Embolization of a ruptured pseudoaneurysm with massive hemorrhage following pancreas transplantation: a case report

Pseudoaneurysm associated with an arterioenteric fistula is rare, but its clinical manifestations may represent a dramatic event that involves diagnostic and therapeutic problems. We report a case of an arterioduodenal fistula related to a ruptured pseudoaneurysm after simultaneous pancreas-kidney transplantation (SPK) with massive gastrointestinal hemorrhage treated by embolization of the Y graft. A 51-year-old man with type I diabetes and end-stage renal disease underwent SPK. No rejection episodes were documented; the patient was discharged with normal pancreatic and renal function. Two months later the patient was readmitted for an episode of massive lower digestive bleeding and hypotension. The Y-graft was embolized in order to obtain a prompt arrest of the bleeding. The procedure was successful and the patient progressively recovered. Once the hypovolemia was completely corrected, the graft was removed. An arterioenteric fistula between donor mesenteric artery and duodenum was confirmed. Few reports exist in the literature regarding the development of a pseudoaneurysm after pancreas transplantation. To our best knowledge only one case of pseudoaneurysm rupture into donor duodenum has been recently published. In our case angiography recognized the site of the pseudoaneurysm and its rupture into donor duodenum. Embolization of the Y-graft appeared the most rapid, simple, and safe approach to obtain the prompt arrest of the massive bleeding. Embolization of the Y-graft may represent a valid option in the presence of life-threatening hemorrhage.     

Massive hemorrhage secondary to metastatic testicular carcinoma

Massive bleeding secondary to metastatic foci of testicular carcinoma is a rare finding. Two cases of metastatic testicular carcinoma in which massive intraabdominal and gastrointestinal hemorrhage occurred are reported. The first patient, who had metastasis to the duodenum and stomach, first underwent surgery because of the concern that chemotherapy might result in rapid tumor necrosis and bowel perforation. The bleeding was controlled, postoperative chemotherapy was administered, and the patient was alive 15 months after chemotherapy. In the second case, in which metastasis was to the liver and lungs, aggressive chemotherapy was begun because of the patient's poor pulmonary status. Three days later, the patient began to hemorrhage. Operative and massive resuscitative measures failed, and the patient died shortly after surgery.     

Jejunal varices with extra hepatic portal vein obstruction: A case report

Introduction and importanceExtrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare.Presentation of caseWe report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices.DiscussionPortal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices.ConclusionJejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.     

Primary aortoduodenal fistula due to septic aortitis.

We report the second case of a primary aortoenteric fistula resulting from septic aortitis with a contained aortic leak into the retroperitoneum and finally erosion into the duodenum. An emergency laparotomy revealed a fistula between the third part of the duodenum and a decompressed sac (false aneurysm) arising from a nonaneurysmal, grossly infected pararenal aorta. The purpose of this report is to present this rare case in detail and to review primary aortoenteric fistulas reported in the English language literature. Most fistulas form in association with an abdominal aortic aneurysm and rarely are due to infection. Only 6% of patients presented with the classic triad of abdominal pain, a palpable mass, and gastrointestinal bleeding. Although 29% of patients presented with massive hemorrhage, adequate time usually existed for surgical treatment of these complications. A patient with ill-defined abdominal pain and fever who suddenly develops a palpable abdominal mass should have an emergency ultrasound or CT scan to exclude the possibility of an infected aortic aneurysm or a contained rupture of an infected nonaneurysmal aorta. If the symptoms are associated with bleeding and the patient is hemodynamically stable, emergent endoscopy should also be performed. If a primary aortoenteric fistula or an aortic pseudoaneurysm is confirmed, emergent surgery should be undertaken to avoid rupture into the bowel or retroperitoneum.     

Primary aortoenteric fistula. Report of a case

Primary aortoenteric fistulas (PAEF) are rare entities associated with a high mortality. Although several causes have been reported, their occurrence is usually due to erosion of an abdominal aortic aneurysm into the intestinal tract. The most common sites for the fistula are the third and fourth portions of duodenum. The classical triad of gastrointestinal hemorrhage, abdominal mass and abdominal or back pain, though highly suggestive for PAEF, is uncommon. The typical bleeding pattern associated with PAEF is characteristically intermittent, starting with a brief "herald bleeding" followed eventually by major gastrointestinal hemorrhage, often with fatal outcome. The pre-operative examinations are often not helpful and can lead to delayed diagnosis and surgery. In a patient with risk factors for atherosclerosis and significant upper gastrointestinal bleeding in the absence of an evident source, PAEF should be suspected. A high index of suspicion of this condition allows correct diagnosis and definitive treatment to be carried out. If PAEF is suspected and the patient is unstable the surgeon should be prepared to skip the preoperative investigations in favour of early surgical exploration. Definitive treatment includes primary duodenal repair and aortic aneurismal resection with graft "in situ" replacement. The authors present a successfully treated case and stress the importance of clinical suspicion in order to achieve correct diagnosis and treatment.     

Massive upper gastrointestinal bleeding due to a ruptured superior mesenteric artery aneurysm duodenum fistula

This case report describes sudden massive upper gastrointestinal bleeding due to a ruptured superior mesenteric artery aneurysm-duodenal fistula following mitral and aortic valvular replacement surgery due to infectious endocarditis. The superior mesenteric artery false aneurysm was diagnosed by computed tomography scanning. The intraoperative findings included a rupture at the trunk of superior mesenteric artery (SMA) and a perforation on the anterior wall of the third portion of the duodenum. The patient was treated by emergency surgery, which consisted of an interposition repair of the SMA with a saphenous vein graft for the superior mesenteric artery and a duodenojejunal Roux-en-Y anastomosis for the perforation of the duodenum. At 30-months follow-up, the patient is alive and well with no abdominal pain and eating a regular diet.     

Evaluation and management of massive lower gastrointestinal hemorrhage.

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.     

Duodenopancreatectomy with conservation of the pylorus

The authors report on their initial experience with pylorus-preserving pancreatoduodenectomy. In the last three years 11 patients with neoplastic disease of the pancreatic head and ampullary region underwent the above mentioned procedure. The surgical technique carefully preserved the blood supply and innervation to the antro-pyloric region and duodenum was transected 2 cm distal to the pylorus. Postoperative mortality was 9%. Postoperative nasogastric suction was required for eight days (median). Long term results are quite good with a satisfactory restoration of intestinal function and a weight gain of 95% of pre-illness weight. At the present time preserving the pylorus appears an usefull modification of Whipple procedure.     

Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.     

术中纤维肠镜对急性小肠大出血诊疗价值

目的探讨纤维结肠镜在不明原因急性小肠大出血手术中的应用价值。方法对我院2002年2009年37例不明原因的急性小肠大出血病人,剖腹探查后行全小肠纤维结肠镜检查．在明确出血原因和部位,结合快速病理检查,给予相应外科治疗。结果全组37例病人均明确了出血原因和部位,其中十二指肠降部以下至Treitz韧带出血13例,空回肠出血24例;病理检查小肠恶性肿瘤出血12例（32．4％）,小肠良性肿瘤出血8例（21．6％）,小肠其他良性疾病17例（45．9％）。小肠壁部分切除术13例．部分小肠切除吻合术13例,根治性小肠切除吻合术11例。全组术后无伤口感染,腹腔内感染和肠瘘等并发症;围手术期病例亦无发生。术后34例获得随访,随访时间为2年,未发现复发出血,有3例小肠恶性肿瘤复发死亡。全组术后无伤口感染,腹腔内感染和肠瘘等并发症;亦无围手术期病例发生。术后34例获得随访,随访时间为2年,未发现复发出血,有3例小肠恶性肿瘤复发死亡。无手术死亡。结论术中纤维结肠镜检查对原因不明的小肠急性大出血具有及时明确出血原因和部位。它在提供治疗方法的选择有重要的价值;特别适用于小肠大出血病情危重者和急诊检查条件差的医院。     

经导管动脉栓塞治疗急性消化道大出血78例

目的探讨急诊血管造影及动脉栓塞对消化道出血的诊治价值。方法对 1988年 5月至 2 0 0 1年 7月临床收治的 78例消化道大出血患者应用Seldinger法经皮股动脉穿刺插管 ,将导管超选至出血动脉 ,经导管注入明胶海绵颗粒 ,共栓塞 86根动脉 ,其中胃左动脉 4根、胃十二指肠动脉2 1根、肠系膜上下动脉分支 5 9根、隔动脉 1根及肝动脉 1根。全部患者随访 1～ 10年。结果技术成功率 10 0 % (86 /86 ) ,立即止血 10 0 % (78/78) ,2 0 5 % (16 /78)复发出血。 78例患者中 71例出现腹痛、4 9例腹胀等轻微合并症。无胃肠道坏死穿孔等严重并发症发生。结论　经导管动脉栓塞治疗急性消化道大出血 ,定位准确、安全有效 ,同时为外科手术争取了时间。     

Upper digestive haemorrhage of a rare cause: benign duodenal schwannoma

The upper gastrointestinal bleeding is a common cause of admission to hospital. Neurogenic tumors of the duodenum are extremely rare and represent an unusual cause of gastrointestinal hemorrhage. The treatment is endoscopic or surgical total excision. In case of ulcerated large tumors situated periampullary pancreaticoduodenectomy (Whipple's or Traverso-Longmire's) represents an efficient solution. In addition, their high index of malignancy justifies this trend. We present a case of schwannoma of the second portion of the duodenum with several episodes of upper GI bleeding treated by Trasverso-Longmire pancreaticoduodenectomy.     

Management of surgical gastrointestinal complications in renal transplant recipients.

Gastrointestinal (GI) complications developed in 19 (7.2%) of 265 patients after renal transplantation, and 3 (16%) patients died. Complications included colon perforations, colonic bleeding, small-bowel infarction, pancreatitis, subphrenic abscess, and upper GI tract bleeding. Ulcers located in the second portion of the duodenum developed in six patients; four of them required operation for massive hemorrhage, which occurred during or immediately after the administration of high-dose methylprednisolone for rejection. However, the association of methylprednisolone and colon perforation was not clear from this report. Early diagnosis and prompt operation for surgical-type GI complications in transplant recipients contribute to a low mortality.     

Obstructive Jaundice Secondary to Primary Duodenal Lymphoma with CMV Duodenitis Causing Upper GI Bleed in Retro-Positive Patient: A Case Report

Gastrointestinal (GI) tract is the most common site of extranodal lymphoma. Primary GI lymphoma constitutes a small amount of all lymphomas. Primary duodenal lymphoma presenting initially with obstructive jaundice is very rare. Primary B-cell lymphoma of the duodenum was shown to be the cause of biliary obstruction in a retropositive male, which was proved by endoscopic biopsy. Histopathology also showed cytomegalovirus inclusion bodies with duodenitis.     

Massive gastrointestinal bleeding caused by a giant gastric inflammatory fibroid polyp: A case report

INTRODUCTION

Inflammatory fibroid polyps (IFPs) are rare and small benign lesions throughout the digestive tract. The most common location is gastric antrum, but rarely at the upper part. Clinical manifestations of IFPs usually include intestinal obstruction, intussusception, abdominal pain, nausea and vomiting, but rare massive digestive tract hemorrhage.

PRESENTATION OF CASE

We describe a rare case presenting with massive gastrointestinal bleeding due to a huge gastric fundus IFP (11 cm). Finally, the patient was treated successfully by the laparoscopic assisted partial gastrectomy (LAPG) and recovered uneventfully. To our knowledge, this is the first reported case presenting with massive alimentary tract hemorrhage due to giant gastric fundus IFP.

DISCUSSION

Giant IFP rarely originates in the gastric fundus, but occasionally results in serious consequence, such as massive gastrointestinal bleeding. It is important to recognize IFP because it responds favorably to operation with no relapse or metastasis.

CONCLUSION

In the differential diagnosis of alimentary hemorrhage of uncertain etiology, gastric IFP should be considered. For huge gastric IFP, laparoscopic therapy is an apt choice.     

Immunoproliferative small intestinal disease (IPSID)

This study describes the frequency, demographics, clinical presentation, endoscopic findings, histopathological features, treatment and outcome of 'Immunoproliferative small intestinal disease' (IPSID). Archives contained a total of 27 cases of IPSID diagnosed and treated over an 18-year period. A M: F ratio of 2.4:1 was seen with a mean and median ages of 28.7 and 25 years. Most patients (68.8%) presented with abdominal pain and diarrhoea. In the majority (62.5%), duodenum was the primary site of involvement. Endoscopy showed polypoidal, raised or flat lesions. Biopsy findings included blunting or flattening of villi with dense plasma cell infiltrate and lymphoepithelial lesions. Twenty-four cases were categorized as stage A and B (benign and intermediate) and three were categorized as stage C (malignant, diffuse large B-cell lymphoma with plasmacytoid features). Stage A and B patients responded well to antibiotic treatment (tetracycline) with regression of the lesions while for stage C patients standard CHOP chemotherapy was administered.     

A case of multiple recurrent intussusceptions due to multiple lymphomatous polyposis associated with diffuse large B-cell lymphoma of gastrointestinal tract in a 15-year-old child: A rare case report

Introduction and ImportanceMultiple lymphomatous polyposis (MLP) is a distinctive and rare entity of primary gastrointestinal (GI) lymphoma characterized by polypoid lymphomatous tissue in long segments of the gut and a strong tendency for spread throughout the GI tract. Although many cases of MLP presenting as intussusceptions in adults have been reported, we report a rare case of multiple recurrent intussusceptions due to MLP associated with high-grade Diffuse Large B-cell lymphoma (DLBCL) of the entire GI tract in a 15-year-old child.Case presentationA 15-year-old child previously operated for acute intestinal obstruction, presented with intermittent abdominal pain, nausea and vomiting. Imaging studies confirmed the diagnosis of multiple small bowel intussusceptions. Patient was treated by exploratory laparotomy and multiple resection anastomosis. Histopathology confirmed the diagnosis of MLP due to DLBCL. The patient received chemotherapy following surgery. So far, at 6 months of follow-up, Patient is doing well.Clinical discussionMalignant tumors of the small intestine are unusual, with non-specific clinical presentation. Although ultrasound (US), CT, FDG-PET/CT and endoscopic evaluation are essential modalities for the diagnosis of intestinal polyposis. Final diagnosis of MLP can only be confirmed after histopathological examination and immunohistochemistry studies. Surgical resection followed by appropriate chemotherapy is the treatment of choice.ConclusionsMLP due to DLBCL has rarely been described in young patients under the age of 18 years. We should keep a high index of suspicion for malignant GI lymphoma in cases of intussusception, especially in older children.     

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.     

Mesocaval shunt for portal hypertensive small bowel bleeding documented with intraoperative enteroscopy

INTRODUCTIONBesides upper gastrointestinal tract, small bowel has also been implicated as a potential source of hemorrhage in patients with portal hypertension.PRESENTATION OF CASEWe report an interesting case of recurrent massive small intestinal bleeding in a patient with portal hypertension secondary to liver cirrhosis treated with a mesocaval shunt. Endoscopic assessment with gastroscopy and colonoscopy failed to identify the source of hemorrhage. An intraoperative enteroscopy was conducted which revealed a diffuse bleeding pattern from the small bowel mucosa.DISCUSSIONAn interposition mesocaval shunt procedure was successfully carried out on an emergency basis that eventually managed to control bleeding.CONCLUSIONIn cases, where a diffuse pattern of hemorrhage exist or non-operative measures fail emergency mesocaval shunting seems to be an efficacious alternative treatment approach for portal hypertension related intestinal bleeding.