Intestinal obstruction due to dual gastrointestinal atresia in infants: diagnosis and management of 3 cases.

BACKGROUND: Several types of congenital lesions can cause complete or incomplete obstruction of the intestine. Our purpose is to present 3 neonates with dual intestinal type I atresia, i.e., simultaneous obstructive lesions at 2 locations in which the atresia manifested as diaphragm-like tissue. CASE PRESENTATION: All 3 cases were female infants ranging in age from 2 to 14 months. The common symptom in all cases was intermittent persistent vomiting. In some cases the vomitus was bilious, and other symptoms included abdominal distention and delayed meconium passage. Prior surgeries at another hospital were unsuccessful at relieving the symptoms in one case. One case had dual lesions in the colon, one dual lesions in the duodenum, and one atresia at both the distal portion of the ileum and the descending colon. Surgical exploration and removal of the lesions at our hospital was successful in all cases, and the infants were discharged in good condition. CONCLUSIONS: Type I atresia can manifest as a diaphragm-like tissue obstructing the continuity of gastrointestinal tract, and in rare cases multiple areas may be present. Base on the intermittent nature of the associated symptoms, diagnosis can be difficult and is often delayed. Physicians should be aware of this condition during the work-up of an infant with persistent intermittent vomiting.

Increased bowel toxicity in patients treated with a vascular endothelial growth factor inhibitor (VEGFI) after stereotactic body radiation therapy (SBRT).

PURPOSE: Gastrointestinal injury occurs rarely with agents that affect the vascular endothelial growth factor receptor and with abdominal stereotactic body radiation therapy (SBRT). We explored the incidence of serious bowel injury (SBI) in patients treated with SBRT with or without vascular endothelial growth factor inhibitor (VEGFI) therapy. METHODS AND MATERIALS: Seventy-six patients with 84 primary or metastatic intra-abdominal lesions underwent SBRT (median dose, 50 Gy in 5 fractions). Of the patients, 20 (26%) received VEGFI within 2 years after SBRT (bevacizumab, n=14; sorafenib, n=4; pazopanib, n=1; sunitinib, n=1). The incidence of SBI (Common Terminology Criteria for Adverse Events, version 4.0, grade 3-5 ulceration or perforation) after SBRT was obtained, and the relationship between SBI and VEGFI was examined. RESULTS: In the combined population, 7 patients (9%) had SBI at a median of 4.6 months (range, 3-17 months) from SBRT. All 7 had received VEGFI before SBI and within 13 months of completing SBRT, and 5 received VEGFI within 3 months of SBRT. The 6-month estimate of SBI in the 26 patients receiving VEGFI within 3 months of SBRT was 38%. No SBIs were noted in the 63 patients not receiving VEGFI. The log-rank test showed a significant correlation between SBI and VEGFI within 3 months of SBRT (P=.0006) but not between SBI and radiation therapy bowel dose (P=.20). CONCLUSIONS: The combination of SBRT and VEGFI results in a higher risk of SBI than would be expected with either treatment independently. Local therapies other than SBRT may be considered if a patient is likely to receive a VEGFI in the near future.

A multidisciplinary approach to management of autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED).

We present a case of an 18-year-old Caucasian man with a rare autosomal recessive disorder called autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED). This patient had manifestations of all clinical components of this multisystemic disease which included intestinal failure secondary to autoimmune enteropathy. We present a unique multidisciplinary management for this genetic condition. Although patients with APECED do not always have all the disease components (a total of eight exist), the majority have at least 3-5 components. This excludes the psychosexual implications which are often ignored. This case highlights the importance of (1) management of APECED in a multidisciplinary nature that includes a gastroenterologist, immunologist, endocrinologist, dietitians, etc and the (2) management of intestinal failure component of APECED is best suited in a specialist intestinal failure unit where expertise is available for complex malabsorption disorders.

Successful endoscopic therapy of postoperative duodenal fistula by lipiodol injection: a new therapeutic approach.

Postoperative upper gastrointestinal fistulas or anastomotic leaks with peritonitis are rare but serious clinical conditions. Due to severe fluid and electrolyte imbalance and risk of development of sepsis implementation of efficient and timely management is crucial. Various endoscopic interventions have been performed to date for postoperative upper gastrointestinal fistulas. We herein describe a new therapeutical approach involving lipiodol injection, which we performed to treat a patient who had unsuccessfully undergone surgery for a posttraumatic duodenal fistula. The fistula was then successfully managed by endoscopic lipiodol injection. We present this case due to its interesting nature of a postsurgical duodenal fistula without evident fistula tract, and a successful therapy by a new approach, lipiodol injection. We conclude that this new method offers an option for patients with high operation risk or for those with failed surgery, and this new method may decrease morbidity, mortality and the time required for the closure of duodenal fistulas.

Vascular injuries caused by acupuncture.

AIM: To systematically review the literature on vascular injuries caused by acupuncture. METHOD: Systematic literature search in Medline and PubMed. RESULTS: Twentyone cases were identified and the majority developed symptoms in direct connection with the acupuncture treatment. Three patients died, two from pericardial tamponade and one from an aortoduodenal fistula. There were five more tamponades, seven pseudoaneurysms, two with ischaemia, two with venous thrombosis, one with compartment syndrome and one with bleeding. The two patients with ischaemia had remaining sequeleae. Information on follow-up was suboptimal with no information in nine patients. CONCLUSION: Vascular injuries are rare, bleeding and pseudoaneurysm dominating. Follow-up is insufficient in the hitherto published papers.

Aortoduodenal fistula complicated by acupuncture.

Recently, acupuncture has become a common therapeutic procedure for pain control worldwide. Although it has been repeatedly reported that acupuncture is effective and safe, several serious complications were also reported. In this article, we present a case of 68-year-old man who died of massive hematemesis resulting from aortoduodenal fistula (ADF), a rare complication of acupuncture therapy.

Fístula duodeno-cólica benigna: reporte de un caso y revisión del tema / Benign duodenal-colic fistula: a case report and subject review

La fístula duodeno-cólica es una entidad de presentación inusual, descrita en la literatura sólo como reportes de casos aislados. Las FDC benignas son una rara complicación de numerosas enfermedades gastro-intestinales, siendo la causa más frecuente la secundaria a la enfermedad de Crohn. Dolor abdominal, signos de malabsorción (diarrea, baja de peso), asociados eventualmente a náuseas y vómitos son la forma de presentación más frecuentes. El enema baritado es el mejor método diagnosticado. El manejo debe ser integral, considerando tanto el manejo de la enfermedad de base, como el soporte nutricional y la resolución quirúrgica de la fístula. Se presenta un caso clínico de esta patología.

Sigmoidoduodenal fistula as a rare complication of colonic carcinoma: report of a case.

We report a very unusual case of malignant sigmoidoduodenal communication. To the best of our knowledge, this is the first documentation of this entity in the English language literature. A 76-year-old man presented with weakness, severe weight loss, foul-smelling eructations, anemia, constipation, and episodes of diarrhea. A sigmoidoduodenal fistula was found by barium enema, and a diagnosis of ulcerative colonic adenocarcinoma was made from the colonoscopy findings. Thus, we performed sigmoid colectomy with resection of the fistula and the involved anterior wall of the third duodenal part, followed by primary closure of the duodenal defect. Histological examination confirmed a Dukes' B (Stage II - T(4)N(0)M(0)) colonic adenocarcinoma, and the excision margins of the resected duodenal specimen were clear. We gave adjuvant chemotherapy with 5-fluorouracil and leucovorin. The patient is still alive and disease-free, 2 years postoperatively.

[Gastroduodenal intussusception on gastric tumor]. / Invagination gastro-duodénale sur tumeur gastrique.

Gastroduodenal intussusception is a rarely documented condition. A distinction has to be made between complete gastroduodenal intussusception (CGDI) and either prolapse of a pedunculated tumor through the pylorus or mucosal prolapse through the pylorus. CGDI usually occurs secondary to a pedunculated benign gastric tumor. More rarely the tumor is malignant. We report a case of CGDI associated with gastric adenocarcinoma. We emphasize diagnostic difficulties that can be generated by CGDI.

Gastrocolic and duodenocolic fistulas in Crohn's disease.

Crohn's disease is a rare cause of gastrocolic and duodenocolic fistulas. Only 83 examples (27 gastric, 52 duodenal, four both) have been described. Weight loss, abdominal pain, and diarrhea are common features but fail to distinguish a fistula from active inflammatory bowel disease. Fecal vomiting is pathognomic but is present in one third of gastrocolic and only 2% of duodenocolic fistulas. Diagnosis is most readily made by contrast radiography, with barium enema being more sensitive than barium meal. Although several gastrocolic fistulas have been successfully treated with long-term 6-mercaptopurine, surgery is the mainstay of therapy. An isolated duodenocolic fistula should not be regarded as the primary indication for operation because most are asymptomatic. Ileocolonic resection with simple gastric or duodenal repair is safe and effective in most cases. An ileocolonic anastomosis should be positioned away from the stomach or duodenum or protected with omentum to prevent recurrent fistulization. A number of fistulas appear to have arisen from gastric or duodenal Crohn's, but the vast majority originate from diseased colon.

Pancreaticoenteric fistula: no longer a surgical disease?

We report our experience with eight patients with severe persistent pancreatitis associated with peripancreatic fluid collections requiring placement of drainage catheters who subsequently developed pancreatic fistula. The fistulas were diagnosed by endoscopic retrograde cholangiopancreatography, contrast tube study, or Hypaque enema at a mean of 13 weeks after diagnosis of pancreatitis and drain placement. These fistulas involved the duodenum in five patients and colon in three patients. Six patients had fistula resolution with medical therapy (after removal of percutaneous drainage catheters in three and with drain removal in conjunction with transpapillary stenting of a disrupted pancreatic duct in another three). We conclude that in patients with ongoing pancreatitis, pancreaticoenteric fistulas are probably caused by erosion of percutaneous drainage catheters. Such fistulas resolved with conservative treatment in six of eight patients.

[A case of aortoduodenal fistula following radiotherapy of retroperitoneal metastatic disease].

A new case of aortoduodenal fistula was added to the five cases previously reported in the literature, in which malignancy and/or its treatments could be implicated. This 67 year-old woman, six years previously had been placed on a therapy including irradiation on the pelvis for cancer of uterine cervix. For this time she underwent a radiotherapy completed in a total dose of 55.6 Gy combined with hyperthermia and chemotherapy for retroperitoneal metastatic disease with excellent response. Three months later she had hematemesis followed by melena and deteriorated to hemorrhagic shock. Emergent aortography detected contrast extravasation from the aorta with subsequent opacification of the duodenum, and immediate intraaortic balloon occlusion was done, but she died soon thereafter. Postmortem examination revealed the fistula from the aorta just above the bifurcation to a 2 by 1.5 cm. area of the posterior wall of the third portion of the duodenum. Accentuated arteriosclerosis in locally irradiated portion of the aorta, obstruction of small arteries from organized thrombus and hyaline necrosis in the wall of the fistulous tract were defined without evidence of tumor invasion. Based upon the findings of the patient reported herein, radiation might be another possible etiologic factor in aortoduodenal fistula, as well as tumor invasion per se.

[Benign coloduodenal fistula caused by inflammatory pseudotumor of the colon]. / Fístula coloduodenal benigna por pseudotumor inflamatorio del colon.

We present a case of benign coloduodenal fistula, due to an inflammatory pseudotumor of the hepatic flexure of the colon, that was found included in a calcified hepatic cavity, presumably hydatic, that opened through a large fistulous orifice into the second duodenal portion. A barium enema satisfactorily demonstrated the colonic lesion and a fistulous tract. Although the preoperative diagnosis was of colonic neoplasm fistulized into the duodenum, the histopathological study of the surgical specimen did not demonstrate malignancy.

Cholecystoduodenocolic fistula and gallstone ileus.

A patient with cholecystoduodenocolic fistula and gallstone ileus is described. Barium enema and barium meal and follow through demonstrated the passage of the gallstone from the gallbladder region to the small bowel. The clinical features and operative management are discussed in the light of four previously recorded cases.

[Postoperative duodeno-cutaneous fistula in an infant: conservative treatment, total parenteral nutrition]. / Fistola duodeno-cutanea post-operatoria in lattante: trattamento conservativo, N.P.T.

In case of duodeno-cutaneous fistula conservative treatment is advisable. Its successful results, also due to fundamental T.P.N. support and continuous naso gastric suction, has been obtained in an infant with nesidioblastosis, treated by staged pancreatectomy.

First full blown syndrome of acute zinc deficiency in course of long term total parenteral nutrition: a clinical case.

The case of a surgical patient with a full blown syndrome of zinc deficiency is presented and the various implications related to a deficiency of this trace mineral are discussed. The symptomatology involved mental depression, visual disturbances, glucose intolerance, decreased serum alkaline phosphatase levels, wound healing impairment, eczematoid dermatitis and reduced humoral and cellular immune defences. Oral supplementation with zinc sulphate dramatically reversed the signs and symptoms of the syndrome and resulted in rapid wound healing. This case seems to have exhibited most of the different signs and symptoms reported from time to time in the literature. Awareness of zinc deficiency is being brought to light in many medical and surgical conditions. Total parenteral nutrition (T.P.N.) can exacerbate the lack of this trace metal and supplementation with fresh blood derivate are, as demonstrated, useless in these cases. Zinc, as component of various metalloenzymes, accounts for the clinical manifestations of its deficiency.

[Intra- and sub-peritoneal effusions of barium. A report on 16 cases (author's transl)]. / Les épanchements barytés intra et sous-péritonéaux. A propos de 16 observations.

The authors report 16 cases of intra or retro-peritoneal effusion of barium due to colorectal or gastroduodenal perforations. Possible mechanisms and the consequences of barium loss are discussed. Treatment must be directed towards repair of the visceral perforation, usually in the colon or rectum, employing exteriorization or resection but without initial anastomisis, and must treat associated peritonitis by very careful extensive cleaning of the peritoneal cavity. In certain well-defined cases, sub-peritoneal perforation can be treated conservatively. The high mortality rate of about 40% can be explained by the particular type of bacterial potentiation due to barium sulfate. Preventive measures are outlined, including the use of water soluble contrast media in some selected cases.

Benign duodenocolic fistula.

Benign duodencolic fistula is a rare complication of a number of gastrointestinal diseases and it is seldom considered in diagnosis. Diarrhoea and weight loss are characteristic presenting features which may be masked by coexisting disease. Barium enema is the most useful diagnostic procedure. Prognosis is good if surgery is undertaken at an early stage after adequate correction of the metabolic consequences of the fistula, by administration of fluid, electrolytes and parenteral nutrition. This paper reports 4 cases of this condition and reviews the clinical features, investigation, aetiology and management.