Aneurisma de aorta abdominal roto al duodeno: causa infrecuente de hemorragia digestiva masiva / Rupture of abdominal aortic aneurysm into the duodenum: uncommon cause of massive gastrointestinal bleeding

Primary aortoenteric fistula is the spontaneous communication between the lumen of the aorta and a portion of the digestive tract. The most common cause is the erosion of an abdominal aortic aneurysm into the 3rd or 4th portion of the duodenum. It manifests clinically as gastrointestinal bleeding, with or without abdominal pain and a pulsatile abdominal mass on physical exam. Gastrointestinal bleeding is initially recurrent and self-limiting and progresses to fatal exsanguinating hemorrhage. Endoscopic examination diagnoses only 25% of aortoenteric fistulas because these are usually located in the distal duodenum. Contrast computed tomography of the abdomen and pelvis is diagnostic in only 60% of cases. We report three cases with this condition. A 67-year-old male presenting with an upper gastrointestinal bleeding. He was operated and a communication between an aortic aneurysm and the duodenum was found and surgically repaired. The patient is well. A 67-year-old male with an abdominal aortic aneurysm presenting with abdominal pain. He was operated and anticoagulated. In the postoperative period he had a massive gastrointestinal bleeding and a new CAT scan revealed an aorto enteric fistula that was surgically repaired. The patient is well. An 82-year-old male with an abdominal aortic aneurysm presenting with hematochezia. A CAT scan revealed a communication between the aneurysm and the third portion of the duodenum, that was surgically repaired. The patient died in the eighth postoperative day.

Fístula aorto-duodenal primaria: caso clínico / Primary aorto-duodenal fistula: clinical case

Resumen Introducción Las fístulas aorto-entéricas (FAE) son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno. Caso clínico Reportamos el caso de una mujer de 66 años intervenida por un aneurisma sacular aórtico abdominal (AAA) yuxtarrenal, con rotura contenida, fistulizado al duodeno. Presentó una hemorragia digestiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio. La paciente fue sometida a reparación quirúrgica urgente con instalación de una prótesis aórtica bifemoral y resección duodenal. En el postoperatorio inmediato presentó una trombosis parcial de las ramas de la prótesis aórtica e isquemia de extremidades, siendo reintervenida exitosamente. Discusión La FAE es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación de la fístula. Es preferible la resección duodenal ante la simple duodenorrafia.

Introduction Aorto-enteric fistulae (AEF) are a rare cause of gastrointestinal bleeding. The prognosis tends to be ominous, depending greatly in a high level of clinical suspicion and prompt diagnosis. Clinical case We report a case of a 66-year-old female with a saccular juxta-renal abdominal aortic aneurysm (AAA), with a contained rupture. The patient was urgently submitted to surgical repair using an bifemoral aortic prosthesis. A duodenal partial resection was performed. During the immediate postoperative time she presented partial thrombosis of prosthesis and ischemia of lower extremities so she was reoperated successfully. Discussion AEF is a potentially fatal cause of gastrointestinal bleeding. Diagnosis is still troublesome due to its vague presentation and it should always be considered when facing gastrointestinal haemorrhage with no apparent cause. There are several surgical approaches that should be pondered case to case without delaying the repair of the defect.

Large Brunner's gland hamartoma with annular stricture causing gastric outlet obstruction

No abstract available.

Management of Perforated Duodenal Diverticulum: Report of Two Cases / 대한소화기학회지

Duodenal diverticula are common, but perforated duodenal diverticulum is rare. Because of the disease rarity, there is no standard management protocol for perforated duodenal diverticulum. To properly manage this rare complication, a clear preoperative diagnosis and clinical disease severity assessment are important. An abdomino-pelvic CT is an unquestionably crucial diagnostic tool. Perforation is considered a surgical emergency, although conservative treatment based on fasting and broad-spectrum antibiotics may be offered in some selected cases. Herein, we report two cases of perforated duodenal diverticulum, one case managed with surgical treatment and one with conservative treatment.

Pyeloduodenal Fistula Successfully Treated By Endoscopic Ligation without Surgical Nephrectomy: Case Report

A 74-yr-old woman presented with fever and abdominal discomfort. She was in a septic condition caused by urinary tract infection. Her computed tomogram of the abdomen revealed features of hydronephrosis with ureteral stones in both kidneys. During percutaneous nephrostomies, right pyeloduodenal fistula (PDF) was diagnosed. Elective surgery was originally planned but the patient was in a poor condition to undergo surgery. Instead, 2 times endoscopic clipping and ligation by endoloop were applied with parenteral antibiotics for the fistula lesion. On admission day 30, she was discharged from the hospital after confirmation of no more contrast leakage on fistulography. We reviewed the literature and discuss the etiologies, clinical presentations, diagnosis, and treatment of PDF.

Lemmel's Syndrome, an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith: Case Report

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.

Diagnóstico y manejo de la hernia paraduodenal / Diagnosis and management of paraduodenal hernia

Internal hernias cause 1 percent of intestinal obstructions with aproximately 50 percent of these hernias been paraduodenal hernias. Paraduodenal hernias are the product of a malrotation of the midgut during embryogenesis or a non-fusion of the peritoneal folds. These type of internal hernia are more cornmon in males and on the left side of the abdomen. The usual presentation age is in the 4th decade of life. The clinical presentation of these patients is non specific and varies, ranging from mild dyspepsia to intestinal perforation and septic shock. The radiographic studies of these patients show a dumping of the intestinal loops on the upper quadrant of the abdomen with an image of abdominal compartamentalization. The surgical management of these patients should follow three simple principles. The intestines should be reduced, their perfusion and viability must be verified and the hernia sack entrance should be repaired with interrupted non absorbable sutures.

Las hernias internas causan el 1 por ciento de las obstrucciones intestinales. De estas, aproximadamente la mitad son causadas por hernias paraduodenales. Las hernias paraduodenales son producto de una embriogénesis defectuosa, donde el intestino no rota o los pliegues mesentéricos no se fusionan adecuadamente. Estas hernias son más comunes en el género masculino, del lado izquierdo y por lo general se diagnostican en la cuarta década de la vida. La presentación clínica es inespecífica con manifestaciones que varían desde la dispepsia hasta la perforación intestinal y el choque séptico. Los estudios de imagen muestran el agrupamiento de las asas intestinales en el abdomen superior dando una imagen de compartamentalización de la cavidad abdominal. Para el manejo quirúrgico de estos pacientes se debe reducir el intestino herniado, verificar que este sea viable y posea una adecuada perfusión y reparar el orificio hemiario con material no absorbible.

Síndrome de Rapunzel (tricobezoar gástrico con extensión a duodeno y yeyuno): a propósito de un caso / Rapunzel syndrome (gastric trichobezoar extending into duodenum and jejunum): report of a case

El síndrome de Rapunzel, corresponde a un raro fenómeno con pocos casos comunicados y descritos en la literatura mundial. Así pues, compartimos un nuevo caso. Se trata de paciente femenino de 6 años de edad, que consulta por presentar desde hace 2 meses crisis de epigastralgia, vómitos a repetición y pérdida de peso. Su sintomatología ha empeorado en la última semana y refiere sensación de masa en epigastrio. Como antecedente importante tricofagia de dos años de evolución. Al examen se palpa masa epigástrica alargada. Al ecosonograma abdominal se aprecia en epigastrio, en la zona que corresponde a la cámara gástrica, una línea hiperecogénica, curvilínea, discretamente heterogénea, que produce sombra acústica completa, sugestivo de masa ecogénica de más de 5 cm de longitud . La radiología de estómago muestra una imagen de defecto que se extiende desde el cuerpo hasta la región antropilórica, de 6 x 4 cms. La Videogastroscopia muestra una concreción de pelos (tricobezoar), que se extiende a través del píloro. El 26-02-2009 es intervenida quirúrgicamente, se realiza gastrostomía con extracción de tricobezoar que se extiende a través del duodeno hasta el yeyuno. En ocasiones el tricobezoar se extiende más allá del estómago, alcanzando duodeno, yeyuno, ileon, e incluso colon, dándosele entonces, el nombre de Síndrome de Rapunzel...

The Rapunzel syndrome is a rare condition with few cases reported and described in the literature. Thus, WE SHARE a new case. Is a 6 years old female patient who went to consult because she had had from 2 months ago epigastralgia`s crisis, vomits and regurgitation, and lost of weight. Her symptomatology has gotten worst in the last week and refers a sensation of a mass in the epigastrium. As an important background she had had trichophagia of two years evolution. An elongated epigastric mass is felt on examination. The abdominal echosonogram shows a hyperechoic curvilinear line, discretely heterogeneous, in the epigastrium, specifically, in the gastric zone, which produces a complete acoustic shadow allusive of echogenic mass of more than 5 cm. of length. The stomach radiography shows a defect image of 6 x 4 cm. that extends from the body to the antro-pyloric region. The video-gastroscopy reveals a hair concretion (trichophagia) that extends through the pylorus. On February 26, 2009 the patient underwent surgical intervention, a gastrostomy with extraction of the trichobezoar that expands through the duodenum to the jejunum. In occasions the trichobezoar extends beyond the stomach reaching to the duodenum, jejunum, ileum and even colon, that's when it's called Rapunzel Syndrome...

Trichosporon peritonitis following duodenal perforation

Fungal peritonitis, which was once a rare entity, is becoming increasingly common due to various immunocompromised conditions. Candida species are considered the common cause of fungal peritonitis in most cases. However, at present, other yeasts and filamentous fungi are replacing the dominance of Candida albicans as well as other Candida species. Trichosporon species are widely distributed in nature and are normal flora in the gastrointestinal tract of humans. Ever since the report of disseminated trichosporonosis in 1970, several cases of infections by various Trichosporon species in different clinical patients have been published. Here, we present a patient with Trichosporon peritonitis after duodenal perforation. To the best of our knowledge, this is the first case report of its kind from India

Upper gastrointestinal bleeding in children in southern Iran.

Objective. To find out whether the causes of upper GI bleeding in our center in a developing country differed from developed countries. Methods. Children presenting to our center with upper GI bleeding from March 2002 to March 2007, were retrospectively evaluated. Informations were retrieved from patient’s history and physical examination and results of upper GI endoscopy regarding etiology of bleeding, managements, use of medications which might predispose patient to bleeding, and the mortality rate. Results. From 118 children (67 boys; with age of 7.7±4.7 yrs) who underwent upper GI endoscopies, 50% presented with hematemesis, 14% had melena and 36% had both. The most common causes of upper GI bleeding among all patients were gastric erosions (28%), esophageal varices (16%), duodenal erosions (10%), gastric ulcer (8.5%), Mallory Weiss syndrome tear (7.8%), duodenal ulcer (6.8%), esophagitis (1.7%) and duodenal ulcer with gastric ulcer (0.8%). The causes of bleeding could not be ascertained in 20.5% of cases. No significant pre-medication or procedure related complications were observed. Endoscopic therapy was performed in 13.5% of patients. In 14.4% of patients, there was a history of consumption of medications predisposing them to upper GI bleeding. Two deaths occurred (1.7%) too. Conclusion. The findings in the present study showed that half of upper GI bleedings in pediatric patients from south of Iran, were due to gastric and duodenal erosions and ulcers. This study concludes that the causes of upper GI bleeding in children in our center of a developing country, are not different from those in developed ones.

A Case of Left Paraduodenal Hernia Combined with Acute Small Bowel Obstruction / 대한소화기학회지

Paraduodenal hernias are rare congenital malrotational anomalies of midgut that arise in the potential spaces and folds of the posterior parietal peritoneum adjacent to the ligament of Treitz and can lead to intestinal obstruction. Also, they have shown several presentation patterns, such as asymptomatic, chronic intermittent abdominal pain, and acute severe abdominal pain. If symptomatic hernias with strangulation are untreated, according to the previous reports, they lead to overall mortality exceeding 50%. We report a case of the left paraduodenal hernia combined with small bowel obstruction from the patient who had no history of surgery before and developed abdominal pain after drinking of alcohol heavily. Abdominal CT scan showed sac-like mass of clustered in the left upper quadrant. The patient underwent the surgery of the bowel reduction and adhesiolysis and got uneventful recovery.

Divertículo duodenal en la tercera porción del duodeno como causa de sangrado del tubo digestivo alto y dolor crónico abdominal: informe de un caso y revisión de la literatura / Duodenal diverticulum in the third portion of duodenum as a cause of upper gastrointestinal bleeding and chronic abdominal pain: case report and literature review

BACKGROUND: Duodenal diverticulum is a little-known pathology. The duodenum represents second place in frequency for the presence of diverticula in the digestive tract after the colon. Duodenal diverticulum as a cause of hemorrhage of the upper gastrointestinal (GI) tract has been described as an infrequent complication, although it must be considered in patients with digestive hemorrhage without evident cause at the esophagogastric level. Localization of diverticula in the third or fourth portions of the duodenum is rare and the diverticula are asymptomatic in 90% of cases. Diagnosis is made by endoscopy, contrast X-rays of the upper GI tract, selective arteriography and as a transoperative finding. The objective of this study was to identify and analyze the clinical presentation of duodenal diverticulum to familiarize surgeons and gastroenterologists when there is suspicion of the diagnosis. CLINICAL CASE: We report the case of an 85-year-old female presenting with massive upper GI tract hemorrhage and chronic abdominal pain due to a duodenal diverticulum located in the third portion of the duodenum. Diagnosis was made with upper GI barium series because visualization of the diverticulum was not possible by endoscopy. Other therapeutic options are described in the literature. A successful simple diverticulectomy, manually opened with a two-plane transversal incision, was performed on the patient. After >12 months of follow-up, the patient is completely asymptomatic. DISCUSSION: Clinical diagnosis presents difficulty because a classic presentation does not exist. Symptoms are generally vague, <10% of the duodenal diverticulum are frankly symptomatic, and <1 to 2% will require surgical resolution. CONCLUSIONS: Hemorrhage of the upper GI tract and chronic abdominal pain secondary to duodenal diverticulum present with recurrence and may be associated with the presence of duodenal diverticulum when other sources of bleeding are not found.

Massive recurrent hemorrhage due to duodenal diverticulum--role of tattooing and suture plication.

We report a 79-year-old lady with massive recurrent GI bleeding from a duodenal diverticulum arising at the mesenteric border. We used tattooing during endoscopy as a method for identifying the bleeding source at surgery. The diverticulum was treated with suture plication.

A Case of Duodenal Diverticulum Accompanied with Choledochoduodenal and Pancreaticoduodenal Fistulas / 대한소화기학회지

Choledochoduodenal fistula (CDF) occurring simultaneously with pancreaticoduodenal fistula is extremely rare. CDF has known to be a chronic sequela of cholelithiasis, but it is unknown whether pancreaticoduodenal fistula results from chronic cholelithiasis as well. We report a case of cholelithiasis accompanied with choledochoduodenal and pancreaticoduodenal fistula opening into small suprapapillary diverticulum in a 80-year-old woman.

Left paraduodenal hernia: an uncommon cause of chronic abdominal pain.

We report the case of a paraduodenal hernia treated by reduction of the hernia and closure of the hernial orifice.