Probiotic intake unmasking a gastro-pleural fistula.

OBJECTIVE: Gastropleural fistula represents a rare clinical event often resulting in an iatrogenic complication of gastrointestinal surgery. Clinical presentation is insidious, patients complain of chronic and non-specific respiratory symptoms and may be conservatively treated for lung infections for several months until detailed tests finally reveal the correct diagnosis. PATIENTS AND METHODS: We describe a case of a healthy patient with an unexpected diagnosis of empyema due to a gastropleural fistula. RESULTS: A 51-year-old man with a past history of splenectomy for cyst was admitted because of high fever and cough. A chest radiography and CT-scan revealed a left-side pneumonia complicated with pleural empyema. Broad spectrum empirical antibiotics and pleural drainage did not significantly improve the clinical picture. While the need for a surgical complex thoracic approach becomes a collective awareness, questions about causes of empyema and its unfavorable evolution in our patient did not initially find a common satisfactory answer. It was only by the identification of probiotics bacteria in the pleural fluid that a gastropleural fistula was suspected, and then, it was confirmed by CT-scan and by digestive endoscopy. A combined thoraco-abdominal surgical treatment was therefore scheduled, leading to progressive improvement till total healing. CONCLUSIONS: Although gastropleural fistula is rare, it is necessary to include this pathological condition in the differential diagnosis of a persistent complicated pneumonia, because early diagnosis and, consequently, surgical management, may significantly impact on the prognosis of these patients. In our case, the detection of probiotics bacteria in the pleural fluid helped us to suspect and to look for the fistula.

The Role of Medication in Spontaneous Gastrocutaneous Fistula Closure.

PURPOSE: Factors precipitating persistence of gastrocutaneous fistulas (GCFs) are not clearly understood. The role of proton pump inhibitors (PPIs) or histamine receptor antagonists in GCF closure is not yet studied. We aimed to identify whether these medications influence spontaneous GCF closure. METHODS: Retrospective review was performed on children who underwent gastrostomy tube insertion and removal from January 2010 to February 2013. Spontaneous GCF closure rates and medication use during gastrostomy tube removal were investigated. RESULTS: Of the 97 patients included, 48 had spontaneous GCF closure, whereas 49 required operative closure. When comparing these two groups, no significant difference existed in spontaneous GCF closure rates among patients who were on ranitidine, PPIs, or both (p = 0.09, p = 0.83, p = 0.06 respectively). Spontaneous closure occurred more in older patients (2.7 ± 4.1 vs. 0.9 ± 1.6 years, p < 0.01) and in patients without fundoplication at time of tube insertion (12.5 vs. 30.6%, p = 0.05). There were more laparoscopic placements in the group that closed spontaneously (83 vs. 61%, p = 0.02). Mean gastrostomy tube presence was longer in patients who required surgery than those with spontaneous closures (18.7 ± 10.3 vs. 35.5 ± 36.6 months, p < 0.01). CONCLUSION: Ranitidine or PPI use upon removal of gastrostomy tubes does not seem to facilitate spontaneous GCF closure in children.

Double pylorus in a patient with Behçet's syndrome.

We report a patient with Behçet's syndrome who presented with upper gastrointestinal haemorrhage. Gastroduodenoscopy showed a gastroduodenal fistula which caused the appearance of double pylorus in the antrum. The possibility of peptic ulcer disease related to non-steroidal anti-inflammatory drug use or Behçet's syndrome itself, as the cause of this rare condition in this patient is discussed.

Double pylorus in the era of proton pump inhibitors.

Double pylorus and gastroduodenal fistula are rare conditions and can be either congenital or acquired. We report a case of a 58-year-old man with epigastric pain and dyspepsia in which the upper gastrointestinal endoscopy revealed an acquired double pylorus, probably caused by a gastric ulcer.

Double pylorus in the era of proton pump inhibitors / Doble píloro en la era de los inhibidores de la bomba de protones

Double pylorus and gastroduodenal fistula are rare conditions and can be either congenital or acquired. We report a case of a 58-year-old man with epigastric pain and dyspepsia in which the upper gastrointestinal endoscopy revealed an acquired double pylorus, probably caused by a gastric ulcer.

El doble píloro y la fístula gastroduodenal son condiciones raras y pueden ser congénitas o adquiridas. Se reporta un caso de un varón de 58 años con dolor epigástrico y dispepsia en quien la endoscopía digestiva alta mostró un doble píloro adquirido, probablemente causado por una úlcera gástrica.

Closure of a large high-output gastrocutaneous fistula with combined postpyloric feeding and aggressive medical therapy.

Widening of the exit site of a percutaneous gastrostomy tube is a rare but difficult to manage complication, which leads to significant morbidity as a result of caustic material leak and associated cutaneous injury. Such defects fail to close with conservative measures such that invasive (surgical or endoscopic) intervention is often required. The authors present a 49-year-old woman with neurological dysphagia, 2 years after gastrostomy tube insertion with several months' history of leakage and widening of the hole at the exit site. Following gastrostomy tube removal; the patient was left with a large, high-output gastrocutaneous fistula which was treated aggressively with measures to reduce gastric discharge including 'nil-by-mouth', bypassing the stomach with distal feeding, administration of a somatostatin analogue, high-dose proton pump inhibitor and prokinetics with the aim of preoperatively downsizing the wound. This novel approach led to complete closure of the large gastrocutaneous fistula, obviating the need for surgical intervention.

A case of amoebic liver abscess complicated by a gastric fistula cured with oral medication only.

A 26-year-old man was admitted to our hospital because of a high-grade fever and abdominal pain. A blood test showed marked inflammation. Enhanced computed tomography (CT) showed an 8.0×6.0cm cystic lesion in the left hepatic lobe. Esophagogastroduodenoscopy showed a huge egg-yolk-like mass in the gastric submucosa in the lesser curvature of the gastric body from the gastric angle. There were 3 ulcers on the mass, out of which milky pus flowed. Trophozoites of Entamoeba histolytica were detected from cultures of the liver abscess and a biopsy of the gastric ulcers. The amoebic dysentery antibody titer was increased 1600 times. An amoebic liver abscess complicated by a gastric fistula was diagnosed. As therapy, oral metronidazole was administered for 2 weeks without percutaneous drainage. The systemic inflammatory findings improved immediately and the abscess decreased markedly in size.

Percutaneous endoscopic suturing is an alternative treatment for persistent gastrocutaneous post-PEG fistula.

Persistent gastrocutaneous fistula after the removal of a gastrostomy tube is an unusual complication associated with percutaneous endoscopic gastrostomy (PEG). Surgical closure has been usually the treatment of choice. Several endoscopic methods have been previously attempted to close the fistula, usually with poor results. We report a successful case of percutaneous endoscopic suturing of a persistent gastrocutaneous post-PEG fistula, using a monofilament absorbable suture. A biopsy forceps was used to deepithelialize both ends of the fistulous tract to promote granulation tissue formation. The gastrocutaneous fistula closed completely after the procedure and there were no complications during the follow-up.

Spontaneous gastrosplenic fistula secondary to primary splenic lymphoma.

A gastrosplenic fistula is a rare complication of gastric and splenic lymphomas which can occur spontaneously or secondary to chemotherapy. We report a case of a spontaneous gastrosplenic fistula secondary to a diffuse splenic large B cell lymphoma in a previously well 43-year-old patient. CT imaging demonstrated the fistula, which was subsequently managed with chemotherapy. The clinical management of this rare condition is discussed with a review of the literature.

Therapy for unhealed gastrocutaneous fistulas in rats as a model for analogous healing of persistent skin wounds and persistent gastric ulcers: stable gastric pentadecapeptide BPC 157, atropine, ranitidine, and omeprazole.

OBJECTIVE: This study focused on unhealed gastrocutaneous fistulas to resolve whether standard drugs that promote healing of gastric ulcers may simultaneously have the same effect on cutaneous wounds, and corticosteroid aggravation, and to demonstrate why peptides such as BPC 157 exhibit a greater healing effect. Therefore, with the fistulas therapy, we challenge the wound/growth factors theory of the analogous nonhealing of wounds and persistent gastric ulcers. METHODS: The healing rate of gastrocutaneous fistula in rat (2-mm-diameter stomach defect, 3-mm-diameter skin defect) validates macro/microscopically and biomechanically a direct skin wound/stomach ulcer relation, and identifies a potential therapy consisting of: (i) stable gastric pentadecapeptide BPC 157 [in drinking water (10 microg/kg) (12 ml/rat/day) or intraperitoneally (10 microg/kg, 10 ng/kg, 10 pg/kg)], (ii) atropine (10 mg/kg), ranitidine (50 mg/kg), and omeprazole (50 mg/kg), (iii) 6-alpha-methylprednisolone (1 mg/kg) [intraperitoneally, once daily, first application at 30 min following surgery; last 24 h before sacrifice (at postoperative days 1, 2, 3, 7, 14, and 21)]. RESULTS: Greater anti-ulcer potential and efficiency in wound healing compared with standard agents favor BPC 157, efficient in inflammatory bowel disease (PL-14736, Pliva), given in drinking water or intraperitoneally. Even after 6-alpha-methylprednisolone aggravation, BPC 157 promptly improves both skin and stomach mucosa healing, and closure of fistulas, with no leakage after up to 20 ml water intragastrically. Standard anti-ulcer agents, after a delay, improve firstly skin healing and then stomach mucosal healing, but not fistula leaking and bursting strength (except for atropine). CONCLUSION: We conclude that BPC 157 may resolve analogous nonhealing of wounds and persistent gastric ulcers better than standard agents.

Hipoglucemia grave tras el inicio de somatostatina en una paciente diabética con fístula intestinal tratada con nutrición parenteral total / Severe hypoglycemia after somatostatin in a diabetic patient with gastrointestinal fistula treated with total parenteral nutrition

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Somatostatin versus octreotide in the treatment of patients with gastrointestinal and pancreatic fistulas.

BACKGROUND AND PURPOSE: Gastrointestinal and pancreatic fistulas are characterized as serious complications following abdominal surgery, with a reported incidence of up to 27% and 46%, respectively. Fistula formation results in prolonged hospitalization, increased morbidity/mortality and increased treatment costs. Conservative and surgical approaches are both employed in the management of these fistulas. The purpose of the present study was to assess, evaluate and compare the potential clinical benefit and cost effectiveness of pharmacotherapy (somatostatin versus its analogue octreotide) versus conventional therapy. PATIENTS AND METHODS: Fifty-one patients with gastrointestinal or pancreatic fistulas were randomized to three treatment groups: 19 patients received 6000 IU/day of somatostatin intravenously, 17 received 100 microg of octreotide three times daily subcutaneously and 15 patients received only standard medical treatment. RESULTS: The fistula closure rate was 84% in the somatostatin group, 65% in the octreotide group and 27% in the control group. These differences were of statistical significance (P=0.007). Overall mortality rate was less than 5% and statistically significant differences in mortality among the three groups could not be established. Overall, treatment with somatostatin and octreotide was more cost effective than conventional therapy (control group), and somatostatin was more cost effective than octreotide. The average hospital stay was 21.6 days, 27.0 and 31.5 days for the somatostatin, octreotide and control groups, respectively. CONCLUSIONS: Data suggest that pharmacotherapy reduces the costs involved in fistula management (by reducing hospitalization) and also offers increased spontaneous closure rate. Further prospective studies focusing on the above parameters are needed to demonstrate the clinicoeconomic benefits.

Imatinib (STI-571) heals a gastrocutaneous fistula resulting from a malignant gastric stromal tumor.

The management of inoperable giant malignant gastrointestinal stromal tumor (GIST) of the stomach sed to be a formidable task. We report our success with the use of STI-571 in treating a patient with huge GIST of the stomach complicated by gastrocutaneous fistula after an unsuccessful laparotomy. The patient was a 49-year-old man who presented to our center with a painful epigastric mass in December 2001. Endoscopy, biopsy, and magnetic resonance scan confirmed that it was a malignant stromal tumor arising from the gastric fundus. Laparotomy with an intention to resect the tumor was performed in view of the obstructing symptoms. However, massive bleeding was encountered during dissection of the tumor and gastrectomy was abandoned. The case was further complicated with the development of a gastrocutaneous fistula in the early postoperative period. The patient ws then managed with naso-duodenal tube feeding and enteral STI-571 was prescribed. The fistula healed up in 20 days and the mass became impalpable 1 month afterwards. Follow-up computed tonography (CT) scan 3 months later confirmed significant tumor reduction, and the patient has experienced no side effects from the treatment

Palliation of a malignant gastrocolic fistula by endoscopic human fibrin sealant injection.

We report the case of a female patient with Hodgkin's disease resistant to therapy who developed a gastrocolic fistula as a consequence of her disease, leading to distressing faeculent vomiting. This was not considered to be amenable to surgical resection and her symptoms were successfully palliated endoscopically using injection of human fibrin sealant into the gastric and colonic aspect of the fistula tract. Both mechanical sealing and promotion of healing by human fibrin sealant are likely to be responsible for its efficacy.

Efficient synthesis and gastric (H+/K+)-ATPase-inhibitory activity of 2-aryl-4,5-dihydro-1H-thieno[3,2-e]benzimidazoles.

A series of 2-aryl-4,5-dihydro-1H-thieno[3,2-e]benzimidazoles (1, 2) was prepared by condensation of 5-acylamino-4,5,6,7-tetrahydrobenzo[b]thiophen-4-ones (9, 10) with ammonium acetate under azeotropic reaction conditions. Various congeners, N-methyl and N-phenyl analogues (3-5), 4,5-dihydro-1H-thieno[2,3-e]benzimidazoles (6), 4,5-dihydro-1H-thieno[2,3-g]benzoxazoles (7), and 4,5-dihydro-1H-thieno[2,3-g]benzothiazoles (8), were also prepared. Several compounds in this series were shown to be K(+)-competitive inhibitors of the gastric (H+/K+)-ATPase and more potent inhibitors than SK&F-96067, 3-butyryl-8-methoxy-4-(2-tolylamino)quinoline, on pentagastrin-stimulated acid secretion in chronic gastric fistula rats after intraduodenal administration.