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Background: Duodenal fibrolipoma and duodenum-jejunum intussusception are both rare occasions in clinical practice. The diagnosis of duodenal fibrolipoma mainly depends on endoscopy examination, supplemented by CT and MRI. As the tumor grows, some severe symptoms need surgical intervention. As the development of endoscopic techniques, the operation plan should be made individually., Case Presentation: A 47-year-old female with the complaint of upper abdominal pain and melena was reported. Abdominal examination revealed upper abdomen lightly tender and blood test showed severe anemia. Image and endoscopy examination exhibited "a giant mass" in the descending (D2) part of duodenum, dragged by the tumor into the distal intestinal canal and causing intussusception. Intermittent blood transfusion treatment, enteral and parenteral nutrition were adopted to adjust her general state. Two weeks later, the mass was resected together with the basement intestinal wall via the jejunum incision and then the intussuscepted D2 part was restored. The paraffin pathological diagnosis correlated with the preoperative judgment of fibrolipoma and the patient was discharged healthy on POD 14., Conclusions: Duodenal fibrolipoma is a rare disease, infrequently causing intussusception and severe upper GIB. Duodenoscopy and endoscopic ultrasound contribute to making an appropriate diagnosis, and for patients with severe symptoms needed surgical intervention, operation plan should be individualized depending on the size and location of the lesion.

Background: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur., Case Report: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump., Conclusion: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Purpose: The purpose of this study is to review published reports and contribute new cases of umbilical cord ulceration (UCU) with perinatal hemorrhage into the amniotic cavity in the setting of duodenal or jejunal obstruction because knowledge of this sequence is poorly disseminated and could be lifesaving., Methods: Published reports of UCU with hemorrhage associated with congenital duodenal or jejunal obstruction were reviewed. Chart review was conducted for the cases encountered at our institutions between January 2008 and March 2017. We noted perinatal complications, method of delivery, gestational age, birth weight, gender, number, location, and pathologic description of umbilical cord ulcers, and outcome., Results: Thirty-one reports and 7 new cases were studied. Perinatal complications included: preterm labor or preterm premature rupture of membranes: 63%; fetal distress: 95%; mean gestational age: 33weeks; premature gestation: 95%; bloody amniotic fluid: 90%. Pathological analysis of UCUs revealed solitary, multifocal, helical and punched-out lesions. There were 12 neonatal deaths (32%), and 12 intrauterine deaths (32%). Survival rate was 37%., Conclusions: UCU with perinatal hemorrhage is associated with duodenal and jejunal obstruction. Knowing the typical clinical signs of this potential catastrophic complication could prompt lifesaving delivery., Type of Study: Prognostic LEVEL OF EVIDENCE: IV., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Neonatal intestinal obstruction is caused by an anatomical abnormality that produces bowel movement failure. Intestinal obstruction presents with three classic clinical signs: vomiting, abdominal distention, and failure to pass meconium. Intestinal obstruction is one of the most common causes for admitting a pediatric patient to the pediatric surgery unit in his or her first weeks of postnatal life. Congenital obstruction of the digestive tract in neonates is a common problem, with the most frequent cause being anorectal malformations (41%), followed by esophageal obstruction (24%), and duodenal obstruction (20%). [Pediatr Ann. 2018;47(5):e220-e225.]., (Copyright 2018, SLACK Incorporated.)

Rationale: Ectopic pancreas, which is a kind of rare congenital disease, forms during embryonic development. It can occur throughout the whole gastrointestinal tract, but has a low tendency to develop in the wall of the small intestine. It is easy for patients with ectopic pancreases to be misdiagnosed because the symptoms are untypical and can vary., Patient Concerns: In the present study, we reported two rare cases of ectopic pancreatic tissue in the wall of the small intestine, which presented with obvious abdominal pain and distention., Diagnosis: The laboratory tests and computed tomography (CT) scans didn't reveal any evidence of ectopic pancreas., Interventions: The two patients received small intestine masses resection and intestinal anastomosis., Outcomes: During surgery, an intestinal mass with a diameter of 4.0 cm was found in the first patient. An intestinal mass with a diameter of 0.8 cm, jejunum perforation, and diffuse peritonitis were found in the second patient. Histological analyses of the dissected intestinal masses confirmed them as ectopic pancreatic tissue. Interestingly, for the second patient, the intestinal perforation and diffuse peritonitis were not induced by the ectopic pancreas, but by a jujube pit that was found in the perforated site of the intestine., Lessons: Our study demonstrated that an ectopic pancreas should be considered in cases of untypical abdominal symptoms with intestinal masses.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Guideline was also reviewed and endorsed by the British Society of Gastroenterology (BSG). It addresses the roles of small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders. Main recommendations 1 ESGE recommends small-bowel video capsule endoscopy as the first-line investigation in patients with obscure gastrointestinal bleeding (strong recommendation, moderate quality evidence). 2 In patients with overt obscure gastrointestinal bleeding, ESGE recommends performing small-bowel capsule endoscopy as soon as possible after the bleeding episode, optimally within 14 days, in order to maximize the diagnostic yield (strong recommendation, moderate quality evidence). 3 ESGE does not recommend the routine performance of second-look endoscopy prior to small-bowel capsule endoscopy; however whether to perform second-look endoscopy before capsule endoscopy in patients with obscure gastrointestinal bleeding or iron-deficiency anaemia should be decided on a case-by-case basis (strong recommendation, low quality evidence). 4 In patients with positive findings at small-bowel capsule endoscopy, ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by capsule endoscopy (strong recommendation, high quality evidence). 5 ESGE recommends ileocolonoscopy as the first endoscopic examination for investigating patients with suspected Crohn's disease (strong recommendation, high quality evidence). In patients with suspected Crohn's disease and negative ileocolonoscopy findings, ESGE recommends small-bowel capsule endoscopy as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known stenosis (strong recommendation, moderate quality evidence).ESGE does not recommend routine small-bowel imaging or the use of the PillCam patency capsule prior to capsule endoscopy in these patients (strong recommendation, low quality evidence). In the presence of obstructive symptoms or known stenosis, ESGE recommends that dedicated small bowel cross-sectional imaging modalities such as magnetic resonance enterography/enteroclysis or computed tomography enterography/enteroclysis should be used first (strong recommendation, low quality evidence). 6 In patients with established Crohn's disease, based on ileocolonoscopy findings, ESGE recommends dedicated cross-sectional imaging for small-bowel evaluation since this has the potential to assess extent and location of any Crohn's disease lesions, to identify strictures, and to assess for extraluminal disease (strong recommendation, low quality evidence). In patients with unremarkable or nondiagnostic findings from such cross-sectional imaging of the small bowel, ESGE recommends small-bowel capsule endoscopy as a subsequent investigation, if deemed to influence patient management (strong recommendation, low quality evidence). When capsule endoscopy is indicated, ESGE recommends use of the PillCam patency capsule to confirm functional patency of the small bowel (strong recommendation, low quality evidence). 7 ESGE strongly recommends against the use of small-bowel capsule endoscopy for suspected coeliac disease but suggests that capsule endoscopy could be used in patients unwilling or unable to undergo conventional endoscopy (strong recommendation, low quality evidence)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Pseudomelanosis is a rare finding during upper gastrointestinal endoscopy, and is most commonly seen in the duodenum. Involvement of other organs in the upper gastrointestinal tract is extremely rare, with only 1 reported case involving the stomach, duodenum, and jejunum. We present a case of a 60-year-old woman with mild anemia and hematemesis, who was found to have characteristic speckled pattern of gray-black pigmentation on endoscopic examination. To the best of our knowledge, this is the second reported case of pseudomelanosis involving the stomach, duodenum, and jejunum.

Background: The advent of wireless capsule endoscopy (WCE) has revolutionized the diagnostic approach to small-bowel disease. However, the task of reviewing WCE video sequences is laborious and time-consuming; software tools offering automated video analysis would enable a timelier and potentially a more accurate diagnosis., Objective: To assess the validity of innovative, automatic lesion-detection software in WCE., Design/intervention: A color feature-based pattern recognition methodology was devised and applied to the aforementioned image group., Setting: This study was performed at the Royal Infirmary of Edinburgh, United Kingdom, and the Technological Educational Institute of Central Greece, Lamia, Greece., Materials: A total of 137 deidentified WCE single images, 77 showing pathology and 60 normal images., Results: The proposed methodology, unlike state-of-the-art approaches, is capable of detecting several different types of lesions. The average performance, in terms of the area under the receiver-operating characteristic curve, reached 89.2 ± 0.9%. The best average performance was obtained for angiectasias (97.5 ± 2.4%) and nodular lymphangiectasias (96.3 ± 3.6%)., Limitations: Single expert for annotation of pathologies, single type of WCE model, use of single images instead of entire WCE videos., Conclusion: A simple, yet effective, approach allowing automatic detection of all types of abnormalities in capsule endoscopy is presented. Based on color pattern recognition, it outperforms previous state-of-the-art approaches. Moreover, it is robust in the presence of luminal contents and is capable of detecting even very small lesions., (Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.)

Objective: Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The "suspected blood indicator" (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding., Methods: This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC)., Results: In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%)., Conclusion: The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

Context: Acute pancreatitis in ectopic pancreatic tissue is an uncommon cause of acute abdominal pain and can be difficult to diagnose on imaging. Our aim is to raise awareness and aid in the diagnosis of this entity by highlighting helpful dynamic contrast-enhanced MRI imaging findings., Case Report: We report a 51-year-old man with acute onset epigastric pain presented to ER. With the presence of elevated serum lipase, the clinical diagnosis of acute pancreatitis was made. Contrast enhanced CT demonstrated normal pancreas and a focal mass at the duodenojejunal flexure, mimicked a neoplasm. Subsequent dynamic contrast enhanced MR images demonstrated enhancement pattern of the lesion similar to the native pancreatic tissue enhancement, a finding raised the possibility of acute pancreatitis in ectopic pancreatic tissue, but tumor was not excluded. Finally, patient undergone surgical bowel resection including the suspected mass that was proved as an ectopic pancreatic tissue on microscopic examination., Conclusion: We concluded that findings on dynamic contrast enhanced MR imaging can be characteristic and diagnostic of acute pancreatitis in ectopic pancreatic tissue in the appropriate clinical setting.

Bowel intussusception is rare in adults but common in children. Almost 90% of adult intussusceptions are secondary to a pathologic condition and the clinical picture can be very aspecific and challenging. In this review we discuss the symptoms, location, etiology, characteristics, diagnostic methods and treatment strategies of this rare and enigmatic clinical entity in adults. We have to highlight the high index of suspicion that is necessary for the operating surgeon, when dealing with acute, subacute or chronic abdominal pain in adults, because any misinterpretation may result in unfavorable outcomes.

Background: Limited data are available on the clinical impact of single balloon enteroscopy., Aims: To evaluate the diagnostic and therapeutic yield of single balloon enteroscopy in patients with suspected small bowel disease., Methods: Data on patients with suspected small bowel disease based on non-invasive imaging, who were subjected sequentially to enteroscopy were prospectively collected., Results: 131 procedures were performed in 111 patients. The mean procedure time was 61±33min for the oral approach, and 78±41min for the anal approach. The mean insertion depth was 223±93cm beyond the ligament of Treitz, and 96±56 beyond the ileo-cecal valve. A diagnosis suspected with prior small bowel tests was confirmed in 82 patients, confidently excluded in 20, while in 9 the suspected area was not reached. Total enteroscopy was deemed clinically unnecessary in 94 patients; when total enteroscopy was attempted, it was achieved in 8 out 17 patients. Endoscopic therapeutic interventions were performed in 39 patients, medical treatment was started in 30, whereas 18 underwent to surgery. No major complications were registered., Conclusions: This study shows that single balloon enteroscopy appears to be an helpful and safe procedure with a high clinical impact, especially when it is placed in decision-making as a third level examination., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Objective: Real-time video capsule endoscopy (CE) with flexible spectral imaging color enhancement (FICE) improves visibility of small-bowel lesions. This article aims to clarify whether CE-FICE also improves detectability of small-bowel lesions., Patients and Methods: A total of 55 patients who underwent CE at Hiroshima University Hospital during the period November 2009 through March 2010 were enrolled in the study. Five patients were excluded from the study because residues and transit delays prevented sufficient evaluation. Thus, 50 patients participated. Two experienced endoscopists (each having interpreted more than 50 capsule videos) analyzed the images. One interpreted conventional capsule videos; the other, blinded to interpretation of the conventional images, interpreted CE-FICE images obtained at settings 1-3 (setting 1: red 595 nm, green 540 nm, blue 535 nm; setting 2: red 420 nm, green 520 nm, blue 530 nm; setting 3: red 595 nm, green 570 nm, blue 415 nm). Lesions were classified as angioectasia, erosion, ulceration, or tumor. Detectability was compared between the two modalities. Time taken to interpret the capsule videos was also determined., Results: Seventeen angioectasias were identified by conventional CE; 48 were detected by CE-FICE at setting 1, 45 at setting 2, and 24 at setting 3, with significant differences at settings 1 and 2 (p = 0.0003, p < 0.0001, respectively). Detection of erosion, ulceration, and tumor did not differ statistically between conventional CE and CE-FICE, nor did interpretation time (conventional CE 36 ± 6.9 min; CE-FICE setting 1, 36 ± 6.4 min; setting 2, 38 ± 5.8 min; setting 3, 35 ± 6.7 min)., Conclusions: CE-FICE is superior in the lesion detection in comparison with conventional CE and improves detection of angioectasia.

We report a case of perforation over duodeno-jejunal junction (DJ) in a healthy 8-month-old baby. The difficulty in diagnosis, management dilemma and probable etiology is discussed.

Single-balloon enteroscopy has emerged as a viable alternative to double-balloon enteroscopy in the management of small bowel disease. Technically, it is easier to perform, may be more efficient, and in the limited literature available, seems to provide similar diagnostic and therapeutic yield when compared with double-balloon enteroscopy. This review provides up-to-date views on this emerging technology and its application.

Balloon enteroscopy is a method that allows endoscopic inspection of the entire small bowel, or large parts of it, while simultaneously making it possible to obtain histologic samples and carry out treatment measures. Studies of double-balloon enteroscopy (DBE) have confirmed the high diagnostic yield of the procedure, with an acceptably low complication rate (approximately 1% for diagnostic DBE and 3% to 4% for therapeutic DBE). The principal indication for the procedure is midgastrointestinal bleeding, that is, when the bleeding source is located in the small bowel. With good patient selection, the diagnostic yield here is 70% to 80%, and this has a substantial influence on subsequent treatment measures. Single-balloon enteroscopy appears to be a simplification of the technique that is easier to handle, but few original studies have been published on the topic to date, and the results of prospective and controlled studies with larger numbers of patients must therefore be awaited. At present, DBE must still be regarded as the standard method for diagnostic and therapeutic endoscopy in the small bowel, avoiding the need for intraoperative enteroscopy or therapeutic laparotomy.

Spiral enteroscopy is a new technique for endoscopic evaluation of the small bowel. Currently, more than 3000 cases have been performed worldwide. The Discovery SB device has been approved by the Food and Drug Administration and has been granted a CE mark. The technique is safe and effective for management and detection of small bowel pathology. Recent studies of spiral enteroscopy have demonstrated diagnostic yield, total time of procedure, and depth of insertion that compare favorably with double and single balloon enteroscopy. The strengths of spiral enteroscopy are rapid advancement in the small bowel and controlled, stable withdrawal that facilitates therapy. Future studies will be needed to compare competing technologies. Push enteroscopy is a readily available, safe and effective technique for detecting and treating proximal gut pathology. If performed without an overtube, complications are rare. Use of a dedicated push enteroscope with an overtube is generally reserved for specific indications in which a moderate increase in depth of insertion into the small bowel is required. When capsule endoscopy and deep small bowel enteroscopy are not available, push enteroscopy is a reasonable option with low risk and moderate yield. Push enteroscopy will remain an important part of the armamentarium of the modern endoscopist.

Double-balloon endoscopy (DBE) was developed based on the principle of preventing stretching of the intestinal tract by anchoring the convoluted intestinal tract with an endoscope and overtube fitted with inflatable balloons. The DBE system includes the main body of the endoscope with a built-in air channel, a balloon attached to the tip of the endoscope, an overtube with a hydrophilic coating equipped with an inflatable balloon, and a balloon controller that safely inflates/deflates the two balloons. At present, there are three different types of endoscopes for DBE. The indications for DBE include the diagnosis or treatment of various small intestinal conditions such as obscure gastrointestinal bleeding, Crohn's disease, and benign and malignant tumors. In addition, DBE can be used to approach the surgically modified intestinal tract; conventional endoscopes have difficulty in that situation. DBE can be used for colonoscopy in cases in which it is difficult to insert a conventional colonoscope. In the future, DBE will have the potential for wider use in routine colonoscopy because the insertion technique is easy and reliable.

Although the small intestine has long been considered the final frontier of endoscopy, a vast amount of progress has led to increased diagnostic and therapeutic capabilities. With the increasing prevalence of capsule endoscopy, the need for enteroscopy also continues to increase. The endoscopic options currently available include double and single balloon-assisted enteroscopy, spiral enteroscopy, and lastly, intraoperative enteroscopy. The majority of published literature has focused on double balloon enteroscopy, but further studies have to provide information on the safety and yield of the newer techniques. Although intraoperative enteroscopy may be practiced less frequently, it has a role in the management of lesions that may not be approachable by other endoscopic means and a role in the guidance of surgical management.

Background: An 18-year-old adolescent with cystic fibrosis developed massive gastrointestinal bleeding., Methods: History, physical examination, upper and lower endoscopy and wireless capsule endoscopy were performed., Results: Upper and lower endoscopy did not reveal cause of persistent bleeding. Wireless capsule endoscopy revealed pan-gastrointestinal ischemic injury. Further discussion with the patient revealed recent cocaine ingestion., Conclusion: Most reported cases of gut injury following cocaine abuse describe juxtapyloric and colonic injury; this case demonstrates that ischemic gut injury after cocaine use can be extensive and may be the reason for the associated high mortality.

Enteroenteric intussusceptions are rarely observed in adults. Most of these are associated with tumors. We operated a 25-year old female with suspected stricture in the third part of the duodenum. However during laparotomy, duodenojejunal intussusception was found along with an adenoma in the third part of the duodenum associated with a lax ligament of Treitz. The intussusception was reduced and the parts of the duodenum containing the adenoma were resected, followed by an end-to-end duodenojejunal anastomosis. To the best of our knowledge, this is the first reported case of tubulovillous adenoma in the third part of the duodenum presenting as intussusception in an adult.

The authors present a case review of a patient with relapsing diverticulosis of the large and small intestine. They describe surgical strategy in the patient and discuss ethiopathogenesis of the diverticular disorder, as well as options and extent of the surgical treatment.

Background and Study Aims: Patients with familial adenomatous polyposis (FAP) are at increased risk of developing duodenal and jejunal adenocarcinomas. The aim of this study was to assess the usefulness of double-balloon enteroscopy- (DBE-) assisted chromoendoscopy for the detection and characterization of small-bowel polyps in patients with FAP., Patients and Methods: We performed a prospective evaluation of patients with clinically and genetically proved FAP who were enrolled in an endoscopic surveillance program. DBE was performed using a Fujinon intestinoscope (FN 450P 5/20; Fujinon Corp., Omiya, Japan), and chromoendoscopy was performed using indigo carmine. The severity of small bowel polyposis was based on the Spigelman-Saurin classification., Results: Nine patients underwent DBE-assisted chromoendoscopy. Small-bowel polyps (including papillary adenomas) were detected in seven patients (88 %). The mean depth of small-bowel insertion was 180 cm (range 120-320 cm). The mean Spigelman-Saurin score was 4.6 (range 0-8). Jejunal polyps were detected in six patients (67 %). Chromoendoscopy aided in the detection of additional polyps in two patients. In one patient the polyps were flat and only visible with chromoendoscopy (biopsy confirmed these to be adenomas). Jejunal polyps and advanced neoplasms were more frequent in patients with APC gene mutations in exon 15. The following endoscopic therapies were performed: polypectomy (n = 1), duodenal mucosectomy (n = 1), and ablation therapy with argon plasma coagulation (n = 2)., Conclusions: DBE was found to be a helpful method for the evaluation of small-bowel polyps in patients with FAP. DBE-assisted chromoendoscopy was of further assistance for the detection of jejunal polyps.

Anticoagulation therapy may be complicated by spontaneous onset of an intramural hematoma of the duodenum and small intestine. Other causes were published only as case reviews. Radiological literature describes typical findings, which are fundamental for the diagnostics. However, only a fraction of patients present with them. This article describes a case of a female patient, treated for stomach pains. Based on her history, laboratory findings, ultrasound and CT findings, the condition was mistaken for acute pancreatitis and the pancreatic body necrosis with pseudocysts, drained under the CT control. The correct diagnosis was established a year later. Surgical revision indicated for a cystoid relaps and difficulties with intestinal passage revealed an old intramural hematoma within the duodenojejunal junction wall, the hematoma was evacuated and gastroenteroanastomosis performed.

Gallstone ileus is an uncommon condition that may result when a gallbladder or commonduct stone enters into the intestinal tract, usually as a result of an internal fistula between the gallbladder and the duodenum. It most frequently occurs in the terminal ileum. Gastric outlet obstruction syndrome due to the impaction of a gallstone in the duodenum passing through a cholecystoduodenal fistula was first reported in 1896 by Bouveret concern in 1-3% of patients with gallstone ileus. Since the first case-report, 300 other cases has been documented in the literature. Here we report a case of Bouveret's syndrome in order to increase awareness of this unusual cause of gastric outlet obstruction.

Congenital internal hernias often remain unrecognized since they are infrequent and produce nonspecific abdominal symptoms. Abdominal imaging during a symptomatic episode leads to the diagnosis. Surgical treatment is essential regarding the risks of incarceration. We report a case of left paraduodenal hernia misdiagnosed for over thirty years despite extensive imaging and surgical exploration.

Jejunojejunal intussusception is a rare complication of jejunostomy, and its preoperative diagnosis and surgical treatment have not been reported. A 78-year-old man suffered from vomiting off and on after emergency exploratory laparotomy with omentoplasty for perforated duodenal ulcer. He also received Witzel jejunostomy for early feeding. Ileus developed postoperatively and plain X-ray of the abdomen showed distended small bowel loop with scanty colon gas. Small bowel series performed with water-soluble contrast medium revealed substantial fluid retention in the stomach, duodenum and proximal jejunum. Infusion of contrast medium into the feeding tube revealed normal caliber of the distal small bowel. Abdominal sonogram revealed target sign as well as the feeding tube in a dilated jejunum. Abdominal computed tomography confirmed the sonographic impression of jejunojejunal intussusception. Reduction of intussusception was done during exploratory laparotomy. The jejunostomy feeding was continued and the postoperative course was uneventful.

Results of treatment of 43 patients with acute intestinal obstruction due to gall-stones are analyzed. Forty patients were operated, 3 patients were not because of extremely severe state. Enterolythotomy was performed in 27 cases, incision of intestinal wall was carried out directly above the stones (14 cases, group 1), above or below it (13 cases, group 2). Insufficiency of enteral suture was seen in 4 patients of group 1 that required repeated surgery. Lethality in group 1 was 21.4%, in group 2-7.1%. Intestinal resection was performed in 12 patients of group 3, there were no cases of suture insufficiency, and lethality was 8.3%. It is concluded that enterotomy should be performed above or below strangulated stone. Intestinal resection should be performed when concrement is immovable or in cases of intestinal necrosis.

An elderly man who presented with colicky abdominal pain had gastric volvulus which was reduced after barium meaL More than a year later the symptoms recurred and at laparotomy a gastroduodenojejunal intussusception was found and its apex was formed by a polypoidal gastric tumour (leiomyoma). The patient did very well without any recurrence after the resection of the tumour.

History and Clinical Findings: A 58-year-old man was admitted to our hospital after an acute onset of rectal bleeding. He was known to have had recurrent duodenal ulcerative disease, once with upper gastrointestinal haemorrhage. Clinical examination was remarkable only for rectal bleeding., Investigations: After application of a nasogastric tube cherry-red blood was evacuated. Upper endoscopy showed only very small mucosal erosion in the stomach and coloscopy demonstrated several non-bleeding diverticula. Small bowel enteroclysis showed severe diverticulosis of the duodenum and jejunum., Diagnosis, Treatment and Course: We assumed that the extensive duodenojejunal diverticulosis was the most probable cause of this episode of gastrointestinal bleeding because of simultaneous signs of upper and lower gastrointestinal haemorrhage. Because this was the first such episode we preferred a conservative approach. At nineteen months follow-up there was no recurrence of bleeding., Conclusion: Gastrointestinal hemorrhage is a common cause of hospitalization. After exclusion of the more common bleeding sources small bowel diverticula should be considered as a possible rare cause. Surgical resection of the bleeding bowel part is the procedure of choice, but one of the major problems in such cases is to locate exactly the bleeding site. If the location is uncertain, a more conservative approach may be preferable, especially in haemodynamically stable patients with first-time diverticular bleeding.

Background: Our series of secondary aorto prosthetic fistulas (PEF) to identify if and how different surgical treatment affect outcome is reviewed., Methods: Between 1982 and December 1999, in the authors department, 42 patients were investigated for a secondary PEF. Mean age was 65 years: the mean time interval since the primitive aortic procedure was 49 months. Twenty patients were treated in emergency surgery: 29 presented evidence of gastrointestinal bleeding. The preoperative work-up included esophagogastroduodenoscopy, CT scan, and aortography. The vast majority of PEF were in a duodenal location. Surgical procedure carried out was graft excision, bowel suture or bowel resection, aortic stump closure and axillofemoral (AXF) bypass (11), new in situ revascularization by synthetic prosthesis (5), simple suture (9), graft excision without revascularization (1), in situ revascularization using arterial homograft (13)., Results: The mean surgery duration was 4 hours and 53 minutes, the mean blood loss was 1845+/-1132. Two patients died shortly after proximal aortic control was obtained. Early overall mortality was 50%, the early overall bypass occlusion rate was 12.5%, the early overall amputation rate was 10%, and the early new PEF rate was 12.5%. Late overall mortality was 22.5%, the late overall bypass occlusion rate was 20%, the late overall amputation rate was 7.5%, and the late new PEF rate was 10%., Conclusions: Bleeding of the gastrointestinal tract in patients with a history of intra-abdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existence of a PEF unless the diagnostic procedure excludes this possibility. All treatment methods resulted in catastrophic failure, related to recurrent PEF or septic complication. Perhaps, in the presence of PEF extra-anatomical bypass associated with aortic ligature remains an interesting surgical solution.

A 47-year-old man with primary amyloidosis confined to the small intestine is reported. Thickening of the folds and multiple polypoid protrusions were found in the duodenum by upper gastrointestinal endoscopy. Because the patient presented with a persistent intestinal pseudo-obstruction, partial jejunectomy was performed. Histological examination of the resected tissue revealed massive deposits of amyloid throughout the jejunal wall. Neither a predisposing condition nor any other sites of deposition were found, and primary amyloidosis of the small intestine was diagnosed. This rare form of amyloid deposition should be recognized so that an early diagnosis can be made.

A case of massive intestinal blood loss from multiple duodeno-jejunal diverticula is described. A 39-year-old man was referred to our hospital because of recurrent bloody stool and worsening anemia. Upper and lower endoscopy, selective abdominal angiography, and radionuclide scanning were performed to seek the cause of the intestinal bleeding, but none of these studies revealed the source of bleeding. Small-bowel barium follow-through examination showed numerous diverticula in the distal duodenum and proximal jejunum. Excision of the duodenal diverticulum and resection of the involved portion of the jejunum cured the patient. On histopathological examination, an ulcerative lesion with an exposed vessel suggestive of the source of bleeding was seen in the resected duodenal diverticulum. Although duodeno-jejunal diverticula are rare, the importance of a careful search for this malformation in a patient with intestinal blood loss is stressed.

Aims: To describe retrospectively the characteristics of inaugural, symptomatic Crohn's disease of the upper gastrointestinal tract., Methods: Eighteen patients (12 male and 6 female) with symptomatic Crohn's disease of the upper intestinal tract and without previous distal localisation were studied., Results: Mean age of patients at diagnosis (21.3 years) was less than that usually reported in Crohn's disease. The time elapsed from first symptoms to diagnosis (mean = 29.8 months) was remarkably long for some patients, mainly as a result of an unusual clinical presentation. Abdominal pain and weight loss were the most common presenting features; diarrhea was rarely the main symptom. Persistent anorexia and weight loss without digestive symptoms had led to a diagnosis of anorexia nervosa in 4 patients. Zollinger-Ellison syndrome was the initial diagnosis in 3 other patients. Sixteen patients were followed during at least 2 years. All were treated with steroids for their first attack and 75 % required immunosuppressive therapy for steroid dependence. At the end of follow-up, 6 patients only were in remission without treatment or under mesalamine., Conclusion: Crohn's disease with initial symptomatic lesions of the upper gastrointestinal tract occurs mainly in young male patients. The clinical presentation may be very unusual, leading to misdiagnosis. The clinical course is close to that of diffuse jejunoileitis.

Objective: We describe antegrade intussusceptions of duodenum and jejunum around gastrojejunostomy tubes seen on sonography and fluoroscopic contrast tube studies. Reduction of the intussusception was achieved by bolus injection of air or contrast medium through the tube or exchange over a wire., Conclusion: Sonography and fluoroscopic contrast tube studies permit diagnosis of intussusception around gastrojejunostomy tubes.