ABSTRACT
Background: The coexistence of Crohn's disease (CD) and acute appendicitis (AA) is rare. In this situation, therapeutic experience is lacking and the strategy is paradoxical and intractable. Appendectomy is the gold standard for the treatment of AA whereas a nonsurgical approach is recommended for CD. Case summary: A 17-year-old boy was hospitalized for right lower abdominal pain with fever of 3 days. He had the CD for 8 years. Two years ago, he underwent surgery for anal fistula with the complication of CD. His temperature was elevated at 38.3°C at admission. On physical examination, there was McBurney tenderness with mild rebound tenderness. Abdominal ultrasonography showed that the appendix was notably enlarged and dilated at 6.34 cm long and 2.76 cm wide. These findings were suggestive of uncomplicated AA in this patient with active CD. Endoscopic retrograde appendicitis therapy (ERAT) was performed. The patient had complete pain relief immediately after the procedure without tenderness in the right lower abdomen. During 18 mo follow-up, he had no more attacks in his right lower abdomen. Conclusion: ERAT was effective and safe in a CD patient with coexisting AA. Such cases can avoid surgery and its-related complications.
ABSTRACT
BACKGROUND: Pancreaticobiliary maljunction (PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct (CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum (PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition. Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct. CASE SUMMARY: A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain. CONCLUSION: We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases, especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.
ABSTRACT
BACKGROUND: Diagnostic peritoneoscopy is typically performed by using a rigid laparoscope. Inspired by gastric submucosal tunneling for peritoneal natural orifice transluminal endoscopic surgery access and peroral endoscopic myotomy for the treatment of achalasia, we developed a novel esophago-cardial-gastric tunneling (ECGT) peritoneoscopy technique with a flexible endoscope. This study aims to evaluate its feasibility and safety. MATERIALS AND METHODS: The study comprised 10 Beagle dogs. A longitudinal mucosal incision was made on the esophageal wall, and a submucosal tunnel was created through the cardia into the stomach. An incision was made in the muscular layer of the stomach, and then the endoscope was advanced into the peritoneal cavity. Peritoneoscopy with the flexible endoscope was performed. After intraperitoneal exploration, the esophageal mucosal entry was closed with endoclips. All dogs resumed food intake 12 hours after the procedures. Diets, behavior, and body temperature of all of the dogs were observed. Endoscopic examinations were performed 4 weeks after the procedure, and then the animals were sacrificed for necropsy. RESULTS: The ECGT peritoneoscopy was successfully done in all dogs. Diets, behavior, and body temperature were normal in all dogs. The entry of the esophagus was healed well in 9 dogs; the mucosa of the entry was torn in 1 dog, but the submucosal tunnel was healed well at the cardia. Necropsy showed complete closure of the gastric serosal exit, and no intraperitoneal abscess was found. Histopathological examinations showed submucosal tunnels healed well. CONCLUSIONS: The ECGT peritoneoscopy is feasible and safe for peritoneal exploration. It should be a good choice for the clinical application of diagnostic peritoneoscopy.
