Gangliocytic paraganglioma in association with a duodenal diverticulum.

Gangliocytic paraganglioma is an extremely rare benign neurogenic tumor nearly exclusively located in the second portion of the duodenum, also the most common site of duodenal diverticula. A case is reported of a gangliocytic paraganglioma presenting in a 65-yr-old woman with a 1-yr history of postprandial cramping abdominal pain culminating in a single episode of melena leading to laparotomy. The tumor was identified with difficulty by endoscopy following negative barium studies. Histologically, the tumor is composed of carcinoid-like cells admixed with varying numbers of ganglion cells in a substratum of neuroid spindle cells. The epithelioid cells contain argyrophilic cytoplasmic granules confirmed by electron microscopy to be dense core membrane-bound secretory granules. Review of the literature suggests the tumor described is typical both clinically and pathologically of gangliocytic paraganglioma of the duodenum, except for its unprecedented occurrence in association with a duodenal diverticulum.

Transhepatic balloon dilation of the distal common bile duct and ampulla of Vater for removal of calculi.

In 17 patients with common bile duct calculi, percutaneous transhepatic balloon dilation of the distal common bile duct and the ampulla of Vater (hepaticopancreatic ampulla) was performed. The calculi were pushed into the duodenum with the catheter, and all were removed without significant complications. This method of calculus removal is an effective alternative to surgery or endoscopic sphincterotomy.

Massive azoturia and failure to achieve positive nitrogen balance in a botulism patient.

Observations of a patient with botulism requiring mechanical ventilatory support for 59 days and hospitalization for approximately 3 months are reported. During the time of greatest muscular paralysis, urinary urea nitrogen excretion exceeded 20 g per day. This degree of azoturia was thought to be due to obligate loss of lean body tissue secondary to paralysis and not to stress or starvation related demands. A contributing factor to the magnitude of azoturia was the presence of a large premorbid body frame and muscle mass. The nutritional goal was not to achieve nitrogen balance but to maintain visceral protein stores. As the patient improved neurologically, the azoturia decreased allowing a positive nitrogen balance with a rebuilding of skeletal muscle.