空肠Dieulafoy病致消化道出血一例报道并文献复习

Dieulafoy病是由于胃肠道供血动脉分支在进入黏膜后未形成毛细血管,而保持恒定管径,在高压力血流的冲击下血管受到损伤造成的疾病。Dieulafoy病是一种少见的血管畸形,主要发生在胃部,可引起消化道尤其是上消化道出血。小肠部位的Dieulafoy病非常罕见,鲜有报道。本研究报道1例经单气囊小肠镜(SBE)诊断为空肠Dieulafoy溃疡的诊治过程并进行文献复习,以期为临床医生诊治不明原因所致的消化道出血提供参考。     

Intra-operative Total Enteroscopy for the Management of Peutz-Jegher's Syndrome

We present a case of Peutz-Jegher's syndrome in an 18 year old female who was followed for gastrointestinal polyps for 13 years from the age of 5 years. The patient was treated four times with surgical or endoscopic polypectomy for gastrointestinal polyps. At the age of 14 years, a combined surgical and endoscopic approach for the management of Peutz-Jegher's syndrome was carried out. A large polyp of the ileum required enterotomy for its removal, and another smaller polyp of the upper jejunum was identified and removed by intra-operative total enteroscopy via the anus. Intra-operative enteroscopy allows one to identify polyps that would previously have been missed. A more complete polypectomy can be performed using this technique, allowing the patient with Peutz-Jegher's syndrome a longer interval between laparotomies and a reduction in symptoms attributed to polyps.     

Solitary Metastatic Malignant Melanoma of the Small Intestine: Findings Obtained during Intraoperative Enteroscopy

Abstract: A 59-year-old male with an established diagnosis of malignant melanoma of the nasal cavity plus multiple pulmonary metastases was referred to our hospital because of abdominal pain and vomiting. Double-contrast study of the small intestine revealed a filling defect in the middle of the ileum. lntraoperative enteroscopy revealed that the ileal tumor was ulcerated, and that it was covered by ileal mucosa of normal appearance. Because no other lesions were identified within the intestine, the ileal segment with the tumor was surgically removed. The tumor was diagnosed as malignant melanoma with a histology similar to that of nasal mass. The patient has survived for the subsequent 13 months, during which no gastrointestinal symptoms recurred. Our case suggests that metastasis should be included in the differential diagnosis of a single small intestinal tumor. (Dig Endose 1999; 11: 47–51)     

DIAGNOSIS AND TREATMENT OF SMALL BOWEL DISEASES WITH A NEWLY DEVELOPED SINGLE BALLOON ENDOSCOPE

Background: Recent advances in capsule endoscopy (CE) and double balloon endoscopy (DBE) have enabled an endoscopic approach to small bowel diseases. However, CE is simply a diagnostic tool and DBE is fairly complicated to handle. Methods: We developed a single balloon endoscopy (SBE) in cooperation with Olympus Medical Systems. The single balloon enteroscope consists of an endoscope and a splinting tube. In this system, a balloon is attached to the splinting tube, but not to the scope itself. The single‐person insertion method was effective for SBE cases, but two persons were needed for DBE. The patients we examined had undergone upper and lower gastrointestinal endoscopy and were suspected of having small intestinal diseases. We examined a total of 30 cases (nine women, 21 men; range 19–78 years), and carried out a total of 48 examinations. Results: In fifteen cases, the cause of bleeding was diagnosed as either ulcer, angiodysplasia, Crohn's disease, inflammatory polyp, or metastatic cancer, but in eight cases, the cause was not identified. Four obstruction cases comprised ulcers, adhesion, and jejunal volvulus. For treatment, clippings were performed for bleeding in three patients, polypectomy for two, reversal of volvulus for one, and balloon dilation for ilial stenosis in one. The entire small intestine was observed in 71% of patients when the intention was to examine the whole bowel. No complications were encountered. Conclusions: The newly developed SBE is useful for diagnosis and treatment of small bowel diseases.     

Capsule enteroscopy and radiology of the small intestine

In a very few years, the video capsule for small bowel enteroscopy has gained widespread clinical acceptance. It is readily ingested, disposable, and allows for a complete, low-invasive endoscopic examination of the entire mucosa of the small bowel. It is a patient-friendly method and a first-line procedure in the difficult evaluation of obscure gastrointestinal bleeding. It has the highest proven figure of diagnostic sensitivity for detecting lesions of the mucosa, irrespective of aetiology. The limitations of capsule endoscopy include difficulty in localising mucosal lesions anatomically and its restricted use in patients with dysphagia, strictures or motor dysfunction. Strictures, transmural and extra-mural lesions in patients with small bowel Crohn’s disease are evaluated by MRI- enterography and CT-enterography.     

ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients with postsurgical anatomy. We assessed the technical success of performing ERCP with the double balloon enteroscope (DBE) in patients with Roux-en-Y anastomosis.

Methods

This is a prospective evaluation of patients with Roux-en-Y anastomosis who underwent ERCP with the DBE. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to treat the underlying disorder. Complications of ERCP were defined according to standard criteria.

Results

ERCP using the DBE was performed on 17 occasions in 11 patients (10 men; mean age, 59.7 (range, 36–77) years) with Roux-en-Y anastomosis with or without hepaticojejunostomy. Indications for ERCP: biliary obstruction or cholestasis (n = 11). The overall diagnostic success was 82%, and the therapeutic success was 58%. Reasons for failed biliary cannulation included: inability to reach the proximal end of the afferent loop (n = 1), impossibility to advance the wire into the CDB despite adequate insertion of the biliary catheter into the distal CBD (n = 2), and inability to advance the stent over an adequately placed guidewire (n = 1). One major complication occurred (5.8%): perforation of the hepaticojejunostomy in a patient with recurrent choledocolithiasis, which was successfully resolved surgically.

Conclusions

ERCP using the DBE is feasible in patients with complex postsurgical anatomy, permitting diagnostic and therapeutic interventions in 82% and 58% of cases, respectively. Nevertheless, due to the complex anatomy, presence of adhesions, and looping of the usually long limbs complications can occur.     

双气囊小肠镜在胶囊内镜检查阴性小肠疾病诊断中的作用

目的通过双气囊小肠镜对胶囊内镜检查阴性疾病的诊断,探讨胶囊内镜在不同小肠病变的诊断作用。 方法对156例疑诊为小肠疾病患者行胶囊内镜检查,随后对87例阴性患者进一步行双气囊小肠镜检查。 结果156例患者中69例胶囊内镜检查阳性,其中不明原因消化道出血52例,有警报症状和体征17例,总体阳性诊断率44．2％（69／156）,检出的主要病变有：小肠炎症（粘膜糜烂、溃疡）32例,小肠肿瘤24例,小肠血管发育不良9例,小肠憩室1例,白塞病2例,小肠结核钙化灶1例。87例胶囊内镜检查阴性患者经双气囊小肠镜检查额外检出小肠病变12例,对于胶囊内镜检查阴性患者双气囊小肠镜诊断率为13．8％（12／87）,其中不明原因消化道出血9例,有警报症状和体征3例,检出病变有：小肠憩室5例,小肠血管发育不良4例,小肠溃疡1例,小肠肿瘤2例。 结论胶囊内镜对于表现为隆起性、浸润性、溃疡和多发性病灶小肠疾病具有较高的的诊断能力,但对小肠憩室和病变局限病灶较小的小肠血管发育异常者诊断能力有限,与双气囊小肠镜有效结合运用能大为提高小肠疾病的诊断率和准确性。