Surgical and Medical Treatment of Pyloric and Duodenal Pythiosis in a Dog.

A 5 yr old, male, neutered mixed-breed dog was referred for persistent vomiting 2 wk following a pyloric biopsy for a pyloric outflow obstruction. Histopathology at the time of initial surgery was suggestive of pythiosis. Following referral, the dog underwent radical surgical treatment with a Billroth II procedure, partial pancreatectomy, and cholecystoduodenostomy. Histopathology and serology confirmed the diagnosis of pythiosis and medical treatment consisting of itraconazole and terbinafine was started postoperatively. Serology titers were checked again at 8, 12, and 24 wk postoperatively revealing a positive response to treatment and no reoccurrence of pythiosis. Since surgery, the patient experienced waxing and waning elevations of liver values and laparoscopic liver biopsies 10 mo postoperatively revealed hepatic cirrhosis with fibrosis, bile duct hyperplasia, and chronic inflammation. This report documents successful treatment of pyloric/duodenal pythiosis and the long-term (17 mo) consequences associated with the Billroth II, partial pancreatectomy, and biliary rerouting in the dog.

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.

Divertículo de la tercera porción del duodeno: presentación de un caso y revisión de la literatura / Diverticulum in the third portion of the duodenum: case report and review of the literature

Introducción: el duodeno representa el segundo sitio más común de desarrollo de divertículos, después del colon. Se encuentran generalmente a 2,5 cm de la ampolla de Vater o en la primera porción duodenal, en casos relativamente raros, se presentan en la tercera y cuarta porción duodenal. Objetivo: presentación de un caso de divertículo en tercera porción duodenal, así como también la metodología diagnóstica y terapéutica para resolverlo. Discusión: el diagnóstico clínico de los divertículos duodenales presenta dificultad debido a que no existe una presentación clínica característica. Sólo el 10% y 25% de los pacientes son sintomáticos. Las manifestaciones clínicas se desarrollan por las complicaciones de las diverticulitis. El diagnóstico se basa en los estudios contrastados como las seriadas esofagogastroduodenales, TAC multicorte, así como también, la realización de una endoscopía, deben contribuir a un diagnóstico acertado. El tratamiento quirúrgico de los divertículos asintomático en pacientes adultos no está justificado, mientras que en el paciente con síntomas el criterio es quirúrgico para evitar complicaciones como: hemorragia, perforación, diverticulitis, pancreatitis y obstrucción. Conclusión: el tratamiento de los divertículos duodenales varía según el tipo, localización y extensión del proceso inflamatorio. La cirugía se encuentra reservada en un 1 al 3% de los pacientes con divertículos duodenales en tercera porción, considerando aquellos enfermos con dolor abdominal persistente o complicaciones asociadas a la diverticulitis.

Introduction: The duodenum is the second most common site of diverticula development after the colon. They are usually found to 2.5 cm of the ampulla of Vater or the first part of the duodenum, in relatively rare cases, occur in the third and fourth duodenal portion. Objective: A case of duodenal diverticulum in the third portion, as well as diagnostic and therapeutic methodology to solve it. Discussion: The diagnosis of duodenal diverticula have difficulty because there is no characteristic clinical presentation. Only 10% and 25% of patients are symptomatic. The clinical manifestatiions are developed by the complications of diverticulitis. The diagnosis is bases on serial contrast studies such as upper GI, multislice CT, and also carrying out an endoscopy, should contribute to an accurate diagnosis. Surgical treatment of asymptomatic diverticula in adult patients is not justified, whereas in patients with symptoms on surgical approach is to avoid complications such as bleeding, perforation, diverticulitis, pancreatitis and obstruction. Conclusion: The treatment of duodenal diverticula varies according to the type, location and extent of the inflammatory process. Surgery is reserved on a 1 to 3% of patients with duodenal diverticula in the third portin, whereas those patients with persistent abdominal pain or complications associated with diverticulitis.

[Recurrent Crohn's disease in the ileocolonic anastomosis complicated with duodenal fistula]. / Boala Crohn recidivanta în anastomoza ileo-colica complicata cu fistula duodenala.

Duodenal fistulas in patients with Crohn's disease are rare, and up to one hundred cases were described in the medical literature. We report an additional case of a 40-year-old male who underwent an ileo-ascending colectomy 13 years ago for Crohn's disease and was admitted to our unit with palpable abdominal mass and persistent cutaneous fistula. Preoperative fistulography and barium enema demonstrated Crohn's disease recurrence in the site of the ileocolonic anastomosis and external fistula communicating with the pre-anastomotic ileum. At surgery, Crohn's disease recurrence in the site of ileocolonic anastomosis with ileo-cutaneous fistula was confirmed and an additional ileo-duodenal fistula was detected incidentally. The patient underwent resection of the affected bowel and simple closure of the duodenal fistula with omental pedicle graft transposition between the duodenum and the ileocolonic anastomosis. Postoperative period was uneventful. We review the literature and discuss the incidence and treatment strategy of duodenal fistulas complicating recurrent Crohn's disease in the site of the ileocolonic anastomosis. The authors highlight that simple closure of the duodenal defects is appropriate only for small duodenal fistulas and omental transposition between ileo-colonic anastomosis and duodenum during the primary and repeated resection should be considered as an effective prevention method of duodenal fistulas formation.

Case report: Spontaneous isolated mesenteric fibromatosis presenting as megaduodenum.

A case of spontaneous isolated mesenteric fibromatosis presenting as megaduodenum is reported. The lesion was small, only 2 cm in its greatest diameter. However, because of its location near the ligament of Treitz and because of its characteristic infiltrative growth pattern, the tumour involved the distal duodenum and resulted in acute angulation and obstruction early in its course. We successfully resected the mass and the patient is in fair physical condition 6 months after operation.

Pseudomelanosis duodeni in an adolescent male: case report and review of the literature.

Pseudomelanosis duodeni is rarely seen in children. It manifests endoscopically as peppery speckles in the duodenal mucosa. This pigment corresponds principally to accumulation of ferrous sulfide in macrophages within the lamina propria. We report the case of a 16-year-old boy with ectodermal dysplasia who underwent renal transplantation for vesicoureteral reflux and later developed epigastric pain. Endoscopic and pathologic findings in the duodenal mucosa were typical of pseudomelanosis duodeni. A review of the literature reveals shared clinical features among reported adult and pediatric cases, including chronic renal failure, use of antihypertensive medication and oral iron supplementation, and/or presence of gastric hemorrhage.

Clinical and pathologic features of the nodular duodenum.

Nodular duodenum, frequently described as nodular duodenitis, is endoscopically characterized by multiple erythematous nodules in the proximal duodenum and may represent a variant of duodenal inflammation. This study examines the incidence, clinical presentation, histologic correlates, natural history, and response to therapy of nodular duodenum in 83 patients who presented with epigastric pain, heartburn, early satiety, bloating, nausea, vomiting, or gastrointestinal bleeding. There was a previous history of peptic ulcer disease in 58% of patients and gastroesophageal reflux in 33%. None of the patients had associated end-stage renal disease. Endoscopically, in addition to nodular duodenum, esophagitis was found in 17% of patients and gastritis in 32%. Histology of duodenal nodules revealed chronic inflammation in 58% of patients, Brunner's gland hyperplasia in 9%, gastric heterotopia in 7%, and normal mucosa in 26% of patients. In a group of 34 patients studied prospectively, high dosage (300 mg orally bid) therapy with the H2-antagonist ranitidine for 8 wk significantly improved symptoms and endoscopic appearance (p < 0.05). In 26 patients who completely or partially failed H2-antagonist therapy, continuation of therapy with omeprazole (40 mg orally qd) for 8 wk significantly improved symptoms and endoscopic findings (p < 0.05) in 10 patients. These therapeutic approaches led to improvement in the endoscopic findings, but to no statistically significant changes in the underlying histologic appearance of the duodenum. We conclude that nodular duodenum is an endoscopically distinct entity that may respond clinically to antisecretory therapy, but remains difficult to eradicate completely.

Fish oil reduces ethanol-induced damage of the duodenal mucosa in humans.

Eight healthy volunteers were studied before and after 3 weeks of dietary supplementation with fish oil (10.5 g day-1, 18% (1.9 g) eicosapentaenoic acid). Duodenal mucosal lesions were induced by instillation of 40 ml ethanol (40%). Mean endoscopic lesion score was lower after fish oil treatment (1.62 +/- 0.32; mean +/- SEM) than before (3.25 +/- 0.31; P less than 0.01). Histologic lesion score fell from 22.75 +/- 1.98 before treatment to 13.50 +/- 1.51 after fish oil (P less than 0.01). Basal and pentagastrin-stimulated gastric acid output remained unaffected. Release of prostaglandin E2, 6-keto-prostaglandin F1 alpha, and thromboxane B2 from biopsy specimens of the duodenal mucosa in vitro was not significantly altered after fish oil ingestion. In the same in vitro system calcium ionophore A23187-induced release of total leukotriene C (LTC) increased from 10.6 +/- 1.5 ng g-1 mucosa 20 min before treatment to 30.4 +/- 3.2 ng after fish oil. High pressure liquid chromatography analysis showed that this increase was partly due to formation of LTC5 as after fish oil 28% of total LTC were identified as LTC5 whereas 72% were LTC4. We conclude that in humans fish oil reduces ethanol-induced damage of the duodenal mucosa without inhibiting gastric acid secretion or stimulating prostaglandin formation. It remains to be clarified if the changes in leukotriene formation are relevant for the mucosaprotective fish oil effect.

Pseudomelanosis duodeni: a case report with electron-probe X-ray analysis.

Pseudomelanosis of the duodenum is rare. Only 17 cases have been documented in the world literature. A 59-year-old man presented to Bankstown Hospital, New South Wales with dysphagia. On endoscopy, he was found to have melanosis of the duodenum in addition to oesophageal ulceration. It has been previously suggested that the pigment ferrous sulphide is derived from gastro-intestinal bleeding and lodged in the macrophages. A detailed examination of the pigment, including X-ray probe micro-analysis at various levels of the intestinal epithelium as well as in macrophages is presented.

NSAID-associated gastroduodenal damage: does famotidine protection extend into the mid- and distal duodenum?

Eighteen healthy volunteers were included in a cross-over, double-blind study where 500 mg naproxen b.d. was given for 1 week with 20 mg famotidine b.d., 40 mg nocte or placebo. Endoscopic evaluation of the gastroduodenal mucosa was performed before and after each treatment period, with separate evaluation of the mid- and distal duodenum. 51Cr-EDTA-permeability tests were done to study effects on the mid- and distal gut, and, in addition, symptom registration was performed. The mucosal damage was significant in all treatment periods, and a statistically significant reduction was seen with 20 mg famotidine b.d. for erosive lesions in the stomach/duodenal bulb region as well as for the sum of damage score in the mid- and distal duodenum. The reduction was considerable in a few subjects with extensive duodenal damage. The reduction was considerable in a few subjects with extensive duodenal damage. Intestinal permeation increased significantly in all periods, and was not reduced by famotidine. Symptoms were modest and equal in all periods.

Clinical and ultrastructural studies in duodenal pseudomelanosis.

Nine patients with duodenal pseudomelanosis are described: seven had endstage renal failure while one other patient had undergone renal transplantation. Eight of the nine had been on oral iron supplements. The pigment stained positively with Perls' stain for iron in five patients, positively with the Masson-Fontana method normally used to identify melanin in one, and positively with both methods in three. Electron probe x-ray analysis of the pigment on samples from six patients showed iron to be present in all six, while sulphur was present in five. Varying sulphur content of the pigment in different patients could account for differences in histochemical characteristics. Iron was also shown in the duodenal biopsies of 34 of 48 uraemic patients on oral iron supplements, but was present in only 22 of 120 patients endoscoped for miscellaneous conditions (p less than 0.001). We postulate that the pigment of duodenal pseudomelanosis is derived from iron absorbed from the lumen.

The enhancement by dietary zinc deficiency of the susceptibility of the rat duodenum to colchicine.

1. The incidence of colchicine-induced lesions in the germinal epithelium oof the rat duodenum was studied in young rats in an early stage of zinc deficiency and in their pair-fed controls. At both dose levels of colchicine used, a marked increase in the amount of cell damage was observed in the duodenum of Zn-deficient rats as compared with the pair-fed, control (Zn-supplemented) rats. 2. No statistical interaction between Zn and colchicine was demonstrable, and no lesions were found in the duodenum of animals that had not been treated with colchicine. 3. The results are discussed in relation to the effects of Zn deficiency in animals and the possible involvement of Zn in the maintenance of the integrity of microtubular structures.