Endoscopic treatment of duodenal bleeding caused by direct hepatocellular carcinoma invasion with an ethanol injection

We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.     

Treatment of radiation-induced hemorrhagic gastritis with prednisolone: A case report

Radiation-induced gastritis is an infrequent cause of gastrointestinal bleeding.It is a serious complication arising from radiation therapy,and the standard treatment method has not been established.The initial injury is characteristically acute inflammation of gastric mucosa.We presented a 46-year-old male patient with hemorrhagic gastritis induced by external radiotherapy for metastatic retroperitoneal lymph node of hepatocellular carcinoma.The endoscopic examination showed diffuse edematous hyperemicmucosa with telangiectasias in the whole muscosa of the stomach and duodenal bulb.Multiple hemorrhagic patches with active oozing were found over the antrum.Anti-secretary therapy was initiated for hemostasis,but melena still occurred off and on.Finally,he was successfully treated by prednisolone therapy.We therefore strongly argue in favor of perdnisolone therapy to effectively treat patients with radiation-induced hemorrhagic gastritis.     

Factors associated with failure of initial endoscopic hemoclip hemostasis for upper gastrointestinal bleeding

BACKGROUND: Endoscopic hemoclip is widely used for the management of bleeding peptic ulcers. The major difficulty in clinical application of the hemoclip is deployment to the lesion during initial hemostasis. The aim of this study was to define factors associated with the failure of endoscopic hemoclip for initial hemostasis of upper GI bleeding. PATIENTS AND METHODS: From January to December 2003, we prospectively studied 77 randomized patients with clinical evidence of upper GI bleeding due to either active bleeding or a visible vessel identified by upper GI endoscopy in our emergency department. RESULTS: Among the 77 patients, 13 (16.9%) failed treatment (Group 1) and 64 (83.1%) were successfully (Group 2) treated by endoscopic hemoclip for lesions related to upper GI bleeding. There were no differences due to gender, blood pressure, initial heart rate, and hemoglobulin before or after endoscopic treatment, platelet count, serum creatinine, and albumin between groups. The mean age of Group 1 was higher than that of Group 2 (73.31+/-9.38 years vs. 65.41+/-16.45 years, respectively; P=0.083). Most patients who did not achieve initial hemostasis by endoscopic hemoclip had upper GI lesions over the gastric antrum and duodenal bulb. Among the 13 patients who failed to achieve endoscopic hemoclip initial hemostasis, four lesions were located over the posterior wall of the antrum, and four lesions over the lesser curvature side of the duodenal bulb. CONCLUSION: Endoscopic hemoclip is an effective hemostatic method for upper GI bleeding. Age, gastric antrum, and duodenal bulb lesions may be associated with the failure of initial hemostasis by endoscopic hemoclip.     

CASE REPORT: Successful obliteration of a bleeding duodenal varix using endoscopic ligation

The occurrence of duodenal varices is rare and experience in the control of haemorrhage from duodenal varices is limited. A 69-year-old man with hepatocellular carcinoma presenting with upper gastrointestinal bleeding is reported. Emergency upper gastrointestinal endoscopy indicated one varix 1.5 cm in diameter with white nipple sign at the anterior wall of the duodenal bulb. Endosonography confirmed the diagnosis of duodenal varix. The patient was treated with endoscopic ligation and follow-up endoscopy showed complete eradication of duodenal varix 3 weeks later.     

An Endoscopically Resected Case of Early Carcinoma of the Duodenal Bulb

We report here on a case of early carcinoma originating in the duodenal bulb. The patient was a 70-year-old woman who complained of nausea. A gastrointestinal endoscopy disclosed a lesion protruding from the duodenal bulb and a biopsy revealed adenocarcinoma. According to the results of the endoscopy, the tumor was subpedunculated and probably confined in the mucosal layer. Based on these findings, we performed an endoscopic tumor resection. A histological examination of the resected specimen revealed a papillotubular adenocarcinoma (1.7 × 1.2 × 0.8 cm) localized in the mucosal layer. No carcinomatous lesion was left in the resected margin. No symptoms of recurrence have been noted during the last 6 months. When considering clinical pathology of the present case, we assessed 39 cases of primary early carcinoma in the duodenal bulb previously reported in the Japanese literature. We considered that our patient was the 14th in Japan with an early carcinoma of the duodenum which was completely excised via endoscopic resection. We expect that endoscopic resection of early duodenal carcinoma will be widely used in the future.     

Successful resection, using pancreas-sparing duodenectomy, of extrahepatically growing hepatocellular carcinoma associated with direct duodenal invasion

A 50‐year‐old man with extrahepatically growing hepatocellular carcinoma (HCC) associated with direct duodenal invasion underwent a right posterior segmentectomy associated with pancreas‐sparing duodenectomy. Neither periduodenal lymph‐node metastasis nor pancreatic invasion was detected, thus we separated the supra‐ampullary duodenum from the pancreatic head and performed pancreas‐sparing supra‐ampullary duodenectomy. The resected specimen was observed to be a centrally necrotic tumor that had infiltrated the duodenal wall, resulting in exposure of the lumen. Pathology examination revealed that the tumor consisted of poorly differentiated HCC, which had extensively infiltrated the mucosa of the duodenum. Gastrointestinal tract involvement in patients with HCC is rare, and pancreas‐sparing duodenectomy is a safe and effective treatment for patients with HCC associated with direct duodenal invasion.     

A case of nodal malignant lymphoma presenting with arterial bleeding related to its duodenal penetration

A 62-year-old man with a chief complaint of dysphagia visited our hospital. Enhanced computed tomography showed the tumor near the duodenal wall and lymphadenopathy in the left supraclavicular fossa and para-aortic lymph node. Upper gastrointestinal endoscopy showed an ulcer accompanied with a fistula in the anterior wall of duodenal bulb, suggesting that the tumor penetrated into duodenal wall. Biopsy from the lymph node in the left supraclavicular fossa indicated diffuse large B-cell lymphoma. Although chemotherapy was planned, massive arterial bleeding occurred from the part of duodenal penetration. Endoscopic hemostasis was unsuccessfully performed. Therefore, we performed transcathether arterial embolization for hemostasis. After the procedure, the patient received six cycles of chemotherapy, and he achieved complete response. He has been alive 5 years without recurrence. There were many cases of gastrointestinal bleeding from primary gastrointestinal lymphomas, while there were few cases with nodal involvement by malignant lymphoma resulting in bleeding from gastrointestinal tract. We herein report a case of duodenal bleeding by nodal involvement of diffuse large B-cell lymphoma with review of literature.     

Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: treatment with transjugular intrahepatic portosystemic shunt

We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had undergone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The postoperative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.     

A Case of Duodenal Carcinoid Tumor Associated with Carcinoma of the Head of the Pancreas

Abstract: We describe a case of duodenal carcinoid tumor associated with carcinoma of the head of the pancreas. The patient was a 77-year-old man who was admitted to our hospital with jaundice and pruritus cutaneous. Carcinoma of the head of the pancreas was diagnosed on the basis of findings obtained by abdominal computed tomographic scan and endoscopic retrograde cholangiopancreatography. Upper gastrointestinal endoscopy revealed a protrusive hemorrhagic lesion with a flushed surface and a diameter of about 1 cm in the anterior wall of the duodenal bulb. On May 25, 1996, pancreaticoduodenectomy was performed. On histopathological examination, this carcinoma of the pancreatic head was found to be a well-differentiated tubular adenocarcinoma. Immunohisto-chemically, the protrusive lesion in the duodenal bulb stained positive for chromogranine and IMSB and was slightly positive for S-100 protein. It was also slightly positive on Grimelius staining and negative on Masson-Fontana staining. These findings led to a diagnosis of carcinoid tumor arising from the anterior intestinal line.     

Endoscopic management of upper gastrointestinal bleeding from a duodenal diverticulum

Hemorrhage from duodenal diverticulum is a rare cause of upper gastrointestinal hemorrhage. The side-viewing endoscope was used for almost all cases of diagnosis and endoscopic hemostasis. However, a forward-viewing endoscope is used in emergent endoscopic study for upper gastrointestinal hemorrhage. We report a case in which the endoscopic hemostasis of bleeding duodenal diverticulum was performed during emergent forward-viewing endoscopic study.     

Liver abscess that developed after a long interval of transcatheter arterial embolization followed by formation of hepatoduodenal fistula

A 55‐year‐old male patient with hepatocellular carcinoma underwent transcatheter arterial embolization (TAE). He became febrile and experienced pain at the right hypochondrial region 323 days later, which led to the discovery of a liver abscess that fistulated into the duodenal bulb. There have been no reports on the fistulation of liver abscesses into the digestive system following TAE. Rhodococcus equi was isolated as a causative agent, which distinguished the case further.     

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis.ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation(EPLBD) with a size of 15 mm.Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla.Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis.Therefore, we placed a 10 mm fully covered selfexpandable metallic stent(SEMS) across the duodenal papilla, and the hemorrhage stopped immediately.After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct.A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct.We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.     

Successful treatment of life-threatening bleeding from a duodenal posterior bulb peptic ulcer by an over-the-scope-clip

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome.In this article,we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall,using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock.Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.     

Obstructive Jaundice Due to Duodenal Ulcer Induced by Lenvatinib Therapy for Hepatocellular Carcinoma

An 82-year-old man with hepatocellular carcinoma presented with upper abdominal pain, vomiting, and jaundice. He had been taking a standard lenvatinib dose for three months. Although acute cholangitis was suggested, imaging studies failed to detect the biliary obstruction site. An endoscopic examination following discontinuation of lenvatinib and aspirin revealed multiple duodenal ulcers, one of which was formed on the ampulla of Vater and causing cholestasis. Endoscopic biliary drainage and antibiotics improved concomitant Enterobacter cloacae bacteremia. Ulcer healing was confirmed after rabeprazole was replaced with vonoprazan and misoprostol. Our case shows that lenvatinib can induce duodenal ulcers resulting in obstructive jaundice.     

Hepatocellular carcinoma with duodenal invasion and metastasis

Background and Aim: Hepatocellular carcinoma (HCC) is the leading cause of cancer‐related deaths in Taiwan. HCC with duodenal involvement are rare and are associated with a poor prognosis. The purpose of this retrospective study was to collect clinical information and data regarding survival following various treatments. Methods: Between 1996 and 2009, 21 cases (17 men) were diagnosed with HCC and duodenal invasion and metastases by diagnostic imaging, endoscopy with biopsy, or surgically collected specimens sent to pathology. The clinical course was analyzed from the patients' medical records. Results: Gastrointestinal bleeding was reported in 18/21 patients. Diagnostic imaging showed that the majority of cases involved direct tumor invasion (predominantly from the right liver lobe) and six cases from metastasis. Tumor mass and ulcerations were the most common features noted on endoscopy. In addition to the component therapy and medication treatment, panendoscopic hemostasis, surgery, transcatheter arterial embolization, and radiotherapy were performed for the management of duodenal involvement and gastrointestinal bleeding. Survival duration after duodenal involvement ranged from 0.2 to 57.8 months (mean 10.5 months). Conclusions: Gastrointestinal bleeding in advanced HCC should raise suspicions of duodenal involvement. HCC can involve the duodenum by direct invasion (from either the left or right liver lobes) or metastasis. The prognosis for HCC patients with duodenal involvement is poor, but is improved by supportive care and application of various treatment modalities.     

Gastrointestinal complications after radiation therapy in patients with hepatocellular carcinoma

BACKGROUND/AIMS: With the recent technical advancement to deliver high doses of radiation to a liver mass, radiation treatment has been increasingly used in patients with hepatocellular carcinoma. The aim of this study was to investigate the clinical characteristics of the gastrointestinal adverse effects after radiation therapy in patients with hepatocellular carcinoma. METHODOLOGY: Between 1994 to 2002, 153 patients with hepatocellular carcinoma have been treated with radiation therapy. Medical records were systemically reviewed. RESULTS: Upper endoscopic examinations were done in 34 patients. Radiation-induced ulcers were found in the stomach (n=9) and duodenum (n= 14). Radiation-induced gastroduodenitis was found in 9 patients. Bleeding from radiation-related lesions in 11 patients (7.2%) was caused by gastroduodenitis (n=7), gastric ulcer (n=2), and duodenal ulcer (n=2). There were 7 patients with rebleeding. Bleeding was fatal in only one patient. Two patients with obstruction were treated by stent insertion. Two patients with perforation improved after surgical repair. Hematologic toxicity was found in 53 patients (34.6%) and hepatobiliary complications were found in 40 patients (26.1%). Radiation-induced pneumonitis was found in 3 patients (2%). CONCLUSIONS: We found that radiation-induced complications in patients with hepatocellular carcinoma are rather frequent. However, most complications were effectively managed by intensive treatments including endoscopic hemostasis, stent insertion and surgery.     

Massive upper gastrointestinal hemorrhage due to invasive hepatocellular carcinoma and hepato-gastric fistula

A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia.He was diagnosed with a liver mass that was resected 8 years ago described as a benign tumor in his home country.He had received trans-arterial chemoembolization(TACE)four months ago after subsequent diagnosis of unresectable hepatoma,and currently was receiving chemotherapy with Sorafenib.After resuscitation,a contrast enhanced computerized tomography was performed which showed fistulization of hepatocellular carcinoma into adjacent stomach.This finding was confirmed during endoscopy with direct visualization of the fistulous opening.Hepatocellular carcinoma(HCC)invading the gastrointestinal(GI)tract is rare.We present a case and literature review of HCC with local invasion of the stomach causing massive upper GI bleeding after receiving TACE.     

Peroral direct cholangioscopic-guided biopsy and photodynamic therapy using an ultraslim upper endoscope for recurrent hepatocellular carcinoma with intraductal tiny nodular tumor growth

Bile-duct invasion is rare in patients with hepatocellular carcinoma (HCC). We report a case that received peroral direct cholangioscopy (PDCS)-guided endoscopic biopsy and photodynamic treatment (PDT) for recurrent HCC with intraductal tiny nodular tumor growth. A 64-year-old woman presented with recurrent right upper-quadrant pain. Six months previously she had been diagnosed with HCC with bile-duct invasion in the right anterior segment and had received right anterior segmentectomy. On pathological examination, the margin of resection was clear, but macroscopic bile-duct invasion was noted. On admission, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed a 0.5-cm-sized polypoid mass at the hilar portion. ERCP-guided biopsy failed, and an ampullary stricture was noted. PDCS-guided endoscopic biopsy was thus performed, and histopathology of the retrieved specimen revealed HCC. The patient submitted to PDT. There was no procedure-related complication. After 1 month of PDT the polypoid lesion and scar change at the hilar lesion had disappeared.     

十二指肠球部类癌的内镜切除临床疗效分析

目的探讨十二指肠球部类癌的内镜切除治疗的效果。方法回顾性分析2009年6月至2012年6月经内镜切除治疗且术后病理证实的17例十二指肠球部类癌患者资料,其中男11例、女6例,年龄22～52岁,平均（36．3±8．4）岁。结果17例患者术前均应用超声内镜诊断,其中考虑为异位胰腺4例,类癌13例,最大直径0．4～1．0cm,均与固有肌层分界清晰。内镜治疗均取得成功,采用透明帽辅助切除法,术中与术后无并发症出现。术后病理及免疫组化染色均证实为类癌,因此超声内镜的术前诊断准确率为76．5％。患者平均随访观察（20．5±12．4）个月,无复发和转移病例。结论超声内镜可以有效地判定十二指肠球部病变的浸润深度,评价内镜下切除指征,但无法术前定性诊断。内镜透明帽辅助下切除治疗十二指肠类癌是安全有效的。     

十二指肠球部多发隆起病变与幽门螺杆菌和胃上皮化生的关系

目的探讨内镜下十二指肠球部多发隆起病变与幽门螺杆菌（Hp）感染和胃上皮化生等组织学异常关系.方法连续调查86例经胃镜检查证实十二指肠球部多发隆起病变患者,并以40例球部基本正常患者作为对照.病变组Hp阳性患者接受三联根除治疗（奥美拉唑20mg、克拉霉素250mg、甲硝唑400mg,每天2次）,疗程7 d,停药后随访6个月后复查胃镜;病变组Hp阴性者接受奥美拉唑20 mg,每天1次治疗,疗程4～6个月,停药后2周复查胃镜.比较2次胃镜检查结果,包括胃镜下隆起病变程度及球部黏膜胃上皮化生等组织学异常,分析Hp感染与上述胃镜下表现及组织学异常关系.结果对照组患者组织学仅部分发现轻度慢性炎症,未发现球部Hp感染.病变组患者Hp检出率为58.1%,胃上皮化生检出率为57.0%.Hp阳性与Hp阴性患者胃镜下隆起病变程度差异无统计学意义（P＞0.05）,但胃上皮化生检出率更高,程度更严重（P＜0.05）.76例患者复查胃镜,根除Hp或奥美拉唑治疗对Hp阳性或阴性患者球部多发隆起病变无明显作用,但根除Hp后6个月,53.6%（15/28）患者胃上皮化生消失,61.0%（25/41）患者绒毛萎缩恢复正常,所有患者淋巴滤泡完全消失（26/26）,杯状细胞减少完全恢复（25/25）,同时炎症和活动性显著减轻（P值均＜0.01）.奥美拉唑疗效不显著.结论十二指肠球部多发隆起病变患者半数以上有Hp感染.Hp感染与隆起病变伴随组织学炎症密切相关,而与其内镜下表现及严重程度无关.根除Hp可使炎症显著减轻,胃上皮化生范围缩小或消退.