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Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A woman in her 20s presented with 6 weeks of fever, persistent vomiting and 28% loss of body weight. Symptoms were refractory to treatment with antiemetics and broad spectrum antibiotics.Further investigation via oesophageogastroduedenoscopy revealed a large gastric ulcer and pyloric stricture, causing gastric outlet obstruction (GOO). Biopsies of the stomach and duodenum showed plasma cell infiltration with a large proportion being IgG4 positive.Treatment with methylprednisolone, and later prednisolone, quickly improved inflammatory markers and symptoms. Balloon dilatation of the pyloric stricture also improved vomiting, allowing eventual re-establishment of oral nutrition. The patient made a full recovery with maintenance treatment on mycophenolate mofetil.IgG4-related disease (IgG4-RD) is a multisystem disorder with unpredictable presentation. The case highlights diagnostic challenges in IgG4-RD and identifies it as a rare differential in upper gastrointestinal symptoms. To our knowledge this is the first published case of IgG4-RD in the duodenum causing GOO., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Cases with multiple molecular diagnoses are challenging to diagnose clinically, yet may be resolved by unbiased exome sequencing analysis. We report an infant with developmental delay, severe growth delay, dysmorphic features, and multiple congenital anomalies including retinal coloboma, congenital pyloric stenosis, and circumferential skin creases. Exome sequencing identified a homozygous missense variant in MAPRE2 and a homozygous stopgain (nonsense) variant in CDON. Variants in MAPRE2, encoding a regulator of microtubule dynamics, lead to congenital symmetric circumferential skin creases type 2, with associated dysmorphism, small growth parameters, and congenital cardiac and genital anomalies. Monoallelic variants in CDON, encoding a coreceptor for sonic hedgehog, have been associated with autosomal dominant pituitary stalk interruption syndrome and holoprosencephaly. Cdon-/- mice have multiple eye defects including coloboma, consistent with the observed human phenotype. Thus, the complex phenotypic presentation of the infant may potentially be attributed to a dual molecular diagnosis. Furthermore, we present CDON as a candidate gene for coloboma formation in addition to the known holoprosencephaly phenotype, and propose to expand the allelic spectrum of CDON to variants associated with autosomal recessive inheritance in addition to dominant inheritance., (© 2019 Wiley Periodicals, Inc.)

Background: Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. Currently, there are no evidence-based guidelines regarding OGT/NGT placement in these patients. This study examines whether OGT/NGT placement before arrival in the operating room was associated with a longer time to readiness for surgery as defined by normalization of electrolytes. Secondary outcomes included time from surgery to discharge and ability to tolerate feeds by 6 hours postoperatively in patients with and without early OGT/NGT placement., Methods: In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. Multivariable linear regression and Cox proportional hazard models were constructed to evaluate the association between placement of an OGT/NGT at the time of admission with increased time to readiness for surgery (defined as the time from admission to the first set of normalized laboratory values) and increased time from surgery to discharge. Multivariable logistic regression was used to evaluate the association between early OGT/NGT placement and the ability to tolerate oral intake at 6 hours postsurgery. Analyses were adjusted for site differences., Results: Among patients admitted with electrolyte abnormalities, those with an OGT/NGT placed on presentation required more time until their serum electrolytes were at acceptable levels for surgery by regression analysis (19.2 hours difference; 95% confidence interval, 10.05-28.41; P < .001), after adjusting for site. Overall, patients who had OGTs/NGTs placed before presentation in the operating room had a longer length of stay from surgery to discharge than those without (38.8 hours difference; 95% confidence interval, 25.35-52.31; P < .001), after adjusting for site. OGT/NGT placement before surgery was not associated with failure to tolerate oral intake within 6 hours of surgery after adjusting for site, corrected gestational age, and baseline serum electrolytes., Conclusions: OGT/NGT placement on admission for pyloric stenosis is associated with a longer time to electrolyte correction in infants with abnormal laboratory values on presentation and, subsequently, a longer time until they are ready for surgery. It is also associated with longer postoperative hospital stay but not an increased risk of feeding intolerance within 6 hours of surgical repair.

Background: Gastric antral webs are mucosal structures, varying from fenestrated diaphragms to mucosal crescents, resulting in varying degrees of foregut obstruction. Patients commonly present with vomiting, failure to thrive, and abdominal pain. Prevalence is unknown, and diagnosis can be difficult., Methods: We performed an IRB-approved retrospective review of patients from 4/1/2015-4/1/2018 at a Level I Children's Surgery Center undergoing gastric antral web resection. Data obtained included demographics, preoperative workup, surgical repair, and outcomes., Results: Twenty-one patients were identified; 67% were male with an average age of 30 months at diagnosis. Initial diagnosis was established by a combination of fluoroscopy and esophagogastroduodenoscopy (EGD) in all patients. Patients presented with emesis (76%), failure to thrive (57%), need for post-pyloric tube feeds (33%), and abdominal pain (14%). Web localization without intraoperative EGD (n = 3) was initially challenging. As a result, intraoperative EGD was combined with operative antral web resection to facilitate web localization (n = 18). Web marking techniques have evolved from marking with suture (n = 1) and tattoo (n = 2), to endoscopic clip application (n = 12). All 21 patients underwent web resection, 2 were performed laparoscopically. Twenty underwent Heineke-Mikulicz pyloroplasty during the initial surgery. Average length of stay was 5.5 days. There were no intraoperative complications or deaths. Permanent symptom resolution occurred in 90% of patients immediately, with a statistically significant decrease in emesis (p < 0.001), failure to thrive (p < 0.001), and need for post-pyloric tube feeding (p = 0.009) within 6 months of surgery., Conclusion: Gastric antral webs should be considered in the differential diagnosis for a child with persistent vomiting. Web resection with the use of intraoperative endoscopic localization can result in permanent symptom resolution in the majority of these patients.

Secondary pyloric stenosis quickly leads to homeostatic and nutritional disorders that determines the importance of early diagnosis and surgical treatment. In two clinical cases, we have shown that staged endoscopic balloon dilatation of the pylorus is devoid of the most of the known problems and shortcomings of conventional surgery and makes it possible to restore effectively gastrointestinal passage and to improve child's quality of life. This procedure has a high diagnostic and curative value and is followed by positive dynamics of condition of the child with pyloric stenosis.

Treatment of complicated giant duodenal ulcers is one of the most difficult problems in abdominal surgery. Simultaneous course of diabetes mellitus and giant duodenal ulcer has clinical features and requires correction of the treatment. It is presented case report that may be useful regarding accumulation of knowledge about comorbid course of these pathologies. The patient 58-year old was urgently delivered with signs of gastrointestinal bleeding, ulcerative anamnesis for 15 years, diabetes mellitus type 2 for 8 years. Gastroduodenoscopy revealed chronic giant (2.5×3.5 cm) duodenal ulcer complicated by bleeding and subcompensated pyloric stenosis. Endoscopic hemostasis included drug injection and argon-plasma coagulation. Recurrent bleeding occurred after 22 hours. It was performed Billroth II procedure with resection of 2 / 3 of the stomach and manual formation of 'difficult' duodenal stump. Cicatricial ring was used as a frame for the stump. Postoperative period was uneventful, patient was discharged after 14 days. This clinical case demonstrates the need for more active surgical strategy in patients with diabetes mellitus and reliability of the proposed method of 'difficult' stump forming.

Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

This study's aim was to describe the management of ulcerous pyloroduodenal stenosis in Sylvanus Olympio teaching hospital of Lomé (Togo). It was a retrospective study of medical files of all patients managed for peptic pyloroduodenal stenosis at the visceral surgery department of Sylvanus Olympio teaching hospital in Lomé (Togo) from january 1(st), 2002 to december 31(th), 2011. Twenty-five patients were selected. Mean age was 38 ± 7.4 years. Sex-ratio was 5. Twenty four patients underwent upper digestive tract endoscopy, completed by upper gastrointestinal series in 18 cases. One patient had only an upper gastrointestinal series. Pyloroduodenal stenosis was improved by antisecretory therapy in 3 cases. Twenty two patients underwent laparotomy. Truncal vagotomy was performed in 15 cases associated with pyloroplasty in 8 cases, and gastrojejunostomy in 7 cases. An antrectomy was performed in 5 cases. Selective vagotomy was associated with pyloroplasty in 1 case, and a gastrojejunostomy in 1 case. One patient died in postoperative period. Functional results were classified Visick I (17 cases) and II (4 cases). Peptic pyloroduodenal stenosis affects young adults. Its tight nature requires association of upper gastrointestinal series and esophagogastroduodenoscopy for diagnosis. Its surgical treatment is exclusively performed by laparotomy at present. Mortality is low and functionnal prognosis is good.

Background: Surgical resection of tumors of the upper gastrointestinal (GI) tract represent complex procedures and are still associated with a relevant morbidity and mortality. A targeted preoperative risk analysis and patient selection with consideration of the nutritional status and comorbidities are important in order to reduce the perioperative complication rate., Results and Discussion: Anastomotic leaks still remain the most feared surgical complication and in addition to early recognition, immediate initiation of an appropriate therapy are essential. Conservative treatment can be considered for small and adequately drained fistulas as well as in cervical leakages. Indications for surgical reintervention are leaks that occur in the early postoperative course, fulminant defects with diffuse mediastinitis and conduit necrosis. The majority of anastomotic leaks can be successfully managed with minimally invasive endoscopic techniques, e.g. stent placement and endoluminal vacuum therapy. Delayed gastric emptying is frequently observed following esophageal resection and usually shows a satisfactory response to medicinal treatment and endoscopic interventions. The benefits of pyloroplasty in the primary intervention is still a matter of debate. Chylothorax is a rare but serious complication which should initially be managed with conservative measures., Conclusions: For the successful management of postoperative complications following surgical resection of tumors of the upper GI tract both an interdisciplinary approach and the availability of an appropriate infrastructure with defined algorithms are of paramount importance. Therefore, a concentration of these procedures in specialized centers would be highly desirable.

Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.

A 17-year-old female was referred to our hospital with worsening dietary intake and abdominal bloating. She had epigastric fullness, but no abdominal pain. Gastrointestinal endoscopy revealed food residue and pyloric stenosis. A contrast-enhanced radiograph also showed pyloric stenosis, and gastrografin was not passed well through her pylorus. Computed tomography revealed similar findings. The biopsy results indicated hyperplasia of the gastric glands. The patient was diagnosed with a benign lesion, and underwent endoscopic balloon dilation several times. However, her stenosis worsened and we decided to perform surgery. In consideration of the cosmetic outcome, we performed laparoscopic distal gastrectomy. The postoperative course was good, and the patient was discharged on postoperative day 10. The final diagnosis was pyloric stenosis caused by heterotopic glands. No malignant lesions were found. Since gastric stenosis caused by heterotopic glands has not been reported previously, we consider this to be a very rare case.

Aim: We hypothesized that recent trends towards earlier diagnosis of hypertrophic pyloric stenosis continued throughout the early part of the 21st century., Methods: We reviewed the medical records of patients with HPS at a single institution during two periods: 1/03-12/05 and 4/09-7/13., Results: A total of 433 patients with hypertrophic pyloric stenosis who underwent pyloromyotomy were included (modern cohort = 259; historic = 174). The two cohorts did not differ in terms of age, weight, or median time from symptom onset to physician (5 vs 6.5 days; p = 0.3) or surgeon (7 days for both) evaluation. The percentage of patients who presented late (>7 days of symptoms) (27 % modern vs 25 % historic; p = 0.15) or with an elevated serum bicarbonate (22 % for both; p = 0.8) did not change over time. There was a shift to laparoscopic procedures: 99 % modern vs 57 % historic (p < 0.0001) with no associated change in operative length (28 vs. 27 min; p = 0.06), or operative (3 % for both, p = 0.8) or respiratory (4 vs 2 %, p = 0.4) complications., Conclusion: Most infants with hypertrophic pyloric stenosis are diagnosed early, prior to significant electrolyte abnormalities; however, continued improvement in awareness is necessary given that a fourth of patients are diagnosed after over 1 week of symptoms.

A 16-year-old girl presented with free gas under the diaphragm after endoscopic balloon dilation for pyloric stenosis. There was no perforation site identified on laparotomy. However, there was massive pneumatosis intestinalis involving the entire small bowel., (2015 BMJ Publishing Group Ltd.)

A 34-year-old woman presented at our hospital with abdominal distention due to overeating. Acute gastric dilatation was diagnosed. The patient was hospitalized, and nasogastric decompression was initiated. On hospitalization day 3, she developed shock, and her respiratory state deteriorated, requiring intubation and mechanical ventilation. Nasogastric decompression contributed to the improvement in her clinical condition. She was discharged 3 mo after admission. During outpatient follow-up, her dietary intake decreased, and her body weight gradually decreased by 14 kg. An upper gastrointestinal series and endoscopy revealed pyloric stenosis; therefore, we performed gastrojejunostomy 18 mo after her initial admission. The patient was discharged from the hospital with no postoperative complications. Gastric necrosis and perforation due to overeating-induced gastric dilatation are life-threatening conditions. Surgical intervention may be required if delayed pyloric stenosis occurs after conservative treatment. We report a case of pyloric stenosis due to overeating-induced gastric dilatation treated by gastrojejunostomy 18 mo after the initial presentation.

Herniation through a congenital mesenteric defect is a rare cause of intestinal obstruction in the newborn. Early diagnosis and surgical treatment improves the prognosis. We present a case of a full-term infant who presented with respiratory distress at birth. Enteral feeding was not started because abdominal distension and delayed passage of meconium. Bowel obstruction was suspected. Radiological investigation did not provide a clear diagnosis. Surgical exploration revealed transmesenteric congenital hernia. After surgical repair, enteral feeding was tolerated and patient was discharged with an uneventful outcome. Diagnostic difficulties were discussed.

Aim: To evaluate the safety and efficacy of partially covered self-expandable metallic stents (SEMSs) in benign pyloric obstruction., Methods: We retrospectively analyzed data from 10 consecutive patients with peptic ulcer-related pyloric obstructive symptoms (gastric outlet obstruction scoring system (GOOSS) score of 1) between March 2012 and September 2013. The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center. We assessed the technical success, symptom improvement, and adverse events after stenting., Results: Early symptoms were improved just 3 d after SEMS placement in all 10 patients. The GOOSS score of all patients improved from 1 to 3. There were no serious immediate adverse events. The overall rate of being symptom free was 90% at a median of 11 mo of follow-up (range: 4-43 mo). Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation. Among them, four patients had sustained symptom improvement after the SEMS procedure. During the follow-up period, migration of the SEMS was observed in two patients (20.0%), both of whom had previous endoscopic balloon dilatation before SEMS insertion., Conclusion: Despite the small number in this study, partially covered SEMSs showed a favorable and safe outcome in the treatment of naïve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

We studied age-specific features of peripheral electrogastroenterography (PEGEG) parameters and their influence on the assessment of findings. In 28 individuals divided into "young" (mean age 21.4 ± 2.7 years) and "elderly" (63.0 ± 7.2 years) subgroups, parameters of PEGEG were analyzed by comparing the group mean values (Mann-Whitney test) and by using discriminant analysis. Discriminant analysis revealed fi ve PEGEG indicators that allow discriminating the groups of young and older people; the most significant indicators were basal electrical activity of the stomach and colon. The influence of these differences on evaluation of gastrointestinal motility was studied in 57 patients with ulcerative pyloroduodenal stenosis (mean age 50.5 ± 19.1 years) distributed into two groups depending of the disease severity. The use of "elderly" normal values instead of "mean-aged" norm (in discriminant analysis) significantly improved the accuracy of patient distribution in groups from 85.2 to 96.4%.

A pregnant woman presented at the emergency department with severe nausea and vomiting at 20 weeks of gestational age; she was known with gastric banding. Advanced imaging studies were avoided of fear to harm the fetus. The patient continued to vomit and at 23 weeks intrauterine fetal death was noted. The symptoms did not resolve after delivery and CT scan demonstrated slippage of the gastric band over the pylorus resulting in a high digestive obstruction as the cause of hyperemesis and finally resulting necrosis of the vasa brevia. The gastric band was laparoscopically removed along with the necrotic tissue. Avoidance of radiological and endoscopic investigations of fear to harm the pregnancy resulted in complications and possibly in fetal death.

A 65-year-old man was admitted to our hospital with nausea, vomiting and appetite loss. First upper endoscopic examination and X-ray examination showed a peptic ulcer and a pyloric stenosis. Fiberscope could not go through the pyloric ring. Computed tomography examination and biopsy showed no evidence of malignancy. Though we considered surgical resection of the stenosis at first, he could eat a staple food with therapy of proton pump inhibitor. So we followed up with upper endoscopic examinations. Second, third and forth upper endoscopic examinations showed no evidence of malignancy. Fifth upper endoscopic examination showed an ulcer scar on the pyloric ring and a 0-IIc carcinoma in the antral greater curvature. Distal gastrectomy with D2 lymph node dissection and B-II reconstruction. Pathologically, a mucosal carcinoma with no lymph node metastasis and U1-III peptic ulcer were diagnosed.

A 67-year-old patient was admitted to our hospital with lack of appetite and upper gastrointestinal bleeding. The immediately performed emergency gastroscopy showed a giant subepithelial tumour with ulceration located in the antrum. Emerging from the tumourous ulcer was a peg-shaped outgrowth reaching through the pylorus down to the duodenum causing gastric outlet obstruction. Based on this unusual presentation of a gastric giant lipoma we have reviewed the literature concerning differential diagnosis and treatment options., (© Georg Thieme Verlag KG Stuttgart · New York.)

Metallic pyloric stenting (also termed as metallic enteral stenting) performed endoscopically, stands as first-line treatment for malignant gastric outlet obstruction. With reported evidence, these self-expandable metallic stents (SEMS) re-enable oral food intake, preventing patients having to face invasive techniques such as surgical gastroenterostomy. We report a patient having received a covered pyloric SEMS insertion following a tumour growth causing stenosis in the gastric antropyloric region. After 3 weeks, the patient presented with a fracture of the pyloric SEMS, a rare complication, resulting in a second pyloric SEMS insertion.

A 10 year old boy with mucinous carcinoma of rectum is a rare case at this age. Here the patient presented with constipation, mucus in stool & abdominal pain since one month. He got consultation from several physicians & went through sonology of whole abdomen several times. There he was missed diagnosed as a case of pyloric stenosis. We came to a probable diagnosis by doing simple digital rectal examination which seemed to be a hard rectal swelling. The diagnosis was established by colonoscopy followed by biopsy. Carcinoma rectum must be considered as a differential diagnosis if patient presents with altered bowel habit, per rectal bleeding, abdominal pain in conjunction with weight loss.

Aim: the paper presents a rare case of metachronous gastric metastasis of uterine cervix cancer, clinically manifested through severe pyloric stenosis., Method: 49-year-old patient, operated on in January 2009, with uterine cervix cancer (Squamous cell carcinoma T2bN1M0), is hospitalized in August 2011 with pyloric stenosis: epigastric pains, abundant, stasis, late postprandial emesis, significant weight loss, stomach form visible upon abdomen inspection. Endoscopy: antral stenosis with intact gastric mucosa, and CT-scan: circumferential intramural gastric tumor, stomach dilated in the upper part, lack of cleavage between the tumor and the liver bed of the gall bladder. CEA increased to 13,78 (below 5), CA 19-9 slightly increased 29.9 (below 27). The case is considered as a second neoplasia and a D2 subtotal gastrectomy was performed, with 1 positive ganglion out of 27 on block with atypical hepatectomy of segments 4-5 for liver invasion, the final mounting being Y Roux., Results: The histopathological examination shows a gastric metastasis of squamous carcinoma, of uterine cervix origin, the invaded perigastric ganglion having the same aspect of uterine cervix carcinoma. The post-surgery evolution was favorable, under chemo radiotherapy the patient being alive without relapse at 9 months post-surgery., Conclusion: In the literature there are 2 more cases of gastric metastasis of uterine cervix carcinoma, and 4 of uterine carcinoma without topographic indication, but without the histological documentation of the tumor filiation, without data related to resecability or follow-up, the case at hand being, from this perspective, the first documented resectable metachronous gastric metastasis from a cervix uteri carcinoma., (Celsius.)

Diagnosis of Pyloric stenosis is rare in preterm babies. A case of pyloric stenosis diagnosed at 33(+6) postmenstrual age is reported. To our knowledge, this is the youngest postmenstrual age in the literature for a preterm infant to have a confirmed diagnosis of pyloric stenosis. The report also discusses issues that could delay the diagnosis of this condition in this patient population.

The purpose of this report is to demonstrate a step-by-step process of clinical decision making. A case study is presented in stages to simulate the way such information emerges in clinical practice. The focus is on the diagnostic process of this pediatric surgical patient's presentation, with particular attention to the unusual sequence of events and the diagnostic dilemmas that emerged for the clinicians involved. This case also represents three very rare conditions related to the same patient that have never been presented in the literature occurring in combination or in relationship to one another., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aims: In infants with pyloric stenosis we explored (a) if males develop symptoms and present to hospital earlier than females and (b) does any delay in presentation influence the severity of metabolic derangement., Method: A retrospective casenote review of 99 infants who underwent pyloromyotomy (with confirmation of pyloric stenosis) over a two year period (Jan 2006-Dec 2007) in our hospital. The data collected included: sex, age at onset of symptoms, age at presentation to hospital and initial blood results., Results: The group comprised 84 males and 15 females. Symptoms developed at 26 (0-70) days in males and 35 (0-77) in females. (Mann-Whitney U=428, p=0.04 two tailed). Males presented to hospital at 34 (13-91) days, females at 45 (13-98) days (Mann-Whitney U=391, p=0.01 two tailed). The differences between males and females for (1) age at onset of symptoms and (2) age at presentation to hospital became more significant when weighted averages were calculated using SPSS (Statistical Package for Social Sciences). The lower weighted averages for male infants can be seen in the final table. Increasing duration of symptoms showed a positive correlation with fall in Chloride level. (Spearman's rho: rs= -0.2, p=0.049 two tailed). There was a positive correlation between duration of symptoms and bicarbonate level but this was not significant. (rs=0.06, p>0.05 two tailed). There was a positive correlation between duration of symptoms and pH, but this was not significant (rs=0.12, p>0.05 two tailed)., Conclusion: In our hospital, females with pyloric stenosis develop symptoms and present significantly later than males. This should be considered when assessing a female with vomiting outside the usual 20-40 day range.

Gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is even rarer. We describe the multidetector computed tomographic diagnosis of small bowel obstruction resulting from a gallstone impacted in the distal ileum and of gastric outlet obstruction from a gallstone impacted in the pyloric antrum (Bouveret syndrome).

A case of gastric outlet obstruction secondary to prepyloric antral web in a four-year-old boy with cerebral pareses is reported. Routine roentgenographic examination was initially misinterpreted as duodenal obstruction. Prepyloric antral web was suspected by subsequent endoscopy and was confirmed by operation. The patient underwent antropyloroplasty that resulted in excellent recovery. The possibility of a prepyloric antral web should be considered in any infant or child with persistent vomiting when pyloric stenosis is excluded.