Concomitant Sigmoid Diverticulitis and Periampullary Duodenal Diverticulitis Complicated by Lemmel Syndrome: A Case Report.

Diverticular disease is a major cause of hospitalizations, especially in the elderly. Although diverticulosis and its complications predominately affect the colon, the formation of diverticula in the small intestine, most commonly in the duodenum, is well characterized in the literature. Although small bowel diverticula are typically asymptomatic, and diagnosed incidentally, a complication of periampullary duodenal diverticulum is Lemmel syndrome. Lemmel syndrome is an extremely rare condition whereby periampullary duodenal diverticula, most commonly without diverticulitis, leads to obstruction of the common bile duct due to mass effect and associated complications including acute cholangitis and pancreatitis. Here, we present the first case, to our knowledge, of periampullary duodenal diverticulitis complicated by Lemmel syndrome with concomitant colonic diverticulitis with colovesical fistula. Our case and literature review emphasizes that Lemmel syndrome can present with or without suggestions of obstructive jaundice and can most often be managed conservatively if caught early, except in the setting of emergent complications.

Gastric emphysema and pneumatosis intestinalis in two common marmosets with duodenal dilation syndrome.

BACKGROUND: Common marmosets (Callithrix jacchus) are widely used as primate experimental models in biomedical research. Duodenal dilation with chronic vomiting in captive common marmosets is a recently described life-threatening syndrome that is problematic for health control. However, the pathogenesis and cause of death are not fully understood. CASE PRESENTATION: We report two novel necropsy cases in which captive common marmosets were histopathologically diagnosed with gastric emphysema (GE) and pneumatosis intestinalis (PI). Marmoset duodenal dilation syndrome was confirmed in each case by clinical observation of chronic vomiting and by gross necropsy findings showing a dilated, gas-filled and fluid-filled descending duodenum that adhered to the ascending colon. A diagnosis of GE and PI was made on the basis of the bubble-like morphology of the gastric and intestinal mucosa, with histological examination revealing numerous vacuoles diffused throughout the lamina propria mucosae and submucosa. Immunostaining for prospero homeobox 1 and CD31 distinguished gas cysts from blood and lymph vessels. The presence of hepatic portal venous gas in case 1 and possible secondary bacteremia-related septic shock in case 2 were suggested to be acute life-threatening abdominal processes resulting from gastric emphysema and pneumatosis intestinalis. CONCLUSIONS: In both cases, the gross and histopathological findings of gas cysts in the GI tract walls matched the features of human GE and PI. These findings contribute to clarifying the cause of death in captive marmosets that have died of gastrointestinal diseases.

Surgical management of duodenal crohn's disease.

BACKGROUND: Operative options for duodenal Crohn's disease include bypass, stricturoplasty, or resection. What factors are associated with operation selection and whether differences exist in outcomes is unknown. METHODS: Patients with duodenal Crohn's disease requiring operative intervention across a multi-state health system were identified. Patient and operative characteristics, short-term surgical outcomes, and the need for future endoscopic or surgical management of duodenal Crohn's disease were analyzed. RESULTS: 40 patients underwent bypass (n = 26), stricturoplasty (n = 8), or resection (n = 6). Median age of diagnosis of Crohn's disease was 23.5 years, and over half of the patients had undergone prior surgery for CD. Operation type varied by the most proximal extent of duodenal involvement. Patients with proximal duodenal CD underwent bypass operations more commonly than those with mid- or distal duodenal disease (p = 0.03). Patients who underwent duodenal stricturoplasty more often required concomitant operations for other sites of small bowel or colonic CD (63%) compared to those who underwent bypass (39%) or resection (33%). No patients required subsequent surgery for duodenal CD at a median follow-up of 2.8 years, but two patients required endoscopic dilation (n = 1 after stricturoplasty, n = 1 after resection). CONCLUSION: Patients who require surgery for duodenal Crohn's disease appear to have an aggressive Crohn's disease phenotype, represented by a younger age of diagnosis and a high rate of prior resection for Crohn's disease. Choice of operation varied by proximal extent of duodenal Crohn's disease.

Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review.

BACKGROUND: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection. METHOD: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure. RESULTS: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure. CONCLUSIONS: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity.

A rare cause of intestinal obstruction: right paraduodenal hernia.

Internal herniation is an extremely rare cause of intestinal obstruction. Paraduodenal hernias result from abnormal rotation of the bowel. Symptoms that may range from recurrent abdominal pain to acute obstruction may occur. If it is not diagnosed and treated in time, the disease may result in intestinal ischemia. This article aimed to present the diagnosis and treatment process of a 47-year-old male presenting with acute abdomen symptoms by evaluating retrospectively with the accompaniment of literature. During the abdominal exploration of the patient, nearly all of the intestines were observed to be herniated from the right paraduodenal region to the posterior area. The opening of the hernial sac was repaired primarily by reducing the intestinal bowel loops into the intraperitoneal region. The patient undergoing anastomosis by performing resection of the ischemic part after reduction of herniated bowel loops was discharged uneventfully on the post-operative 10th day. Paraduodenal hernia is a condition that should be considered in patients with abdominal pain and intestinal obstruction symptoms. Early diagnosis is of vital importance to prevent the complications which can develop.

Sonographic features of Lemmel's syndrome: Differential diagnosis from stones in the lower portion of the common bile duct.

BACKGROUND AND STUDY AIMS: Periampullary diverticula (PAD), a location-specific type of duodenal diverticula, can cause serious complications. PAD is difficult to differentially diagnose, mainly due to its nonspecific symptoms. This study aimed to identify sonographic features of PAD and to evaluate their value in the differential diagnosis of PAD from stones in the lower common bile duct (CBD). PATIENTS AND METHODS: A total of 30 patients with PAD and 60 patients with lower CBD stones were retrospectively enrolled, and sonographic features were analyzed. Measurements of sonographic features included echo shaped, posterior echo changes, location and relation to surrounding organs, and status of intrahepatic and extrahepatic bile duct dilation, and their diagnostic performance was assessed. RESULTS: Characteristic sonographic features of PAD were identified, including strong echoes (28/30, 93.3 %), strip shape (28/30, 93.3 %), multiple reflections in the posterior echo (27/30, 90.0 %), and location outside the CBD or near the biliary wall in connection with the duodenum (27/30, 90.0 %). Inter-observer agreement was good (Kappa values = 0.69-0.82). Comparative analysis of sonographic features revealed significant differences in echo shape, posterior echo changes (multiple reflections and acoustic shadowing), location and relation to surrounding organs, and intrahepatic and extrahepatic bile duct dilatation status between the dilatation status of the two groups. In particular, these characteristics achieved a sensitivity of 100 % and a specificity of 98 % for the differential diagnosis of PAD and lower CBD stones. CONCLUSIONS: This study identified characteristic sonographic features of PAD, which could be used as potential diagnostic indicators to distinguish PAD from lower CBD stones.

[Primary aortoduodenal fistula - a rare cause of life-threatening upper gastrointestinal bleeding]. / Primär aortoduodenal fistel.

Primary aortoduodenal fistula is a rare condition caused mainly by a bulging infra-renal aortic aneurysm with subsequent erosion of the duodenum and formation of a fistula. We present a patient who suffered from a herald upper gastrointestinal bleeding followed by circulo-respiratory collapse only hours after, due to bleeding from the fistula. The mortality is reported to be 100 %, requiring emergency EVAR or open aortic graft repair to control any further bleeding.

Brunner's gland hamartomas: Not always benign.

Brunner's gland hamartoma (BGH) is a rare, benign tumor of the duodenum. It is mostly asymptomatic and usually found incidentally on routine esophagogastroduodenoscopy (EGD). However, some BGHs present with major complications including anemia, bleeding, obstruction, or dysplasia, requiring management and resection of these lesions. Herein, we present two cases of large BGHs of the duodenum, one presenting as severe gastrointestinal bleeding and the other, noted on EGD for iron deficiency anemia, found to have high grade dysplasia. This literature review discusses the rare serious complications of BGH, including iron deficiency anemia, overt gastrointestinal bleeding, and malignant potential.

[Intestinal malrotation accompanied by a right paraduodenal hernia in an adult: a case report].

A 72-year-old woman was admitted to our department in March 2020 for an evaluation of nausea, vomiting, diarrhea, liver dysfunction, and hypokalemia, which had persisted intermittently since 2013. Thickening of the descending duodenal wall and a sac-like appearance the intestinal tract in the vicinity of the duodenal papilla were observed in abdominal computed tomography. No duodenojejunal curvature, with two intestinal loops identified in the descending region, was detected in contrast-enhanced upper gastrointestinal imaging. Based on these imaging findings, the patient was diagnosed with intestinal malrotation (incomplete rotation and fixation) accompanied by a right paraduodenal hernia based on the Nishijima classification. Thus, surgery was performed at our hospital. Gastrointestinal symptoms did not recur, and liver dysfunction and hypokalemia improved postoperatively.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula.

BACKGROUND: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach. CASE PRESENTATION: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications. CONCLUSIONS: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Spontaneous duodenal wall hematoma.

59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms.

Multi-slice spiral computed tomography diagnosis of juxta-papillary duodenal diverticulum and its relationship with biliopancreatic diseases.

BACKGROUND: Juxta-papillary duodenal diverticula (JPDD) are common but are usually asymptomatic, and they are often diagnosed by coincidence. OBJECTIVE: To analyse the anatomy and classification of JPDD and its relationship with biliary and pancreatic disorders, and to explore the diagnostic value of multi-slice spiral computed tomography (MSCT) in patients with JPDD. METHODS: The imaging data of patients with JPDD, which was obtained via abdominal computed tomography examination and confirmed via gastroscopy and/or upper gastrointestinal barium enema, in our hospital from 1 January 2019 to 31 December 2020 were retrospectively analysed. All patients were scanned using MSCT, and the imaging findings, classification and grading were analysed. RESULTS: A total of 119 duodenal diverticula were detected in 96 patients, including 73 single diverticula and 23 multiple diverticula. The imaging findings were mainly cystic lesions of the inner wall of the duodenum protruding to the outside of the cavity. The thin layer showed a narrow neck connected with the duodenal cavity, and the shape and size of the diverticula were different: 67 central-type cases and 29 peripheral-type cases. There were 50 cases of type I, 33 cases of type II, 19 cases of type III and six cases of type IV. Furthermore, there were seven small, 87 medium and 14 large diverticula. The differences in the location and size of the JPDD in MSCT grading were statistically significant (P< 0.05). CONCLUSION: The MSCT method has an important diagnostic value for the classification of JPDD, and MSCT images are helpful in the clinical evaluation of patients with JPDD and the selection of treatment options.