Pyloric stenosis as a manifestation of isolated gastric Crohn's disease responding to intralesional steroid injection and balloon dilation: a case report.

BACKGROUND: Crohn's disease is a chronic inflammatory condition that can affect the gut from mouth to anus. Gastroduodenal involvement is seen in less than 5% of all patients with Crohn's disease. Among those cases, isolated gastric Crohn's disease is even rarer. Although most patients with isolated gastric involvement have nonspecific complaints, very few of them do develop features of pyloric obstruction. There is a paucity of data on specific management of gastric Crohn's disease owing to its rarity and its frequent coexistence with colonic or ileal disease. We report a case of a patient who had pyloric stenosis as a manifestation of isolated gastric Crohn's disease responding to intralesional steroid injection and balloon dilation. CASE PRESENTATION: A previously healthy woman presented with recurrent postprandial vomiting, epigastric discomfort, and unintentional weight loss over 6 months. She had no diarrhea or extraintestinal manifestations. Clinically, she was pale and dehydrated. Examination of systems was unremarkable except for mild epigastric tenderness. Her initial laboratory findings were normocytic normochromic anemia, high inflammatory markers, and hypokalemia. Esophagogastroduodenoscopy revealed an inflamed pyloric mucosa with features of pyloric obstruction. Furthermore, magnetic resonance enterography confirmed the pyloric stenosis. Histopathological examination of a biopsy from the pylorus revealed noncaseating granuloma with superficial ulceration. Tuberculosis and sarcoidosis were excluded by appropriate investigations, and a diagnosis of gastric Crohn's disease was made. Following the initial resuscitation, intralesional steroid injection and controlled radial expansion balloon dilation of the pylorus were carried out. The patient was commenced on azathioprine as a maintenance treatment, which led to a successful dilation and remarkable symptom improvement. CONCLUSION: Symptoms of pyloric obstruction as a manifestation of isolated gastric Crohn's disease are extremely unusual in clinical practice, awareness of which would facilitate early appropriate investigations and treatment.

Milk vomiting or regurgitation in the first 3 months of life: Something old-something new.

The age of presentation of reflux symptoms and their self-cure in babies without a sliding hernia parallel those of mild pyloric stenosis of infancy (PS). It is proposed that this is because PS and, at least some cases of reflux, share the same cause-a temporary hold-up at the pyloric sphincter owing to acid provoked hypertrophy of the pyloric sphincter. In support of this theory, the written observations of John Thomson, Pediatrician from Edinburgh, in 1921 and Isabella Forshall, Pediatric Surgeon from Alder Hey Hospital, Liverpool, in 1958 are revisited. An analysis of both papers provides supportive evidence that, in at least some cases diagnosed as simple reflux, an underlying temporary hold up is present owing to early hypertrophy of the sphincter. It is recommended that sphincter thickness measurements should be made by ultrasonic assessment whenever uncomplicated reflux is diagnosed within the first 3 months of life.

Laparoscopic distal gastrectomy for pyloric stenosis caused by heterotopic glands in a young female: report of a case.

A 17-year-old female was referred to our hospital with worsening dietary intake and abdominal bloating. She had epigastric fullness, but no abdominal pain. Gastrointestinal endoscopy revealed food residue and pyloric stenosis. A contrast-enhanced radiograph also showed pyloric stenosis, and gastrografin was not passed well through her pylorus. Computed tomography revealed similar findings. The biopsy results indicated hyperplasia of the gastric glands. The patient was diagnosed with a benign lesion, and underwent endoscopic balloon dilation several times. However, her stenosis worsened and we decided to perform surgery. In consideration of the cosmetic outcome, we performed laparoscopic distal gastrectomy. The postoperative course was good, and the patient was discharged on postoperative day 10. The final diagnosis was pyloric stenosis caused by heterotopic glands. No malignant lesions were found. Since gastric stenosis caused by heterotopic glands has not been reported previously, we consider this to be a very rare case.

[Gastric ulcer suspected of being a carcinoma part 2]. / Karzinomverdächtiges Magenulkus Teil 2.

Differentiation between pseudoneoplastic regenerative epithelium and gastric carcinoma can be challenging. In cases with pseudoneoplastic regeneration, so-called lateral expansion of tubules and changing of nuclear rows within one gland should not be present. The gastritis status is of particular significance as gastric cancer is a rare occurrence without Helicobacter pylori infections.

[Heterotopic accessory pancreas in surgical pathology: review of 23 years experience]. / Pancreasul accesor heterotopic in patologia chirurgicala: experienta a 23 de ani.

BACKGROUND: The abnormal presence of the pancreatic tissue in other digestive organs is rare but sometimes is the cause of some surgical diseases. MATERIAL AND METHOD: This retrospective study is focussed on heterotopic pancreas cases diagnosed in 2nd Surgical Clinic of "Sf. Spiridon" Emergency Hospital from Iasi between Jan. 1986 and Dec. 2008. RESULTS: 22 patients (15 males/68.2% and 7 females/31.8%) aged between 23 and 76 years were grouped in A group--clinical symptomatic cases (3 patients/13.6%), group B--coincidental cases (17 patients/77.3%) and group C--incidental cases (2 patients/9%). Group A patients presented with obstructing prepyloric polypoid tumors and recquired antrectomy and gastroduodenal anastomosis. 13 patients of group B (76.4%) recquired surgery for pyloroduodenal stenosis and in 4 cases of this group with severe upper-GI bleeding, a subtotal gastric resection (3 patients) or antrectomy (1 case) was performed. In group C patients jejunal HP was histopathologically diagnosed during extensive intestinal resection for colonic malignancies (ascendant colonic and transverse colonic cancers) with jejunal invasion. HP cases were categorized as type I in 40.9% cases (ducts, acini and pancreatic islets), type II in 45.4% cases (ducts and acini) and type III (exclusively with ducts) in 13.6% cases. In 76% patients HP was localized in mucosal and submucosal layers, in 16% intramucosal and in 8% in subserous layer. CONCLUSION: HP is most often an unexpected symptomless coincidental diagnosis during gastrointestinal surgical diseases.

[Administration of S-1 after gastrojejunostomy for unresectable gastric cancer with pyloric stenosis].

We evaluated the efficacy of chemotherapy using S-1 after gastrojejunostomy for unresectable gastric cancer with pyloric stenosis. We performed gastrojejunostomy to relieve obstruction in 40 patients from 1993 to 2007. After gastrojejunostomy, 15 patients were treated with S-1(S-1 group), 12 patients were treated with another anticancer drug(non S-1 group)and the other 13 patients received no chemotherapy. After informed consent was obtained, S-1(80 mg/m(2)day)and another anticancer drug was administered. The mean period of administered was 16(range 2-56)weeks in the S-1 group. In the non S-1 group, 5-FU was used in 1 patient, 5'-DFUR in 2, UFT in 3, FP chemotherapy in 3, CPT- 11/CDDP chemotherapy in 1, and 5-FU/PTX chemotherapy was conducted in 2 patients. The one-year survival rate was 63% and the median survival time was 394 days in the S-1 group, against 33% and 169 days, respectively, in the non S-1 group. Appetite loss of grade 3 was observed in one(7%)patient with nonhematological toxicity, but no patient suffered grade 3 hematological toxicity. We observed the course of all patients on an outpatient basis. In conclusion, S- 1 administration after gastrojejunostomy appears to be an effective treatment modality for far advanced gastric cancer patients with pyloric stenosis in view of toxicities, antitumor effects and QOL of the patients.

[Gastrojejunostomy for irresectable gastric cancer with pyloric stenosis-new role of surgery in the era of S-1].

We report a patient with an advanced gastric cancer complicated by pyloric stenosis who was effectively treated by S-1 mono-therapy after gastrojejunostomy. A 62-year-old man consulted a general practitioner for abdominal pain and anorexia. Gastric roentgenography and upper gastrointestinal endoscopy showed gastric cancer(Borrmann Type 3) with pyloric stenosis. He was referred to our department. He underwent laparotomy, which revealed a T4 tumor invading the pancreas head, but neither liver nor peritoneal metastasis. A gastrojejunostomy was made. After the operation, chemotherapy of S-1(120 mg/day, day 1-21)+cisplatin(100 mg/day, day 8)was administered. After 2 courses, level of tumor marker decreased remarkably and abdominal enhanced computed tomography showed a significant size reduction of lymph nodes and that direct invasion to the pancreas was not clear any more. Second laparotomy was carried out and curative surgery was performed. After 4 courses of S-1(120 mg/day, day 1 approximately 28)mono-therapy as adjuvant chemotherapy, bone metastasis was confirmed by scintigram. Then methotrexate+5-FU, irinotecan+cisplatin and cisplatin+paclitaxel were chosen as second-, third-and fourth-line chemotherapy, which were not effective for long. He died 572 a days after the initial surgery. In the past, gastrojejunostomy was regarded as useful palliative treatment for those with gastric outlet stenosis to ameliorate the QOL. As S-1 is taking major role in the chemotherapy for advanced gastric cancer recently, usefulness of bypass surgery for such patients is highlighted even for longer survival time.

[Stenotic bleeding pyloric ulcers].

Treatment results in 110 patients with stenotic bleeding pyloroduodenal ulcers (SBPU) were analyzed. Correlation dependence of hemorrhage severity and recurrence frequency from the degree of pyloroduodenal stenosis was revealed. Recurrence of ulcer gastroduodenal bleeding - is the main factor that determines lethality at SPBU. The total lethality against a background of SPBU recurrence was 16%, whereas in the absence of recurrence it was 10%. Treatment tactics in patients with SPBU was worked out. The best results were received after urgent operations which had been carried out after short-term preoperative preparation, aimed to blood replacement and correction of water-electrolytic and protein-energy disturbances at pyloroduodenal stenosis.

[A case of advanced gastric cancer with pyloric stenosis and obstructive jaundice responding to s-1/paclitaxel combination therapy after endoscopic balloon dilatation and endoscopic biliary drainage].

A 65-year-old female who complained of appetite loss and upper abdominal pain was diagnosed as unresectable advanced gastric cancer with pyloric stenosis and obstructive jaundice by peritoneal and lymph node metastases. After endoscopic balloon dilatation and endoscopic biliary drainage, S-1(80 mg/m(2)/day, days 1-14 with 1 week rest)/pacli- taxel(PTX)(50 mg/m(2)/day, day 1, day 8)combination therapy was done. After one course of the chemotherapy, subjective symptoms were relieved and oral intake was increased. Computed tomography showed that the volume of gastric wall, the size of paraaortic lymph node, and the amount of pleural effusion and ascites were decreased. Grade 1 alopecia, vasculitis and grade 2 neutropenia were observed as adverse reactions to the treatment. S-1/PTX combination therapy after endoscopic intervention was effective in this case of advanced gastric cancer with pyloric stenosis and obstructive jaundice.

Serotoninergic system in the development of pyloric stenosis and pancreatitis.

Pyloric stenosis and pancreatitis were simulated before and after administration of serotonin and spiperone (5-HT2 receptor blocker). Activation of the serotoninergic system prevented the development of pancreatitis, but led to more severe course of pyloric stenosis.

[On the issue of pylorostenosis modeling].

Pylorostenosis was modeled by putting a slightly compressing ligature in the boundary between the antral part of the stomach and the duodenum. Subcompensated pylorostenosis developed on the 10th day; decompensated pylorostenosis developed on the 15th day.

[Infrared spectroscopy in assessment of the morpho-functional stomach changes at ulcerous pyloroduodenal stenosis].

In the present study authors have analyzed the suitability of the infrared (IR) spectroscopy for diagnosis of morphological and functional changes of the stomach in ulcer pyloroduodenal stenosis. Data obtained from 64 patients have shown that the IR spectroscopic features of the stomach were dependent on the stage of stenosis, secretory function of the stomach and the presence of the Helicobacter Pylori (HP) infection. IR spectroscopy can be a multi-purpose mean of assessment of the morphological and functional properties of the stomach in pyloroduodenal stenosis. IR spectroscopy provides the opportunity to assess the secretory state of the stomach at different stages of the disease. Using IR spectroscopy we were able to reveal the presence of HP in the stomach and the dynamics of its eradication during of conservative treatment and at any time after surgical intervention.

[A case report of highly advanced gastric cancer with ascites with long survival and improved QOL from combined chemotherapy of paclitaxel and 5-fluorouracil].

The patient was a 63-year-old male who came to our hospital with the chief complaints of dyspepsia and abdominal fullness. Endoscopic findings showed Type 3 gastric cancer with pyloric stenosis. CT examination revealed a large amount of peritoneal fluid, invasion to the pancreas, peritoneal dissemination and paraaortic lymph node metastasis. Intraperitoneal administration of weekly CDDP 10 mg/body was in vain, and combined chemotherapy of paclitaxel and 5-fluorouracil was carried out. Ascites was significantly reduced and oral intake became possible two courses after this regimen. The tumor decreased in size after 3 courses, and the tumor markers returned to within normal limits. The patient was then discharged, and followed as an outpatient thereafter. Endoscopic examination showed improvement in narrowing of the antrum. However,tumor invasion to pancreas, peritoneal dissemination and lymph node metastasis relapsed. He died one year and one month after the onset.

Choice of incision: the experience and evolution of surgical management of infantile hypertrophic pyloric stenosis.

PURPOSE: This study evaluated the impact of laparoscopic pyloromyotomy since it came into use at our institution in March 1999. MATERIALS AND METHODS: The recovery profiles and intraoperative and postoperative complications of 170 infants who underwent laparoscopic, semicircumumbilical incision, or right upper quadrant incision pyloromyotomies between March 1999 and April 2005 were analyzed. RESULTS: Eighty-one (48%) of operations were undertaken laparoscopically, 51 (30%) by traditional right upper quadrant incision, and 38 (22%) by semicircumumbilical incision. Patient group demographics were similar across all groups. There was no significant difference in overall complication rate between procedures: laparoscopic group, 12.3% (10/81); semicircumumbilical incision group, 18.4% (7/38); and right upper quadrant incision group, 9.8% (5/51). Early in the laparoscopic series there were 2 inadequate pyloromyotomies and 2 conversions to open procedures due to perforation (n = 1) and poor visibility (n = 1). Infections were more common with open surgery: laparoscopic, 1.2% (n = 1), right upper quadrant incision, 7.8% (n = 4), and semicircumumbilical incision, 13.2% (n = 5). Operative correction was required for herniation at 3 laparoscopic incision sites (3.6%), 2 semicircumumbilical incision sites (5.3%), and 2 right upper quadrant incision sites (3.9%). Patients who underwent laparoscopy returned to full feeds faster (laparoscopic, 18.1 hours; right upper quadrant incision, 28.1 hours; and semicircumumbilical incision, 28.9 hours) (P < 0.05), required less analgesia (laparoscopic, 2.1 doses; right upper quadrant incision, 4.0 doses; and semicircumumbilical incision, 4.3 doses) (P < 0.05), and had less emesis (laparoscopic, 1.6 episodes; right upper quadrant incision, 2.9 episodes; and semicircumumbilical incision, 3.5 episodes) (P < 0.05), resulting in faster discharge (laparoscopic, 2.0 days; right upper quadrant incision, 3.1 days; and semicircumumbilical incision, 3.2 days) (P < 0.05). CONCLUSION: Laparoscopic pyloromytomy is as effective and safe as open procedures and is associated with an improved recovery profile. We conclude that, where laparoscopic skills exist, laparoscopy should be the management of choice for hypertrophic pyloric stenosis.