Superior mesenteric artery syndrome in a patient with Charcot Marie Tooth disease

The extrinsic compression of the third part of the duodenum as it passes through the aorto-mesenteric angle is known as the superior mesenteric artery syndrome(SMAS).This syndrome is a rare mechanical cause of upper intestinal obstruction,with a reported incidence of between 0.2% and 0.78%.Clinical manifestations of SMAS may be chronic or acute;chronic symptoms include intermittent gastric pain,fullness and occasional episodes of postprandial vomiting,while acute symptoms include incoercible vomiting,oral intolerance,mainly epigastric abdominal distension and abdominal pain.Surgery is recommended only when initial conservative treatment fails.Here,we report what appears to be the third published case of SMAS associated with hereditary motor and sensory neuropathy or Charcot Marie Tooth disease.     

Obstructive jaundice and renal masses.

An 82-year-old patient with obstructive jaundice secondary to simple renal cyst also suffered pain and vomiting from partial duodenal obstruction. The symptoms were relieved by aspiration of 1,750 ml of fluid. This reaccumulated over a five-year period when aspiration again relieved his symptoms, which then only consisted of epigastric fullness. Review of the literature shows jaundice to be an extremely rare symptom of renal cyst.     

A perforated duodenal ulcer presenting as inferior lead ST elevation following amphetamine use

Typical symptoms of duodenal ulcers include epigastric pain, nausea, vomiting, chest pain and shortness of breath. Here we present the case of a 39-year-old man who had a sudden onset of chest and epigastric pain following the use of recreational amphetamines. There were ST changes in the inferior leads of his electrocardiogram, indicating the possibility of a myocardial infarction. Following double contrast computed tomography of the abdomen and an urgent laparotomy, a diagnosis of a perforated duodenal ulcer was made. We discuss the aetiologies, presentation, investigation and treatment of the disorder, and make recommendations on the management.     

Multimedia article. Laparoscopic management of median arcuate ligament syndrome

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or fibrous bands of the celiac nervous plexus. The syndrome is characterized by weight loss, postprandial abdominal pain, nausea, vomiting, and an epigastric bruit. Surgical management entails complete division of the median arcuate ligament. The video demonstrates the laparoscopic release of the median arcuate ligament in a patient with median arcuate ligament syndrome. The patient is a 22-year-old male with a 6-month history of epigastric abdominal pain, nausea, vomiting, a 140-lb. weight loss, and an epigastric bruit on physical exam. Aortography demonstrated a >or=90% extrinsic compression of the celiac artery. A full laparoscopic skeletonization of the celiac artery and branch vessels was performed. Intraoperative duplex U/S demonstrated flow rate reduction after the median arcuate ligament release. A postoperative CT angiogram demonstrated no residual stenosis. The patient was discharged on postoperative day 3 and remained asymptomatic after 7 months of follow-up. Laparoscopic release of the median arcuate ligament is a novel approach to the management of celiac artery compression syndrome. The role of minimally invasive techniques to manage median arcuate ligament syndrome is evolving but they appear to be a safe alternative to open surgery.     

Rare cause of small bowel obstruction secondary to epiploic appendagitis: Diagnostic dilemma and role of minimal invasive surgery

Acute abdomen is the most common emergency surgical presentation, often caused by small bowel obstruction (SBO). There are many underlying causes of SBO, of which post-operative adhesions are the commonest. Acute epiploic appendagitis is a rare cause of SBO with only a few reported cases in the literature. We report a rare case of SBO secondary to sigmoid appendagitis presenting with colicky epigastric pain and delayed onset obstructive symptoms (intractable vomiting and constipation).We chose to highlight this case given the unusual presentation and diagnostic dilemma, particularly the unusual localisation of pain. In addition, we wanted to highlight the laparoscopic management of this case, as opposed to laparotomy (described in the literature), which minimised surgical morbidity for the patient.     

A rare cause of obstructive jaundice and gastric outlet obstruction

Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal obstruction,and is characterized by 3 rd duodenal obstruction between the abdominal aorta and the superior mesenteric artery.Classical symptoms are postprandial epigastric pain,nausea,vomiting,and weight loss,or acute upper gastrointestinal obstruction.We herein describe an unusual presentation,with jaundice due to compression of the common bile duct by the gastric obstruction and dilated duodenum.     

Gastric outlet obstruction by a gallstone (Bouveret's syndrome)

Gastric outlet obstruction caused by a gallstone in the duodenum or pylorus(Bouveret's syndrome) is a very rare complication of gallstone disease. Presenting symptoms include epigastric pain, nausea, and vomiting. Preoperative diagnosis is not easy. Oral endoscopy is one of the diagnostic procedures. We present a case in which the diagnosis was made by endoscopic examination. Multiple attempts at endoscopic extraction of the gallstone from the duodenum were unsuccessful. A one-stage surgical procedure consisting of the removal of the impacted stone, fistula repair, and cholecystectomy was performed in this case. The postoperative course was uneventful.     

Acute scrotal pain as sole presentation of acute pancreatities

Pancreatitis has a myriad of different presentations although commonly presents with epigastric pain radiating to the back, nausea and vomiting. There are five case reports in the English literature of scrotal pain and swelling in severe alcoholic pancreatitis, two of which underwent surgical exploration. We present the first case of mild pancreatitis presenting with scrotal pain in the absence of any other symptoms or signs. We conclude that in any patient with unexplained scrotal pain, even in the absence of physical signs the possibility of pancreatitis should be considered.     

Bouveret's syndrome: a rare clinical variant of gallstone ileus

Bouveret's syndrome is a rare complication of gallstone disease characterized by gastric outlet obstruction due to impaction of single or multiple gallstones which have migrated through a bilio-enteric fistula. The main symptoms are nausea, vomiting and epigastric pain. The diagnosis is achieved by plain film of the abdomen, ultrasonography and CT scan, which reveal aerobilia (an indirect sign of bilio-enteric fistula), and the obstructing gallstone. The treatment of this condition requires removal of the stone through an endoscopic or surgical approach, and possible cholecystectomy with closure of the fistula. The Authors report a case of Bouveret's syndrome in an 86-year-old female patient who underwent successful surgical treatment.     

Emergent laparoscopic reduction of acute gastric volvulus with anterior gastropexy

Gastric volvulus is characterized by abnormal rotation of the stomach around an axis made by two fixed portions. Symptoms of gastric volvulus range from anemia and weight loss to severe epigastric or chest pain associated with nonproductive vomiting or upper gastrointestinal bleeding. Ischemia, necrosis, and perforation will occur if this condition remains untreated. We report a case of a 92-year-old patient with acute gastric volvulus treated with laparoscopic reduction and anterior gastropexy. We suggest that the laparoscopic approach to gastric volvulus is safe and feasible and should be considered. High-risk and elderly patients can particularly benefit from minimally invasive access. Anterior gastropexy palliates the symptoms and can be considered a definitive treatment in this patient population.     

Gastrointestinal Stromal Tumour Presenting Acutely as Gastroduodenal Intussusception

Introduction : Gastrointestinal stromal tumours (GISTs) are uncommon tumours of the gastrointestinal (GI) tract. We report a case of a gastric GIST that presented acutely as a gastroduodenal intussusception. Case presentation : A 59-year-old woman presented with a week’s history of vomiting anything she swallowed. Physical examination revealed a mildly tender abdomen without guarding or rebound tenderness. An epigastric mass was, however, palpated. Abdominal ultrasonography suggested an intussusception. At laparotomy, a tumour on the anterior wall of the stomach causing intussusception of the stomach into the duodenum was found. After reducing the intussusception, a wedge resection of the tumour was performed, which proved to be a GIST.

Discussion : GISTs represent a rare group of neoplasms of the GI tract. Gastric intussusception is a rarely documented condition. Symptoms range from intermittent epigastric pain to sudden onsets of severe pain with vomiting and shock. Pre-operative diagnosis can be difficult and diagnosis cannot be confirmed until surgery. The treatment of choice for localised gastric GIST is surgical resection.

Conclusion : Although gastroduodenal intussusception, particularly secondary to a GIST, is uncommon, clinicians need to have a high index of suspicion in acutely vomiting patients, especially if they have experienced similar symptoms intermittently in the immediate past.     

Partially obstructing antral web—A distinct clinical entity

Partially obstructing antral webs can cause perplexing feeding problems and poorly defined pain syndromes in infants and children. Three infants with recurrent postprandial vomiting and a fourth older child with recurrent post-prandial epigastric discomfort were diagnosed by upper GI series using a technique which specifically attempts to visualize the often elusive web. Excision of the web and pyloroplasty resulted in complete resolution of symptoms and a return to normal growth and development.     

Midgut nonrotation in adults: An aggressive approach

Five adults with midgut nonrotation were treated at Tripler Army Medical Center between January 1, 1966 and January 1, 1974. These patients usually presented with vague epigastric or lower abdominal symptoms. Initial diagnosis was generally based on barium enema studies revealing an entirely left-sided colon. However, on upper gastrointestinal series the absence of a normal duodenal “c” loop with straightening is also seen. Duodenal obstructive bands are rarely documented radiographically. Surgical intervention is frequently delayed in these patients due to the “atypical” symptoms and lack of correlation of these symptoms with objective radiographic changes. The high incidence of associated duodenal ulcer disease, the frequent occurrence of bowel obstruction, the persistence of chronic abdominal pain in the untreated patient, and the resolution of symptoms after anatomic correction point to the need for an aggressive approach to treatment in those patients who have chronic recurrent symptoms secondary to midgut nonrotation.     

Laparoscopic management of median arcuate ligament syndrome

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or fibrous bands of the celiac nervous plexus [1, 3]. The syndrome is characterized by weight loss, postprandial abdominal pain, nausea, vomiting, and an epigastric bruit [2]. Surgical management entails complete division of the median arcuate ligament [4]. The video demonstrates the laparoscopic release of the median arcuate ligament in a patient with median arcuate ligament syndrome.The patient is a 22-year-old male with a 6-month history of epigastric abdominal pain, nausea, vomiting, a 140-lb. weight loss, and an epigastric bruit on physical exam. Aortography demonstrated a ≥90% extrinsic compression of the celiac artery. A full laparoscopic skeletonization of the celiac artery and branch vessels was performed. Intraoperative duplex U/S demonstrated flow rate reduction after the median arcuate ligament release. A postoperative CT angiogram demonstrated no residual stenosis. The patient was discharged on postoperative day 3 and remained asymptomatic after 7 months of follow-up.Laparoscopic release of the median arcuate ligament is a novel approach to the management of celiac artery compression syndrome [2]. The role of minimally invasive techniques to manage median arcuate ligament syndrome is evolving but they appear to be a safe alternative to open surgery.Video presented at the annual meeting of the society of American Gastrointestinal Endoscopic Surgeons (SAGES) annual scientific session in Denver, Colorado, March 31–April 3, 2004     

Unusual presentation of Rapunzel syndrome

Background

The Rapunzel syndrome is an unusual form of trichobezoar found in patients with a history of psychiatric disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing their hair) who subsequently develop gastric bezoars. The principal symptoms are vomiting and epigastric pain.

Case presentation

A 15-year-old female presented with a two-month history of continuous dull aching epigastric pain, vomiting, loss of appetite and weight loss. Further examination and imaging showed a large trichobezoar. Nevertheless, the patient refused any intervention. A few days later, she presented to the emergency department with features of peritonitis. After adequate resuscitation, she was taken for exploratory laparotomy. Her postoperative course was uneventful.

Conclusion

Delayed treatment of Rapunzel syndrome can lead to a complication such as gastric perforation which albeit extremely rare, could prove catastrophic.     

Superior mesenteric artery syndrome as a rare cause of duodenal obstruction

Superior mesenteric artery syndrome is a rare cause of duodenal obstruction. The syndrome can present as acute small bowel obstruction or intermittent compression symptoms such as postprandial epigastric pain, fullness or vomiting. The obstruction is caused by compression of the third part of the duodenum against the posterior structures by the narrow‐angled superior mesenteric artery. The diagnosis is easily confused with gastric outlet obstruction or proximal small bowel obstruction. A high index of clinical suspicion is crucial for diagnosis and computed tomography provides confirmatory evidence. We report two cases of superior mesenteric artery syndrome and a review of the literature for this condition.     

Duodenogastric and gastroesophageal bile reflux

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.     

Biliopancreatic Limb Obstruction in Gastric Bypass at or Proximal to the Jejunojejunostomy: A Potentially Deadly,Catastrophic Event

Background: Although unusual, but not rare, obstruction in the vicinity of the jejunojejunostomy in Roux-Y gastric bypass (RYGBP) can progress in a very short period of time to a life-threatening situation. Methods: Over a 10-year period in 1,174 RYGBP's, we have seen seven instances of acute and subacute partial to complete small bowel obstructions in the vicinity of the jejunojejunostomy, which can lead to acute gastric dilatation due to obstruction of the bilio-pancreatic limb. Signs and symptoms of the obstruction may include tachycardia, oliguria, hypotension, severe epigastric pain with or without a palpable mass in the epigastrium, chronic bile regurgitation and bilious vomiting, and a possible increase in serum amylase. Laboratory data otherwise has not been helpful, and although a palpable abdominal mass may be diagnostic, the best tools have been radiologic, i.e. the acute abdomen series, limited upper GI series in the patients that appear to be only partially obstructed, abdominal ultrasound and probably most importantly, CT of the abdomen. Results: In the seven cases presented, diagnoses included internal hernia, adhesions, an idiopathic spontaneous hematoma of the bowel wall and retrograde intussusception at the jejunojejunostomy. Conclusions: Since many surgeons who perform bariatric surgery are alone in their community, they should train their non-bariatric surgical colleagues and associates to be aware of these potential deadly problems.     

Reflux bile gastritis

Reflux bile gastritis is seen in patients after gastric surgery. This clinical syndrome produces epigastric pain, anorexia, pyrosis, bilious vomiting especially at night, weight loss, and anemia. Diagnosis is made with gastroscopy and biopsy of the gastric mucosa. Only effective biliary diversion employing the Rouxen-Y surgical principle will relieve the symptoms.     

Duodenal Crohn's disease

The Authors report on an uncommon case of duodenal Crohn's disease in an adult man. The patient was admitted for a history of epigastric pain, recurrent vomiting, weight loss and low grade fever. He was evaluated with esophagogastroduodenoscopy and with radiological double-contrast technique. Then, due to these untreatable clinical manifestations, he underwents a surgical treatment.