Severe complications of chronic cholelithiasis treatment.

BACKGROUND: Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible. CASE PRESENTATION: We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management. CONCLUSION: Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

A giant Brunner's gland hamartoma being treated as a pedunculated polyp: a case report.

BACKGROUND: With the development and application of endoscopic technology, most pedunculated polyps can be absolutely resected with a complete specimen by hot snare polypectomy (HSP). Brunner's gland hamartoma (BGH) is a rare benign small bowel tumor. The majority of BGH measuring about 2 cm in diameter, rarely larger than 5 cm. Most patients are asymptomatic, some may present with gastrointestinal hemorrhage or intestinal obstruction. Symptomatic larger lesions leading to bleeding or obstruction should be excised either endoscopically or surgically. Whether it is safe and effective that removing a BGH measuring about 7 cm by HSP is not known. CASE PRESENTATION: Here, we reported a rare case of a proximal duodenum pedunculated mass measuring about 7 cm which was responsible for the patient's severe anemia. we treated it as a pedunculated polyp. After being pretreated the stalk with an endoloop which was placed around the base of the mass to prevent post-polypectomy bleeding (PPB), the pedunculated BGH was removed by HSP completely. The stalk of the mass was negative. We achieved a curative resection. CONCLUSION: It is a safe and effective for our patient to treat the pedunculated BGH measuring about 7 cm as a pedunculated polyp and remove it by HSP. And future prospective studies in larger cohorts are needed to confirm it.

A Case of Recurrent Secondary Aortoenteric Fistula 4 Months after Surgery Treated by Endovascular Coiling of the Aortic Stump and Bilateral Chimney Stent Grafts to Renal Arteries.

The treatment of recurrent aortoenteric fistula (AEF) previously repaired by surgery is challenging, with a high mortality rate. Open repair is often limited by "hostile abdomen," while endovascular treatment is difficult when the distance between the aortic stump and the origin of the renal arteries is short, with high risk of their occlusion. We describe a recurrent AEF repaired by surgery 4 months earlier, treated by endovascular coiling of the aortic stump after deployment of 2 renal artery stent grafts with the chimney technique.

Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report.

BACKGROUND: Primary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate. CASE PRESENTATION: We report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta. CONCLUSIONS: A timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

Dieulafoy's lesion of the duodenum: a comparative review of 37 cases.

Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.

An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children.

BACKGROUND: Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function. PURPOSE: This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).

Palliative end ileostomy and gastrojejunostomy for a metastatic distal transverse colonic malignancy complicated by a proximal duodenocolic fistula: a case report.

BACKGROUND: Fistulae between the colon and upper gastrointestinal tract are distressing and uncommon complications of malignancies involving this region. We report a case of a middle-aged man with a locally advanced and metastatic distal transverse colon malignancy who presented with a duodenocolic fistula proximal to the primary tumor and underwent palliative surgery. CASE PRESENTATION: A 50-year-old Sri Lankan man presented to our hospital with a history of feculent vomiting of 1 week's duration preceded by worsening constipation and abdominal fullness of 2 months' duration. He also complained of anorexia and significant weight loss over the previous month. His physical examination was unremarkable except for his wasted appearance. Flexible sigmoidoscopy done at his local hospital had not revealed any abnormality in the left colon. Gastroduodenoscopy did not reveal fecal matter or any mucosal abnormalities in the stomach or duodenum. An abdominal contrast-enhanced computed tomographic scan showed a mid-to-distal transverse colonic tumor with a duodenocolic fistula proximal to the primary lesion. At laparotomy, he was found to have an unresectable, locally advanced mid transverse colon tumor with diffuse peritoneal and mesenteric deposits and mild ascites. Palliative end ileostomy and gastrojejunostomy were performed before closure. Histology from the malignant deposits revealed a well-differentiated adenocarcinoma. He made an uneventful recovery with good symptomatic relief. CONCLUSIONS: Malignant gastric or duodenocolic fistulae are uncommon complications of locally advanced colonic malignancies with direct invasion to the stomach or duodenum. Although the characteristic clinical presentation of feculent vomiting suggests the diagnosis, cross-sectional imaging is confirmative in addition to staging the disease. Management is guided by disease stage, nutritional status, and the general condition of the patient and ranges from extensive bowel resection including the fistula to palliative options.

Endoscopic Manifestations and Clinical Characteristics of Cytomegalovirus Infection in the Upper Gastrointestinal Tract.

We retrospectively analyzed the cases of 14 patients (9 women, 5 men, mean age: 51.6 years) with cytomegalovirus (CMV) involvement in the esophagus, stomach, and/or duodenum diagnosed at a single center, to determine their endoscopic features and clinical backgrounds. Thirteen patients (92.9%) had hematologic disease; the other had rheumatoid arthritis. Of the former, 12 patients underwent allogeneic hematopoietic stem cell transplantation, and 9 of these patients had graft-versus-host disease (GVHD) before undergoing esophagogastroduodenoscopy (EGD). All 14 patients had been taking one or more immunosuppressive agents including cyclosporine (n=10), corticosteroids (n=9), mycophenolic acid (n=6), tacrolimus (n=3), and methotrexate (n=1). Tests for CMV antigenemia were positive in 11 patients (78.6%). EGD examinations revealed esophageal (n=3), gastric (n=9), and duodenal involvement (n=6). Macroscopically, esophageal lesions by CMV infection presented as redness (n=1), erosions (n=1), and ulcers (n=1). Gastric lesions manifested as redness (n=7), erosions (n=3), exfoliated mucosa (n=2), and verrucous erosions (n=1). Mucosal appearances in the duodenum varied: redness (n=2), ulcers (n=2), multiple erosions (n=2), single erosion (n=1), edema (n=1). CMV was detected even in the intact duodenal mucosa (n=1). In conclusion, physicians must recall the relevance of CMV infection when any mucosal alterations exist in the upper gastrointestinal tract of immunosuppressed patients.

Ranitidine Can Potentiate The Prokinetic Effect Of Itopride At Low Doses- An In Vitro Study.

BACKGROUND: Gastroparesis and GERD occur concomitantly in 40 percent of the cases. Prokinetic drugs and acid blockers are employed as the main treatment modality. Ranitidine is an acid blocker with additional prokinetic activity and Itopride is a known prokinetic drug. This study was designed to observe the synergistic potentiating prokinetic effect of Ranitidine on itopride on isolated duodenum of rabbits. METHODS: Ranitidine (10-5-10-3) and itopride (10-6-10-5) were added in increasing concentrations to isolated duodenum of rabbits and contractions were recorded on PowerLab Data acquisition unit AHK/214. Cumulative dose response curves were constructed. The potentiating prokinetic effect of Ranitidine on itopride was seen by using a fixed dose of ranitidine and cumulatively enhancing doses of itopride on iWorx. RESULTS: Ranitidine and itopride produced a dose dependent reversible contraction of the isolated tissue of rabbits with ranitidine showing a max response of 0.124mV and itopride showing a maximum response of 0.131mV. Ranitidine was able to potentiate the prokinetic effect of itopride at low doses but at high dose the effect began to wane off. CONCLUSIONS: Ranitidine and itopride produce a statistically significant synergistic potentiating prokinetic effect at low doses in vitro.

[The consequences of cholecystectomy]. / Posledstviya kholetsistektomii (s kommentariem).

AIM: to analyze the consequences of cholecystectomy. MATERIAL AND METHODS: 348 patients were under observation within 10  years after cholecystectomy. Surgery for destructive and chronic cholecystitis was performed in 115 and 233 patients respectively. The consequences of cholecystectomy were assessed using bile acids level in blood plasma, stomach and duodenal pressure, pancreatic and stomach changes. RESULTS AND DISCUSSION: It was established that lithocholic, deoxycholic, taurodeoxycholic acids were increased by 44% within 10 years after surgery. At the same time glycocholic and tauroursodeoxycholic acids were decreased by 21.5% in 5 years after surgery. Bile acids level changes were associated with changes of stomach and duodenal pressure. The most pronounced disorders were observed in distal duodenum. There was more than 2.8-fold excess of normal pressure in this area. Duodenal hypertension was accompanied by pancreatic ducts enlargement in 9.5% of cases and increased echogenicity in 93% of cases. CONCLUSION: Changes of the level and proportion of blood plasma bile acids and hypertension in upper gastrointestinal tract are the most important in chronic pancreatitis pathogenesis after cholecystectomy. Such conditions occur within first 3 years after surgery.

Extra-ampullary Peutz-Jeghers polyp causing duodenal intussusception leading to biliary obstruction: a case report.

BACKGROUND: Duodenal Peutz-Jeghers polyp is a rare cause of duodenal or biliary obstruction. However, a sporadic Peutz-Jeghers polyp leading to simultaneous biliary and duodenal obstruction has not been reported. CASE PRESENTATION: We report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical "Peutz-Jeghers polyp". As there was not enough evidence to diagnose Peutz-Jeghers syndrome this was considered to be a sporadic Peutz-Jeghers polyp. CONCLUSION: Rare benign causes such as a duodenal polyp should be considered and looked for in initial imaging, when the cause for concurrent biliary and intestinal obstruction is uncertain, particularly in young individuals.

Complete Ipsilateral Femoral Approach Using an Iliac Branch Device to Preserve a Sole Internal Iliac Artery After Aortic Stent-Graft Placement.

PURPOSE: To report implantation of an iliac branch device (IBD) for preserving antegrade blood flow to a sole internal iliac artery (IIA) via an ipsilateral approach during endovascular repair to reline an aortobi-iliac allograft. TECHNIQUE: The technique is described in a 55-year-old man with an enteric fistula involving an aortobi-iliac Y-prosthesis. After complete excision, the prosthesis was replaced by an allograft. Due to rebleeding and resuturing of the graft, total stent-graft relining of the allograft was planned with preservation of the sole left IIA using an iliac side branch (ZBIS). During introduction of a 12-F sheath over the allograft's neobifurcation to establish a femorofemoral through-and-through approach, the allograft ruptured. A compliant balloon was inflated to control the hemorrhage. The IBD was first fully deployed, followed by stent-graft relining. Consequently, stent-graft implantation in the left IIA using a crossover maneuver was no longer feasible, so a 0.035-inch super stiff wire was introduced through the IBD's 20-F sheath. A 12-mm semi-compliant balloon was inflated in the common iliac artery above the iliac branch to act as an abutment for a 7-F sheath to run over the stiff wire into the IIA for delivery/deployment of a stent-graft. CONCLUSION: It is feasible to use a complete ipsilateral femoral approach for IBD implantation after aortic stent-graft placement.

[THE REMOTE RESULTS OF SIMULTANEOUS LAPAROSCOPIC CORRECTION OF CHRONIC DUODENAL OBSTRICTION AND CHOLECYSTECTOMY IN CHOLELITHIASIS].

The aim of the research was to investigate the remote results of surgical treatment of 75 patients with cholelithiasis combined with chronic duodenal obstruction. Control group was composed of 40 patients who underwent laparoscopic cholecystectomy. Compensated stage of cholelithiasis with chronic duodenal obstruction was detected in 16 (21.3%) patients, subcompensated in 37 (49.3%) and decompensated stage in 17 (22.7%) patients. In 14 patients (18.7%) with cholelithiasis combined with chronic duodenal obstruction laparoscopic cholecystectomy was conducted due to the positive results of preoperative conservative treatment. In the long-term quality of life after surgery in the main group of patients were average 35.4% higher than in the control group; in the main group postcholecystectomical syndrome was diagnosed in one case (2,1%) and in 13 (32,2%) cases in the control group.