Search

Objectives: Whether gastric infection with Helicobacter pylori increases the risk of gastric mucosal injury during long term/low dose aspirin therapy is unknown. We examined whether H. pylori infection enhances upper GI mucosal damage, assessed endoscopically, in volunteers given low dose aspirin. We studied 61 healthy men and women, 29 with and 32 without active H. pylori infection., Methods: We treated volunteers for 45 days with a placebo or aspirin (either 81 mg every day or 325 mg every 3 days). Gastroduodenal mucosal damage was then assessed by endoscopy, as was gastric histology and ex vivo gastric mucosal prostaglandin E2 and F2alpha synthesis rates., Results: Erosive disease from low dose aspirin (erosions and/or ulcers) occurred in 50% of H. pylori-infected volunteers and in 16% of their noninfected counterparts (p = 0.02). Aspirin caused a significantly higher average mucosal injury score in the gastric antrum in H. pylori-infected participants than in noninfected subjects (p = 0.03), and two H. pylori-infected subjects developed antral gastric ulcers. Subjects with H. pylori gastritis treated with the placebo had nearly 50% higher gastric mucosal prostaglandin (E2 plus F2alpha) synthesis rates than their noninfected counterparts (108 +/- 6 ng/g/min versus 75 +/- 6 ng/g/min, p < 0.001). Aspirin reduced mucosal prostaglandin synthesis to similar levels in infected and noninfected participants., Conclusions: Long term/low dose aspirin therapy led to more gastric mucosal damage when H. pylori gastritis was present than when it was absent, despite similar degrees of gastric mucosal prostaglandin depletion.

Most cases of enterolith have been reported in association with the diverticula of small bowel. We report here a case of a patient in whom a huge enterolith developed in the afferent loop of Billroth II anastomosis with ensuing obturation obstruction. The enterolith was clearly shown on the preoperative abdominal computed tomograph and was removed through a duodenotomy. The postulated mechanism of the enterolith formation is impaired duodenal evacuatory motor activity due to previous gastrectomy.

Gastrointestinal tuberculosis (TB) is rare, but its incidence is increasing in industrialized countries because of the growing numbers of individuals at risk for TB. Herein, we report the exceptional case of a young, HIV-negative, African refugee who presented with acute perforation of an isolated duodenal tuberculous ulcer. Clinical patterns of duodenal TB are discussed. The difficulty of obtaining a diagnosis on the basis of clinical features, endoscopy, and imaging is emphasized, as well as the importance of obtaining a biopsy specimen and its limitations.

Objectives: The aim of this study was to investigate the etiological role of periampullary extraluminal duodenal diverticula (PEDD) in acute pancreatitis (AP)., Methods: The study included 433 consecutive patients who underwent successful ERCP during the period 1992-1994; PEDD were discovered in 58 cases (13.4%); patients without PEDD (n = 375) were considered the control group. Indication for ERCP and final diagnosis were recorded in each case., Results: The age of patients with PEDD was significantly higher (p < 0.0001) than that of controls. The incidence of biliary lithiasis was 65.5% in PEDD and 40.8% in controls (p = 0.0001). A recent episode or acute phase of AP constituted the indication for ERCP in 62% of PEDD and 24.8% of controls (p < 0.0001); idiopathic AP was found more often (p = 0.04) in PEDD patients (13.7%) than in controls (1.8%)., Conclusions: PEDD should be included in the list of possible etiological factors of AP. The presence of PEDD should be verified, mainly in elderly patients, before defining an AP episode as idiopathic.

Gastroduodenal tuberculosis occurs in underdeveloped areas and, although rarely, also in western countries, affecting mainly immigrants, immunodepressed, or low socioeconomic classes. We report a case of gastroduodenal tuberculosis presenting as pyloric outlet obstruction. We describe the clinical features and the diagnostic approach to the patient, emphasizing the role played by surgery in the diagnosis and treatment of the established complication. Developments are needed in the diagnostic area (video-laparoscopy, polymerase chain reaction of mycobacterial DNA) and in the mini-invasive treatment of obstructive complications (endoscopic balloon dilatation, video-laparoscopic surgery).

Double pylorus is either a congenital abnormality or an acquired complication of peptic ulcer disease. We had followed two patients for 3 and 5 yr, respectively, to observe the processes of formation and the prognosis of double pylorus. Initially, duodenal ulcer was found in one patient with diabetes mellitus and chronic renal failure, and gastric ulcer was found in the other with chronic obstructive pulmonary disease. Both developed double pylorus with refractory courses. In spite of intensive medical treatment, both of them had persistent ulcers in the fistulous tract and failed to develop reepithelization. Helicobacter pylori was found in all of the specimens of gastroduodenal biopsies in both cases. Therefore, we believe that the refractory courses of double pylorus may be related to the underlying diseases and/or the presence of H. pylori. Antibacterial treatment of H. pylori or surgical intervention should be considered for patients with this condition.

Objectives: The aim of this study was to characterize the clinical presentation, pathological features, and outcome of a series of patients with Brunner's gland hamartomas., Methods: We reviewed the clinical and pathological features of 27 patients who presented with Brunner's gland hamartomas, and we obtained follow-up information., Results: Patients (12 men and 15 women) presented predominantly in the fifth and sixth decades of life either with gastrointestinal hemorrhage (n = 10) or obstructive symptoms (n = 10); there were also patients whose tumors were discovered as an incidental finding (n = 7). The tumors were generally pedunculated, were located in the first portion of the duodenum, and were in the range of diameter from 1 to 6 cm. Histologically, the hamartomas were characterized by the presence of nondysplastic, lobulated Brunner's glands with intervening bands of fibrous tissue and variable adipose and lymphoid tissue. Focal sclerosis was found in 93% of the hamartomas, possibly mimicking an adenocarcinoma. Whether managed surgically (24 patients) or endoscopically (three patients), the outcome was uniformly favorable. After a median period of 7-yr-follow-up, no tumors recurred, and no additional morbidity was identified., Conclusions: Brunner's gland hamartomas are rare duodenal tumors occurring in middle age that present either with gastrointestinal hemorrhage, obstructive symptoms, or as an incidental finding. Surgical or endoscopic excision is uncomplicated, and the long-term outcome is favorable.

Small bowel obstruction secondary to an enterolith formed within a duodenal diverticulum is a rare complication. Twenty-nine cases of enterolith ileus have been reported in the literature. This is a case report of the 30th, with review of the literature. Enterolith ileus closely resembles gallstone ileus in its clinical presentation. Diagnosis is established by documenting normalcy of gallbladder and the presence of small bowel diverticula.

Although metastases from primary carcinoma of the lung to the small intestine appear to be more common than previously suspected, they rarely produce symptoms. Such metastases may present as bowel perforations. Overt gastrointestinal bleeding has been described only as a prelude to perforation. We describe the case of a 55-yr-old man with carcinoma of the lung that had metastasized to the brain and to the third part of the duodenum. The duodenal metastasis presented with massive upper gastrointestinal hemorrhage. The metastasis was seen to be actively bleeding at endoscopy, and a direct fistula from a branch of the superior mesenteric artery to the third part of the duodenum was shown angiographically. Arterial invasion and destruction by tumor was confirmed at postmortem examination. This complication of metastatic carcinoma of the lung has not been previously described in the English literature.

We describe a case of massive gallstones discharged into the stomach through a cholecystoduodenal fistula and the successful removal of these stones by endoscopic electrohydraulic lithotripsy (EEHL) and endoscopic mechanical lithotripsy (EML) for the prevention of gallstone ileus. A 60-yr-old woman was admitted with epigastric pain and nausea. Upper gastrointestinal tract examination demonstrated backflow of contrast medium from the duodenal bulb into the gallbladder. Endoscopic examination revealed a large fistula on the anterior wall of the duodenal bulb, and two brown stones (about 3 cm in diameter) were found in the stomach. To prevent gallstone ileus, removal of these stones was attempted. They were broken into pieces by EEHL, then crushed into smaller pieces by EML and removed orally. Chemical analysis showed the composition of the gallstones to be at least 98% cholesterol. The patient was discharged one month after removal of the gallstones and has remained asymptomatic.

"Sump syndrome" is a rare complication of side-to-side choledochoenterostomy operations which develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate. We report here a patient who developed spontaneous sump syndrome as a result of the formation of choledochoduodenal fistula, and who presented with multiple pyogenic liver abscesses. The patient's symptoms and liver abscesses resolved completely after treatment by endoscopic sphincterotomy and antibiotics. This case demonstrates that sump syndrome may occur spontaneously, that it can be a cause for pyogenic liver abscess formation, and that it may be treated effectively by endoscopic sphincterotomy.

We report a case of dorsal pancreatic hypoplasia complicated with atresia of the vagina, type-A chronic atrophic gastritis, duodenal papillary dysfunction, and insulin-requiring diabetes mellitus, in a 32-yr-old woman. The laboratory data showed elevated hepatobiliary enzymes. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a slightly dilated common bile duct and a short major pancreatic duct connected with a minor pancreatic duct. Ultrasonography and computerized tomography could not identify any pancreatic tissue in the region of the body or tail of the pancreas. The pancreatic tissue weight calculated by the serial thin slice of computerized tomography was 43.1 g, approximately 45% of the standard Japanese adult pancreas. Reevaluated pancreatic exocrine function based on this weight showed a hypersecretory state. The pancreatic ductal pressure was slightly increased, and the motility of the sphincter of Oddi (SO) was abnormal when measured with a 4Fr. microtransducer inserted through a duodenoscope. These findings suggest that dysfunction of the sphincter of Oddi may play some role in the pathophysiology in the hypoplasia of the dorsal pancreas and pancreaticobiliary diseases associated with it.

Fistulization to the duodenum or stomach from a diseased segment of bowel in Crohn's disease is rare, with only 63 cases reported. We report an additional two cases of Crohn's disease with recurrent fistulization to the duodenum. Although one or both patients complained of pain, diarrhea, and/or weight loss at presentation, neither of them experienced vomiting or feculent eructation. A review of 46 of the 63 reported cases of gastric and duodenal fistulization indicated that patients with gastric fistulas commonly present with vomiting (39%), and with histories of feculent eructations or frank feculent vomiting (44%), but that patients with duodenal fistulas rarely present with vomiting (3.6%), and never have feculent vomiting or eructations. This difference is an important clue to the diagnosis and localization of upper gastrointestinal fistulas in Crohn's disease.

Early and serial endoscopic examinations were performed in patients with head injury to determine the actual incidence and course of the acute gastroduodenal lesions. Acute gastroduodenal lesions were found in high incidence of 35 in 47 patients (75%). It was stressed that the lesions were found in 16 of 25 cases without obvious gastrointestinal bleeding. The lesions were mainly found in the stomach (78%) and of these lesions erosive gastritis was seen in the greatest frequency. Gastric ulcer was found in 11 patients. Erosive gastritis was found within one week after the trauma, while gastric ulcer usually developed after one week. Erosive gastritis was mainly located in the body of the stomach and usually healed within ten days. Gastric ulcer also had a good course. There was no case in which the erosive lesion extended to the ulcer. Among 22 patients with gastrointestinal bleeding, three had intractable bleeding. Steroid administration seemed to have little effect on the occurrence of acute gastroduodenal lesions.

Gangliocytic paraganglioma is an extremely rare benign neurogenic tumor nearly exclusively located in the second portion of the duodenum, also the most common site of duodenal diverticula. A case is reported of a gangliocytic paraganglioma presenting in a 65-yr-old woman with a 1-yr history of postprandial cramping abdominal pain culminating in a single episode of melena leading to laparotomy. The tumor was identified with difficulty by endoscopy following negative barium studies. Histologically, the tumor is composed of carcinoid-like cells admixed with varying numbers of ganglion cells in a substratum of neuroid spindle cells. The epithelioid cells contain argyrophilic cytoplasmic granules confirmed by electron microscopy to be dense core membrane-bound secretory granules. Review of the literature suggests the tumor described is typical both clinically and pathologically of gangliocytic paraganglioma of the duodenum, except for its unprecedented occurrence in association with a duodenal diverticulum.

An elderly patient with an acute small bowel obstruction due to an enterolith that evolved within a duodenal diverticulum is reported. Twenty-four prior instances of small bowel obstruction due to an enterolith formed within a small bowel diverticulum have been culled from the world literature and tabulated. In toto, 18 subjects are female and seven are male. The median age is 68 yr. Optimal surgical management is either to break up the enterolith and milk the components into the cecum without an enterotomy or, as is more often necessary, to milk the enterolith orad removing the concretion through an enterotomy made in less edematous small intestine. As in managing gallstone ileus, the bowel should be "run" seeking additional enteroliths. The diagnosis can be established only by documenting the normalcy of the gallbladder and the presence of duodenal and/or jejunal diverticula.

The fourth reported patient with acute pancreatitis associated with Crohn's disease of the duodenum is presented and the clinical features compared with previously described cases. The pathogenesis of the pancreatitis was not clear but the inflammatory process was found to involve the ampulla of Vater making ampullary incompetence with duodenal reflux or ampullary obstruction the most likely mechanisms. High dose prednisone combined with nasogastric suction and subsequently long-term Cimetidine resulted in a rapid improvement which has been maintained.