Lipoma within inverted Meckel’s diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: A case report and review of literature

Lipoma within an inverted Meckel's diverticulum presen- ting with hemorrhage and partial intestinal obstruction is an exceptional clinical entity. We report a case of 47-year-old male with a history of recurrent episodes of partial intestinal obstruction and melena due to a subserosal lipoma located in the base of an inverted Meckel's diverticulum. According to our knowledge, this is the first case of a lipoma within a Meckel's diverticulum giving rise to this clinical scenario without the existence of heterotrophic gastric or pancreatic tissues.     

Diagnostic effect of capsule endoscopy in 31 cases of subacute small bowel obstruction

AIM： TO evaluate the effectiveness and safety of capsule endoscopy （CE） in patients with recurrent subacute small bowel obstruction.METHODS： The study was a retrospective analysis of 31 patients referred to hospital from January 2003 to August 2008 for the investigation of subacute small bowel obstruction, who underwent CE. The patients were aged 9-81 years, and all of them had undergone gastroscopy and colonoscopy previously. Some of them received abdominal computed tomography or small bowel follow-through.RESULTS： CE made a definitive diagnosis in 12 （38.7%） of 31 cases： four Crohn＇s disease （CD）, two carcinomas, one intestinal tuberculosis, one ischemic enteritis, one abdominal cocoon, one duplication of the intestine,one diverticulum and one ileal polypoid tumor. Capsule retention occurred in three （9.7%） of 31 patients, and was caused by CD （2） or tumor （1）. Two with retained capsules were retrieved at surgery, and the other one of the capsules was spontaneously passed the stricture by medical treatment in 6 too. No case had an acute small bowel obstruction caused by performance of CE.CONCLUSION： CE provided safe and effective visualization to identify the etiology of a subacute small bowel obstruction, especially in patients with suspected intestinal tumors or CD, which are not identified by routine examinations.     

Eosinophilic enteritis presenting as a rare cause for ileo-ileal intussusception

Eosinophilic enteritis,a relatively rare entity,usually involves gastric antrum or proximal small bowel. Our case is rarer in its involvement of the distal small bowel and presents unusually as intussusception. The disease if diagnosed in the initial stages responds well to medical treatment but if associated with complications or misdiagnosed,surgical modality is the treatment of choice. In our case,the patient presented with acute intestinal obstruction due to intussusception and emergency laparotomy with ileoileal anastomosis was done. Histopathology confirmed the diagnosis as eosinophilic enteritis. This case with such a presentation is discussed here.     

Intestinal anisakiasis treated successfully with conservative therapy: Importance of clinical diagnosis

Intestinal anisakiasis is not only a rare parasitic disease,but is also difficult to diagnose.The symptoms are not specific and are often very severe and abrupt,and the findings of clinical imaging are very remarkable.Therefore,intestinal anisakiasis is often misdiagnosed as acute abdomen or intestinal obstruction and is treated surgically.However,if intestinal anisakiasis could be diagnosed correctly,it is well treated conservatively.We experienced three cases of intestinal anisakiasis,which were diagnosed correctly and treated successfully with conservative therapy.A correct clinical history and imaging interpretation helped us diagnose intestinal anisakiasis correctly and thus treat the patients successfully with conservative therapy.     

Ubiquitous Expression of Intestinal Trefoil Factor （ITF） in Barrett＇s Esophagus

To elucidate the differences of the clinical course and treatments between intestinal Behcet‘s disease and Simple ulcer, we surveyed 17 patients with intestinal Behcet‘s disease and 4 patients with Simple ulcer diagnosed from 1974 to 1997. There were no essential differences of clinical course between intestinal Behcet‘s disease and Simple ulcer. Regarding the treatments, 8 of 17 patients (47 per cent) with intestinal Behcet‘s disease were managed without surgical operation, whereas all patients with simple ulcer required operation. Treatments of intestinal Behcet‘s disease were based on corticosteroids,salazosulfapyridine,colchicine,indometha cin,and cyclosporin.     

Gastrointestinal autonomic nerve tumors:A surgical point of view

AIM:Gastrointestinal autonomic nerve tumors areuncommon stromal tumors of the intestinal tract.Theirhistological appearance is similar to that of othergastrointestinal stromal tumors.We report two cases andperformed an analysis of the literature by comparing ourfindings with the available case reports in the medicalliterature.METHODS:Two patients were admitted with abdominaltumor masses.One occurred in the stomach with largemultiple liver metastases and the second originated inMeckel's diverticulum.The latter site has never beenreported previously.Both patients underwent surgery.Inone patient gastrectomy,right liver resection and colontransversum resection were performed to achieveaggressive tumor debulking.In the other patient the tumorbearing diverticulum was removed.RESULTS:Postoperative recovery of both patients wasuneventful.Histological examination,immunohistochemicalanalysis and electron microscopy revealed the diagnosisof a gastrointestinal autonomic nerve tumor.The patientwith the tumor in Meckel's diverticulum died 6 mo aftersurgery because of pneumonia.The patient with livermetastases have been alive 13 years after initial tumordiagnosis and 7 years after surgery with no evidence oftumor progression.In light of our results,we performed athorough comparison with available literature reports.CONCLUSION:Radical surgical resection of gastrointestinalautonomic nerve tumors seems to be the only availablecurative approach to date,and long term survival is possibleeven in large metastasized tumors.     

Clinical application of metallic stents in treatment of esophageal carcinoma

AIM: To evaluate the effects of self-expanding metal stents (SEMS) in patients with malignant esophageal obstruction and to analyze their prognosis and complications. METHODS: Seventy-four metallic stents were placed under fluoroscopic guidance in 66 patients with esophageal obstruction secondary to carcinoma, of whom, 6 cases were complicated by fistula. RESULTS: After seventy-two stents were successfully used in 66 cases without any severe complications (technical successful rate was 97%), the dysphagia score improved from 3.3±0.6 to 0.8±0.5 (P<0.01), and life quality improved significantly in all these patients. All fistulae were sealed immediately after coated stents were inserted in the six patients. New stents were placed in two patients: the stent migrated more than 2 cm, in one patients and the stent slipped into stomach in the other. Minor bleeding was found only in 28 patients during the operation. Reobstruction was found in 12 patients, but was successfully cured under endoscopy. The survival rate was 78%, 57% and 11% for 6 mo, 1 year and 2 years respectively. CONCLUSION: Placement of SEMS is a simple, safe, quick and efficient surgical method for treating esophageal carcinoma obstruction. It may be used mainly as a palliative treatment of esophageal obstruction secondary to carcinoma.     

What is a reliable CT scan for diagnosing splenosis under emergency conditions？

Splenosis is a condition in which splenic tissue is present in a non-anatomical position. Implants of splenic tissue can mimic neoplasms and only specific examinations can confirm the correct diagnosis. Here we report a case of a 23-year-old male patient with a history of surgical splenectomy during childhood after trauma, He was admitted to the emergency department with acute bowel obstruction. An abdominalpelvic computed tomography （CT） scan revealed small bowel obstruction and the presence of two rounded, solid masses located in the rectal-vescical pouch. Quantitative analyses of the different density values in the arterial phase and early portal venous phase demonstrated that these lesions were highly vascularised （92 and 97 Hounsfield Units, respectively）. The hypothesis of an ectopic splenic mass was made after evaluation of the CT images and clinical history. The acute bowel obstruction caused by adhesive intestinal syndrome was resolved by surgical adhesiolysis. The smallest mass adherent to the rectum was removed. Histopathologic examination confirmed the benign nature of the lesion, which consisted of splenic tissue.     

Giant vesical diverticulum： A rare cause of defecation disturbance

Vesical diverticula frequently result from bladder outlet obstructions. However, giant vesical diverticula which cause acute abdomen or intestinal obstruction are very rare. Our review of the English medical literature found 3 cases of bladder diverticula which caused gastrointestinal symptoms. Here, we present a 57-yearold man with a giant diverticulum of the urinary bladder who complained of abdominal pain, nausea and vomiting, constipation, no passage of gas or feces, and abdominal distension for 3 d. A 20 cm x 15 cm diverticulum was observed upon laparotomy. The colonic obstruction was secondary to external compression of the rectum against the sacrum by a distended vesical diverticulum. We performed a diverticulectomy and primary closure. Twelve months postoperatively, the patient had no difficulty with voiding or defecation.     

Ileo-colonic intussusception secondary to small-bowel lipomatosis:A case report

Intestinal lipomatosis is a rare disease with an incidence at autopsy ranging from 0.04% to 4.5%.Because the lipomas are diffusely distributed in the intestine,most patients are symptom-free,and invasive intervention is not advised by most doctors.Here,we describe a case with intussusception due to small-bowel lipomatosis.Partial small bowel resection and anastomosis were performed because the intestinal wall was on the verge of perforation.This case indicates that regular followup is necessary and endoscopic treatment should be considered to avoid surgical procedures if the lipoma is large enough to cause intestinal obstruction.     

A case of recurrent intestinal obstruction caused by Meckel's diverticulum]

Meckel's diverticulum is the most common anomaly of the intestine. It is usually asymptomatic but approximately 4% are symptomatic with complications such as bleeding, intestinal obstruction, and inflammation. Gastrointestinal bleeding is the most common presenting symptoms of Meckel's diverticulum in children, however, intestinal obstruction is the most common complications in adult patients. Reported mechanism of intestinal obstruction in Meckel's diverticulum include intussusception, adhesion, and volvulus. Recently, we experienced a case with Meckel's diverticulum associated with ileal stricture causing recurrent partial intestinal obstruction in a 48-year-old man. In contrast to other published cases of small bowel obstruction in Meckel's diverticulum, this case was caused by ileal stricture associated with Meckel's diverticulum.     

Enterolith intestinal obstruction owing to acquired and congenital diverticulosis

Diverticulosis of the small bowel, complicated by enterolith formation with ensuing obturation obstruction, was recently documented in two patients. One patient had an enterolith formed within a Meckel's diverticulum; the other had an enterolith dislodged from an acquired diverticulum. Both patients presented with signs and symptoms of acute small bowel obstruction. Only 20 such cases of bowel obstruction secondary to jejunal enterolithiasis and five cases secondary to Meckel's enterolithiasis have been reported. The mechanism of obstruction may involve local encroachment or enterolith expulsion with distal bowel obstruction, although the latter is much more common. Optimally, enteroliths are broken up and milked into the proximal colon without incising the bowel. Alternatively, the enterolith may be milked proximally to a less edematous portion of bowel and an enterotomy may be performed. At times, the primary diverticulum is resected with the contained enterolith.     

A double Meckel's diverticulum as obscure gastrointestinal bleeding cause. Report of a case

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.     

Clinical implications of jejunoileal diverticular disease

Congenital and acquired diverticula of the jejunum and ileum in the adult are unusual and occur in approximately 1 percent to 2 percent of the population. They are pulsion diverticula thought to be the result of intestinal dyskinesia. These lesions can produce a significant diagnostic and therapeutic dilemma. They are multiple in the jejunum and solitary distally and are characteristically found in 60- or 70-year-old males. The diagnosis may be confirmed with contrast studies of the small intestine, arteriography, or nuclear scan. Consider these disorders in patients with 1) unexplained gastrointestinal bleeding, 2) unexplained intestinal obstruction, 3) an unexpected cause of acute abdomen, 4) chronic abdominal pain, 5) anemia, or 6) malabsorption. Medical therapy is helpful in controlling diarrhea and anemia, while surgical therapy is reserved for hemorrhage, obstruction, perforation, or failure of medical management. Asymptomatic diverticula discovered on routine contrast studies need not be resected. At surgery, incidental diverticula should be removed when evidence of dilated, hypertrophied loops of small bowel with large diverticula is found. Intraoperative air distention will aid in diagnosis. Resection and primary anastomosis is the preferred treatment for non-Meckelian diverticula. Diverticulectomy is reserved for a Meckel's diverticulum without evidence of ulceration. An incidental Meckel's diverticulum should be removed in the presence of mesodiverticular bands or ectopic tissue. Removal of a Meckel's diverticulum is not advised in the patient with Crohn's disease but may be performed in the patient undergoing restorative proctocolectomy for ulcerative colitis.     

Recurrent Hemorrhage from an Invaginated Meckel''s Diverticulum in a 78-Year-Old Man

Complications arising from Meckel's diverticulum are uncommon in adults and are seldom, if ever, seen in the elderly. When they do occur in adults, intestinal obstruction or inflammation is the usual mode of presentation, hemorrhage being much less common. The patient described in this case report was 78 yr old, presented initially with iron deficiency anemia and, later, developed severe acute hemorrhage. The cause of the hemorrhage was ulceration at the tip of an invaginated Meckel's diverticulum. The ulceration was not peptic in origin, as is usually the case in similar presentations in children, no ectopic oxyntic mucosa being detected in the diverticulum of our patient. In previous reports, invaginated Meckel's diverticula have always been accompanied by intussusception, and abdominal pain has been an important part of the symptom complex in such patients. Our patient had no abdominal pain, and no intussusception was noted at surgery. This case emphasizes the need for considering a Meckel's diverticulum as the source of acute or chronic hemorrhage, irrespective of the patient's age. The utility of radionuclide blood pool imaging in arriving at a diagnosis in these cases is discussed.     

Intraluminal thrombus and bowel obstruction in acute leukemia due to bleeding Meckel's diverticulum

Gastrointestinal bleeding from Meckel's diverticulum resulted in small bowel obstruction by thrombus in two patients with acute myelogenous leukemia during bone marrow aplasia and recovery from induction chemotherapy. Although gastrointestinal symptoms and complications are common in acute leukemia, these two cases are unique and describe a new syndrome that requires prompt recognition and surgical intervention. The complication of localized bowel obstruction by intraluminal thrombus is heretofore unreported.     

Adenocarcinoma in Meckel''s Diverticulum: Report of a Case and Review of 30 Cases in the English and Japanese Literature

A 54-yr-old man who complained of abdominal pain was found to have an adenocarcinoma arising in Meckel's diverticulum, as preoperatively diagnosed with 99mTc-pertechnetate scintigraphy. Angiography of the superior mesenteric artery revealed multiple branched arteries and tumor stain, but the vitelline artery was not clearly identified. Surgery revealed that the tumor had invaded the urinary bladder and the ileum, including the diverticulum, and the bladder had to be partially resected. Histopathological examination of the lesion revealed a diverticulum containing normal small bowel mucosa, ectopic normal gastric tissue, and adenocarcinoma. In a review of 30 cases of adenocarcinoma in Meckel's diverticulum in the English and Japanese literature, our case was the first to be diagnosed preoperatively.     

Meckel's diverticulum in Crohn's disease.

Meckel's diverticulum is a congenital abnormality of the distal ileum associated with failed vitelline duct closure. Detailed pathological studies have estimated its frequency to be about 2% of the general population, and it has been anecdotally recorded in patients with Crohn's disease. Most patients with Crohn's disease have imaging studies of the small intestine during the course of their disease, and often, an intestinal resection. Thus, it seems possible to estimate the prevalence of Meckel's diverticula in Crohn's disease. In addition, patient characteristics may be important, especially if management of Crohn's disease is altered. Of 877 patients with Crohn's disease, 10 (about 1%) had a Meckel's diverticulum diagnosed, including six men and four women. All were diagnosed with Crohn's disease before age 50 years and seven were diagnosed before age 30 years. There were five with ileocolonic disease, two with colon-only disease and three with ileum-only disease. The clinical behaviour of five patients could be classified as penetrating and two as stricturing. A total of 311 patients had an ileocolonic resection, including eight (about 2%) with a Meckel's diverticulum. In contrast to some case reports, no heterotopic mucosa was detected and the Meckel's diverticulum was incidental and, apparently, an unexpected finding. In each case, the diverticulum was not involved with Crohn's disease but was included in the ileal resection. These results suggest that the overall prevalence of a Meckel's diverticulum is not increased in Crohn's disease but may result in resection of additional small intestine.     

Gangrene of Meckel's diverticulum.

Gangrene of Meckel's diverticulum is uncommon and its pre-operative diagnosis is difficult. We report three cases with different presentations--simulating acute appendicitis, intestinal obstruction, and strangulation of the bowel.     

Gastrointestinal stromal tumor of Meckel's diverticulum: A rare cause of intestinal volvulus

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Most cases are asymptomatic; however, when symptomatic, it is often misdiagnosed at presentation. Common complications presenting in adults include bleeding, obstruction, diverticulitis, and perforation. Tumors within a Meckel's diverticulum are rare. Herein, we present a gastrointestinal stromal tumor arising from the Meckel's diverticulum that led to intestinal obstruction by volvulus.