Spontaneous duodenal wall hematoma

59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms. (AU)

Successful nutritional therapy for superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome is an uncommon cause of duodenal outlet obstruction. Symptoms and signs suggestive of this condition are nonspecific, and a high index of suspicion coupled with appropriate imaging studies are necessary for diagnosis. We present the case of a 70-year-old man who developed SMA syndrome following prolonged hospitalisation for a surgically treated bleeding duodenal ulcer. His SMA syndrome resolved after successful nonoperative management based on accepted guidelines for nutritional therapy, thus avoiding the need for reoperation and its attendant risks in a malnourished patient.

Octreotide infusion for malignant duodenal obstruction in a 12-year-old girl with metastatic peripheral nerve sheath tumor.

Malignant bowel obstruction is a common complication of some adult malignancies. In childhood cancer, malignant bowel obstruction is relatively rare. Octreotide, an analogue of the hormone somatostatin, has been shown to be an effective treatment for this condition in adults. However, explicit description of its use for this indication in children was not discovered in the pediatric literature by this group of authors. The following report is that of a 12-year-old female who had copious bilious emesis secondary to malignant obstruction of the distal duodenum, which abated after treatment with a continuous intravenous octreotide infusion.

Combined arterial infusion and stent implantation compared with metal stent alone in treatment of malignant gastroduodenal obstruction.

Many patients with malignant gastroduodenal obstruction have an unresectable primary lesion and distant metastases, which may prompt palliative management to allow the patient to eat and to improve the quality of life. Intraluminal metallic stent implantation (MSI) under fluoroscopic guidance has been reported to be an effective option for symptomatic relief in these patients, with a good safety record. An alternative, dual interventional therapy (DIT), has been used during the last decade, in which prosthesis insertion is followed by intra-arterial chemotherapy via the tumor-feeding arteries. The aim of this study was to compare success rates, complication rates, and survival time between MSI and DIT in patients who presented with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. All consecutive patients with malignant gastroduodenal obstruction seen at our center between October 2002 and August 2007 were retrospectively studied. Patients were treated palliatively by either MSI or DIT by the patient's or the next of kin's decision. Outcomes included technical and clinical success, complication rates, and survival. Of the 164 patients with malignant gastric and duodenal outlet obstructions, 80 (49%) underwent stent insertion as the primary therapy, while the remaining 84 (51%) received DIT. Clinical characteristics were similar between the two groups. In the MSI cohort initial stent implantation was successful in 73 patients (91%), two stents were used in 5 patients, and delayed additional stent insertion for stent obstruction related to tumor overgrowth was required in 3 patients during follow-up. In the DIT cohort the technical success rate was 94%, 3 patients required two stents, and stent obstruction occurred in 2 patients after initial stent placement. Early postprocedural clinical success, indicated by average dysphagia score, improved significantly in both groups: MSI group, from 4.56 to 1.51 (P < 0.01); and DIT group, from 4.38 to 1.48 (p < 0.01). There were no short-term complications. Late complications including hematemesis (n = 3), migration (n = 12), and stent occlusion due to tumor overgrowth (n = 5) were evenly distributed between the groups. In the DIT group chemotherapy-induced neutropenia and transient renal dysfunction were detected in six patients, which improved after symptomatic management. Mean survival time after the procedure was 5.9 and 11.1 months for MSI and DIT, respectively (P < 0.001). In conclusion, both MSI and DIT offer effective palliation for malignant gastroduodenal obstruction, but DIT appears to offer superior survival over MSI alone. Ideally, a prospective randomized trial comparing these two techniques should be carried out to validate this result.

[Dual interventional therapy for malignant gastroduodenal obstruction].

BACKGROUND & OBJECTIVE: The patients with malignant gastroduodenal obstruction usually have unresectable primary lesion and distant metastasis. Intra-luminal metallic stent implantation followed by intra-arterial chemotherapy via the tumor feeding arteries, so-called "dual interventional therapy", could temporarily relieve obstructive symptoms. This study was to evaluate the clinical safety and efficacy of dual interventional therapy on advanced malignant gastroduodenal obstruction. METHODS: A total of 65 patients with malignant gastroduodenal obstruction underwent dual interventional therapy. Of the 65 patients, 33 had pyloric antrum obstruction, 22 had duodenal obstruction, and 10 had gastroduodenal obstruction with gastrojejunostomal obstruction; 9 had liver metastasis. The patients' survival was analyzed by log-rank test. RESULTS: Stents were successfully implanted into all enrolled patients. No severe adverse events were observed in these patients. The cumulative survival rates at 3, 6, 9, and 12 months after dual interventional therapy were 90%, 66%, 49%, and 28%, respectively. The median survival time was 11.9 months. CONCLUSION: The dual interventional therapy, with metallic stent implantation to relieve malignant obstruction and high-selective intra-arterial chemotherapy to control tumor growth, is a safe, feasible and effective treatment for malignant gastroduodenal obstruction.

Infiltrating Strongyloides stercoralis presenting as duodenal obstruction.

Small intestinal obstruction due to Strongyloides stercoralis is rare and has not been reported in an immunocompetent patient. We describe a 70-year-old immunocompetent man presenting with duodenal obstruction secondary to severe S. stercoralis infestation, as documented on duodenal biopsy. He was treated with ivermectin, with which he recovered remarkably.

Obstructing Crohn's disease of the duodenum: is surgery always mandatory?

Crohn's disease may involve any part of the alimentary tract. But, Crohn's disease of the duodenum is a very rare condition. Systemic steroid therapy had been shown to be effective in patients with Crohn's disease, and the most common indication for surgical intervention is duodenal obstruction. We report a case with Crohn's disease of the duodenum presenting with duodenal obstruction. Medical treatment option was successful as a first line of therapy because of young age and new diagnosis. The patient was administered mesalazine as a treatment, and the obstruction was resolved. The patient is still in remission for the last 2 years.

Duodenal obstruction caused by malposition of the gallbladder in a heifer.

A heifer with clinical findings suggesting obstruction of the proximal portion of the intestine was admitted for diagnostic evaluation. Ultrasonographic examination of the abdomen failed to locate the gallbladder in its normal anatomic position. Exploratory laparotomy and manual examination of the proximal portion of the intestine revealed obstruction of the duodenum caused by abnormal positioning of the gallbladder. The obstruction was relieved by replacing the gallbladder to its normal position; however, relapse occurred within 2 days. To resolve and prevent the recurrence of the obstruction without compromising gallbladder function, a novel surgical technique to provide fixation of the gallbladder to the liver was performed. The heifer recovered rapidly, proceeded to develop normally during the following year, and became pregnant.

The successful medical management of severe duodenal strictures secondary to eosinophilic gastroenteritis in an infant.

Eosinophilic gastroenteritis is an uncommon condition of unknown etiology that has only been relatively recently reported. Its clinical manifestations range from a mild disease to more severe forms resembling Crohn's disease. Enteric strictures are a rare but recognized complication of this condition. We report a case of eosinophilic gastroenteritis in an infant presenting with severe duodenal strictures that was successfully managed with oral prednisolone. We believe that this is the first reported case of duodenal strictures secondary to eosinophilic gastroenteritis.

Retroperitoneal fibrosis with duodenal stenosis.

Retroperitoneal fibrosis is a rare disease characterized by the formation of dense plaque of fibrous tissue covering the retroperitoneal structures. This disease is commonly presented as ureteral obstruction, but the involvement of duodenum is rare. We report a case of retroperitoneal fibrosis which was complicated with duodenal stenosis and was successfully treated with corticosteroids. A 58-yr-old man, who had history of aorto-iliac bypass graft due to arteriosclerosis obliterans with infrarenal aortic occlusion was admitted to the hospital with abdominal pain and a mass. Abdominal CT scan revealed the periaortic soft tissue mass encircling grafted aorta and stenosis of duodenal third portion. Retroperitoneal fibrosis with duodenal stenosis was diagnosed and prednisolone therapy was initiated. Follow-up CT scan showed that the patient responded to prednisolone therapy with eased pain, shrinking periaortic mass, and reduced duodenal stenosis.

Idiopathic retroperitoneal fibrosis with duodenal obstruction successfully treated with corticosteroids.

We report a case of idiopathic retroperitoneal fibrosis presenting with duodenal obstruction. A 55-year-old man suddenly developed severe epigastric pain and was admitted to our hospital. On abdominal computed tomography (CT), a large retroperitoneal mass was found. Hypotonic duodenography showed obstruction of the third portion of the duodenum. He was diagnosed as idiopathic retroperitoneal fibrosis and was treated with prednisolone. The patient improved dramatically. He has been well for twelve months without any further treatment.

Peptic ulcer and duodenal stenosis: role of Helicobacter pylori infection.

A 17-year-old boy who developed a symptomatic duodenal ulcer at 10 years of age with melena, and was then treated continuously for 6 years with ranitidine therapy that only partially controlled symptoms and peptic lesions, came to us with vomiting due to duodenal bulb stenosis and active ulcer. Four months of omeprazole (40 mg/die o.m.) did not modify the endoscopic picture. The diagnosis of H. pylori infection and its treatment with triple therapy led to the cure of both duodenal ulcer and bulbar stenosis. Afterwards he remained asymptomatic without any lesions or complications for 18 months. This case illustrates that H. pylori eradication: a) is able to cure refractory duodenal ulcer; b) resolves severe complications such as duodenal stenosis.

Successful monochemotherapy of extensive gastrointestinal Kaposi's sarcoma with bowel obstruction in acquired immunodeficiency syndrome.

We report the case history of a 28-year-old homosexual man of Caucasian origin whose diagnosis of acquired immunodeficiency syndrome was established one year before admission on the basis of a positive human immunodeficiency virus serology and cutaneous Kaposi's sarcoma. Severe postprandial vomiting pointed to bowel obstruction in an emaciated, poor risk patient. Endoscopy revealed multifocal, violaceous tumours throughout the upper gastrointestinal tract which, eventually, obstructed the duodenum. Histology confirmed the putative diagnosis of gastrointestinal Kaposi's sarcoma, which responded well to monochemotherapy with vincristine. Significant clinical improvement and repeat endoscopy indicated tumour regression and resolution of bowel obstruction.

The successful medical management of gastric outflow obstruction associated with the use of non-steroidal anti-inflammatory drugs in the elderly.

One hundred and nineteen consecutive elderly patients with endoscopically diagnosed peptic ulceration were reviewed. Associated gastric outflow obstruction was present in 10.1%. The presenting clinical features differed significantly from typical younger patients and most (11/12) were taking non-steroidal anti-inflammatory drugs, suggesting a possible role for these agents in the pathogenesis of gastric outflow obstruction. These elderly patients have been successfully managed by medical therapy alone.

A complication of the Infusaid pump: duodenal atony reversed by urecholine.

The totally implantable infusion pump (Infusaid pump) for treating metastatic disease to the liver is a new treatment that is gaining widespread acceptance. However, as might be expected for any new major surgical procedure, there are increasing reports of complications. We report a complication in which duodenal atony was caused by the infusion of the chemotherapeutic agent (FUDR) into the stomach and duodenum. The atony was totally reversed by the subcutaneous administration of urecholine.