Gastric perforation biopsy: is it obsolete?

PURPOSE: The aim of the study was to test the established hypothesis that biopsies of spontaneous gastric perforations should be taken to rule out cancer. METHODS: A prospective observational study was performed. Consecutive patients with spontaneous gastric perforation were included. Biopsies of the edges of the perforation were submitted for histological evaluation. The epithelial type as well as the nature of the pathology were evaluated. RESULTS: Sixty-eight patients were included. Eight (12%) biopsies revealed duodenal origin. Sixty (88%) biopsies revealed gastric mucosa of which 33 (48%) could be specifically typed. All biopsies revealed benign ulceration. No malignancies were detected in these biopsies or on subsequent gastroscopic follow up. CONCLUSION: This study suggests that routine intraoperative biopsy of gastric perforation may be questioned. Biopsy is probably better performed endoscopically after recovery.

Perforation of gastric metastasis during chemotherapy with ramucirumab.

A 59-year-old man received fifth line chemotherapy with ramucirumab and protein-bound paclitaxel for gastric metastasis from esophagogastric junction cancer. On day 3 of the third course, he had severe chest pain and a high fever. Esophagogastroduodenoscopy revealed gastric perforation at the point of the metastatic lesion.

Neonatal Gastric Perforation: Case Series and Literature Review.

PURPOSE: We reported clinical findings of neonatal gastric perforation in a tertiary children's hospital. PATIENTS AND METHODS: Retrospective chart reviews were conducted for neonatal gastric perforation between 1980 and 2016. Factors including sex, gestational age, birth weight, age, main symptoms and signs, white blood cell count (WBC), surgical intervention time (time between development of main symptom and surgical intervention), surgical findings, pathologic results, clinical outcomes, and causes of death were collected. RESULTS: Sixty-eight patients were identified. In total, 76.5% were male infants, the median age was 4 days, median birth weight was 2500 g, and 42.6% were premature. Abdominal distention and vomiting were the most common symptoms, and pneumoperitoneum was the most common radiographic finding. The median surgical intervention time was 51 h (range 8-312). In total, 73.5% of perforations occurred in the great curvature, 17.6% in the lesser curvature, and 8.9% unspecified. The median perforation size was 4 cm (range 0.2-16). Associated gastrointestinal anomalies were found in 20.6% of patients, and the most common anomaly was intestinal malrotation. Of the 51 patients with pathologic results, 11 showed the presence of musculature in the perforated gastric wall, while 40 showed the absence of musculature. Of the 66 patients with known clinical outcomes, 26 (39.4%) died, 23 of who died of infection. Among those aforementioned factors, WBC has a significant impact on survival. The mortality for four arbitrary divided year groups (1980-1989, 1990-1999, 2000-2009, and 2010-2016) was 100, 50, 31.6, and 16.7%, respectively. CONCLUSIONS: The mortality of neonatal gastric perforation is constantly decreasing. Associated gastrointestinal anomalies and the presence of musculature are found in a minority of this condition.

Gastric perforation following cytoreductive surgery and perioperative intraperitoneal chemotherapy: a case series of six.

BACKGROUND: Incidence of gastric perforation following cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) is not widely reported. METHODS: Suitable patients were identified from our database of 1028 procedures. Relevant information was then gathered via medical records and operation reports for these patients. RESULTS: Six patients suffered early postoperative gastric perforation following the procedure (0.58%), all of whom received heated intraoperative intraperitoneal chemotherapy (HIPEC). Surgical exploration revealed protrusion of nasogastric (NG) tube through stomach wall defects which were either located at or near the greater curvature of stomach. These patients were managed successfully with operation, and no mortality was recorded. CONCLUSIONS: Gastric perforation following CRS and PIC is most likely the result of a multifactorial process. To reduce the risk of such complication, avoiding nasogastric suction in these patients may prove helpful. Any suspected perforated viscus must be addressed promptly to avoid unwanted morbidity and mortality from the procedure. To our knowledge, conservative management has not been documented to work in this subgroup and surgery remains the mainstay of treatment.

Diffuse Infiltrative Gastrointestinal Lipomatosis in a Guinea Pig (Cavia porcellus).

An intact adult male guinea pig (Cavia porcellus) went into cardiopulmonary arrest during a surgical procedure, and efforts at resuscitation were unsuccessful. Gross examination revealed a gastric rupture along the greater curvature of the stomach, which was associated with free blood and ingesta in the abdominal cavity, and a 2-cm nodular, partially circumferential, soft-to-firm mass within the pyloric region. Histologically, the pyloric mass was composed of sheets of infiltrative adipocytes expanding the muscular wall. Similar infiltrative sheets of adipocytes were present adjacent to the rupture site and within the small intestine, cecum, and colon. These findings are consistent with diffuse infiltrative lipomatosis, an exceedingly rare condition in human and veterinary species. This report is the first description of this rare disease in guinea pigs, and the concurrent involvement of both the stomach and intestines has not been reported in any veterinary species.

Primary gastric rupture in 47 horses (1995-2011).

The purpose of this retrospective case-control study was to identify factors associated with primary gastric rupture and to investigate if there were differences between etiologies of primary gastric rupture. Compared to the general colic population, Quarter horses were under-represented and Friesians and draft breeds were over-represented in 47 cases of primary gastric ruptures. Horses with primary gastric rupture typically presented with severe clinical and clinicopathological derangements. There were 24 idiopathic gastric ruptures, 20 gastric impaction associated ruptures, and 3 perforating gastric ulcers. Thoroughbred horses were over-represented in the idiopathic gastric rupture group compared to other breeds and etiologies. This study suggests the presence of important breed predispositions for development of gastric rupture. Further study is necessary to identify if these predispositions are associated with management factors or breed-specific disorders.

Rupture gastrique primaire chez 497 chevaux (1995­2011). Le but de cette étude rétrospective de cas témoins était d'identifier les facteurs associés à la rupture gastrique primaire et de faire une enquête afin de déterminer s'il y avait des différences entre les étiologies de la rupture gastrique primaire. Comparativement à la population générale de coliques, les chevaux Quarter horse étaient sous-représentés et les Frisons et les races de trait étaient surreprésentées dans 47 cas de ruptures gastriques primaires. Les chevaux atteints de rupture gastrique primaire étaient présentés avec de graves dérangements cliniques et clinicopathologiques. Il y avait 24 ruptures gastriques idiopathiques, 20 ruptures associées à l'impaction gastrique et 3 perforations ulcéreuses gastriques. Les chevaux pur-sang étaient surreprésentés dans le groupe des ruptures gastriques idiopathiques comparativement à d'autres races et étiologies. Cette étude suggère la présence de prédispositions importantes des races pour le développement de la rupture gastrique. De nouvelles études sont nécessaires pour identifier si ces prédispositions sont associées aux facteurs de gestion ou à des troubles spécifiques aux races.(Traduit par Isabelle Vallières).

Total gastrectomy performed in emergency conditions for gastric necrosis due to acute gastric dilatation.

Acute massive gastric dilatation is a rare event, with a pathogenesis still debated. Acute massive gastric dilatation invariably leads to necrosis and perforation. We present the case of a 50 year-old woman, admitted in emergency conditions with circulatory collapse and abdominal distension with the onset 12 hours prior to presentation. An emergency laparotomy was performed revealing a stomach occupying the entire abdominal cavity with necrosis and anterior pyloric perforation. The operation consisted in total gastrectomy with stapled Roux-en-Y anastomosis. The postoperative evolution was simple, without complications. Acute massive gastric dilatation is a severe, lethal condition with multiple etiologic factors like anorexia nervosa, trauma, diabetes, postoperative period in abdominal surgery, electrolyte disturbances. In most cases emergency surgical treatment is necessary, dictated by gastric necrosis or perforation. Conservative treatment may represent an option if it is early instituted.

Noniatrogenic neonatal gastric perforation: the role of interstitial cells of Cajal.

Noniatrogenic neonatal gastric perforation is a rare and life-threatening condition whose etiology is often unclear. Interstitial cells of Cajal act as gastrointestinal pacemaker cells and express the proto-oncogene c-Kit. Six new cases were identified at our institution which presented with no mechanical, pharmacologic, or otherwise medical-related intervention prior to rupture. The number of interstitial cells of Cajal in nonnecrotic muscularis propria from five random high-power fields per specimen was compared using immunohistochemical stains for c-Kit. The authors show that a lack of interstitial cells of Cajal in the stomach musculature may be implicated in the development of noniatrogenic gastric perforation (p = 0.008). Further large-scale studies, including molecular and genetic analysis, may help to better understand this phenomenon.

Ruptura gástrica idiopática en niño preescolar: informe de un caso / Idiopathic gastric rupture in toddler: case report

La ruptura gástrica idiopática es una patología muy poco frecuenteen niños. La gran mayoría de los casos ocurre en el período neonatal. Comunicamos el caso de una paciente preescolar de 2 años, sexo femenino, sin antecedentes mórbidos. Consultócon antecedente de 48 h de dolor abdominal, náuseas y vómitos.Ingresó al servicio de urgencia en malas condiciones generales, con un abdomen distendido y signos de irritación peritoneal. Se realizó laparotomía exploradora de emergencia que reveló ruptura gástrica en pared posterior ocasionada por múltiples perforaciones. Se efectuó gastrectomía parcial. Ingresó a UCIen shock. Recibió asistencia ventilatoria mecánica, reanimación con fluidos (260 ml/kg en 12 h), fármacos vasoactivos y tratamiento antibiótico con cefotaxima-metronidazol. El laboratorio evidenció leucopenia y trombopenia. El estudio etiológico fue negativo para ingesta de tóxicos y medicamentos. Se descartócolagenopatía y su gastrinemia fue normal. Su postoperatorio se caracterizó por persistencia de fiebre originada porcolección subfrénica izquierda (cultivo positivo para Candida galabrata). Se realizó limpieza quirúrgica mediante laparotomía y drenaje percutáneo de las colecciones residuales. Completótres semanas de terapia antibiótica y antifúngica con evolución satisfactoria. El control ambulatorio de la paciente a los 12 meses fue normal.

Pathological evidence of pancreatitis in 43 horses (1986-2011).

REASONS FOR PERFORMING STUDY: Definitive ante mortem diagnosis of pancreatitis in horses is difficult. Reports summarising the most common clinical signs, clinicopathological features and concurrent disorders in horses with a definitive diagnosis of pancreatitis that may aid in the recognition of disease are lacking. OBJECTIVES: To describe case details, clinical signs, clinicopathological data and necropsy findings in horses with a definitive diagnosis of pancreatitis. METHODS: This was a retrospective study (1986-2011) and inclusion criteria consisted of horses with a definitive diagnosis of pancreatitis. A medical records database search was performed and data extracted included case details, clinical signs, clinical laboratory data and post mortem findings. Pancreatitis was defined as acute, active chronic or chronic and presumed primary or secondary, based on postmortem findings. RESULTS: Pancreatitis was diagnosed in 43 horses (acute pancreatitis in 34, active chronic in 4 and chronic in 5). A presumed diagnosis of primary pancreatitis was made in 6 horses. Pancreatitis was associated with gastrointestinal disorders in 28 horses (14 large colon, 10 small intestine and 4 gastric ruptures) and primary hepatic disease in 3 horses. Six horses had pancreatitis associated with other disorders: multiple endocrine neoplasia syndrome (one horse), strychnine toxicosis (one horse) and compromised immune system (4 horses). CONCLUSION: Pancreatitis is an uncommon disorder that can occur as a primary problem or secondary to gastrointestinal, hepatic or immunocompromising disorders, and when it occurs it affects adult horses more commonly. POTENTIAL RELEVANCE: Unexplained abdominal pain, gastric dilation or rupture, peritonitis and/or the presence of white fibrinous plaques and fat necrosis in the peritoneum and mesentery or mass-like structures in the root of the mesentery during an exploratory celiotomy should raise a suspicious of pancreatitis.

[Expression of c-kit and Cx43 in neonates with spontaneous gastric perforation].

OBJECTIVE: To study the clinical significance of interstitial cell of Cajal (ICC) in spontaneous neonatal gastric perforation by examining the expression of c-kit and Cx43 in neonates with this disorder. METHODS: The gastric specimens of 19 cases of neonatal gastric perforation from 2001 to 2010 and 8 cases of accidental death without digestive tract malformations (control) were collected. Immunohistochemical staining was employed to examine the expression of c-kit and Cx43 (immunomarkers of ICCs) in gastric tissues. RESULTS: The muscular layer of the stomach wall became thinner or deficient in the gastric perforation group. C-kit and Cx43 positive cells in gastric tissues decreased significantly in the gastric perforation group compared with those in the control group (P＜0.01). CONCLUSIONS: The development of spontaneous neonatal gastric perforation is associated with the decreased quantity of ICCs and damaged gap junction structure of the stomach wall.

[Clinicopathological characteristics and potential etiologies of neonatal spontaneous gastric perforation].

OBJECTIVE: To study the etiology and clinicopathological features of neonatal spontaneous gastric perforation. METHODS: The clinical data of 15 cases with neonatal gastric perforation seen from 2001 to 2009 were retrospectively analyzed. Immunohistochemical staining was adopted for all the cases. RESULTS: The typical clinical manifestations of this disease were vomiting, abdominal distention and respiratory distress. Abdominal orthostatic X-ray showed free gas under diaphragm and seroperitoneum. In most of the cases the stomach perforation occurred at the greater curvature. Eight of the cases died in this group, the mortality was 53.33%. Six of the deaths occurred within 1 day after birth with symptoms. There were thinning and defect of stomach wall muscle and interstitial cells of Cajal (ICC) reduction as demonstrated by microscope. CONCLUSIONS: Spontaneous neonatal gastric perforation is associated with abnormal gastric wall structure and reduction of ICC. Prognosis is closely related to the time of onset and the timely surgical operation.

[Extramural Gastral GIST Manifested by Spontaneous Perforation with Acute Intraabdominal Bleeding and Haemoperitoneum]. / Extramuraler GIST des Magens mit Manifestation durch Spontanruptur und akuter intraabdomineller Blutung mit Hämatoperitoneum.

We report on the case of a 38-year-old male patient with a huge extramural gastrointestinal stromal tumour (GIST) of the stomach, located in the left upper and middle abdominal cavity that was diagnosed on the basis of a spontaneous -rupture and consecutive haemoperitoneum. The lesion was resected completely in an emergency operation. The tumour was classified as a high-risk lesion for aggressive biological behaviour and with regard to tumour rupture with perforation of the serosa, an adjuvant systemic therapy was indicated.

Acute tension pneumothorax and tension pneumoperitoneum in a patient with anorexia nervosa.

Gastric rupture secondary to bulimia is a rare complication of anorexia nervosa first described in 1968. We present a case of an 18-year-old woman who presented to the Emergency Department with acute gastric rupture leading to both tension pneumoperitoneum and tension pneumothorax. Although case reports of spontaneous pneumoperitoneum and separate reports of spontaneous pneumothorax in anorexic patients have been published, none of them has been associated with gastric rupture.

[Stomach rupture associated with noninvasive ventilation]. / Rupture gastrique au décours d'une séance de ventilation non invasive.

Noninvasive positive-pressure ventilation (NIPPV) is a safe method to treat acute respiratory failure and is known to decrease the need for intubation and the length of ICU-stay. Few severe complications have been reported even when the indications are respected. Some rare cases of gastric distension were recently described. We report the case of a gastric perforation associated with NIPPV. The treatment was closure with a primary interrupted two-layer suture. Recovery was complete and the patient was transferred to the ward on Day 11.

Gastric perforation and death after the insertion of an intragastric balloon.

We report a case of a patient who presented with an acute abdomen 2 days after the insertion of an intragastric balloon system and discuss in detail the advantages and drawbacks of these devices in the therapy of morbid obesity. A 43-year-old morbidly obese man was admitted to the department of surgery in shock with a 2-h history of severe diffuse abdominal pain and the initial diagnosis of visceral perforation. The patient had been subjected to intragastric placement of an inflatable balloon 48 h prior to his presentation. Abdominal exploration revealed the presence of a large linear perforation in the fundus of the stomach.