Tratamiento endoscópico de la obstrucción del tracto de salida gástrico de origen péptico-cicatricial en un niño de 4 años / Endoscopic treatment of cicatricial pyloric stenosis of peptic origin in a 4-year-old boy

La obstrucción de la salida gástrica es una afección infrecuente en la edad pediátrica. Tradicionalmente, la cirugía ha sido el modo de tratamiento estándar, pero está asociada a mayor morbimortalidad. El tratamiento endoscópico ha surgido como una alternativa al tratamiento convencional. Presentamos el caso de un paciente de 4 años con estenosis prepilórica secundaria a enfermedad ulceropéptica. El cuadro clínico empezó con vómitos y dolor abdominal de 2 meses de evolución. Frente a la falta de respuesta al tratamiento médico y a la dilatación endoscópica con balón, se realizaron incisiones radiadas con electrocauterio e inyecciones de esteroides. La terapéutica endoscópica con balón debería ser el primer gesto terapéutico en este tipo de estenosis refractarias al tratamiento médico

Gastric outlet obstruction is an uncommon condition in children. Traditionally, surgery has been the standard mode of treatment, but it is associated with higher morbidity and mortality. Endoscopic treatment has emerged as an alternative to conventional treatment. We present the case of a 4-year-old patient with refractory prepyloric stenosis secondary to peptic ulcer disease. The picture begins with vomiting and abdominal pain of 2 months of evolution. Pre-pyloric stenosis was confirmed. Faced with the lack of response to medical treatment and balloon dilation, radiated incisions were made with electrocautery and steroid injections. When medical treatment is not sufficient, endoscopic balloon therapy should be the first therapeutic gesture in this type of stenosis; given its refractoriness, we believe it is important to highlight the usefulness of endoscopic treatment, which could prevent surgery and associated morbidity and mortality.

Obstrução gástrica por bezoar / Gastric obstruction due to bezoar

A obstrução por bezoar é um acúmulo de material parcialmente ou não digerido no estômago. Bezoares gástricos são raros e ocorrem com mais frequência em pacientes com transtornos de comportamento, esvaziamento gástrico anormal ou após cirurgia gástrica. Podem ser assintomáticos ou apresentar sintomas como dor abdominal e vômitos incoercíveis. Podem ainda ter composições diversas e ocorrer em todas as faixas etárias. O objetivo deste relato foi demonstrar um caso de bezoar gástrico em paciente previamente submetido à cirurgia bariátrica e internado com quadro de vômitos incoercíveis e hemorragia digestiva alta, com a demonstração de que sua resolução completa ocorreu na realização da segunda endoscopia.

Bezoar obstruction is an accumulation of partially digested or undigested material in the stomach. Gastric bezoars are rare and occur more frequently in patients with behavioral disorders, abnormal gastric emptying, or after gastric surgery. They may be asymptomatic or present with symptoms such as abdominal pain and incoercible vomiting. They can have diverse compositions and occur in all age groups. The aim of this report was to demonstrate a case of gastric bezoar in a patient who previously underwent a bariatric surgery and was hospitalized with incoercible vomiting and upper gastrointestinal hemorrhage, with the demonstration that its complete resolution occurred during the second endoscopy.

EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center

SUMMARY INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

RESUMO INTRODUÇÃO: A gastroenterostomia ecoguiada é um novo procedimento para paliação da obstrução maligna gastroduodenal. Nosso objetivo foi avaliar os resultados dessa técnica em nossa experiência inicial. MÉTODOS: Foram incluídos pacientes com obstrução maligna gastroduodenal de nossa instituição. O sucesso técnico foi definido como a realização adequada de uma gastroenterostomia. O sucesso clínico foi definido como boa aceitação de dieta pastosa durante a internação. Os eventos adversos e a aceitação alimentar foram avaliados um mês após o procedimento. RESULTADOS: Três pacientes foram incluídos. Os sucessos técnico e clínico foram alcançados em todos os casos. Não houve eventos adversos e a aceitação alimentar permaneceu adequada um mês após o procedimento nos pacientes incluídos. CONCLUSÃO: O EUS-GE é um tratamento promissor para pacientes com obstrução maligna gastroduodenal.

Gastric outlet obstruction as manifestation of eosinophilic gastroenteritis / Obstrucción gástrica como manifestación de gastroenteritis eosinofílica

RESUMEN La gastroenteritis eosinofílica (EG) es una entidad poco frecuente. Presentamos un varón de 55 años sin antecedentes de atopía ni alergia, que presentó dolor abdominal y vómitos. La tomografía computarizada abdominal y la ecoendoscopia demostraron engrosamiento de la pared gástrica con engrosamiento de la pared del duodeno superior, sin masa definida ni colección de líquido. La endoscopia gastrointestinal confirmó engrosamiento de pliegues prepilóricos y duodeno superior con estenosis luminal. Se realizó gastrectomía parcial por ausencia de diagnóstico definitivo y sospecha de posible malignidad y diagnóstico de obstrucción de la salida gástrica. La histopatología fue compatible con EG, tratada con un tratamiento con corticoides de 8 semanas de duración, mostró mejoría clínica, aumento de peso y normalización del recuento de eosinófilos en sangre periférica.

ABSTRACT Eosinophilic gastroenteritis (EG) is a rare entity. We report a 55-year-old man had no previous atopy or allergic history, who presented abdominal pain and vomiting. Abdominal computed tomography and endoscopy ultrasonography demostrated gastric wall thickening with wall thickening of the superior duodenum, without defined mass or fluid collection. Gastrointestinal endoscopy confirmed thickening of prepyloric folds and superior duodenum with luminal stenosis. Parcial gastrectomy was performed due to absence of definitive diagnosis and suspicion of possible malignancy and diagnosis of gastric outlet obstruction. Histopathology was compatible with EG, treated with an 8-week long corticosteroid therapy, showed clinical improvement, weight gain and normalization of eosinophil count on peripheral blood.

Pseudoquiste pancreático intramural gástrico en páncreas heterotópico, una causa infrecuente de retención gástrica: caso clínico / Gastric intramural pseudocyst in a heterotopic pancreas causing gastric outlet obstruction: report of one case

Heterotopic pancreas is a silent gastrointestinal malformation that may become clinically evident when complicated by inflammation and pseudocyst formation. We report a 26 year-old male presenting with vomiting, pain and abdominal distention. An abdominal CT scan showed an important gastric distention secondary to a 4-cm cystic lesion located in the antrum wall. An endosonography showed that the lesion obstructed the gastric outlet and was compatible with a pseudocyst. A cysto-gastrostomy was performed draining the cyst. Its high lipase and amylase content confirmed that it was a pancreatic pseudocyst. Six months later, the lesion appeared again and a subtotal gastrectomy was performed Histopathology confirmed ectopic pancreatic tissue.

Intususcepción intestinal debido a un pólipo fibroide inflamatorio (tumor de vanek) / Intestinal intussusception due to an inflammatory fibroid polyp (vanek tumor)

La intususcepción en un adulto debe hacer sospechar un tumor (benigno o potencialmente riesgoso); el diagnóstico certero es crucial para el tratamiento adecuado del paciente1. Alrededor del 90% de estos casos se dan en el intestino delgado y colon, el 10% restante se originan en el estómago y en estomas creados quirúrgicamente2. En los adultos, aproximadamente 90% de los casos de intususcepción son secundarios a una lesión definible3. El tumor de Vanek o pólipo fibroide inflamatorio, se conoce como una lesión benigna, rara, de localización submucosa, no encapsulada, cuya ubicación puede darse a lo largo del tracto digestivo, siendo más común en el antro gástrico (80 %), aunque también se ha descrito en la unión gastroesofágica, duodeno, yeyuno, íleon y colon4.

Intussusception in an adult must make us suspect the presence of a tumor (benign or potentially dangerous) as the most frequent cause. Accurate diagnosis is of great importance in order to provide appropriate treatment and improve patient prognosis1. About 90% of these cases occur in the small intestine and colon, and the remaining 10% originate in the stomach and surgically created ostomas2. In adults, approximately 90% of cases of intussusception are secondary to a definable lesión3. The Vanek's tumor or inflammatory fibroid polyp (IFP) is a rare benign lesion of submucosal location, not encapsulated, that may be located throughout the digestive tract, being more common in the gastric antrum (80%), although it has also been described in the gastroesophageal junction, duodenum, jejunum, ileum and colon4.

Quiste de duplicación duodenal, diagnóstico prenatal y exéresis postnatal / Duodenal duplication cyst, prenatal diagnosis and postnatal excision

Introduction: duodenal duplication cysts are rare congenital anomalies, usually originate in the 2nd -3rd portion of the duodenum. The prenatal echography diagnosis shows a cyst in the right hypochondrium, and we should perform a differential diagnosis with other pathologies. Prenatal diagnosis will allow a correct and precocious postnatal management. Elective excision is the treatment of election preventing the development of complications. Clinical case: We present a rare case of duplication of the first portion of the duodenum that required precocious excision because obstruction to gastric emptying.

Introducción: Los quistes de duplicidad duodenal son anomalías congênitas raras, que generalmente se originan en la 2ª-3ª porción duodenal. Ante el hallazgo en la ecografía prenatal de un quiste en hipocondrio derecho se debe realizar un diagnóstico diferencial con otras patologías. El diagnóstico prenatal, permitirá un correcto y precoz manejo postnatal. La exéresis electiva es el tratamiento de elección evitando la aparición de complicaciones posteriores. Caso clínico: Presentamos un caso excepcional de duplicidad de la primera porción duodenal, que precisó de exêresis precoz por causar obstrucción al vaciamiento gástrico.

Can the duration of vomiting predict postoperative outcomes in hypertrophic pyloric stenosis?

Hypertrophic pyloric stenosis [HPS] is a common cause of gastric outlet obstruction [GOO] in infants. Prolonged GOO is believed to result in acid and electrolyte disturbances, gastric atony, and delayed postoperative recovery. We studied the impact of prolonged vomiting as an indicator of GOO symptoms on the post-operative outcomes in HPS. A retrospective chart review of all patients who underwent pyloromyotomy at a tertiary care center between February 1997 and February 2009. The duration of pre-operative vomiting was correlated with presenting electrolytes and acid-base balances, postoperative time to full feed, postoperative morbidity and duration of hospitalization. Forty-seven patients were identified. At presentation, the median [range] for duration of symptoms was 14 [3-60] days, and surgeries were performed at 2 [0-6] days after admission. Apart from one case of postoperative wound infection, all patients had an unremarkable recovery. The unusually prolonged duration of vomiting in our cohort did not correlate with the mean [SD] preoperative chloride level of 93.9 [8.8] mEq/L, mean [SD] pH level of 7.5 [0.9], mean postoperative time to full feeding of 31 [15.1] hours, or mean duration of hospitalization of 5.1 [2.2] days. Duration of vomiting in HPS at presentation does not seem to have a significant impact on the postoperative outcomes

Surgical management of peptic ulcer disease in proton pump inhibitor era

To evaluate the important risk factors involved in complications of peptic ulcer disease and the need, timing, extent and outcome of surgery with the evolution of proton pump inhibitors. Descriptive study. POF Hospital Wah Cantt, from December 2006 to December 2008. All the patients presenting with complications of peptic ulcer disease [perforation, bleeding duodenal ulcers and gastric outlet obstruction] were included in this study. A total of 46 patients were included in this study. Thirty five patients had peptic ulcer perforation, 8 patients presented with bleeding peptic ulcer that failed to respond to medical and endoscopic treatment and 3 patients presented with gastric outlet obstruction. Smoking was the most common risk factor followed by the use of non streroidal anti inflammatory [NSAID] drugs and steroids. Ramadan fasting was also a factor in patients with history of dyspepsia. Peptic ulcer perforation was more common in patients in second and third decade of life as compared to bleeding which was more prevalent in fourth decade. Modern medical and endoscopic therapy has caused a decline in complications of peptic ulcer disease but they are still prevalent in developing world. Smoking is one of the most common and important risk factors

Obstrucción intestinal causada por tricobezoar: Síndrome de Rapunzel / Intestinal obstruction due to a tríchobezoar or Rapunzel Syndrome: report of one case

Rapunzel syndrome or gastrointestinal trichobezoar is caused by hair ingestion. The diagnosis may be suspected in young females with important weight loss, who deny hair eating. We report a 16 year-old female consulting in the emergency room for abdominal pain. She was subjected to an exploratory laparotomy and a big mass was palpated in the stomach. A gastrostomy and enterostomy were performed and a 17x6x5 cm trichobezoar was extracted. The patient had an uneventful postoperative outcome and was derived to Psychiatry.

Bouveret's syndrome

Gastric Outlet Obstruction [GOO] due to impaction of a gallstone in the duodenum after migration through a bilioduodenal fistula is known as Bouveret's syndrome. Its clinical symptoms are entirely vague and nonspecific. Because of its rarity, insidiousness and unpredictable symptomatology, Bouveret's syndrome is never thought of in the differential diagnosis as aetiology of gastric outlet obstruction. Recent advances in fiberoptics technology, advent of modern imaging modalities and minimally-invasive techniques like endoscopy and laparoscopy has brought a great revolution in the management of Bouveret's syndrome and have tremendously decreased morbidity and mortality associated with this rare clinical entity

Hypertrophic pyloroduodenal tuberculosis

Hypertrophic pyloroduodenal tuberculosis is a rare cause of Gastric Outlet Obstruction [GOO] often forgotten in the differential diagnosis of gastric outlet obstruction. Since laboratory and radiological investigations often prove inconclusive in reaching the diagnosis of hypertrophic pyloroduodenal tuberculosis, surgery has a key role in the management of hypertrophic pyloroduodenal tuberculosis. Postoperative anti-tuberculosis chemotherapy [ATT] becomes imperative for complete resolution of hypertrophic pyloroduodenal tuberculosis. This case report describes the condition and management in a young girl

Obstructed Morgagni's hernia.

Morgagni's Hernia is the direct herniation of the intra-abdominal organs through the anterior retrocostoxiphoid diaphragmatic defect. We are presenting a case of obstructed Morgagni's hernia in a five-year-old child. Who presented with colicky abdominal pain, distention of upper abdomen, vomiting with constipation of three days duration.. Morgagni hernia is a rare disease even rarer in pediatric age group, and is usually diagnosed incidentally; presentation of this disease with obstruction had been reported in adult but not in children.

Gastric trichobezoar presenting as gastric outlet obstruction--a case report.

Trichobezoars are impactions of swallowed hairs in the stomach and occasionally in the intestine. They occur in emotionally disturbed, depressed, or mentally retarded patients who have trichotillomania and trichophagia. Removal of gastric trichobezoar by open surgery (gastrotomy) is a standard approach. Psychiatric follow-up is needed to diminish the recurrence of trichotillomania and trichophagia. Here, we report a case of large gastric trichobezoar presenting as gastric outlet obstruction in a 13-years-old girl. She was treated with open surgical extraction of the bezoar and behavioral therapy.

Primary duodenal signet-ring cell carcinoma presenting as gastric outlet obstruction

Small bowel tumors occur rarely. We present an unusual case of a 68 year old man with gastric outlet obstruction secondary to a non-ampullary primary duodenal signet ring cell carcinoma. A review of the literature of small bowel malignant tumors is presented along with the case.

Phytobezoar as a late complication of vertical banded gastroplasty

In the last two decades, bariatric surgery has become a popular mean for treating morbid obesity. Although the newer procedures are claimed to have less complications than the older ones, the world is still at a learning curve. Numerous complications of this surgery are known and require recognition to be appropriately treated. Phytobezoar is one of the rare late complications following Bariatric surgery and various factors can contribute to its development including hypochlorhydria, diminished antral motility, and incomplete mastication. The case being presented is a rare case of gastric outlet obstruction due to phytobezoar almost two years following vertical banded gastroplasty. The patient was successfully treated with Sodium Docusate, which is a faecal softener and weak stimulant laxative. To our knowledge, this is the first case report presenting such a complication following vertical banded gastroplasty. Phytobezoar should be considered in the differential diagnosis of epigastric symptoms in patients with a history of gastric surgery. Sodium docusate was an effective medical therapy in this patient