[Successful portal vein stent placement for chronic portal vein stenosis 5 years after pancreatoduodenectomy:a case report].

A 73-year-old man underwent pancreatoduodenectomy 5 years previously, and portal vein stenosis was observed immediately after surgery. A collateral vein with varices around the hepaticojejunostomy gradually developed. The patient experienced repeated episodes of melena that required transfusion. Enteroscopy confirmed varices around the hepaticojejunostomy, caused by portal vein stenosis, which was the source of intestinal bleeding. Varices were treated by placing an expandable metallic stent in the stenotic portal vein through a percutaneous transhepatic route. Although the portal vein stenosis was severe, the guidewire was successfully maneuvered into the superior mesenteric vein and stent placement was successful. Subsequently, the collateral vein disappeared and no further melena was observed.

Jejunal arteriovenous malformation and multiple acquired extrahepatic portosystemic shunts in a juvenile dog, presenting with melena.

A juvenile dog referred with a 1-month history of persistent melena and severe anaemia, was diagnosed with a jejunal arteriovenous malformation, and multiple acquired extrahepatic portosystemic shunts. A midline coeliotomy was performed, the jejunal arteriovenous malformation was localised intraoperatively and was successfully removed via an enterectomy. Histopathology confirmed a true arteriovenous malformation. Despite the initial improvement, the patient developed seizure episodes secondary to hepatic encephalopathy 8 months after surgery. Fifteen months after surgery, the owner opted for euthanasia due to the ongoing seizure episodes. Post-mortem histologic examination of the liver showed features consistent with portal vein hypoplasia. A congenital arteriovenous malformation should be considered as a differential diagnosis in juvenile patients with a chronic history of haemorrhage from the gastrointestinal tract. In addition, acquired portosystemic shunts may occur in patients with portal vein hypoplasia and jejunal arteriovenous malformations.

Jejunal Dieulafoy lesion with intraintestinal calcification on computerized tomography: A case report.

RATIONALE: A Dieulafoy lesion is a rare cause of gastrointestinal (GI) bleeding, especially in the jejunum, and the presence of calcifications on CT might be suspicious of the diagnosis. PATIENT CONCERNS: We describe a 72-year-old woman with anemia and melena. Hemoglobin was 6.0 g/dL, and the stools were positive for occult blood (4+). Blood pressure was 116/54 mm Hg. Physical examination showed pale face and pitting edema in both lower limbs. Abdominal computerized tomography showed calcification in the small intestine of the left lower abdomen. Capsule endoscopy showed a blood clot. DIAGNOSES: Dieulafoy lesion. INTERVENTIONS: Single balloon endoscopy was performed via the oral approach and showed a blood clot on the suspected submucosal tumor of jejunum. A hemostatic clip was placed at the base of the lesion to allow the surgeon to locate it during the operation. Laparoscopy was performed, and the lesion was resected. OUTCOMES: The postoperative pathology showed a Dieulafoy lesion. The lower extremity edema subsided. GI bleeding did not recur over 1 year of follow-up, and hemoglobin was 12.2 g/dL. A Dieulafoy lesion is a rare cause of GI bleeding, and it is even rarer in the jejunum. LESSONS: A Dieulafoy lesion does not have special imaging features, but the presence of calcifications in the small intestine on computerized tomography might be suspicious of the diagnosis. When endoscopic treatment is difficult, surgical treatment could be considered.

Small bowel racemose hemangioma complicated with obstruction and chronic anemia: A case report and review of literature.

BACKGROUND: Gastrointestinal hemangiomas are rare benign tumors. According to the size of the affected vessels, hemangiomas are histologically classified into cavernous, capillary, or mixed-type tumors, with the cavernous type being the most common and racemose hemangiomas being very rare in the clinic. Melena of uncertain origin and anemia are the main clinical manifestations, and other presentations are rare. Due to the rarity of gastrointestinal hemangiomas and lack of specific manifestations and diagnostic methods, preoperative diagnoses are often delayed or incorrect. CASE SUMMARY: We report a 5-year-old girl who presented with abdominal pain, nausea, and vomiting for a duration of 10 h. The laboratory studies showed prominent anemia. Computed tomography and contrast-enhanced computed tomography of the abdomen revealed a small bowel obstruction caused by a giant abdominal mass. Segmental resection of the ileal lesions was performed through surgery, and the final pathology results revealed a diagnosis of racemose hemangioma complicated by a small bowel obstruction and simultaneous chronic anemia. CONCLUSION: The current report will increase the understanding of the diagnosis and treatment of gastrointestinal hemangiomas and provide a review of the related literature.

Upper Gastrointestinal Tract Hemorrhage: Unexpected Discovery.

Pica is a serious condition that is characterized by ingesting inedible things which can prove to be fatal (glass, pebbles, etc.) We present the case of a 64-year-old male patient who is admitted to the emergency room with the following complaints: upper GI tract bleeding manifested through hematemesis and melena, epigastric pain, lack of bowel movements. A contrast computed tomograohy is performed showing the presence of a hyper-dense stomach content, gastric wall thickening, abdominal fluid but with no signs of intestinal occlusion. A laparotomy is performed and ollowing an anterior gastrotomy a large quantity of pebbles is found along with a hemorrhagic and stenotic tumor of the lesser curvature. Taking into account the intraoperative aspect the decision was made to perform an end-to-side stapled esophago-jejunal anastomosis on an omega loop with a Braun entero-entero anastomosis following total gastric resection and D1 lymphadenectomy. Postoperative course is uneventful. A barium swallow carried out on the 10th day following surgery shows a functional anastomosis without leakage. On day 11, the patient is discharged. Pica is usually discovered by accident, most frequently on the operating table which is why thorough preoperative examination and investigations are required.

Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India.

BACKGROUND/PURPOSE OF THE STUDY: Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality. METHODS: Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge. RESULTS: A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis. CONCLUSION: Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.

Importance of Heparin Provocation and SPECT/CT in Detecting Obscure Gastrointestinal Bleeding on 99mTc-RBC Scintigraphy: A Case Report.

We presented a pediatric case with a history of intermittent melena for 3 years because of angiodyplasia of small intestine. The results of frequent upper gastrointestinal endoscopies and colonoscopies as well as both Tc-red blood cell (RBC) and Meckel's scintigraphies for several times were negative in detection of bleeding site. However, Tc-RBC scintigraphy with single-photon emission computed tomography (SPECT)/computed tomography (CT) after heparin augmentation detected a site of bleeding in the distal ileum which later was confirmed during surgery with final diagnosis of angiodysplasia.It could be stated that heparin provocation of bleeding before Tc-RBC scintigraphy accompanied by fused SPECT/CT images should be kept in mind for management of intestinal bleeding especially in difficult cases.

Lower gastrointestinal bleeding.

This article examines causes of occult, moderate and severe lower gastrointestinal (GI) bleeding. The difference in the workup of stable vs unstable patients is stressed. Treatment options ranging from minimally invasive techniques to open surgery are explored.

Obstructive jaundice and melena caused by hemocholecyst: a case report.

A hemocholecyst (HC) is a clot-filled gallbladder caused by bleeding into its lumen. Obstructive jaundice caused by the compression of HC to the hilar biliary tract is likely to be misdiagnosed as cholangiocarcinoma and is extremely rare. We herein report a case of obstructive jaundice and melena caused by HC. A 57-year-old male patient presented with right upper quadrant pain associated with icteric sclera and melena was suspiciously diagnosed as having malignant cholangiocarcinmoa by abdominal ultrasonography, computed tomography and magnetic resonance imaging. Laparotomy found a hematoma in the gallbladder. The hematoma spread to the left hepatic lobe forming an exogenous mass which compressed the hilar biliary tract. Radical cholecystectomy and bile duct exploration with T-tube drainage were performed. Histopathological examination revealed massive necrosis of the gallbladder mucosa with inflammatory cells infiltration as well as intraluminal hematoma formation. One month after operation, a T-tube cholangiography revealed a normal biliary tree. We suggest that HC should be considered in patients with obstructive jaundice and melena after common causes are ruled out.

Angiodysplasia and bleeding in the small intestine treated by balloon-assisted enteroscopy.

OBJECTIVE: This study aimed to evaluate the outcomes in patients undergoing balloon-assisted enteroscopy (BAE) with heat probe or argon plasma coagulation and to identify risk factors for recurrent bleeding. METHODS: Data of the patients who were consecutively referred to our institution with angiodysplastic bleeding of the small intestine between August 2005 and February 2010 were reviewed. These 39 patients underwent BAE and were followed up for 6 months. RESULTS: In all, 31 patients had melena and 8 had hematochezia. On BAE, 26 patients received endoscopic therapy, 3 underwent surgical intervention due to endoscopic therapy failure, and 10 underwent observation because a definite source of bleeding was not identified. Ten patients (25.6%) had recurrent bleeding during follow-up, including eight patients in the endoscopic therapy group and two in the observation group. Higher rates of recurrent bleeding were observed in association with the presence of melena initially (P = 0.028), but there were no significant differences in the rate of recurrence between patients who did and did not receive endoscopic therapy (P = 0.470). Age greater than 65 years (P = 0.058) and jejunal bleeding (P = 0.050) tended to increase the risk of recurrent bleeding compared with other factors. CONCLUSIONS: BAE may be a beneficial approach to treat angiodysplastic bleeding in the small intestine. Elderly patients and those with melena or jejunal bleeding should be closely monitored for recurrent bleeding.

Renal cell carcinoma presenting with Melena from direct invasion into the duodenum: a case report and a review of literature.

Today the classic triad of flank pain, hematuria and a palpable abdominal mass is rarely present at initial diagnosis of renal cell carcinoma due to the growing number of cases diagnosed incidentally on imaging studies. We report a case of a 58-year-old female who presented with melena where a subsequent esophagogastroduodenoscopy demonstrated a bleeding duodenal lesion. Pathologic study of a biopsy revealed Clear Cell RCC and an ensuing abdominal CT revealed the direct duodenal invasion of a primary renal mass. We also provide a brief review of nephrectomy in the face of metastatic renal cell carcinoma.

Meckel's diverticulum causing severe hemorrhage.

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.

Tension pneumoperitoneum: a rare complication of upper gastrointestinal endoscopy.

INTRODUCTION: Tension pneumoperitoneum is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure. Various iatrogenic procedures are responsible for this complication. We herein report a case of tension pneumoperitoneum resulting from upper gastrointestinal endoscopy. CASE DESCRIPTION: A 45-y-old man was referred to our department because of melena. Esophagogastroscopy was unsuccessful because of failure to inflate the stomach, and sudden abdominal distension was noted immediately after the procedure. The hemodynamic status of the patient was compromised, and the imminent collapse was prevented with emergent needle paracentesis. Decompression of the abdominal cavity restored vital signs to normal allowing definitive surgical treatment. DISCUSSION: Upper gastrointestinal endoscopy is a rare cause of this life-threatening complication. The combination of acute abdominal distension with hemodynamic instability following endoscopic procedures should raise suspicion of tension pneumoperitoneum. Needle decompression is life-saving and should be performed instantly upon recognition of this condition.