Gastric ectopic pyloric opening: an unusual case.

Stomach is the most dilated part of the digestive tube. The shape of the stomach could vary frequently without any clinical symptoms. Abnormality of pylorus including double pylorus and congenital pyloric stenosis has been reported but pyloric ectopic opening has not been reported before. We found a rare case of pyloric ectopic opening in the stomach body with a "hammer" shape stomach in a 72-year-old man. The patient complained of upper left abdominal with no past medical history or surgery history. The double-contrast examination showed a "hammer" shape stomach, with the pylorus opening high at the lesser curvature and enlarged distal end of the stomach. The gastrointestinal endoscopy showed that the pyloric antrum was approximately 3 cm below the cardia with a round and poor functioning opening. No obvious abnormalities in the bulb and descending part of the duodenum were observed. A large ulcer with whitish exudate covering the base was found on the posterior wall. Histological examination of the ulcer showed broken mucosal glands with atypical hyperplasia and focal carcinogenesis. This case shows a probably congenital pyloric ectopic opening in the gastric body with a "hammer"-shaped stomach, adding a new gastric morphological variation.

Treatment of Congenital Gastric Outlet Obstruction due to a Web: A Retrospective Single-center Review.

BACKGROUND: Congenital gastric antral web and congenital pyloric atresia are rare reasons of congenital gastric outlet obstruction (CGOO). Depending on the different forms, the symptoms vary from unspecific epigastric pain to nonbilious "projectile" vomiting, ileus and failure to thrive. Throughout the years, many different treatment options are described, like simple surgical dilatation, incision or excision of the membrane, possibly combined with a pyloroplasty. PATIENTS AND METHODS: In this retrospective single-center observation study, we present 9 cases with different kinds of webs leading to CGOO. In a time period of 45 years (1970 to 2015) different treatment strategies and limitations of minimal invasive endoscopic treatment on the basis of complications and outcome are discussed. RESULTS: Six patients had an incomplete antrum web. One patient suffered from a complete antrum web. In addition, in 2 patients a complete pyloric web, as well as an incomplete pyloric web was found. During the past 45 years, the treatment options for CGOO due to webs changed, and with the development of smaller and more flexible video endoscopes an endoscopic treatment has become feasible. The treatment strategy and follow-up examination was specific to every patient. CONCLUSION: On the basis of our review, minimal endoscopic procedures in small newborns and toddlers require a high level of experience. They are technically challenging and need suitable equipment. Overall, endoscopists and pediatric surgeons should equally be prepared for all possible complications in every treatment step. The endoscopic approach to managing this unusual disease may require multiple interventions and is associated with a risk of perforation. Therefore, we are convinced that centers undertaking this treatment modality should be equipped with the proper instrumentation, prepared to perform multiple endoscopic interventions, and supported with an ability to emergently convert to surgery if required.

Diagnosis and treatment of gastric antral webs in pediatric patients.

BACKGROUND: Gastric antral webs are mucosal structures, varying from fenestrated diaphragms to mucosal crescents, resulting in varying degrees of foregut obstruction. Patients commonly present with vomiting, failure to thrive, and abdominal pain. Prevalence is unknown, and diagnosis can be difficult. METHODS: We performed an IRB-approved retrospective review of patients from 4/1/2015-4/1/2018 at a Level I Children's Surgery Center undergoing gastric antral web resection. Data obtained included demographics, preoperative workup, surgical repair, and outcomes. RESULTS: Twenty-one patients were identified; 67% were male with an average age of 30 months at diagnosis. Initial diagnosis was established by a combination of fluoroscopy and esophagogastroduodenoscopy (EGD) in all patients. Patients presented with emesis (76%), failure to thrive (57%), need for post-pyloric tube feeds (33%), and abdominal pain (14%). Web localization without intraoperative EGD (n = 3) was initially challenging. As a result, intraoperative EGD was combined with operative antral web resection to facilitate web localization (n = 18). Web marking techniques have evolved from marking with suture (n = 1) and tattoo (n = 2), to endoscopic clip application (n = 12). All 21 patients underwent web resection, 2 were performed laparoscopically. Twenty underwent Heineke-Mikulicz pyloroplasty during the initial surgery. Average length of stay was 5.5 days. There were no intraoperative complications or deaths. Permanent symptom resolution occurred in 90% of patients immediately, with a statistically significant decrease in emesis (p < 0.001), failure to thrive (p < 0.001), and need for post-pyloric tube feeding (p = 0.009) within 6 months of surgery. CONCLUSION: Gastric antral webs should be considered in the differential diagnosis for a child with persistent vomiting. Web resection with the use of intraoperative endoscopic localization can result in permanent symptom resolution in the majority of these patients.

Uncommon congenital antral web misdiagnosed twice as a pyloric ulcer: successful treatment with endoscopic balloon dilatation.

Congenital antral webs are quite rare and easily overlooked or misdiagnosed. We report the case of a five-year-old boy who presented with symptoms of gastric outlet obstruction for four years; his condition was misdiagnosed twice as pyloric ulcer. Detailed gastroscopy revealed a congenital antral web. The stricture was successfully treated with endoscopic balloon dilatation without surgery.

Pyloroduodenal duplication cysts: treatment of 11 cases.

INTRODUCTION: Abdominal enteric duplications are found in 1 out of 4,500 autopsies, and only 4 to 5% of them are located in the duodenum, where they may be connected with the biliary or pancreatic ducts. The aim of this study was to describe the clinical features, management, and outcome of a large series of duodenal duplication cysts. MATERIALS AND METHODS: The charts of all patients treated at our institution between 1985 and 2011 were reviewed retrospectively with particular attention to imaging, surgical technique, pathology, and outcome. RESULTS: During that period, 11 cases (81.8% females) were treated. Out of the 11 patients, 8 were symptomatic (vomiting in 3, recurrent acute pancreatitis in 2, and abdominal pain in 3) and 3 were tentatively diagnosed prenatally as choledochal cysts. Median age at surgery was 2.3 years (0 to 13.7) and preoperative diagnosis was correct in five cases. Five cysts were developed intraluminally and three communicated with the biliary duct (one), pancreatic duct (one), or both (one). Surgical treatment consisted of complete resection (four cases, including one pancreaticoduodenectomy), partial removal including all mucosa (four cases), and internal marsupialization (three cases). In all cases, the ductal communications were divided and opened into the duodenal lumen. In six cases, ectopic gastric mucosa was found. All patients recovered uneventfully. CONCLUSION: Duodenal duplication cysts are rare and may have bizarre anatomical patterns due to biliopancreatic involvement. Optimal treatment is complete surgical removal, and, if this is not possible, partial removal including the mucosa or marsupialization are also good alternatives. In cases with biliary and pancreatic tract connections, these have to be taken down carefully and drained into the duodenum.

Isolated intramuscular fibrous band masquerading antral web in a premature neonate. A case report.

Isolated fibrous gastric antral band in a neonate causing partial gastric obstruction and mimicking prepyloric antral web is not reported in the English literature, and we would like to report the first case. A premature neonate with feeding difficulties and bilious aspirate underwent upper gastrointestinal contrast examination. The upper gastrointestinal series showed a thin, radiolucent, circumferential band in the antrum with delayed gastric emptying. Radiographic diagnosis of prepyloric antral web with partial gastric obstruction was made. Intraoperatively, a circumferential fibrous cord was found in the muscle layer (tunica muscularis) of the antrum, which was completely divided. Clinically and radiographically, the 2 conditions could not be differentiated but require 2 separate surgical techniques for their management.

[Prepyloric antral web--a rare cause of gastric outlet obstruction]. / Præpylorisk antral web--en sjælden årsag til pylorusobstruktion.

A case of gastric outlet obstruction secondary to prepyloric antral web in a four-year-old boy with cerebral pareses is reported. Routine roentgenographic examination was initially misinterpreted as duodenal obstruction. Prepyloric antral web was suspected by subsequent endoscopy and was confirmed by operation. The patient underwent antropyloroplasty that resulted in excellent recovery. The possibility of a prepyloric antral web should be considered in any infant or child with persistent vomiting when pyloric stenosis is excluded.

Elimination of postoperative pyloric stricture by endoscopic electrocauterization and balloon dilatation in an infant with congenital antral web.

We, herein, report a male infant who presented with recurrent pyloric stricture after two surgeries (web excision and antropyloroplasty), which were done, respectively, at 5 days of age for congenital antral web and 6 months of age for the subsequent pyloric stricture. The patient suffered from anorexia, progressed vomiting, and weight loss gradually after the first and second surgeries, and then, endoscopy revealed severe pyloric deformity and stricture. Poor inflation was noted during endoscopic balloon dilatation because of tight pylorus; a subsequent electrocauterization and balloon dilatation were done, and the patient's clinical symptoms improved significantly 2 weeks later. A follow-up endoscopy was performed 1 month and 12 months after endoscopic therapy, showing steady regression of pyloric stricture. The patient had adequate diet intake and growth in the later 12 months.

Hereditary multiple intestinal atresias: 2 new cases and review of the literature.

Intestinal atresias are a common cause of newborn bowel obstruction (Dalla Vecchia LK, Grosfeld JL, West KW, et al, Intestinal atresia and stenosis: a 25-year experience with 277 cases. Arch Surg 1998; 133[5]:490-496). Hereditary multiple intestinal atresias, first reported by Guttman et al in 1973, is the rarest form of multiple atresias (Guttman FM, Braun P, Garance PH, et al, Multiple atresias and a new syndrome of hereditary multiple atresias involving the gastrointestinal tract from stomach to rectum. J Pediatr Surg 1973;8:633-640; Bass J, Pyloric atresia associated with multiple intestinal atresias and immune deficiency. J Pediatr Surg 2002;37:941-942.). It has been proposed to be autosomal recessive, to involve atresias in a variable combination of sites from stomach to rectum, and to be universally fatal (Bilodeau A, Prasil P, Cloutier R, et al, Hereditary multiple intestinal atresia: thirty years later. J Pediatr Surg 2004;39:726-730; Moreno LA, Gottrand F, Turck D, et al, Severe combined immunodeficiency syndrome associated with autosomal recessive familial multiple gastrointestinal atresias: study of a family. Am J Med Genet 1990;37:143-146). Patients have significant intestinal dysfunction and unrelenting sepsis stemming from a poorly defined, severe immunologic defect. Our case report presents 2 full siblings to nonconsanguineous parents with pyloric atresia, multiple small bowel and colonic atresias, and severe immune dysfunction. Care was withdrawn within 3 months of life on both siblings after multiple bouts of sepsis. Data suggest that the immune defect may not be primary, but in fact be secondary to intestinal dysfunction. Although the subjects in this article ultimately had fatal outcomes, a comprehensive immunologic/physiologic picture is presented in hopes of furthering the understanding of this grave disease.

[Clinical and therapeutical considerations regarding a rare case of pre-pyloric stenosis]. / Consideratii clinico-terapeutice privind un caz rar de stenoza prepilorica.

The neonatal obstacle caused by a pre-pyloric diaphragm represent a rare cause of high oclusion in new-born. We present the case of a 6 days old new-born admitted in our department for nonbilious vomiting and feeding intolerance in which the clinical exam and the imagistic explorations (plain and contrast abdominal X-Rays, and ultrasound) could not reveal an evident cause for the oclusion. The surgical intervention imposed by the simptoms revealed the existece of a complete diaphragm in the prepyloric region. The initial excision of the diaphragm was not sufficient, the patient undergoing a second surgical intervention of gastrojejunal anastromosis with favorable evolution this time. The authors are presenting diagnosis and theraputical management peculiarities of this rare condition.

Role of the homeodomain transcription factor Bapx1 in mouse distal stomach development.

BACKGROUND & AIMS: Expansion and patterning of the endoderm generate a highly ordered, multiorgan digestive system in vertebrate animals. Among distal foregut derivatives, the gastric corpus, antrum, pylorus, and duodenum are distinct structures with sharp boundaries. Some homeodomain transcription factors expressed in gut mesenchyme convey positional information required for anterior-posterior patterning of the digestive tract. Barx1, in particular, controls stomach differentiation and morphogenesis. The Nirenberg and Kim homeobox gene Bapx1 (Nkx3-2) has an established role in skeletal development, but its function in the mammalian gut is less clear. METHODS: We generated a Bapx1(Cre) knock-in allele to fate map Bapx1-expressing cells and evaluate its function in gastrointestinal development. RESULTS: Bapx1-expressing cells populate the gut mesenchyme with a rostral boundary in the hindstomach near the junction of the gastric corpus and antrum. Smooth muscle differentiation and distribution of early regional markers are ostensibly normal in Bapx1(Cre/Cre) gut, but there are distinctive morphologic abnormalities near this rostral Bapx1 domain: the antral segment of the stomach is markedly shortened, and the pyloric constriction is lost. Comparison of expression domains and examination of stomach phenotypes in single and compound Barx1 and Bapx1 mutant mice suggests a hierarchy between these 2 factors; Bapx1 expression is lost in the absence of Barx1. CONCLUSIONS: This study reveals the nonredundant requirement for Bapx1 in distal stomach development, places it within a Barx1-dependent pathway, and illustrates the pervasive influence of gut mesenchyme homeobox genes on endoderm differentiation and digestive organogenesis.

Ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum in a newborn with pyloric atresia, annular pancreas and congenital short bowel syndrome.

We report a newborn with bilious vomiting and the rare combination of pyloric atresia, annular pancreas and ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum. Radiologic, sonographic and percutaneous transhepatic transcholecystic cholangiographic (PTTC) findings, with surgical correlation, are presented.