Brunner's gland hyperplasia at the ampulla of Vater.

Brunner's gland hyperplasia (BGH) is a diagnostic challenge where in the pathophysiology and natural history remain poorly understood. This Case Report describes BGH arising at the ampulla of Vater, causing abdominal pain and vomiting in a 46-year-old man. Owing to the inconclusive nature of imaging studies and suspicious intraoperative findings, a Whipple resection was performed without any complications. Histological analysis showed that the obstructing lesion was BGH, with no evidence of malignancy. This is only the second such case of its kind at the ampulla of Vater to be reported. In addition, we present the previously unreported endoscopic ultrasound findings. The subsequent literature review focuses on the pathophysiology, clinical presentation, diagnosis and management of BGH.

Percutaneous endoscopic gastrostomy: 30-day mortality trends and risk factors.

BACKGROUND AND AIMS: 30-day Percutaneous endoscopic gastrostomy (PEG) mortality of 8% (1992). Recent concerns suggest that mortality may have increased, prompting a comparison of current practice with that reported earlier. MATERIALS AND METHODS: Data regarding PEG insertion with relation to case mix, complications, 30-day mortality and associated risk factors, in 2002, in a British University Hospital was compared with that in 1992. Logistic regression analysis was used to determine factors independently predictive of 30-day mortality. RESULTS: In 2002, 112 patients (70% males, mean age 67.5 years; 1992: 63.6 years) underwent PEG. The 30-day mortality increased significantly from 8% (1992) to 22% (2002), P= 0.03. During this time, PEG insertion rate increased ten-fold, however, procedure-related mortality decreased from 2% to nil. In terms of percentage, the indications for PEG in 1992 and 2002 respectively were: cerebrovascular disease (33/25), head and neck tumours (16/24), motor neuron disease (27/11, P= 0.01). The proportion of PEGs for non-evidence-based indications increased from 16% in 1992 to 31% in 2002, P= 0.048. The number of PEGs placed radiologically increased (0/17, P= 0.02). Radiological patients received less antibiotic prophylaxis (P< 0.001) and had more PEG site infections than standard placement, P= 0.04. Multivariate analysis identified nil by mouth > or = 7 days or 11.4 (CI 3.2-41.7), albumin< or = 30 g/L or 12 (2.2-66.7) and > 1 cardiac factor or 5.1 (1.02-25.6) as independent predictors of 30-day mortality. CONCLUSIONS: The ten-fold rise in the PEG insertion rate has been accompanied by a three-fold rise in 30-day mortality. This may reflect a lowered threshold of PEG insertion. The risk factors identified may help decision-making in cases where the risk-benefit relationship is not clear-cut.