Acute radiological investigation of oesophagus and stomach in the event of massive upper gastro-intestinal tract bleeding.

Acute radiological investigation of the oesophagus, stomach and duodenum is a routine in patients admitted to the first surgical department of Kommunehospitalet, Copenhagen, with upper gastro-intestinal tract hemorrhage. In the period 1969-1972, 294 patients were admitted with hematemesis and/or melena. The acute radiological study was undertaken in 190 of these patients (65%). Whenever possible, confirmation of the acute primary radiological diagnosis was sought at acute operation, subsequent elective operation, by repeated radiological study, by gastroscopy, or at post mortem. 19 acute investigations were inadequate, and in a further 20 patients no studies subsequent to the acute study were made. There remain 151 patients, and the primary diagnosis could be confirmed in 111 (74%). 45 patients underwent acute operation, and primary diagnosis was confirmed in 66%. The most frequent primary diagnosis was duodenal ulcer (78 of 151 patients), which was verified in 63 instances (81%). In 8% of these patients subsequent definitive diagnosis of gastric ulcer was made, and in 11% no cause of bleeding could be demonstrated. Primary diagnosis of gastric ulcer in 28 patients could be confirmed in 85%. Primary diagnosis of oesophageal varices was made in 9 patients and confirmed in 7 (78%). One patient had a carcinoma of the stomach, and this was also the acute radiological diagnosis. In one patient primary diagnosis of oesophageal ulcer was made, but this could not be confirmed. In 34 patients the acute study failed to point the cause of bleeding, and in 50% of these patients subsequent examination was also non-productive. 26% subsequently evidenced duodenal ulcer; 11% gastric ulcer; 6% carcinoma of the stomach; 3% oesophageal varices; and 3%--one patient--a bleeding vessel in the fundus of the stomach. The acute radiological study was complication free. The place of the study in acute diagnosis of the patient with upper gastro-intestinal tract bleeding is discussed.     

Right common iliac arterio-intestinal fistula caused by tubercular peritonitis: Report of a case

A 59-year-old female was admitted with massive hematemesis and melena. A hematological examination revealed that the red blood cell count was 1.31×10⁶/mm³, Hb 3.4 g/dl, and Hct 12%. No source of bleeding was found by an emergency endoscopic examination of the esophagus, stomach and duodenum, or by superior mesenteric angiography. At laparotomy a right common iliac arterio-intestinal fistula was found. The microscopic examination of this part of the ileum, including the fistula, revealed the presence of tubercular peritonitis. An extra-anatomic bypass graft using a prosthetic graft was performed between the left and right femoral arteries because reconstruction of the right common iliac artery was impossible.     

Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma

We report 3 cases in which duodenal metastases from renal cell carcinoma caused massive upper gastrointestinal bleeding. In 2 patients the initial symptom was melena and 1 experienced hematobilia. In 2 patients the diagnosis was not suspected until a hypervascular mass was seen on arteriography and the bleeding was controlled by embolization of the gastroduodenal artery. In the third patient an aorto-enteric fistula was suspected on contrast-enhanced computerized tomography but arteriography showed hypervascular metastases in the duodenum.     

Primäre aortoduodenale Fistel als Spätkomplikation nach paraaortaler Radiatio Ein Fallbericht

Primary aortoenteric fistulae (AEFs) are rare vascular entities. More than 75% of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Atherosclerosis, leading to formation of an aortic aneurysm, remains the most common etiology, accounting for more than 3/4 of the cases reported. Primary aortoenteric fistulae following radiotherapy are rare. The case of a 49-year-old man with aortoduodenal fistula 22 years after para-aortic radiation is presented. In November 1997, the patient suddenly developed hematemesis and melena. Endoscopy suggested the presence of an ulcus but no definitive bleeding source could be seen. Bleeding stopped spontaneously. Six hours later he developed massive hematemesis and was transferred to our department. An emergency operation was performed. We found an aorto-duodenal fistula in the third portion of the duodenum without an aortic aneurysm. We directly sutured the aortic wall laceration and resected the third and fourth part of the duodenum. Histology revealed typical signs of radiation damage. The patient is alive and well 2 years after surgery. To our knowledge, this is the sixth case of a primary aorto-duodenal fistula following radiotherapy ever to be reported in world literature.     

Large gangliocytic paraganglioma of the duodenum: A rare entity

Gangliocytic paragangliomas are rare tumors that almost exclusively occur within the second portion of the duodenum. Although these tumors generally have a benign clinical course, they have the potential to recur or metastasize to regional lymph nodes. The case report presented here describes a 57-year-old female patient with melena, progressive asthenia, anemia, and a mass in the second-third portion of the duodenum that was treated by local excision. The patient was diagnosed with a friable bleeding tumor. The histologic analysis showed that the tumor was a 4 cm gangliocytic paraganglioma without a malignant cell pattern. In the absence of local invasion or distant metastasis, endoscopic resection represents a feasible, curative therapy. Although endoscopic polypectomy is currently considered the treatment of choice, it is not recommended if the size of the tumor is > 3 cm and/or there is active or recent bleeding. Patients diagnosed with a gangliocytic paraganglioma should be closely followed-up for possible local recurrence.     

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.     

Gallstone obstructing the duodenum. Report of two cases of Bouveret’s syndrome

Bouveret’s syndrome is the obstruction of the duodenum due to a gallstone. It is a rare condition, known for over a century that continues to confound emergency room physicians and surgeons to this day. We present two cases of Bouveret’s syndrome. The first is a 63-year-old female patient with a 4 cm gallstone obstructing the third part of the duodenum. The patient underwent prompt surgery and the gallstone was removed through the jejunum. The other patient’s course, an 88–year-old male, was more complicated. After fluid resuscitation and an attempt at endoscopic removal, a gallstone obstructing the first part of the duodenum was surgically removed through a gastrotomy. Both patients recovered fully and were discharged. Both cases presented many dilemmas and challenges from the diagnosis to the final management.     

Primary aortoduodenal fistula complicated by abdominal aortic aneurysm

A 74-year-old male patient was operated in Vakif Gureba Hospital for aortoduodenal fistula developing from abdominal aortic aneurysm. The patient was diagnosed as abdominal aortic aneurysm after physical examination and computed tomography in another center. Appearing of melena and hematemesis gastroduodenoscopy and radionuclide scanning was performed as diagnosis. After 6 days gastrointestinal bleeding recurred in massive haemorrhage and the patient was operated with a diagnosis of aortoenteric fistula as emergency. A midline laparotomy was performed. There was a fistula between infrarenal abdominal aortic aneurysm (with diameter 8x10 cm) and the 3rd portion of the duodenum. The duodenum was resected segmental and the fistula was disconnected. Following aneurysmotomy a prosthetic graft was placed in the aortobiiliac position. The patient was discharged at the 42nd postoperative day. Primary aortoenteric fistula is a very rare consequence of untreated abdominal aortic aneurysm. The segments of intestine most frequently involved in aortoenteric fistula are the 3rd and 4th portions of the duodenum. Clinical presentation is recurrent episodes of gross gastrointestinal haemorrhage. These cases have high mortality and morbidity unless evaluated as quickly as possible and appropriate surgical intervention performed.     

Nonmarginal-donor duodenal ulcers caused by rejection after simultaneous pancreas and kidney transplantation: a case report

Objective

Pancreas transplantation has been associated with the highest surgical complication rate among routinely performed organ transplant procedures. Complications can be caused not only from the pancreas itself but also from the simultaneously transplanted duodenum: gastrointestinal bleeding, duodenal ulcer, pseudoaneurysm, arterioenteric fistula, and severe rejection. Herein we report a patient who underwent simultaneous pancreas-kidney transplantation (SPKT) and experienced a duodenal perforation because of rejection.

Methods

The 60-year-old man with insulin-dependent diabetes underwent SPKT with enteric drainage. At 15 days there after he displayed melena.

Results

We suspected it to be caused by rejection and ischemic changes. We slightly increased the doses, of tacrolimus and methylprednisolone. But 17 days after SPKT, the ulcer perforated, requiring a repair operation and increased dose of mycophenolate mofetil. However, the ulcers perforated repeatedly, requiring 4 repair operations. Unfortunately the patient developed pneumonia that mitigated continues repairs or rejection therapies, so we expated the duodenum and pancreas but saved the kidney. The pathologic findings showed the ulcer to have been caused by severe rejection. Despite those episodes, the patient was weaned from hemodialysis.

Conclusions

Perforation of the transplanted duodenum is one of the most difficult complications among SPKT patients. This potentially lethal complication may be caused by mucosal rejection, ischemic changes, and the exocrine output from the pancreatic graft.     

Gallbladder ulcer erosion into the cystic artery: a rare cause ofupper gastro-intestinal bleeding Case report

Intra luminal gallbladder bleeding is a rare cause of hemobilia that results in upper gastro-intestinal bleeding. In this case report we present a patient who presented with melena and eventually was diagnosed as bleeding from an ulcer in the gallbladder which was induced by gallstones and eroded into the cystic artery. Surgery revealed perforation of gallbladder which was the result of a pressure sore induced by a second gallstone.     

Intermittent activity-induced hemobilia caused by liver hemangioma

BACKGROUND: Intestinal bleeding of unknown origin can lead to a difficult workup. Abdominal colic, melena/hematemesis, and jaundice represent the pathognomonic triad for hemobilia, but clinical presentation and etiology of this entity are varying. Seldom all of these symptoms are present, and rarely does hemobilia cause melena or hematemesis. Often the correct diagnosis is missed. Patients frequently have a long history of complaints and inadequate therapy. CASE REPORT: We report on a patient who complained of repeated, severe epigastric pain and massive melena induced by exercise activity. After 2 years of complaints and an unnecessary operation, ultrasound detected a liver hemangioma. It was supposed that the hemangioma was causing hemobilia during strenuous physical activity. The patient underwent a partial liver resection to eliminate the hemangioma. All complaints resolved, and the patient remained asymptomatic postoperatively. CONCLUSIONS: Physicians should be aware of hemobilia as a rare cause of upper gastrointestinal bleeding, especially if esophagogastroduodenoscopy cannot demonstrate any bleeding source. Ultrasound is able to visualize many diseases leading to hemobilia and should be integrated into the early workup of unclear intestinal bleedings.     

Primäre und sekundäre aortoenterale Fistel in kurzem zeitlichen Abstand

We performed an emergency laparotomy on a 67-year-old male patient with a known small abdominal aortic aneurysm, who had massive bleeding in the upper gastro-intestinal region. After opening the retroperitoneum a primary aorto-enteric fistula was found between the aneurysm and the descending part of the duodenum. After the implantation of a tube graft and BII-resection there was an uncomplicated post-opera- tive course. Two years later the patient has to be readmitted with tarry stool and a new gastro-intestinal bleeding accompanied by a drop of the haemoglobin value. A further emergency laparotomy shows a secondary aorto-enteric fistula in the region of the distal anastomosis, making it necessary to explant the prosthesis and construct an extra-anatomical bypass. In this case, too, there was a satisfactory post-operative course without complications. In literature no other case of a patient suffering from a primary and secondary aorto-enteric fistula in that short interval was found who in both cases had an uncomplicated postoperative course.     

Duodenal Obstruction by Gallstone in the Absence of Cholecystoenteric Fistula,an Unusual Complication of Total Gastrectomy: Report of a Case

We present a case of gallstone obstruction of the duodenum in a post total gastrectomy patient without a cholecystoenteric fistula. The patient presented with epigastric pain. On abdominal computed tomography and percutaneous transhepatic choangiography imaging, the patient was found to have duodenal obstruction. At operation, the cause of obstruction was found to be a large gallstone in the third part of the duodenum, but there was no associated cholecystoenteric fistula. This report is the first to describe duodenal obstruction by a gallstone formed within the duodenum, in a patient post total gastrectomy with Roux-en-Y reconstruction, and highlights what can be a difficult diagnosis in such patients.     

医源性胆总管远段损伤的临床分析

目的探讨医源性胆总管远段损伤早期诊断及腹膜后严重感染的预防。方法 回顾分析1990年至2004年间处理的17例医源性胆总管远段损伤患者的临床资料。结果 17例患者中,15例为术中损伤,2例为ERCP切开取石所致。术中发现胆管损伤14例,术中未及时发现者1例。胆管损伤前行B超检查16例,MRCP检查2例,6例在胆道探查后行胆道镜检查。10例行胆总管穿孔修补加T管引流,2例行Oddi括约肌切开成形术,2例行胆肠吻合术,1例行十二指肠及胆管修补腹膜后引流术。胆管损伤后术中表现为胆道探子异位于胆管壁外,胆道镜见到胆管远段有2个或多个孔隙,经T管注水见腹膜后水肿和积液,注入美蓝出现腹膜后蓝染。损伤后临床表现为腹胀、发热、腰背胀痛、休克等。治愈13例,术后并发症包括十二指肠瘘1例,切口感染1例,死亡4例,其中3例死于感染性休克,1例死于胃切除术后再出血。结论 胆道远段损伤术后表现缺乏特异性,对可疑患者应作CT检查,早期诊断胆总管下段损伤并进行及时治疗可以取得较好效果。术前完善的影像学检查及在胆道探查前进行胆道镜检查有可能减少胆总管远段损伤。     

八例十二指肠良性肿瘤的诊治体会

目的 探讨十二指肠良性肿瘤的诊断及治疗方法。方法 回顾性分析１９８９年２月～２０００年３月和术切除,并经病理证实的８例十二指肠良性肿瘤。结果 Ｂｒｕｎｎｅｒ腺瘤３例,平滑肌瘤２例,间质瘤２例,脂肪瘤１例。十二指肠良性肿瘤的临床状态多不典型,早期诊断困难。患者均表现为上消化道出血,不同程度的贫血,这对进一步检查有提示意义。上消化道造影及胃十二指肠镜检查是主要的辅助诊断方法。本组患者均行外科手术切除肿     

Inflammatory fibroid polyps of the duodenum: a review of the literature

BACKGROUND/AIM: An inflammatory fibroid polyp (IFP) is a rare benign submucosal gastro-intestinal lesion with an uncertain origin and natural history. An IFP was first described in the stomach and is rare in the duodenum. Presenting signs and symptoms vary according to anatomical site. This systematic literature review was prompted by the recent presentation of a patient with biliary obstruction caused by a duodenal IFP. METHODS: A review of all duodenal IFPs identified in the PubMed database from 1971 onwards is presented within the context of what is known about the lesion at other gastro-intestinal sites. RESULTS: Of approximately 1,000 IFP cases identified, 70% were of gastric origin, and fewer than 1% occurred in the duodenum. Duodenal IFPs typically present with non-specific features, and no pre-operative diagnoses of lesions at this site have been made. Microscopy reveals spindle-shaped cells, prominent capillaries, and an inflammatory cell filtrate. Immunohistochemistry shows the lesions to be CD34 and vimentin positive, but CD117, S100, and factor VIII negative. Local recurrence is most unusual following complete resection. CONCLUSIONS: This rare benign entity in the duodenum should be included in the differential diagnosis of all peripancreatic masses. The advent of endoscopic ultrasound may allow pre-operative diagnosis of the lesion in the duodenum, enabling local resection and potentially avoiding unnecessary pancreatoduodenectomy.     

Aorto-enteric fistulas. Report of 12 cases

Aorto-enteric fistulae are primary or secondary. The primary variant is the rupture of an aortic aneurysm into the gastro-intestinal tract. The secondary fistulae are complications of reconstructive aortic surgery. We report our experience with 12 aorto-enteric fistulae (2 primary and 10 secondary) treated from 1971 to 1989. All patients presented with gastro-intestinal bleeding and the fistula was to the duodenum (3), jejunum (8) or appendix (1). In the secondary patients, a mean of 5 years had elapsed since the aortic replacement. In addition to closure of the enteric defect, three types of treatment were applied: excision of the old prosthesis, infrarenal aortic closure and axillo-bifemoral bypass (5); insertion of a new graft (3) and local repair (3). A patient was not treated due to a triple carcinoma. Hospital mortality was 50%. We conclude that the diagnosis of aortoenteric fistula is difficult and that the mortality is high. The operative management remains imperfect and a subject of controversy. Prevention and early detection request more attention than in the past.     

In Situ Repair of a Secondary Aortoappendiceal Fistula with a Rifampin-Bonded Dacron Graft

Secondary aortoenteric fistulas remain challenging diagnostic and therapeutic problems. Although the duodenum is most frequently involved, other intestinal segments are possible sites for fistulization. We report here a case of graft-appendiceal fistula revealed by recurrent gastrointestinal bleeding 11 years after abdominal aortic aneurysm replacement. The preoperative diagnosis was not achieved by endoscopy or imaging assessment. Despite recommended principles of total graft excision and extraanatomic bypass, appendectomy and in situ rifampin-bonded graft reconstruction were performed because of the advanced age and poor arterial runoff. The postoperative course was uneventful and the patient remains well 17 months after operation.     

Bleeding after endoscopic sphincterotomy.

A total of 194 patients who underwent 235 endoscopic sphincterotomies for common bile duct (CBD) stones were reviewed with respect to bleeding after the procedure. Evidence of bleeding was found in 21, but was occult in 7. Of the 14 patients with overt bleeding, 6 required operation and 2 died. There was also one death prior to surgery. Early consultation with surgical colleagues, observance of the usual surgical criteria for upper gastro-intestinal haemorrhage and the use of non-absorbable suture material to achieve haemostasis may reduce the morbidity and mortality of this complication of endoscopic sphincterotomy.     

Cytomegalovirus Graft Duodenitis Diagnosed by Transanal Double-Balloon Endoscopy Technique in an Enteric-Drained Pancreas Transplant Recipient: A Case Report

Duodenal graft complications are not uncommon after pancreas transplant (PTx). Although direct visualization and biopsy of the duodenal graft are important for accurate diagnosis and management, endoscopic access is often limited in cases of enteric-drained PTx. Herein, we present a case of cytomegalovirus (CMV) graft duodenitis that was successfully diagnosed by transanal endoscopy using the double-balloon technique. The patient was a 54-year-old woman who underwent simultaneous pancreas and kidney transplant for type 1 diabetes mellitus and end-stage kidney disease. Enteric drainage was established by anastomosing the graft duodenum to her ileum. One month after the transplant, she developed fever and complained of lower abdominal pain. Graft duodenitis was suspected by laboratory test and imaging study results. Transanal double-balloon endoscopy was performed, and the biopsy specimen of the mucosa of the graft duodenum revealed CMV duodenitis without histopathologic findings of acute rejection. The postendoscopy course was uneventful. Treatment with ganciclovir was promptly initiated, and the CMV duodenitis was resolved with good function of the pancreas graft. In patients who undergo PTx with establishment of exocrine drainage by enteroanastomosis to the recipient ileum, transanal double-balloon endoscopy might be a feasible and safe technique for the surveillance of duodenal graft complications, including CMV duodenitis.