86 was used to isolate HP diagnoses from the selected subjects. Results: From 1999 to 2011, 549 subjects with HP were identified. A total of 8,574 subjects were diagnosed with benign or malignant tumors of the stomach, intestine or rectum during the same time period. A reviewing of comorbid conditions, showed 54 (0.006%) with an HP infection. 85% of H. pylori infections were associated with benign tumors of GI tract. Nearly 70% of these patients were African American. We found no gender association in HP-infected subjects with benign tumors of the GI tract, whereas there was a slight male predominance in malignant tumors. Conclusion: While HP is accepted as significant risk for gastric cancer, our study suggests a correlation may exist with benign intestinal tumors. Further studies will help define HP associations with specific GI tumors.Table: H. pylori infection among study subjects based on raceTable: H. pylori infection among study subjects based on gender

Purpose: Psychological stress has been shown to be a risk factor for developing, prolonging or re-activating human and experimental colitis. The present study was conducted to understand the role of psychological stress (water avoidance stress, WAS) and its regulation of inflammation and angiogenesis in a mouse model of colitis. To produce a more targeted gut inflammation water avoidance stress (psychological stress) was combined with Citrobacter rodentium infection (CROD) to provoke gut inflammation. Aims: Mice were subjected to both psychological stress (WAS) and CROD infection to assess whether the two factors would exacerbate disease through alterations of the colon microvasculature. Methods: Either 10 days or 30 days after orogastric challenge, mice were subjected to water avoidance stress for 1 hour. One group was inoculated with LB broth + CROD and other group with LB broth only (sham). Colon samples were collected and evaluated for angiogenesis by immunohistochemistry (using MECA-32). Quantification and statistical analysis was performed using one way ANOVA and two way Student's t-test. Results: CROD infection had no effect on the levels of angiogenesis in the infected colon. However, WAS in both sham and CROD infected colons significantly reduced the level of angiogenesis. There was a significant decrease in the number of blood vessels between WAS groups at both 10 days, and 30 days post infection, compared to sham and CROD treated mice not subjected to WAS (P<0.001). Conclusion: These data demonstrates a unique and previously unrecognized role of psychological stress in negatively remodeling colon vasculature. This is in contrast to the role that has been described for stress in both colon and gastric tumor angiogenesis. Mechanisms responsible for this altered regulation are currently under investigation. These findings suggest new links between stress and colitis, with altered blood vessel density affecting tissue perfusion, ischemia and damage to the epithelial barrier during active colitis.Figure 1: Decreased angiogenesis among WAS groups (P<0.001).

It has been conventional teaching that electrosurgical intervention and mucosal polypectomy in the cecum and right colon are associated with higher risk of complications like perforation and post polypectomy syndrome secondary to relatively thin walled right colon compared to left colon. However, the published literature noting regional differences in the colon wall is sparse. In addition there is no data regarding gender differences in colon thickness.The aim of our study was to measure and document the differences in bowel wall thickness, layers and circumference in different parts of the colon.

INTRODUCTION: Indwelling catheter fecal diversion systems such as the Zassi Bowel Management System are commonly used in intensive care units in patients with diarrhea or fecal incontinence. The ability to contain and divert stool can be challenging and is important in the prevention of infection and skin breakdown as well as reducing nursing burden. The system is composed of a tension cuff, which resides in the rectal vault, and a drainage system. The system is largely reported as safe and the use of the device is increasing. The manufacturer states that the device can be used up to twenty nine days and lists infection, obstruction, perforation, pressure necrosis, fecal leakage, and loss of sphincter tone as possible complications of the device. Mucosal pressure necrosis and ulceration are known risks of the device, however, reported cases are rare. Since using the device at our institution, we have seen three cases of rectal bleeding that appears to be related to the devise. The complication of pressure necrosis may be under reported and warrant further study. This report is of severe life-threatening bleeding due to the Zassi Bowel Management System.