IgG4-related disease presenting with gastric outlet obstruction.

A woman in her 20s presented with 6 weeks of fever, persistent vomiting and 28% loss of body weight. Symptoms were refractory to treatment with antiemetics and broad spectrum antibiotics.Further investigation via oesophageogastroduedenoscopy revealed a large gastric ulcer and pyloric stricture, causing gastric outlet obstruction (GOO). Biopsies of the stomach and duodenum showed plasma cell infiltration with a large proportion being IgG4 positive.Treatment with methylprednisolone, and later prednisolone, quickly improved inflammatory markers and symptoms. Balloon dilatation of the pyloric stricture also improved vomiting, allowing eventual re-establishment of oral nutrition. The patient made a full recovery with maintenance treatment on mycophenolate mofetil.IgG4-related disease (IgG4-RD) is a multisystem disorder with unpredictable presentation. The case highlights diagnostic challenges in IgG4-RD and identifies it as a rare differential in upper gastrointestinal symptoms. To our knowledge this is the first published case of IgG4-RD in the duodenum causing GOO.

[Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction].

Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.

Unusual case of Niemeier type II gallbladder perforation: case report and literature review.

Niemeier type II gallbladder perforation (GBP) is caused by inflammation and necrosis of the gallbladder wall followed by bile spilling into the abdominal cavity after perforation. The gallbladder then becomes adhered to the surrounding inflammatory tissue to form a purulent envelope, which communicates with the gallbladder. At present, the clinical characteristics and treatment of type II GBP are not well understood and management of GBP remains controversial. Type II GBP with gastric outlet obstruction is rare and prone to misdiagnosis and delayed treatment. Recent systematic reviews report that percutaneous drainage does not influence outcomes. In this current case, due to the high risk of bleeding and accidental injury, as well as a lack of access to safely visualize the Calot's triangle, the patient could not undergo laparoscopic cholecystectomy, which would have been the ideal option. This current case report presents the use of percutaneous laparoscopic drainage combined with percutaneous transhepatic gallbladder drainage in a patient with type II GBP associated with gastric outlet obstruction. A review of the relevant literature has been provided in addition to a summary of the clinical manifestations and treatments for type II GBP.

Gastric outlet obstruction as an unusual presentation of metastatic breast carcinoma.

Gastrointestinal (GI) metastasis from breast carcinoma is a rare occurrence. If metastasis occurs to the stomach/duodenum, it can present with symptoms of gastric outlet obstruction (GOO). Hence, it clinically mimics a variety of benign as well as malignant causes of GOO, including primary malignancy. GI metastasis from breast carcinoma occurs several years after the primary diagnosis and sometimes may be the first presenting symptom. If clinical records are not available, it may be misdiagnosed as poorly differentiated adenocarcinoma on biopsy. A high index of suspicion, subtle histologic clues, and appropriate immunohistochemistry helps in clinching the right diagnosis. Hereby, we report the case of a 55-year-old female who presented with metastasis to the duodenum 8 years post mastectomy which mimicked a primary ampullary/periampullary tumor.

Endoscopic therapy for Bouveret syndrome, illustrated by a case report.

Bouveret syndrome is an exceptionally rare form of gallstone ileus secondary to a bilioenteric fistula, through which a voluminous gallstone can migrate into the pylorus or duodenum, thereby causing gastric outlet obstruction. In order to increase awareness, we reviewed the clinical features, diagnostic tools and management options for this uncommon entity. We specifically focus on endoscopic therapeutic options, illustrated by a case of a 73 year old woman with Bouveret syndrome, where endoscopic electrohydraulic lithotripsy was successful in relieving gastroduodenal obstruction.

Aetiology and clinical spectrum of gastric outlet obstruction in North West India.

Our study to evaluate the aetiological and clinical spectrum of gastric outlet obstruction (GOO) in North-west India showed malignant cause (54.9%) was more common than benign (45.1%). Common causes of malignancy were gall bladder (37.5%), gastric (31.8%) and pancreatic carcinoma (19.6%); commonest benign causes were opioid abuse (29%), peptic ulcer disease (21.6%), ingestion of corrosives (20.2%) and chronic pancreatitis (12.3%).

Five-year Progress of Gastric MALT Lymphoma Presenting as Gastric Outlet Obstruction.

This paper reports a 70-year-old female with gastric extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (gastric MALT lymphoma) as a rare case of gastric outlet obstruction. Five years earlier, she initially presented with weight loss and anemia. Esophagogastroduodenoscopy (EGD) revealed multiple gastric and duodenal ulcers with a pyloric deformity, while histology revealed chronic active inflammation and a Helicobacter pylori (H. pylori) infection. Three years earlier, she underwent EGD per the National Cancer Screening Program and was diagnosed with antral and duodenal ulcers. A forceps biopsy specimen from one of the ulcers showed the findings of gastric MALT lymphoma, but she did not visit the hospital for proper management. She visited complaining of a loss of appetite. EGD revealed a gastric outlet obstruction (GOO) caused by antral deformity and pyloric narrowing. A staged workup with CT and PET revealed full-layered, encircling antral wall thickening and several enlarged mesenteric lymph nodes. She was finally diagnosed with a gastric MALT lymphoma at Ann Arbor stage I1E with translocation t(11;18). She was treated with palliative surgery for GOO and systemic chemotherapy with a CHOP regimen. This paper reports a gastric MALT lymphoma that progressed from superficial mucosal lesions to an overt mass with regional lymph node metastasis for five years.

Type II Congenital Pyloric Atresia with Desquamative Enteropathy Diagnosed Postoperatively: A Case Report.

Congenital pyloric atresia (CPA) is a rare condition that presents as gastric outlet obstruction in the first few weeks of life. Isolated CPA typically carries a good prognosis but when associated with other conditions such as multiple intestinal atresia or epidermolysis bullosa (EB), the outcomes are generally poor. This report describes a four-day-old infant who presented with nonbilious emesis and weight loss in whom an upper gastrointestinal contrast study revealed gastric outlet obstruction determined to be consistent with pyloric atresia. The patient underwent operative repair via Heineke-Mikulicz pyloroplasty. Postoperatively, the patient continued to have severe diarrhea and was found to have desquamative enteropathy though had no skin findings consistent with EB. This report emphasizes consideration of CPA as a differential diagnosis for neonates presenting with nonbilious emesis and demonstrates the association between CPA and desquamative enteropathy without EB.

Comparison of novel large-bore and conventional-bore covered self-expandable metal stents for malignant gastric outlet obstruction: Multicenter, retrospective study.

OBJECTIVES: Covered self-expandable metal stent (cSEMS) for gastric outlet obstruction (GOO) has been developed to overcome tumor ingrowth but is prone to be associated with an increased risk of migration. Clinical impact of the novel large-bore cSEMS for malignant GOO remains unclear. METHODS: A total of 117 patients undergoing endoscopic cSEMS placement for malignant GOO were enrolled in this multicenter retrospective study. Technical and clinical success, adverse events, recurrent GOO, and survival after stent placement were compared between 24 mm-cSEMS (n = 49) and 20 mm-cSEMS (n = 68). RESULTS: Patient characteristics were well-balanced and thus similar survival was observed between the two groups (136 days vs. 89 days, P = 0.60). Technical success rate of 100% and clinical success rate of 96% were achieved both in 24 mm-cSEMS and 20 mm-cSEMS, respectively. The median cumulative time to recurrent GOO was significantly longer in 24 mm-cSEMS than in 20 mm-cSEMS (380 days vs. 138 days, P = 0.01). The incidence of adverse events and recurrent GOO was comparable: 12% vs. 15% (P = 0.91), and 16% vs. 31% (P = 0.11); however, no stent migration was observed in 24 mm-cSEMS. In a subgroup analysis, the superiority of 24 mm-cSEMS to 20 mm-cSEMS was demonstrated in extrinsic cancers (380 days vs. 121 days, P = 0.01) but not in intrinsic cancers (151 days vs. not reached, P = 0.47). CONCLUSIONS: The 24 mm-cSEMS may improve time to recurrent GOO with ensuring acceptable safety in patients with malignant GOO.

Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review.

BACKGROUND: Visceral artery aneurysms (VAA) are rare with an incidence of up to 0.2% and mortality of up to 40%. Aneurysms larger than 5 cm are referred to as giant visceral artery aneurysms (GVAA). We present a case of a celiac artery aneurysm of 14 cm which required endovascular and surgical management. A review of the literature with focus on treatment is also provided. CASE PRESENTATION: In this case report, a 76-year-old male presented with postprandial nausea and vomitus. An ultrasound and computed tomography scan showed an aneurysm of the celiac artery of approximately 14 cm. Initial treatment was conducted with coiling. Despite this treatment, patient presented again with the same complaints, most likely due to gastric outlet syndrome caused by the aneurysm sac. Partial open removal of the aneurysm sac was performed with release of the duodenum. Due to recurring dysphagia and postprandial nausea, a gastroenterostomy was created, which was later supplemented with a Roux-en-Y anastomosis due to gastroparesis. Patient recovered uneventful after the Roux-en-Y and was discharged from the hospital. CONCLUSION: Giant visceral artery aneurysms sometimes need multimodal treatment. We showed that an endovascular first approach of a giant visceral artery aneurysm is not only technically feasible, but it also facilitates subsequent open surgery due to limiting blood loss and reducing the need for extensive mobilisation of the viscera to gain arterial control.

Gastric Perforation Encountered during Duodenal Stent Insertion.

Gastric outlet obstruction is a major symptom in patients with advanced pancreatic cancer. Endoscopic intervention is often challenging in severe strictures because the guidewire cannot pass beyond the stricture. Sometimes, the air itself cannot pass beyond the stricture, which can result in a severely distended stomach. Such a stomach is vulnerable to excessive air insertion or mechanical stress during endoscopic procedures, and endoscopists may encounter a higher rate of complications. Gastric perforation is rare but could be fatal. However, endoscopic management can show a favorable result if the perforation is noticed early. The authors report a case of the perforation of a gastric tear during duodenal stent insertion in a patient with a gastric outlet obstruction.

Cokeromyces recurvatus Incidentally Found in a Patient with Gastric Outlet Obstruction.

Isolation of Cokeromyces recurvatus, a dimorphic mucormycete fungus, from clinical specimens poses a diagnostic challenge to physicians and laboratorians as this organism may represent a rare colonizer or true pathogen. Here, we report a case of Cokeromyces recurvatus present in a circumferential duodenal lesion. The patient is a 64-year-old with no past medical history, admitted with a three-week history of left upper quadrant abdominal pain. Computerized tomography scan identified duodenitis with significant gastric outlet obstruction, confirmed by the presence of a partially obstructing non-bleeding duodenal ulcer on upper endoscopy. Histology showed variably sized spherical structures without nuclei, reproductive tracts, or alimentary tracts. Small, clustered spherules representing putative endospores were observed within the larger structures and in the exudate. Based on the histology, the differential included Coccidioides spp, Emmonsia spp, or Chrysosporium spp. Additionally, gastric biopsies revealed concurrent Helicobacter pylori gastritis. The fungus was identified as C. recurvatus by broad-range fungal polymerase chain reaction performed on formalin-fixed paraffin-embedded biopsy tissue, as well as morphology and DNA sequencing of the cultured isolate. The fungus had low MICs to all major antifungal classes; however, in the context of the Helicobacter pylori infection, the patient was only treated with amoxicillin and clarithromycin with improvement in his symptoms before hospital discharge. Only three cases of Cokeromyces recurvatus isolated from the GI tract have been reported; this case highlights a unique clinical presentation in the small bowel in a patient without underlying medical conditions.

Endoscopic Ultrasonography-guided Gastrojejunostomy for Patients with Gastric Outlet Obstruction and Pyloric Metal Stent Dysfunction.

A 52-year-old woman with a gastric outlet obstruction (GOO) caused by pyloric cancer underwent pyloric endoscopic self-expandable metal stent (SEMS) insertion. She presented with abdominal distension 40 days later. The SEMS was dysfunctional, and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) was performed using an endoscopic nasobiliary drainage tube. A 16 mm×31 mm Niti-S ™ HOT SPAXUS™ (TaeWoong Medical, Gimpo, Korea) was inserted successfully between the stomach and the adjacent jejunum. After the procedure, the patient had a good oral intake for more than seven months. GOO is a mechanical obstructive condition caused by various benign and malignant conditions. Traditionally, surgical GJ and SEMS insertion have been used to treat GOOs. EUS-GJ is a feasible treatment option for patients with GOO and a pyloric metal stent dysfunction.

High prevalence of peritoneal metastasis in gastric cancer presenting gastric outlet obstruction: A new candidate for consecutive diagnostic staging laparoscopy and laparoscopic gastrojejunostomy.

INTRODUCTION: Gastric cancer presenting gastric outlet obstruction (GC-GOO) is associated with two problems to be considered in its treatment: peritoneal metastasis and an inability to intake food. Because peritoneal metastasis is difficult to identify in standard examinations, laparoscopic gastrojejunostomy (LGJ), which consecutively follows diagnostic staging laparoscopy (DSL), may be a minimally invasive solution to these diagnostic and therapeutic problems. However, whether GC-GOO is a new candidate for DSL has been not evaluated. MATERIALS AND METHODS: GC-GOO patients who were surgically treated at our department between 2005 and 2014 were recruited. Patient backgrounds, preoperative and surgical findings for distant metastasis, and surgical curability were retrospectively evaluated. To predict peritoneal metastasis, the sensitivity, specificity, and positive and negative predictive values of preoperative factors were calculated. The survival outcomes were also evaluated according to surgical curability and non-curative factors. RESULTS: A total of 237 patients with GC-GOO were included in this study. Among them, 167 patients had no distant metastasis identified preoperatively. Seventy-one of 167 patients underwent curative surgery while 75 (44.9%) had peritoneal metastasis including positive lavage cytology. Ascites and large type 3 or type 4 tumors indicated high specificity (86.9% and 76.1%, respectively) and the involvement of gastric angle presented high sensitivity (90.7%) for peritoneal metastasis. The overall survival of patients with incurable surgery was worse than that of patients with curative surgery, regardless of their incurable factors. CONCLUSION: GC-GOO is a new candidate for DSL. DSL followed by LGJ may be proposed, utilizing preoperative predictive factors for peritoneal metastasis.

A gastric outlet thickened mucosal fold associated with cytomegalovirus infection in an extremely preterm infant managed by surgical resection.

Non-bilious vomiting in preterm neonates discharged from neonatal intensive care units is a common complaint and is often associated with benign conditions such as gastro-oesophageal reflux. A neonate of 27 weeks gestation who presented later with vomiting owing to gastric outlet obstruction is described. He was discharged at 11 weeks of age and required re-admission 1 week later. He had persistent non-bilious vomiting from 7 weeks of age, failure to thrive and metabolic alkalosis. Clinical examination demonstrated visible gastric peristalsis, and hypertrophic pyloric stenosis was suspected. Ultrasound of the gastric pylorus and upper gastro-intestinal contrast studies were negative. Exploratory laparotomy after failure of conservative management revealed a thickened mucosal fold in the gastric pylorus, which was excised. Histopathology demonstrated inclusion bodies which are pathognomonic of cytomegalovirus infection. He was treated with valganciclovir for 6 weeks and was asymptomatic and thriving well at follow-up. Gastric outlet obstruction can be one of the manifestations of CMV infection of the gastro-intestinal tract. Diagnosis can be confirmed only by histopathology.Abbreviations: BPD: bronchopulmonary dysplasia; CMV: cytomegalovirus; H&E: haematoxylin and eosin; IHC: immunohistochemistry; IHPS: infantile hypertrophic pyloric stenosis; NEC: necrotising enterocolitis; PCR: polymerase-chain reaction; VGP: visible gastric peristalsis.