Maternal hyperthyroidism increases the prevalence of foregut atresias in fetal rats exposed to adriamycin.

PURPOSE: Gastrointestinal malformations such as esophageal atresia with tracheoesophageal fistula (EA/TEF) and duodenal atresia (DA) have been reported in infants born to hyperthyroid mothers or with congenital hypothyroidism. The present study aimed to test whether maternal thyroid status during embryonic foregut division has any influence on the prevalence of EA/TEF and DA in an accepted rat model of these malformations. METHODS: Pregnant rats received either vehicle or 1.75 mg/kg i.p. adriamycin on gestational days 7, 8 and 9. Transient maternal hyper or hypothyroidism was induced by oral administration of levothyroxine (LT4, 50 µg/kg/day) or propylthiouracil (PTU, 2 mg/kg/day), respectively, on days 7 to 12 of gestation. Plasma cholesterol, total T3, free T4 and TSH were measured at gestational days 7, 12, and 21. At the end of gestation, the mothers were sacrificed and embryo-fetal mortality was recorded. Fetuses were dissected to determine the prevalence of esophageal and intestinal atresias. RESULTS: At gestational day 12, mothers treated with LT4 or PTU had hyper or hypothyroid status, respectively; plasma cholesterol levels were similar. In the adriamycin-exposed fetuses from hyperthyroid mothers, the embryonal resorption rate and the prevalence of both EA/TEF and DA were significantly higher than in the other groups; maternal hypothyroidism during the same period did not have significant effect on the prevalence of atresias. CONCLUSIONS: Maternal hyperthyroidism during the embryonic window corresponding to foregut cleavage increased the prevalence of both EA/TEF and duodenal atresia in fetal rats exposed to adriamycin. This suggests that maternal thyroid hormone status might be involved in the pathogenesis of foregut atresias and invites further research on this likely clinically relevant issue in humans.

Diaphragm disease of duodenum following long-term NSAIDs use: endoscopic management.

We report our experience with endoscopic management of 3 men (aged 62, 63 and 65 years) with duodenal diaphragm disease following NSAID use for 5-15 years. In the first patient a 24 F through-the-scope balloon dilatation was attempted but failed; he subsequently underwent gastro-jejunostomy. The other two patients subsequently underwent radial incisions of the web with mixed cutting and coagulation current using a standard 5 F sphincterotome.

Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs).

BACKGROUND: Chronic ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) has rarely been associated with the development of intestinal diaphragm-like strictures. We have explored the role of laparoscopic surgery for the management of NSAID-related long distal duodenal strictures. METHOD: A 49-year-old woman had been on NSAID therapy (ibuprofen) for backache more than 2 years. She showed symptoms of gastric outlet obstruction and gastrointestinal blood loss, and investigations showed a long stricture in the third and fourth parts of the duodenum. She underwent a laparoscopic pancreas-preserving distal duodenectomy with duodenojejunal anastomosis. RESULT: Relaparoscopy on postoperative day 1 for bleeding showed no active source of bleeding. The patient's subsequent recovery was uneventful, and she was discharged on postoperative day 4. Further symptomatic strictures developed 2 months later at the previously ulcerated pylorus and distal duodenal bulb and were managed by a laparoscopic Roux-en-Y gastrojejunostomy. The patient was discharged on postoperative day 3, but represented 2 months later with symptomatic stenosis at the gastrojejunostomy which was managed by a laparoscopic revision gastrojejunostomy. Discharged on the postoperative day 2, she had regained weight and remained symptom free at follow-up assessment 3 months later. CONCLUSION: Laparoscopic pancreas-preserving distal duodenectomy for the management of benign duodenal strictures is feasible and safe. Moreover, we have demonstrated the beneficial role of relaparoscopy for the management of postoperative complications and for revision surgical procedures.

[A case of upper gastrointestinal system obstruction by duodenal intramural hematoma caused by using an oral anticoagulant drug]. / Oral antikoagulana bagli duodenal intramural hematomun olusturdugu üst gastrointestinal sistem obstrüksiyonu olgusu.

Unwanted haemorrhage can be seen due to long-term oral anticoagulant use. Sometimes these may lead obstructions forming intramural haemotomas. We noticed a case of duodenal obstruction due to an intramural hematoma in a patient who is on chronic oral anticoagulant therapy. In Taksim Hospital 1st General Surgery Department in April 2000, we treated a patient who presented anaemia, jaundice, pyloric obstruction conservatively. As a result we implicated to treat such cases nonoperatively.

Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group.

BACKGROUND: Each year, clinical upper gastrointestinal events occur in 2 to 4 percent of patients who are taking nonselective nonsteroidal antiinflammatory drugs (NSAIDs). We assessed whether rofecoxib, a selective inhibitor of cyclooxygenase-2, would be associated with a lower incidence of clinically important upper gastrointestinal events than is the nonselective NSAID naproxen among patients with rheumatoid arthritis. METHODS: We randomly assigned 8076 patients who were at least 50 years of age (or at least 40 years of age and receiving long-term glucocorticoid therapy) and who had rheumatoid arthritis to receive either 50 mg of rofecoxib daily or 500 mg of naproxen twice daily. The primary end point was confirmed clinical upper gastrointestinal events (gastroduodenal perforation or obstruction, upper gastrointestinal bleeding, and symptomatic gastroduodenal ulcers). RESULTS: Rofecoxib and naproxen had similar efficacy against rheumatoid arthritis. During a median follow-up of 9.0 months, 2.1 confirmed gastrointestinal events per 100 patient-years occurred with rofecoxib, as compared with 4.5 per 100 patient-years with naproxen (relative risk, 0.5; 95 percent confidence interval, 0.3 to 0.6; P<0.001). The respective rates of complicated confirmed events (perforation, obstruction, and severe upper gastrointestinal bleeding) were 0.6 per 100 patient-years and 1.4 per 100 patient-years (relative risk, 0.4; 95 percent confidence interval, 0.2 to 0.8; P=0.005). The incidence of myocardial infarction was lower among patients in the naproxen group than among those in the rofecoxib group (0.1 percent vs. 0.4 percent; relative risk, 0.2; 95 percent confidence interval, 0.1 to 0.7); the overall mortality rate and the rate of death from cardiovascular causes were similar in the two groups. CONCLUSIONS: In patients with rheumatoid arthritis, treatment with rofecoxib, a selective inhibitor of cyclooxygenase-2, is associated with significantly fewer clinically important upper gastrointestinal events than treatment with naproxen, a nonselective inhibitor.

Small-bowel volvulus during treatment for renal tumors.

Intestinal obstruction as a result of postnephrectomy adhesions occurs in up to 7% of children treated for Wilms' tumor. The authors report two children who developed small-bowel volvulus during the treatment of their renal tumor. Both underwent urgent resection of their ischemic bowel with primary anastamosis and are long-term survivors. The risk of this complication may be increased in young children with bulky tumors who receive abdominal radiotherapy.

Nonsteroidal anti-inflammatory drug induced duodenal web.

Duodenal webs represent an unusual cause of intestinal obstruction in adults. These anomalies are generally considered to be congenital in origin and usually present in infancy. However, they occasionally become symptomatic in adulthood. In these cases, because of the delay in symptoms, the etiology of duodenal webs in adults is uncertain. Gastrointestinal webs in adults have also been reported in the small intestine and colon. It is generally accepted that these lesions are an acquired defect related to long term nonsteroidal anti-inflammatory drug (NSAID) use. We report a patient with a history of long term NSAID use who presented with symptoms of gastric outlet obstruction due to the presence of a duodenal web.

Nontraumatic intramural hematoma of the duodenum complicating warfarin therapy.

A 74-year-old man receiving chronic anticoagulant therapy presented with symptoms of acute small bowel obstruction. He was subsequently found to have an intramural hematoma of the duodenum. Early noninvasive diagnosis was possible using computed tomography. Conservative therapy proved successful in allowing resolution of obstructive symptoms. This case illustrates the effectiveness of a conservative approach to intramural hematoma of the duodenum, even in patients requiring anticoagulation.

Congenital anomalies in two infants born after gestational gamma-globulin prophylaxis.

The offspring of two women given prophylactic gamma-globulin 50 and 54 days after their last menstrual periods had congenital duodenal stenosis and a paraoesophageal hiatus hernia, respectively. The possibility that gamma-globulin may have contributed to these malformations is discussed.

Duodenal diaphragmlike stricture induced by acetylsalicylic acid.

Many reports have mentioned the role of nonsteroidal antiinflammatory drugs in inducing diaphragm-like strictures in the small and large bowel. These lesions are mostly seen in patients with chronic use of nonsteroidal antiinflammatory drugs. We report the case of a 57-year-old man who developed a diaphragmlike stricture in the second part of the duodenum. The patient had been using a preparation containing acetylsalicylic acid during many years. Although a congenital origin of the diaphragm is not completely excluded, we postulate that this stricture probably occurred as a result of acetylsalicylic acid-induced ulcerations, followed by submucosal fibrosis.

A rare complication due to sulfuric acid ingestion.

The authors present a case of pyloric and duodenal obstruction in an 8-year-old child, resulting from accidental ingestion of sulfuric acid. A marked pyloric and duodenal cicatrizing stenosis resulting from ingestion of sulfuric acid is seen infrequently, especially in pediatric age. Sulfuric acid produces a coagulation necrosis of the gastric mucosa and submucosa, and the process may involve the entire thickness of the gastric wall, with subsequent ulceration and fibrosis. This dynamic pathophysiologic event imposes postponement of surgical intervention because of various time length between ingestion of acid and onset of gastric outlet obstruction (17 days to 5 years). Clinical features included postprandial epigastric distress, repeated non-bilious vomiting, and marked weight loss. The authors also discuss the various surgical procedures that were employed to relieve the obstruction. Notwithstanding a potential risk of malignant evolution, a gastro-jejunostomy is the treatment of choice because of the age of the patient, and good postoperative results are confirmed by barium studies.

The successful medical management of gastric outflow obstruction associated with the use of non-steroidal anti-inflammatory drugs in the elderly.

One hundred and nineteen consecutive elderly patients with endoscopically diagnosed peptic ulceration were reviewed. Associated gastric outflow obstruction was present in 10.1%. The presenting clinical features differed significantly from typical younger patients and most (11/12) were taking non-steroidal anti-inflammatory drugs, suggesting a possible role for these agents in the pathogenesis of gastric outflow obstruction. These elderly patients have been successfully managed by medical therapy alone.

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.