Primary jejunogastric intussusception: A case report and review of the literature.

INTRODUCTION: Jejunogastric intussusception following gastric surgery is a rare complication that, if not diagnosed early, can have catastrophic outcomes. PRESENTATION OF CASE: We have reported a case, never described previously, of an acute spontaneous retrograde JGI, presenting with obstruction and hematemesis, in a 70-year-old woman who has never, previously, undergone abdominal surgery. DISCUSSION: As in all cases of intestinal intussusception, early diagnosis is important for acute JGI as mortality rates increase from 10% when the intervention occurs within 48 h. to 50% if treatment is delayed for 96 h. The diagnosis of JGI can be determined with many imaging studies, such as endoscopy, ultrasonography (US), barium stadium and CT scan. Although JGI, up to now, has been described as a rare complication after any type of gastric surgery, this disease must, however, be suspected also in patients who have never undergone abdominal surgery, if they present with non-sedable abdominal pain associated with signs of high intestinal obstruction and hematemesis. CONCLUSION: Our hope is to add to the available literature to aid physicians in their diagnostic work-up and in developing management plans for similar cases occurring in the future.

Intestinal obstruction and ischemia by necrotic annular Meckel's diverticulum: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Diagnosis of MD is a challenge because of its rarity and frequent asymptomaticity. Radiological exams generally aren't useful for its diagnosis. Intestinal obstruction represents the most common complication of MD in adults. Surgery is the appropriate treatment of complicated MD. CASE PRESENTATION: A 70-year-old Caucasian male was admitted to the Emergency Department with a two-day history of abdominal pain associated with inability to pass gas or stool, nausea and vomiting. Physical examination revealed abdominal distention and abdominal pain without Blumberg's sign. Abdominal contrast-enhanced computed tomography (CECT) showed small bowel obstruction caused by suspected MD. Laboratory tests reported high serum levels of glycemia, LDH, C-reactive protein and leukocytosis. After diagnosis of intestinal obstruction, the patient underwent exploratory laparotomy: a segmental resection of ischemic distal ileum bearing a necrotic MD was performed. The postoperative course of patient was uneventful. CLINICAL DISCUSSION: MD is found in 2%-4% of the population in large autopsy and surgical series. MD is mostly asymptomatic and incidentally discovered if not complicated; a debate exist about management of asymptomatic MD. Surgery represents the definitive treatment of complicated MD. CONCLUSION: MD is a true diverticulum rarely discovered in adults. Diagnosis of MD is difficult even with the help of radiological exams. Although surgical resection represents the correct treatment of symptomatic MD, nowadays there is no consensus on the optimal treatment of asymptomatic and incidentally discovered MD.

Acute intrathoracic gastric volvulus with retrograde gastric intussusception: A case report of a rare surgical emergency with review of the literature.

INTRODUCTION: The gastric volvulus is a rare condition in which the stomach, or part of it, rotates on its axis, for over 180°, constituting a surgical emergency. Even more rare is gastro-gastric intussusception. A delay in their diagnosis and treatment can have fatal consequences PRESENTATION OF CASE: An 82-year-old woman was admitted to the Surgery Unit with a two-day history of abdominal pain associated at first with coffee vomiting and, subsequently, with unproductive retching and oligoanuria. Physical examination showed severe dehydration, fever, at the abdominal level, palpation caused a marked tenderness of all quadrants, with signs of peritonism. Laboratory test showed showed neutrophilic hyperleukocytosis and high C reactive protein level. Abdominal computed tomography revealed an acute intrathoracic gastric volvulus and a gastrogastric intussuception. The patient was submitted to exploratory laparotomy, subtotal gastrectomy with Roux en Y anastomosis and simple plastic of the esophageal hiatus. At the end of the surgery, however, the patient died of your septic shock. DISCUSSION: The traditional treatment for a patient with acute gastric volvulus is an immediate surgical intervention to derotate the stomach and prevent vascular insufficiency. In the presence of necrosis or gastric perforation, resection should be performed. The few cases of gastrogastric intussusception described in the literature have been treated with sub-total gastrectomy and gastro-jejunal anastomosis. Any delay in diagnosis and treatment can prove fatal. CONCLUSION: Intrathoracic Gastric Volvulus and, even more, retrograde gastrointestinal intussusception are very rare pathologies, difficult to diagnose.

Bouveret's syndrome as a rare complication of cholelithiasis: Disputes in current management and report of two cases.

INTRODUCTION: Bouveret's syndrome is a rare complication of cholelithiasis that determines an unusual type of gallstone ileus, secondary to an acquired fistula between the gallbladder and either the duodenum or stomach with impaction of a large gallbladder stone. Preoperative diagnosis is difficult because of its rarity and the absence of typical symptoms. Adequate treatment consists of endoscopic or surgical removal of obstructive stone. PRESENTATION OF CASES: Two old females patients were admitted to the Emergency Department with a history of abdominal pain associated with bilious vomiting. Physical examination revealed abdominal distension with tympanic percussion of the upper quadrants, abdominal pain on deep palpation of all quadrants and in the first patient positive Murphy's sign. Preoperative diagnosis of gallstone impacted in the duodenum was obtained by abdominal computed tomography (CT) scan in the first patient and by esophagogastroduodenoscopy in the second one. Both patients underwent surgery with extraction of the gallstone from the stomach. Postoperative course of two patients was uneventful and they were discharged home. DISCUSSION: Bouveret's syndrome usually presents with signs and symptoms of gastric outlet obstruction. Preoperative radiological investigations not always are useful for its diagnosis. Appropriate treatment, endoscopic or surgical, is debated and must be tailored to each patient considering medical condition, age and comorbidities. CONCLUSION: Bouveret's syndrome is a very rare complication of cholelithiasis, difficult to diagnose and suspect, because of lack of pathognomonic symptoms. Nowaday there are no guidelines for the correct management of this pathology. Endoscopic or surgical removal of obstructive stone represents the correct treatment.

Tubulo-villous adenoma of the appendix: A case report and review of the literature.

INTRODUCTION: Tubulo-villous adenoma is a rare benign appendiceal neoplasm often asymptomatic with the most clinical manifestation that resembles acute appendicitis. Pre-operative diagnosis is difficult by its rarity and the absence of typical symptoms. Adequate treatment is surgical resection. PRESENTATION OF CASE: A 69-year-old male was admitted to the Emergency Department with a two-day history of abdominal pain associated with constipation. Abdominal examination revealed abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. Laboratory tests showed a normal white blood cell count with 82.3% neutrophils and high C-reactive protein level. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography, which revealed acute appendicitis. The patient was submitted to surgery and open appendectomy was performed. The post-operative course was uneventful and the patient was discharged on the 5th post-operative day. DISCUSSION: Acute appendicitis may be a clinical manifestation of a benign appendiceal neoplasm. Pre-operative radiological investigations not always are useful for an early diagnosis that is mandatory because of the potential risk of malignant degeneration. Appropriate treatment of acute appendicitis is debated: some surgeons suggest operative treatment, but others advocate for non-operative management. In our case the patient was submitted to surgery avoiding the risk of diagnostic delay of neoplasm. CONCLUSION: Appendiceal tubulo-villous adenoma is a rare neoplasm difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. Acute appendicitis is the most common clinical presentation. Appendectomy is the appropriate treatment.