Undifferentiated carcinoma of the duodenal ampulla

This report demonstrates a case of undifferentiated carcinoma of the duodenal ampulla. A 74-year male experienced jaundice lasting for 3 weeks. An upper gastrointestinal series demonstrated a polypoid, ovoid filling defect in the second portion of the duodenum, and duodenoscopy disclosed a protruding mass involving the orifice of the papilla of Vater. Cholangiography demonstrated obstruction due to compression in the terminal common bile duct. Pylorus-preserving pancreatoduodenectomy was performed on the diagnosis of ampullary carcinoma. The gross specimen showed a polypoid mass, measuring 3.5 cm in diameter, in the ampulla, located mainly in the duodenal submucosal layer and invading the terminal common bile duct. Histologically, the tumor was small cell type, undifferentiated carcinoma, arising from the duodenal epithelium adjacent to the ampulla.     

Gallbladder carcinoma with choledochoduodenal fistula: a case report with surgical treatment.

A 79 year-old man was admitted to our hospital because of upper abdominal pain and nausea. A mobile tumor was palpable in the right upper abdomen. Abdominal ultrasonography, computed tomography and celiac angiography revealed a gallbladder tumor. Endoscopic retrograde cholangiopancreatography revealed a fistula 1.5 cm oral to the orifice of the papilla of Vater, dilatation of the common bile duct, and a filling defect in the gallbladder. Pancreatoduodenectomy associated with reconstruction using Imanaga's method was performed under a pre-operative diagnosis of gallbladder carcinoma with choledochoduodenal fistula. The gallbladder contained a tumor and two bilirubin stones impacted in the orifice of the duodenal papilla. Histological studies confirmed that the gallbladder tumor was a mucinous adenocarcinoma and had not infiltrated the bile duct. We speculated that choledochoduodenal fistula stimulated the development of cancer due to chronic irritation from pancreatic juice reflux.     

Adenocarcinoma of the minor duodenal papilla treated with pancreas-sparing segmental duodenectomy: case report and review of the literature

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability.     

Local resection of a gangliocytic paraganglioma near the papilla of Vater

A 69-year-old man was admitted to our hospital with epigastric discomfort. Upper gastrointestinal endoscopy showed a submucosal tumor near the papilla of Vater. Abdominal CT and MRI showed a small, well-enhanced tumor. Endoscopic tumor biopsy was performed before the operation, but pathologic findings showed normal duodenal musosa. Nevertheless, since malignancy could not be ruled out, we resected the tumor with the sphincter of the papilla of Vater, followed by plasty of the orifice for the common bile duct and main pancreatic duct. We identified 3 parts with tumor cells; epithelioid cells, spindle cells, and ganglion-like cells. The tumor was diagnosed as gangliocytic paraganglioma of the duodenum. Treatment by resecting the tumor with the sphincter of the papilla of Vater, followed by the plasty of the orifice for the common bile duct and main pancreatic duct, was selected considering the patient's safety and to achieve radical cure.     

Upper gastrointestinal hemorrhage due to duodenal stromal tumor

BACKGROUND: Gastrointestinal stromal tumor represents a rare neoplasm that originates in the muscular wall of the hollow viscera. AIM: To report gastrointestinal stromal tumor as a source of upper gastrointestinal bleeding, which required urgent surgical control. PATIENT/METHOD: A man with 61 years old was admitted to the emergency service sustaining hematemesis and melena. Endoscopy showed active bleeding from a tumor in the second portion of the duodenum, which was controlled by heater probe cauterization. Surgery was performed through a median laparotomy. A local resection of a 4 cm tumor in the second portion of the duodenum was carried out, together with a primary end-to-end anastomosis and a duodenal diverticulization. No complications happened during the post-operative period. Morphologic examination showed gastrointestinal stromal tumor with no atypical mitosis and a preserved capsule. CONCLUSION: Albeit not being common, gastrointestinal stromal tumors can represent a source of substantial gastrointestinal hemorrhage.     

Choledochoduodenostomy: simple side-to-side anastomosis

Choledochoduodenostomy, using a simple side-to-side anastomosis technique, was performed in a 74 year-old woman with common bile duct stones. She had chronic heart failure and chronic obstructive lung disease. The choledochoduodenostomy was performed with a cholecystectomy. A 2-cm-longitudinal incision was made in the common bile duct, and an adjacent longitudinal incision was made in the first portion of the duodenum. The first sutures to be placed were the two corner sutures of the posterior anastomotic wall. Then the two sides were sutured, one from the hepatic side corner of the common duct to the anal side corner of the duodenum, and the other from the duodenal side corner of the common duct to the oral side corner of the duodenum. This anastomosis was performed with one layer of interrupted 4-0 adsorbable sutures. The anterior wall of the anastomosis was constructed in a similar manner. The patient recovered uneventfully, and had no complaints of abdominal pain or fever. This procedure, our original method, is techni-cally simple and safe, and results in minimal tension of the anastomosis.     

Choledochoduodenal fistula at the anterior wall of the duodenal bulb: a rare complication of duodenal ulcer

A 38 year-old man was admitted to our hospital with the chief complaint of epigastralgia. His laboratory data revealed leukocytosis and increased serum amylase, and abdominal ultrasonography revealed diffuse swelling of the pancreas. Thus, he was diagnosed as having acute pancreatitis. Moreover, abdominal computed tomography showed pneumobilia in the gallbladder and the common bile duct. Gastroduodenal fiberscopy demonstrated peptic ulcer scars around a foramen with smooth margins at the anterior wall of the duodenal bulb. The bile juice flowed from the bottom of the foramen. Endoscopic retrograde cholangiopancreatography revealed the fistula between the common bile duct and the anterior wall of the duodenal bulb, but not the posterior wall. However, there was no pancreatico-biliary maljunction and no stones in the gallbladder or bile duct. This is a rare case of choledochoduodenal fistula at the anterior wall of the duodenal bulb caused by duodenal peptic ulcer disease.     

A case of Lemmel's syndrome with serious jaundice exacerbated by eating

An 86-year old woman rapidly developed serious jaundice (T-Bil 18.3 mg/dl 12.3 mg/dl). Her jaundice was exacerbated by eating, and improved by fasting. Abdominal CT showed a giant diverticulum in the second part of the duodenum and dilation of the proximal common bile duct. Endoscopic findings confirmed juxtapapillary duodenal diverticulum in contact with the distal common bile duct. MRCP revealed extrinsic compression of the distal common bile duct by the diverticulum. Lemmel's syndrome was diagnosed. Jaundice did not recur after surgery. We speculated that in this case the diverticulum filled by duodenal contents easily compressed the distal common bile duct after eating.     

Ectopic papilla of Vater in the pylorus

The major papilla of Vater is usually located in the second portion of the duodenum, to the posterior medial wall. Sometimes the mouth of the biliary duct is located in other areas. Drainage of the common bile duct into the pylorus is extremely rare. A 73-year old man, with a history of duodenal ulcer, was admitted to hospital with the diagnosis of cholangitis. Dilatation of the extrahepatic biliary duct was observed by abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. No area suggesting the presence of the papilla of Vater was found within the second duodenal portion. Finally the major papilla was located in the theoretical pyloric duct.Cholangiography was performed and choledocholithiasis was found in the biliary tree. The patient underwent dilatation of the papilla with a balloon tyre and removal of a 7 mm stone using a Dormia basket, which solved the problem without further complications. This anomaly increased the difficulty of performing therapeutic interventions during ERCP. This alteration in anatomy may increase the risk of complications during papillotomy, with a theoretically higher risk of perforation. Dilatation using a balloon was the chosen therapeutic technique both in our case and in the literature, due to its low rate of complications.     

Recurrence of mucosal carcinoma of the bile duct, with superficial flat spread, 12 years after operation

We report herein a case of recurrent mucosal cancer of the extrahepatic bile duct, with superficial flat spread, 12 years after operation. A 67‐year‐old woman had undergone common bile duct (CBD) resection and Roux‐en‐Y reconstruction. Histologically, the tumor was papillary adenocarcinoma, with superficial flat spread, with no invasive component. The epithelium at the distal margin had been exfoliated, so the absence or presence of any remnant cancerous lesion was unclear. But the superficial flat spread had expanded to within at least 3 mm from the distal margin. About 12 years postoperatively, she was hospitalized with upper abdominal pain, and duodenoscopy demonstrated a tumor in the second portion of the duodenum. Biopsy identified adenocarcinoma. Computed tomography showed a low‐density mass between the duodenum and pancreatic head. Pancreatoduodenectomy was performed. Histologically, papillary adenocarcinoma was found within the whole of the intrapancreatic bile duct, and its histological appearance resembled that of the original tumor. Moderately differentiated tubular adenocarcinoma had invaded around the tissue of the intrapancreatic CBD. These findings suggest that remnant intramucosal flat carcinoma within the intrapancreatic bile duct had developed into invasive carcinoma over the course of 12 years. This case suggests that remnant intraepithelial flat carcinoma within the CBD may develop a late local recurrence.     

Duodenal Crohn''s Disease Complicated by Common Bile Duct Obstruction: Report of a Case and Review of the Literature

A 28-year-old woman with Crohn's disease involving the duodenum and terminal ileum presented with biochemical evidence of incomplete, extrahepatic biliary obstruction. Percutaneous transhepatic cholangiography showed partial obstruction of the intramural duodenal portion of the common bile duct. Cholangiography was complicated by cholangitis. Surgical decompression of the biliary system and bypass of the affected duodenal segment were performed after intraoperative confirmation of Crohn's disease involving the ileum, duodenum, and ampulla of Vater. The patient made a complete recovery and all previously abnormal cholestatic liver function test results returned to normal.     

Real case of primitive embryonal duodenal carcinoma in a young man

We report here the case of a young man suffering from a rare germ cell tumour. The patient was a 25-yearold man who was referred to our centre for asthenia, stinging epigastric pain, and an iron deficiency anaemia. Gastroscopy revealed a circumferential vegetating lesion on the second portion of the duodenum. The lesion was indurated at the third portion of the duodenum, responsible for a tight stenosis. A computerized tomography-scan of the chest, abdomen and pelvis, and a pancreatic MRI showed a circumferential lesion with a bi-ductal dilatation(i.e., of the common bile duct and Wirsung's duct) without metastatic localisation. The patient underwent a pancreaticoduodenectomy with lymph node dissection including all cellular adipose tissues of the hepatic pedicle from the hepatic common artery and of the retroportal lamina. Histological findings were suggestive of a duodenal embryonal carcinoma with pancreatic infiltration. This is the second published case highlighting the duodenal primitive localisation of an embryonal carcinoma with pancreatic infiltration.     

Fatal Ruptured Duodenal Varix: A Case Report and Review of Literature

The incidence of bleeding duodenal varices is exceedingly rare. We report a case of a 35-year-old chronic alcoholic who died of severe fatal upper gastrointestinal bleeding from a ruptured duodenal varix located in the second portion of duodenum. This diagnosis was suspected at endoscopy and was confirmed at autopsy. A review of literature shows 20 case reports of bleeding duodenal varices with two fatalities. While the duodenal bulb is the most common site of varices, the second portion of duodenum appears to be the next most common site. From all of the possible causes of duodenal varix, chronic liver diseases, mainly cirrhosis, remains the predominant etiological factor accounting for 30.7% of reported cases.     

Endoscopic treatment of duodenal obstruction due to a gallstone ("Bouveret's syndrome")

We describe the case of a 73-year-old woman was admitted to our hospital because of constant abdominal pain in her right upper quadrant and postprandial bloating and fullness for several months. On abdominal x-ray the extrahepatic bile ducts were positive for gas and on ultrasound a gallstone in the duodenum was suspected whereas the gallbladder was not detectable. An upper gastrointestinal endoscopy confirmed a large gallstone that was impacted in the duodenal bulb ("Bouveret's syndrome"). The gallstone was fragmented employing mechanical lithotripsy and removed. Duodenoscopy revealed a cholecystoduodenal fistula and a second gallstone in the gallbladder. The patient underwent open cholecystectomy with closure of the cholecystoduodenal fistula and made a full recovery. We conclude that in patients with upper abdominal pain and pneumobilia on x-ray the unusual complication of cholelithiasis with an impacted gallstone in the duodenal bulb should be suspected. In those rare cases of Bouveret's syndrome endoscopic removal of the gallstone should be attempted to minimize the necessary surgical procedure whenever possible.     

Endoscopic Features of Duodenal Metastases from Breast Cancer

Abstract: The endoscopic appearance of gastrointestinal metastasis from breast cancer is demonstrated in this report. A patient with breast cancer was found by panendoscope examination to have duodenal metastases. The endoscopic characteristic was that of multiple umbilicated submucosal tumors in the bulb and second portion of the duodenum. The imprint cytology of duodenal biopsy specimens, which revealed malignant cells identical to those found in the breast lump aspiration previously, supported the initial endoscopic diagnosis of metastatic breast cancer. The histology of these lesions subsequently revealed many tumor emboli in the mucosal and submucosal lymphatic channels. A laparotomy conducted to perform an intestinal bypass disclosed a large fixed metastatic tumor in the upper retroperitoneum with extension to the mesentery, the mesocolon of the transverse colon and the third portion of the duodenum. The findings at laparotomy and the histologic evidence of tumor emboli in the lymphatics of the mucosal and submucosal layers indicated a retrograde lymphatic spread of the tumor from the large retroperitoneal mass to the duodenal wall. A literature review in this report discusses the differential diagnosis from metastatic disease to second primary malignancy and benign disease of the gastrointestinal system.     

Ectopic pancreaticobiliary drainage accompanied by proximal jejunal adenoma： A case report

A patient with obstructive jaundice was examined by multidetector row helical computed tomography （MDCT） and magnetic resonance imaging （MRI）, and his common bile duct was observed to be leading into the distal portion of the horizontal duodenum with a pancreaticobiliary union outside the duodenal wall. A mass was also found in the proximal jejunum. All the above findings were confirmed by subsequent surgery, thus contrast-enhanced MDCT and MRI with appropriate image post-processing could provide non- invasive and accurate information regarding anatomy and lesions of the pancreaticobiliary duct and duodenal union, which may improve the feasibility of surgery and reduce postoperative complications,     

A Case of Groove Pancreatitis with Duodenal Stenosis

A 58‐year‐old man presented with a 2‐month history of nausea and vomiting. Blood levels of hepatic enzymes and pancreatitis markers were slightly elevated. Hypotonic duodenographic and endoscopic examinations revealed stenosis encircling the descending duodenum. A computed tomography (CT) scan showed inflammatory changes in the head of the pancreas and thickening of the duodenal wall. Magnetic resonance cholangiography demonstrated stenosis of the intrapancreatic segment of the common bile duct and diffuse dilatation of the main pancreatic duct, without irregularity. At laparotomy, microscopic examination of a needle biopsy specimen of the head of pancreas revealed no evidence of malignancy. Distal gastrectomy with Billroth II anastomosis was performed. Microscopically, fibrous thickening of the duodenal wall, serositis and hyperplasia of Brunner's glands were found. The presence of duodenal stenosis due to segmental pancreatitis, referred to as groove pancreatitis, was confirmed. The elevated blood levels of pancreatitis markers returned to the normal range 8 months after the operation. Ultrasonic echography and abdominal CT also revealed a marked reduction in dilatation of the extrahepatic bile duct and the main pancreatic duct. In patients suspected of having pancreatic carcinoma or regional pancreatitis, groove pancreatitis should be included in the differential diagnosis.     

Duodenal tuberculosis with a choledocho-duodenal fistula

A 22-year-old man visited our hospital (National Cancer Center Hospital East) complaining of fatigue and anorexia. A laboratory investigation demonstrated a biochemical 'picture' of obstructive jaundice. An abdominal CT showed a low density mass in the retropancreatic area with multiple enlarged periportal lymph nodes. Upper gastrointestinal endoscopy revealed active ulceration on the dorsal wall of the descending part of the duodenum, and histopathology of the biopsy specimen revealed an ulcer with reactive inflammatory cell infiltration; no tumor cells were detected. The possibility of neoplasm had been ruled out by the use of CT and angiography. The jaundice recovered spontaneously and the abdominal mass gradually decreased in size. Endoscopic retrograde pancreatography showed no evidence of pancreatic disease; however, endoscopic retrograde cholangiography showed a choledocho-duodenal fistula. This patient showed hypersensitivity against the tuberculin skin test and Mycobacterium tuberculosis was successfully detected in gastric juice by using a polymerase chain reaction method and culture. Biopsy samples obtained from the duodenal ulcer at the second upper gastrointestinal endoscopy showed chronic inflammation with an epithelioid granuloma, suggesting tuberculosis. We thus diagnosed this case as a duodenal tuberculosis with a choledocho-duodenal fistula. To the best of our knowledge, there has been no report available of duodenal tuberculosis being the cause of a choledocho-duodenal fistula.     

Cholestasis caused by an intradiverticular bezoar. Endoscopic treatment

A 49 year old woman presented with fever. Blood chemistry showed cholestasis. Sonography and abdominal computed tomography showed a dilated biliary tract and a fluid collection in the head of the pancreas. A large, interposed, diverticulum of the second duodenum, filled with a bezoar, was documented by duodenoscopy. The bezoar was fragmented and removed by biopsy forceps. Retrograde visualization of the common bile duct then showed a normal biliary tree with good clearance of contrast material. The ulterior course was uncomplicated. This is the second reported case for cholestasis due to an intradiverticular bezoar in an interposed duodenal diverticula. Diagnosis and treatment were made by duodenoscopy.     

Three cases of groove pancreatic carcinoma in which endoscopic ultrasonography was useful for diagnosis before surgery

We had three cases of pancreatic groove carcinoma. All cases developed obstructive jaundice. Duodenoscopy showed stenosis of the second portion of the duodenum in every case. Thus, endoscopic bile duct drainage could not be performed in two cases. CT revealed a mass between the duodenum and head of the pancreas, which was not well-defined by contrast-enhancement. Endoscopic ultrasonography revealed a hypoechoic mass which was adjacent to the common bile duct and duodenum in the pancreas head in all cases. Therefore, we could diagnose pancreatic groove carcinoma.