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.

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.

[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.

[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.

Freon: accidental ingestion and gastric perforation.

INTRODUCTION: Freons generally have a low order of toxicity, but exposure to relatively high concentrations (>100 ppm) may produce adverse effects on health. Currently, intoxication reports are unintentional inhalation of CFCs. We report an unintentional ingestion of a mixture of CFCs and the results of a rat study. CASE REPORT: A 43-year-old man was admitted to the Emergency Department with a chief complaint of acute abdominal pain that developed minutes after he ingested a clear liquid in a water glass, which contained a mixture of Freon and water. Subsequent surgical evaluation revealed perforation of the stomach and necrosis of the stomach wall. He developed a transient rise in his hepatic transaminases, which resolved spontaneously, and fully recovered from his surgery. METHODS: A murine model of the injury was created to evaluate threshold concentration and effect of time on injury grade. RESULTS: Injury grade increased with delay to histologic analysis from 8 to 24 hours after exposure to Freon. Increasing amounts of Freon also increased the lesion grade score. CONCLUSIONS: Patients ingesting Freon need to be closely evaluated for risk of gastric damage and perforation.

Idiopathic gastric rupture in a 3-month-old girl.

UNLABELLED: This case reports on idiopathic gastric rupture in a 3-mo-old girl who had frequent episodes of vomiting and abdominal distension the day before admission to the clinic. Metabolic acidosis was detected and rotavirus antigen was identified in the stools. Abdominal X-rays and CT scans revealed free air and fluid in the abdominal cavity, leading to a diagnosis of gastrointestinal perforation. During surgery, idiopathic gastric rupture was detected and treated. The postoperative course was uneventful. CONCLUSION: Idiopathic gastric rupture is extremely rare in childhood beyond the neonatal period. Early diagnosis and surgery are mandatory if children with this condition are to be saved.

Unusual presentation of gastric duplication cyst in a neonate with pneumoperitoneum and vertebral anomalies.

An unusual case of communicating, tubular gastric duplication (GD) of the greater curvature of the stomach presenting with pneumoperitoneum is described. The pneumoperitoneum resulted due to simultaneous mechanical rupture of stomach and its duplication cyst due to birth trauma and vigorous post delivery resuscitation. No case of this kind has been reported earlier in English literature, though instances of ulcerative perforation of neonatal stomach and GD are known. There was radiographic evidence of multiple thoracic vertebral anomalies, again a rare occurrence with GD cyst. Further, a diagnostic dilemma was faced in this patient as the presence of radiographic sign of "gastric bubble" on plain radiographs in this patient suggested the source of free intraperitoneal air to be extragastric and the diagnosis could be made only at surgery. The authors have reviewed the pertinent literature on neonatal gastric perforation and GD cysts and uphold "split notochord" theory as etiology for GD in this patient.

A spontaneously ruptured gastric stromal tumor presenting as generalized peritonitis: report of a case.

Among the diverse clinical presentations of gastrointestinal stromal tumor (GIST), spontaneous rupture with peritonitis is extremely rare. We report herein the unusual case of a 75-year-old man found to have a spontaneously ruptured gastric stromal tumor after presenting with generalized peritonitis. The patient was brought to the emergency department of our hospital by ambulance, with generalized severe abdominal pain. On examination, his abdomen was extensively distended with generalized severe rebound tenderness. Abdominal computed tomography scan showed a giant mass arising from the anterior gastric wall with an irregular internal low-density area and a small amount of ascites. An emergency laparotomy revealed a ruptured gastric tumor with dissemination of its necrotic tissue throughout the peritoneal cavity. The tumor was excised together with normal gastric tissue around its base. The tumor, which was 15 x 11 x 4.4cm in size, had a coarse laceration over its well-capsulated smooth serosal surface with massive necrosis and clotted blood inside. Immunohistochemical examination revealed positive reactivity to C-kit protein, which was consistent with the newly introduced diagnostic criteria of GIST. The patient had an uneventful postoperative course and remains well.

[A case report of perforated early gastric cancer].

An 83-year-old woman was seen at the First Department of Medicine Fukui Medical School because of upper abdominal pain. A simple chest film taken in the upright position revealed free air under the diaphragm. She was referred to the department and underwent a laparotomy with a diagnosis of acute panperitonitis due to a perforated gastric ulcer. At laparotomy, there was a perforation measuring 5 x 5 mm at the anterior gastric body of the lesser curvature, covered with abdominal wall. Billroth I gastrectomy was carried out with no lymph node dissection. The histological examination of the surgical specimen showed early gastric cancer of type IIc invading the submucosal layer around the ulcer in the gastric wall, composed of well differentiated adenocarcinoma. The perforated early gastric cancers often present difficulty in diagnosis pre or intra-operatively. So it is important to examine closely the resected specimen intra-operatively and perform frozen section diagnosis whenever possible. Forty-six cases of perforated early gastric cancer collected from the Japanese literature are also discussed.

[Spontaneous ventricular rupture in adults]. / Spontan ventrikelruptur hos voksne.

Since 1928, 60 cases of spontaneous gastric rupture have been described. One third of these cases were seen after vomiting, and two thirds were associated with gastric dilatation after a big meal, of which one third were combined with an intake of antacids. In five cases the patients were suffering from anorexia nervosa. Besides the above mentioned causes, gastric atrophy, "closed-loop" obstruction and postoperative atony are possible pathogenetic factors. Most often the ruptures are located to the lesser curvature. In the period before the rupture associated with dilatation takes place, the patient typically complains of abdominal pain and the abdomen is found asymmetrically distended. After rupture of the stomach the patient is found with very aggressive pain and in shock. The abdomen has become more symmetrically distended and most often free air within the abdominal cavity can be diagnosed on X-ray. The treatment consists of resection of the necrotic area of the stomach, and as the intensive care of the patients both before, during and after surgery has reached a very high priority and standard, the mortality has been reduced from 75% to 30%.