Perforated duodenal diverticulum successfully diagnosed preoperatively with abdominal CT scan associated with upper gastrointestinal series

Although duodenal diverticulum is not uncommon, precise preoperative diagnosis is occasionally difficult. We report a patient with perforated duodenal diverticulum successfully diagnosed preoperatively by an upper gastrointestinal series followed by abdominal computed tomography (CT) scanning. An 81-year-old Japanese woman visited a local hospital because of right-sided abdominal pain. Physical examination revealed diffuse muscle guarding localized in the entire right-side of the abdomen indicative of peritonitis. While plain abdominal X-ray film revealed no free air, abdominal ultrasound and abdominal CT scanning revealed fluid collection and gas in the anterior perirenal space. An emergency upper gastrointestinal series, using water-soluble contrast media, demonstrated multiple diverticula in the descending portion and the horizontal portion of the duodenum. Leakage of the contrast material was found by the upper gastrointestinal series followed by the abdominal CT scanning, suggesting that the peritonitis was caused by the perforated duodenal diverticulum, and an emergency laparotomy was performed. The diverticulum in the descending portion of the duodenum was mobilized from the retroperitoneum and complete resection and peritoneal drainage were performed. The resected specimen showed that the diverticulum was 42 × 23mm in size, and two separate sites of perforation were identified. The present case suggests that upper gastrointestinal series followed by CT scan is useful for the preoperative diagnosis of perforated duodenal diverticulum.     

EUS mini probes in diagnosis of cystic dystrophy of duodenal wall in heterotopic pancreas： A case report

Cystic dystrophy of the duodenal wall is a rare condition characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal wall. A 38-year-old man was admitted to the hospital for abdominal pain and vomiting after food intake. The diagnosis of acute pancreatitis was initially suspected. Abdominal ultrasound examination revealed thickening of the second portion of duodenal wall within which, small cysts (diameter, less than 1 cm) were present in the vicinity of pancreatic head.The head of pancreas appeared enlarged (63 mm×42 mm)and hypoechoic. Upper endoscopy and barium X-ray series were performed revealing a severe circumferential deformation, as well as 4 cm long stenosis of the second portion of the duodenum. CT examination revealed multiple cysts located in an enlarged, thickened duodenal wall with moderate to strong post-contrast enhancement. We suspected that patient had cystic dystrophy of duodenal wall developed in the heterotopic pancreas and diagnosis was confirmed by endoscopic ultrasound (EUS). Endoscopi cutrasound (EUS) revealed drcular stenosis from the duodenal bulb onwards. A twenty megaHertz mini-probe examination further showed diffuse (intramural) infiltration of duodenal wall limited to the submucosa and muscularis propria of the second portion of duodenum with multiple microcysts within the thickened mucosa and submucosa, a. Patient was successfully surgically treated and pancreatoduodenectomy was performed. The pathological examination confirmed a diagnosis of cystic dystrophy of a heterotopic pancreas.Endoscopic ultrasonography features allow preoperative diagnosis of cystic dystrophy of a heterotopic pancreas in duodenal wall, with inb‘alumina120 MHz mini probe sonography being more efficient in cases of luminal stenosis.     

Acute phlegmonous gastritis complicated by delayed perforation

Here,we report on a case of acute phlegmonous gastritis(PG)complicated by delayed perforation.A51-year-old woman presented with severe abdominal pain and septic shock symptoms.A computed tomography scan showed diffuse thickening of the gastric wall and distention with peritoneal fluid.Although we did not find definite evidence of free air on the computed tomography(CT)scan,the patient’s clinical condition suggested diffuse peritonitis requiring surgical intervention.Exploratory laparotomy revealed a thickened gastric wall with suppurative intraperitoneal fluid in which Streptococcus pyogenes grew.There was no evidence of gastric or duodenal perforation.No further operation was performed at that time.The patient was conservatively treated with antibiotics and proton pump inhibitor,and her condition improved.However,she experienced abdominal and flank pain again on postoperative day 10.CT and esophagogastroduodenoscopy showed a large gastric ulcer with perforation.Unfortunately,although the CT showed further improvement in the thickening of the stomach and the mucosal defect,the patient’s condition did not recover until a week later,and an esophagogastroduodenoscopy taken on postoperative day 30 showed suspected gastric submucosal dissection.We performed total gastrectomy as a second operation,and the patient recovered without major complications.A pathological examination revealed a multifocal ulceration and necrosis from the mucosa to the serosa with perforation.     

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

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.     

A case of endocrine cell carcinoma (small cell carcinoma) of duodenum]

Extra-ampullary duodenal endocrine cell carcinoma is extremely rare. A 65-year-old woman visited our hospital, complaining of epigastralgia, anorexia and vomiting. She was admitted for suspected duodenal or pancreas head tumor by abdominal CT. Fiberscopic examination revealed a circumferential tumor in the extra-ampullary duodenal second portion. Histopathological findings of biopsy specimen showed a small cell carcinoma, and positive immunohistochemical staining for synaptophysin revealed this tumor to be endocrine cell carcinoma. Pylorus-preserving pancreaticoduodenectomy with partial transversocolectomy was performed, and intraoperative washing cytology detected tumor cells in the peritoneal cavity. Although she discharged from hospital uneventfully, she died 11 months later of multiple liver metastases and peritoneal dissemination. This case showed the high malignant potential of this tumor.     

A case of gastrointestinal stromal tumor of the duodenum with a huge abscess

A 36-year-old man admitted for upper abdominal pain and fever. Enhanced abdominal computed tomography showed a cystic tumor with an air fluid level, measuring 140mm in size, along the side of the first and second portions of the duodenum. The common bile duct, portal vein, and proper hepatic artery were displaced by the tumor. Upper gastrointestinal endoscopy showed duodenal ulcer, but fistula was not confirmed. Combining all imaging and clinical findings, it was clinically diagnosed as duodenal submucosal tumor with abscess, and elective surgery was performed. There was a huge mass in the Morrison pouch, with severe adhesion to the second portion of the duodenum, gall bladder, common bile duct, and transverse colon. Subtotal stomach-preserving pancreaticoduodenectomy with transverse colectomy was performed. A fistula from the second portion of the duodenum to the tumor was confirmed on the resected specimen. Histological examination showed gastrointestinal stromal tumor originating in the duodenum.     

DUODENAL ADENOMA OF GASTRIC FOVEOLAR PHENOTYPE IN THE SECOND PORTION OF THE DUODENUM

We describe a rare case of duodenal adenoma of a gastric phenotype in the second portion of the duodenum. An 85‐year‐old Japanese man with a history of left nephrectomy was admitted to our hospital with a cerebral transient ischemia attack. Screening upper gastrointestinal endoscopy revealed a subpedunculated polyp with a reddish, erosive, glossy appearance, and a granular surface just above the papilla of Vater in the second portion of the duodenum, which on biopsy was diagnosed as a hyperplastic polyp. Hypotonic duodenography revealed a subpedunculated polyp with irregular granular surface, measuring approximately 20 mm in size, in the second portion of the duodenum. Endoscopic total resection for biopsy was performed. The histopathological examination of the polypectomied specimens revealed an adenoma with moderate dysplasia mimicking gastric foveolar epithelium or hyperplastic polyp accompanied by abundant mucin production. Immunohistochemistry revealed a complete gastric phenotype, suggesting it had probably arisen from heterotopic gastric mucosa. The present case is the eleventh case of duodenal neoplasia arising from heterotopic gastric mucosa and the sixth case of neoplasia with gastric phenotype found in the second portion of the duodenum reported in the world.     

A case of tuberculous lymphadenitis found as an abdominal mass penetrating the duodenum]

A 42-year-old woman who complained of epigastralgia was referred to our hospital because of an abdominal mass found by ultrasonography. CT and MRI scans revealed that the abdominal mass, 4 cm in diameter, located on the left side of the right kidney. Gastroduodenoscopy detected a deep ulcerative lesion covered with a yellowish coat in the second portion of duodenum. A sonolucent area at the bottom of the ulcerative lesion seemed to expand to the abdominal mass on ultrasonic endoscopy. Tuberculosis was one possible differential diagnosis. Pathological examination including Ziehl-Neelsen staining using biopsy specimens taken from the bottom of the ulcerative lesion did not show tuberculosis infection. However, polymerase chain reaction analysis using the biopsy specimens revealed that gene expression of tuberculosis was positive. We determined that tuberculous lymphadenitis penetrated the duodenum forming an ulcerative lesion in the duodenum. The administration of anti-tubercular medicine for 6 months male the abdominal mass disappeared and the duodenal ulcerative lesion formed an ulcer scar. We report here a case of tuberculous lymphadenitis penetrating the duodenum which was successfully treated by conservative therapy without surgical treatment.     

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.     

CASE REPORT OF TRICHOBEZOAR CAUSING GASTRIC PERFORATION

A 17‐year‐old girl with trichophagia (hair eating) habits was admitted to our hospital because of severe acute epigastralgia in June 1997. Abdominal computed tomography showed free air in the abdominal cavity and a heterogeneous mass in the stomach and the duodenum. A perforation on the anterior wall of the lower gastric body was found by urgent laparoscopic surgery and thus a laparoscopic omental patch repair was performed. Endoscopic examination after the operation revealed a large trichobezoar and gastric ulcers. An attempt made by us to extract the bezoar by endoscopy using a flexible outer‐tube was unsuccessful. The gastric ulcer relapsed in November 1997. Another attempt was made to extract the bezoar with laparoscopic instrumentation using a percutaneous gastrostomy port associated with oral gastroendoscopy. Only the part of the bezoar in the duodenum was extracted, and multiple superficial ulcers and erosions in the second part of the duodenum were found. Removal of the entire bezoar in the stomach required surgical gastrostomy. An endoscopic examination after the operation revealed healing of the gastric ulcer and duodenal erosions. Gastric perforation due to trichobezoar is a rare complication. Since the attempt to remove the trichobezoar in a minimally invasive manner failed, a surgical gastrostomy was required.     

Enormous postoperative perforation after endoscopic submucosal dissection for duodenal cancer successfully treated with filling and shielding by polyglycolic acid sheets with fibrin glue and computed tomography-guided abscess puncture

A female in her 70s underwent esophagogastroduodenoscopy (EGD) for screening, and a 0-IIa lesion measuring approximately 15 mm was detected in the descending portion of the duodenum. Due to the malignant potency of the lesion, endoscopic submucosal dissection (ESD) was performed. Microperforation occurred during ESD. The lesion was removed en bloc and the post-ESD ulcer bed was closed with clips. The next day, the patient had abdominal pain and computed tomography (CT) revealed a small amount of free air in the retroperitoneal space. Since there were no findings to suggest panperitonitis, conservative medical management including fasting and antibiotics was continued. Abdominal pain subsequently improved. However, EGD on the 8th day after ESD for follow-up showed shedding of the post-ESD ulcer that penetrated the retroperitoneal space. A surgical approach was not indicated because a few days may have already passed since postoperative perforation occurred and the spread of inflammation to the retroperitoneum was suspected. In an attempt to promote closure of the perforated cavity, we patched polyglycolic acid sheets and fibrin glue to the cavity wall on days 17, 18, and 20 after ESD. The formation of granulation tissue was detected in the cavity one week later. CT showed an abscess in the right retroperitoneum, for which CT-guided abscess puncture was performed. Thereafter, the cavity gradually decreased. After the initiation of oral intake on postoperative day (POD) 63, the general condition of the patient was stable and she was discharged on POD 87. Polyglycolic acid sheets with fibrin glue and CT-guided abscess puncture were useful for closing the large cavity that developed after duodenal postoperative perforation.     

Perforation of the duodenum by an ingested toothbrush

We report a rare case of duodenal perforation caused by an ingested 12-cm long toothbrush handle. A 22-year-old female presented with intermittent epigas- tric pain for 6 d after swallowing a broken toothbrush. The swallowed toothbrush could not be removed from the second portion of the duodenum by endoscopy. Laparotomy revealed a perforation in the anterior wall of the duodenal bulb. The toothbrush was removed via the perforation which was debrided and closed. There were no postoperative complications.     

Ulcerative colitis complicated by gastroduodenal lesions

A case of ulcerative colitis complicated with gastric and duodenal lesions is reported. The patient was a 17-year-old male who was admitted with bloody diarrhea and abdominal pain. Based on the endoscopic and histological findings of the colon, a diagnosis of ulcerative colitis was made. Upper gastrointestinal endoscopy showed multiple erosions and granular changes in the antral greater curvature of the stomach and descending portion of the duodenum. Histological examination of the stomach and duodenum revealed marked inflammatory cell infiltration and crypt abscesses. Clinically, the gastric and duodenal lesions did not respond to antiulcer drugs, but were alleviated by steroid. It was concluded that the pathogenesis of the gastric and duodenal lesions in this patient was similar to that of the colonic lesions of ulcerative colitis.     

Handlebar hernia with jejunal and duodenal injuries: a case report

Traumatic abdominal wall hernia is an uncommon complication of abdominal blunt trauma. Handlebar hernia is even more infrequent. To the best of our knowledge, there are fewer than 30 cases of handlebar hernia reported in the English literature. Associated intra-abdominal injuries are infrequent. We present a case of handlebar hernia with jejunal and duodenal injuries. Emergency surgical intervention included primary repair of the disrupted musculofascial defect and injuries of the duodenum and jejunum. Bile-stained discharge from the drain tube was noted, so a second operation was performed about 7 days after the first. Leakage from the sutured jejunal perforation and another irregular perforation in the posterior wall of the fourth portion of the duodenum were noted. The two perforations were debrided and repaired. The muscular and fascial defects were debrided and closed with interrupted sutures. The patient recovered smoothly and was discharged 30 days after the blunt injury. No other major complication was noted 11 months after surgery.     

Diverticulitis of the Duodenum: Clinical and Radiological Manifestations of Seven Cases

Seven patients with duodenal diverticulitis were evaluated by computed tomography (CT) and various other abdominal imaging techniques. The series included four men and three women who ranged in age from 47 to 84 yr (mean: 65 yr). They had presented with epigastric or periumbilical pain, low-grade fever, leukocytosis, and loss of appetite and weight due to postprandial cramps or vomiting. In each instance, the abdominal CT examination proved crucial in the diagnosis of duodenal diverticulitis, with contained perforation or inflammatory changes involving the adjacent structures. Five patients underwent laparotomy while two others were treated conservatively with antibiotics and/or percutaneous drainage of peridiverticular abscess. The clinical and radiological features of this uncommon entity are herein described, along with a brief review of the medical literature regarding the current approach to its diagnosis and management.     

Intraductal papillary bile duct adenocarcinoma and gastrointestinal stromal tumor in a case of neurofibromatosis type 1

We report our experience with a synchronous case of gastrointestinal stromal tumor(GIST) and intraductal papillary neoplasm of the bile duct(IPNB) in anelderly woman with neurofibromatosis type 1(NF-1). A 72-year-old woman presented with a 2-mo history of right upper abdominal pain unrelated to diet and indigestion. Fourteen years earlier, she had been diagnosed with NF-1, which manifested as café au lait spots and multiple nodules on the skin. Computed tomography(CT) revealed a multilocular low-density mass with septation, and mural nodules in the right hepatic lobe, as well as a 1.7-cm-sized well-demarcated enhancing mass in the third portion of the duodenum. The patient subsequently underwent right hepatectomy and duodenal wedge resection. We present here the first report of a case involving a synchronous IPNB and GIST in a patient with NF-1. Our findings demonstrate the possibility of various tumors in NF-1 patients and the importance of diagnosis at an early stage     

SUCCESSFUL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR MUCOSAL CANCER OF THE DUODENUM

We report a case of mucosal duodenal cancer in a 62‐year‐old woman, which was successfully removed en bloc by endoscopic submucosal dissection (ESD). The patient underwent an upper gastrointestinal endoscopy at our hospital, which revealed an elevated flat mucosal lesion (type IIa) measuring 10 mm in diameter in the second portion of the duodenum. Histopathological examination of a biopsy specimen revealed features suggestive of a tubulovillous adenoma with severe atypia. As the findings suggested that the lesion had an adenocarcinoma component but was confined to the mucosal layer, we decided to carry out ESD and successfully removed the tumor in one piece. The resected tumor was 20 × 15 mm in size. Histopathological examination revealed that the lesion was a well‐differentiated mucosal adenocarcinoma with no lymphovascular invasion. Mucosal duodenal cancer is extremely rare, and ESD of a lesion in the duodenum requires a high level of skill. To the best of our knowledge, this case is the first report of successful ESD carried out in a case of mucosal duodenal cancer.     

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.     

Duodenal obstruction after elective abdominal aortic aneurysm repair: a case report

Gastrointestinal tract complications after abdominal aortic aneurysm (AAA) repair are well known. The reported frequency ranges from 6.6% to 21%. However, the incidence of duodenal obstruction following AAA has probably been underestimated. This report concerns a 78-year-old male who was admitted for elective repair of an infrarenal AAA. On the ninth postoperative day, the patient presented with large quantities of bile-stained vomitus despite passing flatus per rectum. Metoclopramide and ranitidine were given under the initial impression of paralytic ileus. However, the upper gastrointestinal obstruction persisted, and on day 12, computerized tomography (CT) revealed marked distension of the gastric tube and duodenum, down to the level of the third portion, with abrupt change of caliber at the point of the superior mesenteric artery (SMA). SMA syndrome was diagnosed. After nasogastric tube aspiration, parenteral nutrition, and 11 days of conservative treatment, abdominal CT and upper gastrointestinal series showed no apparent duodenal obstruction. The patient was discharged on the 29th postoperative day; follow-up abdominal CT 4 months later was unremarkable.