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.

Intramural Duodenal Hematoma in a Case of Hyper IgM Syndrome.

Three-year-old boy who presented with colicky abdominal pain, diarrhoea and vomiting was investigated with computed tomography which revealed a mass in the peripancreatic region. An imaging possibility of duodenal intramural hematoma was considered after reassessment with ultrasound which was subsequently confirmed by magnetic resonance imaging. The development of a spontaneous duodenal hematoma lead to further evaluation of the patient and revealed X linked hyper IgM syndrome.

A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging.

BACKGROUND: Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis. METHODS: Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation. RESULTS: The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation. CONCLUSIONS: The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.

Diverticulitis associated pancreatitis: a report of 2 cases and review of the literature.

Duodenal diverticula are the second most common type of digestive diverticula after those in the colon. They are present in approximately 27% of patients who undergo upper digestive endoscopy. Most of these diverticula, especially those located near the papilla, are asymptomatic. However, in rare cases, they can be associated with obstructive jaundice (Lemmel Syndrome), bacterial infection, pancreatitis, or bleeding. In this report, we present two cases of acute obstructive pancreatitis caused by duodenal diverticulitis. Both patients were managed conservatively, resulting in a positive outcome.

Case Report: Duodenal Papillary Stenosis Secondary to Strongyloides stercoralis Infection in a Non-Immunocompromised Host.

Strongyloides stercoralis infection is a common infection in tropical and subtropical regions and is considered one of the "neglected tropical diseases." Owing to its life cycle, this infection can remain undetectable for years, preventing an early diagnosis and prompt treatment. We report the case of a 65-year-old woman who presented to us with a history of nausea, abdominal pain, bloating, and weight loss and, after initial radiologic and laboratory workup, was diagnosed with a periampullary mass with no secondary spread. She underwent an uneventful pylorus-preserving pancreatoduodenectomy, and on histopathological study of the lesion, a diagnosis of S. stercoralis infection was confirmed. This case stands out because of the importance of keeping S. stercoralis infections as a differential diagnosis of periampullary masses, particularly when the patient comes from regions where S. stercoralis is prevalent.

Intestinal obstruction secondary to Brunner's glands hyperplasia.

Brunner's gland hyperplasia constitutes 10.6% of benign tumors of the duodenum, with an incidence of 0.008%. It is usually an incidental finding during endoscopy or imaging tests as they are small and asymptomatic. In the case of symptomatic tumors, resection of the lesion is indicated. In lesions ≤2 cm, endoscopic resection can be chosen, reserving surgery for larger lesions or endoscopically inaccessible ones. We present the case of a patient with a history of vomiting and hyporexia of months of evolution who presented peptic ulcer perforation and underwent surgery. During follow-up, she presented intestinal obstruction due to pyloric stenosis. Given the impossibility of ruling out a neoplastic process with certainty in diagnostic tests, surgical resection (antrectomy) was decided with an anatomopathological finding of Brunner's gland hyperplasia.

Factors and techniques associated with endoscopic retrograde cholangiopancreatography outcomes in patients with periampullary diverticulum: Results from a large tertiary center.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) for patients with periampullary diverticulum (PAD) remains a challenge. This study aims to investigate the factors and techniques related to successful and safe ERCP in patients with PAD. Methods: We enrolled patients who underwent ERCP in a large tertiary center. The difficult cannulation rate, technical success rate, clinical success rate, and adverse events (AEs) rate were compared between patients with or without PAD. Three independent logistic regression models were established to identify factors and techniques associated with difficult cannulation, clinical success, and AEs. Results: Five thousand five hundred and ninety patients were included, of which 705 (12.6%) were diagnosed with PAD. Patients with PAD had a significantly higher difficult cannulation rate compared with patients without PAD (10.6% vs 8.0%, P < 0.0001), but the rates of technical success (clinical success (95.2% vs 95.2%, P = 0.951), and AEs (16.5% vs 14.4%, P = 0.156) were similar. Type I PAD (odds ratio [OR] = 2.114, 95% confidence interval [CI]:1.05-5.25) and ERCP indication for pancreatic diseases (OR = 1.196, 95%CI: 1.053-1.261) were independently associated with difficult cannulation. Small endoscopic sphincterotomy (EST) with balloon dilatation (OR = 1.581, 95%CI: 1.044-2.393) was independently associated with clinical success. Somatostatin injection showed no preventive effect on post-ERCP pancreatitis (OR = 1.144, 95%CI: 1.044-1.254). Moreover, the auxiliary cannulation techniques were safe for PAD patients. Conclusions: PAD did not affect ERCP outcomes. However, the choice of techniques and AE prophylactic measures should be more specific, especially for patients with type I PAD.

Delayed duodenal stump fistula after laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer: A case report.

Duodenal stump fistula (DSF) is one of the most serious complications of gastrectomy. The mean time to diagnosis of DSF is approximately 9 days after operation. Our report describes an extremely rare case of delayed DSF 144 days after a laparoscopic distal gastrectomy. A 58-year-old man with drug-induced liver cirrhosis (Child-Pugh class A) underwent laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer. On postoperative day 1, he underwent reoperation because of intra-abdominal bleeding. Ongoing bleeding was observed in the stapler line of the duodenal stump and was controlled using metallic surgical clips. The patient was discharged on postoperative day 14, without complications. After 144 days following the first operation, he visited the emergency room with right flank pain and high fever. Computed tomography revealed free air and abscess near the duodenal stump site. Emergency laparotomy, abscess unlooping, and drain insertion were performed. After surgery, bile was drained by intra-abdominal drainage, and fistulography showed a duodenal fistula. The patient was discharged 55 days after his third surgery. This is an extremely rare case of DSF, which may be caused by the metallic surgical clips used for hemostasis of the duodenal stump stapler line. We believe that the use of metallic surgical clips for hemostasis of the duodenal stump after Billroth-II reconstruction should be avoided.

Endoscopic management of intramural spontaneous duodenal hematoma: A case report.

BACKGROUND: Intramural duodenal hematoma is a rare condition described for the first time in 1838. This condition is usually associated with blunt abdominal trauma in children. Other non-traumatic risk factors for spontaneous duodenal haematoma include several pancreatic diseases, coagulation disorders, malignancy, collagenosis, peptic ulcers, vasculitis and upper endoscopy procedures. In adults the most common risk factor reported is anticoagulation therapy. The clinical presentation may vary from mild abdominal pain to acute abdomen and intestinal obstruction or gastrointestinal bleeding. CASE SUMMARY: The aim of this case summary is to show a case of intramural spontaneous hematoma with symptoms of intestinal obstruction that was properly drained endoscopically by an innovative system lumen-apposing metal stent Hot AXIOS™ stent (Boston Scientific Corp., Marlborough, MA, United States). CONCLUSION: Endoscopic lumen-apposing metal stent Hot AXIOS™ stent is a safe and feasible treatment of duodenal intramural hematoma in our case.