Endoscopic treatment of duodenal obstruction due to a gallstone ("Bouveret's syndrome")

We describe the case of a 73-year-old woman was admitted to our hospital because of constant abdominal pain in her right upper quadrant and postprandial bloating and fullness for several months. On abdominal x-ray the extrahepatic bile ducts were positive for gas and on ultrasound a gallstone in the duodenum was suspected whereas the gallbladder was not detectable. An upper gastrointestinal endoscopy confirmed a large gallstone that was impacted in the duodenal bulb ("Bouveret's syndrome"). The gallstone was fragmented employing mechanical lithotripsy and removed. Duodenoscopy revealed a cholecystoduodenal fistula and a second gallstone in the gallbladder. The patient underwent open cholecystectomy with closure of the cholecystoduodenal fistula and made a full recovery. We conclude that in patients with upper abdominal pain and pneumobilia on x-ray the unusual complication of cholelithiasis with an impacted gallstone in the duodenal bulb should be suspected. In those rare cases of Bouveret's syndrome endoscopic removal of the gallstone should be attempted to minimize the necessary surgical procedure whenever possible.     

USEFULNESS OF ENDOSCOPIC TREATMENT FOR DUODENAL ADENOMA

In recent years, due to the increasing prevalence of upper gastrointestinal endoscopy, there have been an increasing number of reports on duodenal adenoma and early stage cancer. However, endoscopic techniques for the resection of duodenal adenomas are difficult, due to the anatomical features of the duodenum, and the long distance to the lesion. There have only been a few reports on the use of endoscopic techniques for duodenal adenomas compared to those focused on the stomach and large intestine. For duodenal adenomas, we used a conventional endoscope for lesions proximal to the major duodenal papilla, and a short‐type double balloon endoscope for lesions distal to the papilla. The en‐bloc resection rate was 93.8%. There was only one case of microperforation. Endoscopic manipulation is considered difficult in the deep areas of the duodenum, but double balloon endoscopy enabled stable manipulation and successful resection of the tumor in the majority of cases.     

Recurrent gastrointestinal Henoch-Sch?nlein purpura.

A 7-year-old boy was seen for severe abdominal pain, vomiting, and a 2.0-kg weight loss of 2 weeks duration. Stools were Hemoccult positive. Upper gastrointestinal (UGI) endoscopy showed multiple, raised red lesions in the duodenal bulb and descending duodenum. Although the patient did not have the typical cutaneous eruption, other findings such as acute onset of abdominal pain in a previously healthy boy, absence of infectious or surgical lesions, and more importantly endoscopic changes seen typically in the descending duodenum, led to the likely diagnosis of Henoch-Sch?nlein purpura (HSP). The patient was treated with prednisone and the duodenal lesions resolved. The diagnosis of HSP was confirmed 24 weeks after the initial symptom when he developed a palpable purpuric rash over both legs. Thirteen months following the initial symptoms and 6 months after the onset of rash, severe abdominal pain with epigastric tenderness recurred and stools were Hemoccult positive. UGI endoscopy showed multiple, raised red lesions in the descending duodenum as seen earlier. The patient was diagnosed with recurrent HSP. This presentation is atypical because of the abnormally long interval between the onset of abdominal pain and the appearance of the skin rash, and unique because of the endoscopically demonstrated recurrent gastrointestinal lesions.     

Endoscopic ultrasound-guided treatment of bleeding duodenal varix

A 35-year-old man presented with recurrence of upper gastrointestinal bleed after eradication of esophageal varices. Upper gastrointestinal endoscopy revealed submucosal lesion in the duodenum and endoscopic ultrasound (EUS) demonstrated it to be a duodenal varix. Cyanoacrylate glue was injected into the duodenal varix and successful obliteration of the duodenal varix was demonstrated on a follow up EUS.     

Duodenal diverticulum complicated by duodenal inflammation and obstruction secondary to the use of the NSAID diclofenac

In one patient, upper abdominal symptoms developed 6 months after the start of diclofenac. At upper gastrointestinal endoscopy duodenal stenosis was shown next to a large diverticulum containing non-dissolved tablets in the third part of the duodenum. As there was no improvement with medical treatment, resection of the diverticulum and stenosis with primary end-to-end anastomosis was performed. Apart from persistent activity of rheumatoid arthritis the patient has been well since. The possible gastrointestinal side-effects of nonsteroidal antiinflammatory drugs in patients with duodenal diverticula are discussed.     

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.     

十二指肠球部及降部隆起性病变的内镜分析及临床意义

目的通过对十二指肠球部及降部的隆起性病变的内镜分析,提高人们对该病变的认识。方法经电子胃镜、十二指肠镜、超声内镜、ERCP等检查方法,共检出十二指肠球部及降部的隆起性病变1 187例,对其进行内镜分析。结果本组十二指肠球部及降部隆起性病变共1 187例,其中息肉981例,恶性肿瘤69例,间质瘤53例,异位胰腺31例,囊肿27例,脂肪瘤26例,所占比例分别为82.65%、5.81%、4.47%、2.61%、2.27%、2.19%。981例息肉中,经病理证实肿瘤性息肉137例,占13.97%(137/981)。60 748例上消化道内镜检查中恶性肿瘤69例,其发生率为0.11%(69/60 748)。结论十二指肠球部及降部隆起性病变中息肉最为常见,其中肿瘤性息肉所占比例远高于文献报道,恶性肿瘤的发生率也较以前增加,人们应提高对十二指肠球部及降部隆起性病变的警惕。     

Evaluation of duodenal hypersensitivity induced by duodenal acidification using transnasal endoscopy

Background and Aim: Although duodenal hypersensitivity has been suggested as one of the causes of functional dyspepsia (FD), a practical method to clarify this has not yet been established. The aim of this study was to evaluate whether patients with FD have duodenal hypersensitivity to acid, using transnasal endoscopy. Methods: In all, 44 patients with FD and 16 healthy volunteers were enrolled, and all the subjects received transnasal endoscopy in the morning after overnight fasting. After ordinary transnasal endoscopy, an infusion tube was introduced into the duodenal bulb by transnasal endoscopy and acid (20 mL, 0.1 N HCl, 20 mL/min, 36.5°C) was injected via the infusion tube. The severity of 12 symptoms was assessed by each subject using a 100‐mm visual analogue scale. The maximum severity scale was defined as the maximum score of the symptom severity scale. The total score was defined as the aggregate score of the maximum severity scale of the 12 symptoms. The maximum severity scales and the total scores between patients with FD and healthy volunteers were evaluated. Results: The maximum severity scales of nine symptoms increased significantly more after acid infusion in patients with FD than in healthy volunteers (P < 0.05). There were significant differences in the total scores (patients with FD vs healthy volunteers 233.8 ± 37.8 vs 63.9 ± 14.6, mean ± standard error of the mean, P < 0.001). Conclusions: Duodenal acidification using transnasal endoscopy enabled the evaluation of duodenal hypersensitivity to acid in healthy volunteers and patients with FD.     

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.     

原发性十二指肠肿瘤37例临床分析

目的探讨原发性十二指肠肿瘤(PDT)的临床表现、病理特征和诊断方法,总结经验,以减少误诊。方法回顾分析我院2005年1月-2010年12月收治的37例PDT的临床资料。结果本组病例常见症状表现为上腹痛、黄疸、发热、呕吐、消化道出血、纳差、消瘦等。肿瘤好发部位以十二指肠降部尤其是乳头周围居多,占62.1%,病理以腺癌为主,占64.9%。各种检查方法确诊率分别是胃镜44.0%、GI 40.0%、CT 56.3%、MRI+MRCP 41.7%、B超16.0%、ERCP 66.7%、超声内镜100%。29例行手术联合化疗,5例化疗加ERCP支架术,2例动脉血管造影下止血、化疗。结论 PDT以恶性肿瘤为主,早期症状隐匿,误诊率高,诊断首选内镜检查,联合GI、CT等检查可提高检出率,超声内镜对黏膜下肿瘤诊断价值高,胰、十二指肠切除是主要治疗手段。     

Hypotonic duodenoscopy

Inducing duodenal hypotonia by the intravenous injection of propantheline bromide is a simple, safe procedure that will permit this organ to be visualized adequately by endoscopy. Twenty-five consecutive patients with suspected duodenal pathology received an intravenous injection of propantheline at the time the pylorus was being viewed through the endoscope. Immediately after the injection, the pylorus dilated and the endoscope was passed easily into the duodenal bulb, where good visualization was achieved. A small bulb syringe attached to the air channel of the endoscope and gentle insufflation of air permitted good visualization of the second portion of duodenum. While the propantheline method is not necessary in all patients undergoing duodenoscopy, those in whom it is difficult to pass the endoscope through the pylorus or in whom antroduodenal motility precludes adequate examination, injection of the antispasmodic provides one easy, safe method for examining the duodenum by duodenoscopy.     

Case report: duodenal stromal tumor

Tumors of the small intestine are rare lesions, but they should be kept in mind as possible causes of gastrointestinal symptoms. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract. A 78 year-old woman complaining of abdominal pain, nausea and vomiting after meal and weight loss for three months was admitted to our clinic. On physical examination, there was only epigastric tenderness. No mass was palpated. She was anemic and total protein and albumin levels were low. Other laboratory tests were normal. A 9.0 x 7.5 cm heterogeneous mass was detected on the abdominal computerized tomography scan. Endoscopy confirmed a polypoid and vegetative mass in the second part of the duodenum. Histopathological diagnosis of endoscopic biopsy was gastrointestinal stromal tumor. Pancreaticoduodenectomy was performed. On the 11th postoperative day, relaparotomy was performed due to biliary leakage from the subhepatic drain. Biliary leakage was from the choledochojejunostomy. Choledochojejunostomy and pancreaticojejunostomy were revised. She was discharged on the postoperative 25th day. Histopathological examination of the resection specimen revealed duodenal stromal tumor. Although stromal tumors are relatively rare in the duodenum, in the case of upper gastrointestinal obstruction and anemia, this type of tumors should be considered in differential diagnosis.     

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.     

A case of a duodenal gastrointestinal stromal tumor diagnosed with the aid of diffusion-weighted magnetic resonance imaging

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of gastrointestinal tract, and bleeding is among the primary symptoms. If the tumor is located in the small intestine, diagnosis might be difficult because of its inaccessibility by endoscope. This report presents a case of duodenal GIST diagnosed with the aid of diffusion-weighted (DW) magnetic resonance imaging (MRI). A 66-year-old male was admitted to the hospital because of shortness of breath and melena. The patient demonstrated marked anemia. Esophagogastroduodenoscopy and colonoscopy revealed no involvement of the mucosa of the gastrointestinal tract in regard to the observed bleeding. Thereafter, computed tomography was done and showed a tumorous lesion 4.2 cm in diameter located around the ligament of Treitz. The area showed significant high intensity by DW-MRI, strongly suggesting malignant character. Examination with a long endoscope demonstrated a large submucosal tumor with wide ulceration located at the third portion of the duodenum. The biopsy sample contained spindle-shaped cells that were positive for CD34 and c-kit on histochemistry, and the tumor was diagnosed as GIST. The patient underwent surgery and survived for 16 months without any recurrence.     

Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: A case report

Intramural duodenal hematoma (IDH) is a rare complication following endoscopic retrograde cholangiopancreatography (ERCP). Blunt damage caused by the endoscope or an accessory has been suggested as the main reason for IDH. Surgical treatment of isolated duodenal hematoma after blunt trauma is traditionally reserved for rare cases of perforation or persistent symptoms despite conservative management. Typical clinical symptoms of IDH include abdominal pain and vomiting. Diagnosis of IDH can be confirmed by imaging techniques, such as magnetic resonance imaging or computed tomography and upper gastrointestinal endoscopy. Duodenal hematoma is mainly treated by drainage, which includes open surgery drainage and percutaneous transhepatic cholangial drainage, both causing great trauma. Here we present a case of massive IDH following ERCP, which was successfully managed by minimally invasive management: intranasal hematoma aspiration combined with needle knife opening under a duodenoscope.     

An elderly woman with duodenal perforation difficulty diagnose

An 86-year-old woman was referred with acute epigastric pain. She had tenderness, but no muscular guarding of the epigastric lesion. Abdominal ultrasound showed a gallstone with a normal gallbladder wall and no ascites. The white blood cell count was 11,600/mm(3), but she was negative for C-reactive protein (CRP). An upper gastrointestinal tract endoscopic examination revealed only edema of the duodenal mucosa. Although H2-receptor antagonists were given, she had to be admitted due to chills and high fever. While the abdominal symptoms did not change, the CRP concentration became 14.79mg/dl. While plain abdominal X-ray did not show an abnormal gas pattern, subsequent abdominal CT examination showed air and fluid collection around the second portion of the duodenum. We diagnosed duodenal perforation and prepared for emergency operation. However, her general condition had markedly deteriorated during the hours. Laparotomy revealed a free purulent fluid around second portion of the duodenum caused by perforation of a duodenal diverticulum. The patient gradually recovered and was discharged after 58 days. Since a duodenal perforation in an elderly patient is difficult to diagnose early in spite of serious illness, abdominal CT should be encouraged.     

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.     

Clinical results of observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope

Background and Aim: Esophagogastroduodenoscopy through the oral cavity of patients who have undergone percutaneous endoscopic gastrostomy (PEG) causes some distress and puts these patients at risk of aspiration pneumonia. The aim of this study was to evaluate results for the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope. Methods: The study subjects were 43 patients, who underwent exchange of a PEG button or tube, 20‐French or more in diameter. After PEG buttons or tubes were extracted from the gastrostomy tract, an ultrathin endoscope was inserted through the gastrostomy tract. The stomach and the duodenal bulb were observed and the esophagus was observed in retrograde passage. A new PEG button or tube was then inserted. The rate of successful insertion into the esophagus and duodenal bulb, the observation of the gastrostomy site in retroversion in the stomach, and the endoscopic findings were analyzed. Results: Ninety‐nine examinations were carried out. The esophagus could be observed in 95 (96.0%), the duodenum in 92 (92.9%) and the gastrostomy site in the stomach in all. Gastric polyps were detected in four patients, gastric erosions in two, reflux esophagitis in two, polypoid lesion at the gastrostomy tract in two, gastric ulcer scar in one, duodenal ulcer scar in one, early gastric cancer in one and recurrent esophageal cancer in one. Neither discomfort nor complications occurred during transgastrostomic endoscopy. Conclusions: Observation of the upper gastrointestinal tract by transgastrostomic endoscopy using an ultrathin endoscope during a gastrostomy button or tube replacement may be useful and safe.     

Case of intrahepatic cholangiocarcinoma drained through a fistula of the duodenal bulb

A 72-year-old woman presented with epigastric discomfort. A low density tumor was found in the hilum and left liver by CT. Since she complained epigastralgia, upper gastrointestinal endoscopy was performed, showing an ulcer in the duodenal bulb, with poorly-differentiated adenocarcinoma seen on a biopsy specimen from the edge of the ulcer. After admission, poorly-differentiated adenocarcinoma cells were also obtained with ultrasound guided aspiration cytology of the liver tumor. We diagnosed intrahepatic cholangiocarcinoma (IHC), and treated with gemcitabine. During chemotherapy, the duodenal ulcer became a fistula, and the liver tumor diminished with bubbles inside it. It was suggested that liquid material of IHC, such as necrotic tissue and mucin, drained to the duodenal bulb during chemotherapy.     

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.