Rare presentation of Brunner's gland adenoma: another differentiation in patients with recurrent "idiopathic" pancreatitis.

BACKGROUND: Brunner's gland adenoma (BGA) is an unusual benign neoplasm arising from Brunner's glands in the duodenum. When symptomatic it presents either with duodenal obstruction or bleeding. However, pancreatitis secondary to ampullary obstruction from a BGA is very rare. METHODS: A 23-year-old female presented with recurrent episodes of "idiopathic" pancreatitis. She was extensively investigated and was found to have a large polypoid BGA, intermittently obstructing the ampulla. This created a ball-valve effect causing secondary intermittent obstruction of the pancreatic duct resulting in pancreatitis. The condition was cured surgically, through transduodenal excision of the BGA. We reviewed the surgical literature pertaining to these unusual and similar causes of obstructive pancreatitis, not related to gallstones. RESULTS: BGA of the duodenum is a rare cause of pancreatitis. Extensive investigations should be carried out in all cases of unexplained pancreatitis before classifying the condition as "idiopathic". Discovery of a lesion of this nature gives an opportunity to provide a permanent surgical cure. CONCLUSIONS: BGA adds an unusual etiology for pancreatitis. All patients with pancreatitis should undergo extensive investigations before being termed "idiopathic". Surgical excision of the BGA provides a definitive curative treatment for the adenoma and pancreatitis.

Laparoscopic retrieval of a missing pancreatic pseudocyst drain.

A 20-year woman who presented with acute pancreatitis developed a pseudocyst that was successfully drained by endoscopic placement of a stent as a cystogastrostomy. The first stent used went fully into the cyst and was irretrievable. Two years later a computed tomography showed the stent lying anterior to the left kidney. The stent was later successfully retrieved using a retroperitoneal laparoscopic approach, with the help of an image intensifier. Although high technical success rates of endoscopic drainage of pseudocysts are reported complications have been described including hemorrhage, secondary infection, and stent migration. We believe this is the first case described where a pseudocyst drain has migrated into the retroperitoneum and then been retrieved laparoscopically.

Re-introduction of azathioprine in previously intolerant patients.

BACKGROUND AND AIMS: Azathioprine is an important steroid sparing agent in the management of patients with inflammatory bowel disease. However, side effects are a problem in a significant minority of patients. We proposed that desensitization might increase the number of patients able to tolerate the drug. METHODS: Successive inflammatory bowel disease patients who were intolerant to azathioprine in our hospital gastroenterology clinic were invited to recommence the drug at a low dose, gradually building up to a therapeutic dose. Patients were observed for the recurrence of side effects. Patients who did not wish to participate were offered alternative immunosuppressant therapy. RESULTS: Fourteen patients elected to attempt desensitization. Nine of these (64%) were able to tolerate a full dose of azathioprine. The remainder suffered a return of their side effects and were offered alternative treatment. CONCLUSIONS: Azathioprine can be tolerated in some people who have been previously intolerant by the use of desensitization.

Intussusception caused by a heterotopic pancreas. Case report and literature review.

CONTEXT: Intussusception in adults is rare, accounting for 0.1% of adult hospital admissions. In contrast to this, it is the leading cause of obstruction in children. In up to 90% of adults a cause can usually be found, but in children this is rarely the case. CASE REPORT: We report the case of a 27-year-old lady with a subacute bowel obstruction caused by a jejunal heterotopic pancreas and describe its successful surgical management. CONCLUSION: The causes of intussusception in adults are discussed in the literature review.

Making the diagnosis of coeliac disease: is there a role for push enteroscopy?

Coeliac disease is one of the most common genetically based diseases. The wide clinical spectrum of the disease and the availability of highly specific antibody testing have led to an increased number of patients undergoing gastroscopy with distal duodenal biopsies. Histological confirmation of the characteristic small bowel changes with partial or total villous atrophy remain the gold standard for making a diagnosis. Patients with positive antibodies but initially negative or uncertain biopsies pose a particular diagnostic dilemma. Due to the patchiness of the histological changes, push enteroscopy with jejunal biopsies can play a valuable role in this group of patients. Similarly, patients with refractory coeliac disease can benefit from push enteroscopy with jejunal biopsies.