Aneurisma de artéria pancreatoduodenal inferior: tratamento endovascular / Inferior pancreaticoduodenal artery aneurysm: endovascular approach

Resumo Os aneurismas das artérias pancreatoduodenais constituem uma afecção rara. Seu diagnóstico é realizado, na maioria das vezes, em situações de emergência por complicações como a rotura, a qual está associada a altas taxas de mortalidade (21-26%). A embolização do saco aneurismático é o tratamento de escolha, devido à sua alta efetividade e menor mortalidade. Neste artigo, é apresentado e discutido um caso de aneurisma de artéria pancreatoduodenal inferior com diagnóstico obtido durante investigação de sintomas gastrointestinais. O tratamento instituído foi a embolização com micromolas, com completa exclusão do aneurisma e boa evolução clínica.

Abstract Aneurysms of the pancreaticoduodenal arteries are a rare condition. In the majority of cases, diagnosis is made in emergency situations due to complications such as rupture, which is associated with high mortality rates (21-26%). Embolization of the aneurysm sac is the treatment of choice, because of its high efficacy and lower mortality. This article presents and discusses a case of inferior pancreaticoduodenal artery aneurysm that was diagnosed during investigation of gastrointestinal symptoms. The treatment provided was microcoil embolization, with complete exclusion of the aneurysm and a good clinical course.

Clip Ovesco® como tratamiento de rescate en lesión de Dieulafoy duodenal con sangrado activo / Ovesco clip as a rescue treatment of duodenal Dieulafoy lesion with active bleeding

Las lesiones de Dieulafoy se definen como una anomalía vascular que producen un sangrado en la mucosa proveniente de una arteria submucosa anormalmente larga y tortuosa que se ubican principalmente en estómago (80%), con poca frecuencia a nivel duodenal y constituyen el 6% de los sangrados gastrointestinales no asociados a varices y del 1% al 2% de todos los sangrados gastrointestinales. Reportamos el caso de un paciente masculino de 60 años que ingresó por hematemesis, melena y signos de hipovolemia con hemoglobina de 9 g/dl, que luego de realizar su compensación hemodinámica se le realizó una endoscopía alta que evidenció una lesión de Dieulafoy con sangrado activo severo en la segunda porción duodenal realizándosele inyección con adrenalina al 1:10 000 sobre los bordes de la lesión, pero al no lograrse una hemostasia adecuada se le tuvo que realizar la colocación de un clip ovesco con hemostasia efectiva que se corroboró 24 horas después, a través de una segunda endoscopía para poder egresar al paciente sin complicaciones, ni resangrado.

Dieulafoy's lesions are vascular anomalies that produce gastrointestinal bleeding of the mucosa from an abnormally long and tortuous submucosal artery. It is found predominately in the stomach (80%) and less frequently in the duodenum. They constitute the 6% of all non-variceal bleeding and the 1 to 2% of all gastrointestinal bleeding source. We report a case of a 60-year-old man with hematemesis, melena and signs of hypovolemic shock with a hemoglobin level of 9 g/dL. After adequate fluid resuscitation, an upper endoscopy showed an actively bleeding Dieulafoy lesion in the second portion of the duodenum. After epinephrine injection over lesion borders, an adequate hemostasis was not achieved. An over-the-scope clip was placed. Follow-up endoscopy 24 hours later showed an effective hemostasis and the patient was discharged without complications or re-bleeding.

Ruptured duodenal varices arising from the main portal vein successfully treated with endoscopic injection sclerotherapy: a case report / 대한간학회지

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.

unusual cause of gastric outlet obstruction: a pancreaticoduodenal artery aneurysm

We present a rare case of gastric outlet obstruction due to compression of the duodenum by a pancreaticoduodenal artery [PDA] aneurysm 2.5 cm in diameter, in a 43-year-old man from Saudi Arabia who presented with persistent vomiting and epigastric pain. The initial investigations and blood works were negative, and esophagogastroduodenoscopy [EGD] was unremarkable. A CT abdomen demonstrated a mass around the duodenum and dilatation of the stomach, and CT angiography showed the PDA aneurysm. The patient was stabilized and then referred to a tertiary center for embolization. Our case demonstrates a diagnostic challenge that physicians may encounter in patients who present with vomiting and epigastric pain

Anomalous origin of cystic artery from gastroduodenal artery: a case report / Origen nnómalo de la arteria cística desde la arteria gastroduodenal: reporte de un caso

The knowledge of vascular variations, like other anatomical variations, is important during the operative, diagnostic and endovascular procedures in abdomen. Variations in the branching pattern of the common hepatic artery often occur and may be encountered during cholecystectomy. This report describes a variation in the origin of cystic artery from the gastro duodenal artery as found during routine dissection in an approximately 34 years old male cadaver. The embryological development and clinical implications of such a variant have been discussed in the article.

El conocimiento de las variaciones vasculares, al igual que otras variaciones anatómicas, son importantes durante los procedimientos operativos, diagnósticos y endovasculares en el abdomen. Variaciones en el patrón de ramificación de la arteria hepática común se producen con frecuencia y pueden ser encontradas durante la colecistectomía. Este informe describe una variación en el origen de la arteria cística desde la arteria gastroduodenal encontrada durante la disección de rutina, en un cadáver de sexo masculino, de aproximadamente 34 años. El desarrollo embriológico y las implicaciones clínicas de esta variante son debatidas en el artículo.

A Case of Successful Endoscopic Injection Sclerotherapy with N-butyl-2-cyanoacrylate for Ruptured Duodenal Varices / 대한소화기학회지

Duodenal varix is a rare cause of hemorrhage in patients with portal hypertension, however their rupture is serious and often life threatening. Treatments for duodenal variceal bleeding include endoscopic procedures, surgery, or interventional radiologic procedures. We report a case of duodenal varices rupture in a 45-year-old man with alcoholic liver cirrhosis who presented with melena and dizziness. Emergent upper endoscopy revealed large nodular varices with a ruptured erosion on the top in the distal second portion of duodenum. Two consecutive injections with 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany) mixed with 1.0 mL of lipiodol (Laboratoire-Guerbet, France) were performed intravariceally and achieved successful hemostasis. This suggests that endoscopic injection sclerotherapy with histoacryl may be an effective therapeutic option for the control of ruptured duodenal variceal bleeding.

Rupture de varice duodenale. Une cause rare d'hemorragie digestive liee a l'hypertension portale

The duodenal varix rupture is a rare and serious complication of portal hypertension. The authors report one case of duodenal varix rupture in a 38 year old woman, revealing portal hypertension, which caused a massive gastro-intestinal bleeding. The endoscopy didn't allow to conclude to a diagnosis. An emergent laparotomy was necessary regarding the massive bleeding. A duodenal varix suture ligation was performed after pyloroduodenotomy. She had a well recovery. After a review of literature, the authors conclude that this abnormal situation is rare, its diagnostic is difficult and it has several therapeutic strategies

A Case of Multiple Bleeding Pseudoaneurysms Complicating Acute Pancreatitis / 대한소화기학회지

Arterial pseudoaneurysm is rare but potentially a catastrophic complication of pancreatitis because it can cause massive gastrointestinal bleeding. Since surgical treatment of arterial pseudoaneurysm has a high mortality, percutaneous angiographic embolization of bleeding artery has recently been advocated as the alternative therapy. Acute hemorrhage into the peritoneal cavity or pseudocyst complicating chronic pancreatitis was frequently reported. However, multiple pseudoaneurysmal hemorrhage without pseudocyst complicating acute pancreatitis are extremely rare. Here, we present a case of multiple pseudoaneurysmal hemorrhage secondary to acute pancreatitis, which were managed successfully by percutaneous angiographic embolization.

Pseudoaneurysm of gastroduodenal artery associated with mitral valve prolapse presenting as haemobilia.

Pseudoaneurysms of the hepatic or gastroduodenal arteries may cause Haemobilia. Mitral valve prolapse associated with mycotic pseudoaneurysm of cerebral and extracerebral arteries have been reported. We report a case of gastroduodenal artery pseudoaneurysm presenting as haemobilia. The patient was successfully treated with indigenously fabricated steel coil embolization followed by surgery.

A quantitative and comparative study of the ganglionic neurons in the myenteric and submucous plexuses of the small intestine, and in the intramural plexus of the gall bladder of the ginea-pig

Whole-mount preparations of guinea-pig small intestine and gall bladder stained using a modified Giemsa technique were used to estimate neuronal and ganglion density, and neuron area, within the wall of these organs. The myenteric ganglia were long and thin in the jejunum and ileum, and round, triangular, square, rectangular or distinctly elongated in the duodenum. Most of the myenteric neurons were also elongated. The submucosal plexus showed a remarkable regularity of pattern, and, compared with the myenteric plexus, had smaller ganglia which were variable in shape. The pattern of the intramural plexus resembles that of the submucosal plexus. In the myenteric plexus, there were no differences in ganglion density among the duodenum, jejunum and ileum. Neuronal density and the number of neurons/ganglion was greater in the duodenum. The mean ganglion and neuronal densities in the submucosal plexus were greater in the ileum and smaller in the jejunum. The number of neurons/ganglion decreased from the duodenum to the ileum. The intramural plexus of the gall bladder contained 1 ganglion/mm2 and 6 neuron/mm2. In the myenteric plexus, neuron area ranged from 101 to 250 mum2; in the submucous plexus, the value was from 51 to 250 mum2 while in the intramural plexus, the areas of most neurons lay in the ranges of 201 to 300 mum2 and 301 to 400 mum2. These results suggest significant differences in neuronal density in the myenteric plexus among the duodenum, jejunum and ileum, and significant differences between the submucosal and intramural plexuses.

Vascularización del ángulo duodenoyeyunal: importancia anatomoquirúrgica / Duodenal Angle irrigation

Se investigó la irrigación del ángulo duodenoyeyunal en 14 cadáveres adultos formolizados, disecando la arteria mesentérica superior en la raíz del mesenterio, la arteria duodenoyeyunal, arteria primera yeyunal y sus correspondientes arcadas. En 8 casos se observó la existencia de una anastomosis entre la arteria del ángulo duodenoyeyunal con la primera yeyunal, en 4 la de esta última con la arcada al intestino se ubicó entre 1,7 4cm. La presencia de arcadas vasculares evidencian una buena vascularización en la zona, lo que permitiría anastomosis intestinales en la región

Pancreatectomia total no cäo / Total pancreatectomy in dogs

A pancreatectomia total no cao é um procedimento utilizado na autotransplantaçao de ilhotas pancreáticas. O sucesso deste tipo de experimentaçao está na dependência, entre outros fatores, da manutençao da viabilidade do duodeno após a ressecçao pancreática total onde a arcada pancreaticoduodenal é interrompida. Os autores relatam sua experiência na realizaçao da pancreatectomia total no cao com preserevaçao do ramo duodenal da artéria gastroduodenal que conserva suprimento vascular do duodeno. Este aspecto técnico pode contribuir para uma melhor viabilidade do tecido pancreático para a transplantaçao, maior conservaçao funcional das ilhotas de Langerhans e menor isquemia duodenal.

Duodeno--jejunal vascular malformation.

Vascular malformations are rare but an important cause of obscure upper gastrointestinal bleeding. A patient with a large vascular malformation involving the duodenum and proximal jejunum, presenting with a severe bout of melaena, is described. The diagnosis was suspected on endoscopy and confirmed by angiography and surgery.

Estase duodenal crônica por oclusäo aortomesentérica / Chronic duodenal stasis by aortomesenteric occlusion

Estudaram oito casos de pinça aortomesentérica, observados no decorrer de alguns anos de tratamento em seu consultório particular, focalizando principalmente o tipo constitucional do paciente na sua descoberta, a sintomatologia comumente presente, o valor do estudo radiológico bem conduzido para o seu diagnóstico e as medidas terapêuticas adotadas visando melhorar ou fazer desaparecer a sintomatologia presente

Segmentación arterial gástrica comunicación preliminar / Gastric arterial sementation:preliminary communication

Se estudian 25 piezas anatómicas frescas que incluyen el duodeno y cabeza de páncreas, las que fueron diafanizadas después de someterlas a la replesión vascular con tinta china diluída, con el fin de observar la microvascularización arterial de la papila mayor del duodeno. De los resultados obtenidos se concluye que los cuadrantes mediales 12-3 y 3-6 de la esfera horaria que representa a ésta, son los que reciben la mayor irrigación; menos vascularización arterial recibe el cuadrante 6-9 y casi nula el 9-12. Este esquema tendría importancia en cirugía (esfinteroplastía) ya que su conocimiento disminuiría la frecuencia de hemorragias y fístulas post-operatorias