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Immunoglobulin G4 (IgG4)-related diseaseis a systemic inflammatory condition of unknown etiology characterized by increases in serum IgG4 and in the number of IgG4-positive cells in affected tissues. One of the commonly involved locations is the pancreas; this condition is known as type 1 autoimmune pancreatitis (AIP). Type 1 AIP, which shows a biliary stricture in the intrapancreatic bile duct, can be misdiagnosed as a malignancy due to similar cholangiography findings and clinical presentation. In rare cases complicated by post-bulbar duodenal ulcers, differentiating between type 1 AIP and malignancies is even more difficult. An 81-year-old male was referred to our hospital for the treatment of a pancreatic head mass and obstructive jaundice. Serological and radiological findings were consistent with both type 1 AIP and a malignancy. Gastroduodenoscopy revealed a post-bulbar duodenal ulcer with endoscopic features that evoked malignant duodenal invasion. Although biopsies were negative for malignant cells, subsequent bleeding from the lesion suggested the progression of malignancy, which led to surgical resection. Pancreatoduodenectomy and pathological examination indicated that type 1 AIP was present. Simultaneously, the involvement of IgG4-related disease in the ulcerative lesion was suggested. To our knowledge, this is the first reported case of type 1 AIP complicated by post-bulbar duodenal ulcers, which was misdiagnosed as malignancy and considered an IgG4-related gastrointestinal disease associated with type 1 AIP.

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Background: Congenital duodenal obstruction (CDO) is commonly detected antenatally through the presence of the "double bubble" sign on prenatal ultrasound, denoting dilatation of the stomach and duodenum. Subsequent postnatal ultrasonography plays a pivotal role in determining the causes of obstruction, thereby informing surgical strategies and neonatal management. The aim of this study was to investigate the diagnostic accuracy of postnatal ultrasonography in comparison to that of prenatal ultrasound and surgical findings in a cohort of 43 patients with fetal double bubble sign. Methods: A total of 43 patients, comprising 24 males and 19 females, who exhibited double bubble sign on prenatal ultrasound were subjected to postnatal ultrasound assessment at a tertiary care facility during the 2018-2023 period. The accuracy of both pre-and postnatal ultrasonography in the identification and diagnosis of CDO, as well as its underlying causes, was compared to that of the established gold standard of surgical findings. Results: The accuracy rates for prenatal and postnatal ultrasonic diagnosis of CDO were 97.7% (42/43) and 100% (42/42), respectively. In terms of etiological diagnosis, prenatal and postnatal ultrasound correctly identified the causes of obstruction in 45.2% (19/42) and 81.0% (34/42) of cases, respectively, as confirmed by surgical intervention. Conclusions: The presence of the prenatal double bubble sign serves as a highly reliable indicator for CDO. Additionally, postnatal ultrasonography proved to be a valuable tool in refining the diagnosis and determining the underlying causes of obstruction in neonates.

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Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) exerts external compression on the celiac trunk. Most cases are asymptomatic and diagnosed incidentally on radiographic imaging; however, some patients may experience gastrointestinal (GI) symptoms related to foregut ischemia and/or celiac neuropathy. In the following case, we present a patient with hemorrhagic peptic ulcer disease of the duodenum, which resulted in episodes of hemodynamic instability requiring multiple blood transfusions. Upon attempted transarterial angioembolization of the gastroduodenal artery (GDA), celiac stenosis and retrograde arterial flow from the superior mesenteric artery confirmed the presence of MALS. This rendered GDA angioembolization a contraindication, as the GDA became the dominant arterial supply for the distal celiac organs. The patient then received open surgical MAL release with concurrent surgical ligation of the hemorrhaging duodenal artery, which resolved his symptoms without the need for further intervention.

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Paraduodenal hernias (PDH) are a type of internal hernia that results from errors in midgut rotation and failure of mesenteric fusion. Internal hernias themselves are a rare presentation that accounts for less than 1% of total hernias, and paraduodenal hernias contribute more than half of internal hernias. Left paraduodenal hernias (LPDH) occur more frequently as compared to right paraduodenal hernias. Left paraduodenal hernias happen when the small intestine bulges out in the left paraduodenal space, which is also called the space of Landzert. This can cause vague abdominal pain and signs of intestinal blockage, which makes diagnosis difficult. We present a case of a 28-year-old male with recurrent abdominal pain for 7 years, diagnosed with LPDH via laparotomy after inconclusive imaging studies, such as the whirlpool sign on USG. Intraoperatively, jejunal loops were found in Landzert's fossa, hindering hernia repair and adhesiolysis. Clinicians must maintain a high index of suspicion for PDH when assessing nonspecific abdominal symptoms to ensure timely diagnosis and management, optimising patient outcomes.

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Bariatric surgery has evolved and gained in popularity as it has been recognized as the most sustainable and effective treatment for obesity and related diseases. These related diseases are significant causes of obesity related morbidity and mortality. Most bariatric procedures incorporate some component of gastric restriction with or without intestinal bypass, but the full mechanism of these procedures has yet to be elucidated. The most popular surgical procedure remains the sleeve gastrectomy over the last 10 years, while gastric bypass is also still commonly performed. We have also seen growth in revisional bariatric surgery and novel surgical procedures.

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Since ovarian cancer typically spreads intraperitoneally or via lymphatics, a retroperitoneal duodenal obstruction is a rare presentation of ovarian cancer. Such upper gastrointestinal obstruction in a young patient is diagnostically challenging and surgically difficult to address. In this case report, we describe that in an interdisciplinary approach a Whipple pancreaticoduodenectomy could be safely implemented into the interval debulking surgery to achieve complete cytoreduction. No postoperative complications were encountered. The surgical procedure was able to remove the upper gastrointestinal obstruction and thereby the need for a venting gastrostomy tube and total parenteral nutrition and thus provided good quality of life and additional lifetime.

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Functional dyspepsia (FD) is a brain-gut interaction disorder located in the stomach and duodenum, which has complex pathophysiological mechanisms, and there is no effective treatment for FD. Acupuncture and moxibustion have been proven to have definite and significant efficacy on FD. Focusing on the affected area and combined with the potential pathophysiology of FD, here we discuss the possible mechanisms of acupuncture and moxibustion in treating FD to guide future clinical and experimental research. We argue that the pathological causes of FD can be roughly divided into gastrointestinal dysfunction, duodenal low-grade inflammation, visceral hypersensitivity, and duodenal intestinal barrier and microbial imbalance. Correspondingly, the possible mechanisms of acupuncture and moxibustion in treating FD are elucidated from the perspective of how they improve gastric accommodation, regulate gastrointestinal motility, reduce gastric visceral sensitivity, regulate eosinophil-mast cell axis, inhibit low-grade inflammatory responses, and possibly regulate intestinal microbial homeostasis and duodenal barrier function through the microbiota-gut-brain axis. Although some evidence is still lacking, acupuncture remains a promising treatment for FD. In the future, it is necessary to conduct additional clinical and experimental research on acupuncture and moxibustion in treating FD to further explore their effects and mechanisms.

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Introduction: Celiac disease (CD) is an autoimmune enteropathy triggered by gluten ingestion in genetically susceptible individuals. The haplotypes HLA-DQ2 and DQ8, transglutaminase (TGA) antibodies, and biopsy findings are the main tests performed in the evaluation and CD diagnosis. The objective was to establish possible correlations between transglutaminase levels, genetic markers tests, and qualitative intestinal biopsy findings (modified Marsh classification) at the diagnosis. Methods: A retrospective cohort study. The selection criteria were confirmed CD cases with genetic tests performed. Statistical analysis was done mainly through One-way ANOVA, Kendall's correlation coefficient (T), and linear regression. Results: The study included 112 patients, with a mean age of 6 ± 4 years. All cases were tested to HLA-DQ2, and it was positive in 93%. HLA-DQ8 was tested in 73% of cases and it was positive in 61%. The percentage of negative genetic markers (DQ2/DQ8) was 4.5% for patients tested to both haplotypes. A comparison of DQ2/DQ8 (positive and negative) with clinical findings and tests performed did not identify any differences for most of the parameters analyzed. Cases of type I diabetes presented significant negative expression for DQ2(-); p = 0.05 and positive expression for DQ8(+); p = 0.023. The TGA antibody levels ranged from 18 to 36,745 U/ml. An inverse correlation was found between age and TGA-L level (p = 0.043). In 23% of the cases, the TGA levels were greater than 1,000 U/ml and presented a moderate positive correlation with the atrophy biopsy profile (T = 0.245). Patients with an atrophic biopsy profile (Marsh III) had a moderate positive correlation with growth failure (T = 0.218) but a negative correlation with constipation (T = -0.277). Conclusion: In terms of diagnosis tests for CD, transglutaminase levels and age presented an inverse correlation, with the level decreasing as age increased. A moderately positive correlation was found between mean transglutaminase with intestinal atrophy and growth retardation. The genetic test DQ2 was positive for 93% and negative genetic markers (DQ2/DQ8) represented 4.5% of cases studied.

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Cysteamine (CA) induces duodenal ulcers in rodents (Selye and Szabo, Nature 244:458-459, 1973). Cysteine (Cys), a precursor for the formation of CA (via catabolism of coenzyme A), does not cause lesions in the duodenum (Szabo et al., J Pharmacol Exp Ther 223:68-76, 1982). CA also has antimutagenic and anticancer pharmacology (Fujisawa et al., PLoS ONE 7, 2012; Lee, Adv Pharmacol Pharm Sci 2023:2419444, 2023). We propose a mechanism of CA-induced cell death dependent on oxygen and CA dioxygenase (ADO) that can explain the 50-year-old mystery as to why CA is, but Cys is not, ulcerogenic. Those cells expressing coenzyme A-catabolizing enzymes are subject to a unique type of oxygen- and enzyme-bound-Fe2+-dependent death, type II ferroptosis.

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Invasive lobular carcinoma (ILC) represents a rare subtype of breast carcinoma, originating from the lobule. Unlike ductal carcinoma, ILC does not express E-cadherin and thus can metastasize to uncommon sites. We aimed to investigate the clinicopathological characteristics of the rare subgroup of ILC patients with gastrointestinal (GI) metastases. A PubMed search was undertaken using the terms "Lobular Breast Carcinoma" AND "Gastrointestinal Metastasis." We identified 169 cases, with metachronous GI metastatic disease being approximately twice as common as synchronous GI metastases. The median age at initial diagnosis was 56.7 years (24-88). The majority of patients were hormonal receptor-positive and only a small minority was HER2-positive. The appearance of a gastrointestinal lesion was often the mode of revelation of ILC. Differential diagnosis from primary gastrointestinal cancer is sometimes challenging, especially in the case of signet-ring cell carcinoma. The median time from breast cancer diagnosis to GI metastases was 6.5 years (0-33). Most common metastatic sites include the stomach, colon, and rectum, in order of decreasing frequency, whereas metastases were found in every part of the digestive tract. In conclusion, metastases of ILC can arise in the gastrointestinal tract and they should be managed similarly to metastatic breast cancer.

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Duodenal adenocarcinoma is a rare and aggressive gastrointestinal malignancy that frequently presents with symptoms like gastric outlet obstruction and biliary obstruction, leading to delayed diagnosis and challenging prognosis. This case report explores the clinical presentation, diagnostic hurdles, and therapeutic management of late-stage duodenal adenocarcinoma in a 53-year-old woman with no significant prior medical history. The patient presented with severe epigastric pain radiating to the right upper quadrant, nausea, and decreased appetite. Elevated liver enzymes and imaging revealed multiple liver masses and a primary duodenal mass. Biopsies confirmed moderately differentiated adenocarcinoma. Tumor markers were evaluated during the staging phase, showing markedly elevated levels. The patient underwent systemic chemotherapy with FOLFOX but faced complications, including pulmonary emboli and neurological symptoms. Management required a multidisciplinary approach, integrating palliative and supportive care to address symptoms and improve quality of life. The case highlights the necessity of considering duodenal adenocarcinoma when diagnosing persistent gastrointestinal symptoms. It highlights the need for a holistic treatment approach, including tailored chemotherapy regimens and vigilant monitoring of complications. Molecular profiling was crucial in guiding treatment decisions, although MSI, HER2, and PD-1 were negative, and the tumor showed no mismatch repair protein deficiency. This article emphasizes the importance of early integration of palliative care and the value of comprehensive pathological analysis in managing advanced duodenal adenocarcinoma, providing insights into diagnostic and therapeutic strategies for this complex case.

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An increasing number of superficial non-ampullary duodenal epithelial tumors (SNADETs) have been detected recently owing to the development of endoscopic imaging technology and increased awareness of this disease. Endoscopic resection is the first-line treatment for SNADETs, with methods including cold snare polypectomy (CSP), conventional endoscopic mucosal resection (cEMR), underwater EMR (uEMR), and endoscopic submucosal dissection (ESD). Here, we review the current status and recent advances in endoscopic resection for SNADETs. Endoscopic resection in the duodenum is more difficult and has a higher risk of adverse events than that in other organs owing to specific anatomical disadvantages. SNADETs ≤10 mm in size are candidates for CSP, cEMR, and uEMR. Among these lesions, suspected carcinoma lesions should not be treated using CSP because of their low curability. cEMR or uEMR is considered for lesions sized 10 to 20 mm, whereas piecemeal EMR or ESD is considered for tumors >20 mm in size. In particular, ESD or surgical resection should be considered for suspected carcinoma lesions >30 mm in size. The treatment plan should be selected on a case-to-case basis, considering the balance between the risk of adverse events and the necessity of en bloc resection.

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OBJECTIVE: This study was conducted to investigate the imaging information, laboratory data, and clinical characteristics of duodenal papillary malignancies, aiming to contribute to the early diagnosis of these diseases. METHODS: The clinical characteristics, laboratory data, and computed tomography (CT) findings of 17 patients with adenoma of the major duodenal papilla (the adenoma group) and 58 patients with cancer of the major duodenal papilla (the cancer group) were retrospectively analyzed. The measurement data were analyzed using t test and expressed as mean ± standard deviation. The counting data were analyzed using the χ2 test and expressed in n (%). Pearson correlation analysis was also conducted, and a scatter plot was drawn. RESULTS: There were significant differences in the diameter, shape, margin, and target sign of the major duodenal papilla, pancreatic duct diameter, common bile duct diameter, enhancement uniformity, fever, direct bilirubin, total bilirubin, carcinoembryonic antigen, carbohydrate antigen 19-9, and jaundice between the adenoma group and the cancer group (P < .01). The enhancement magnitude of the duodenal papilla was correlated with the lesion size, and the venous phase CT value of the enhanced scan was correlated with the duodenal papilla diameter (P < .05). Additionally, 12 patients in the cancer group suffered from malignant transformation of adenomas. CONCLUSION: Firstly, CT is of high value in the diagnosis of duodenal papilla diseases. Secondly, the enhancement magnitude of the duodenal papilla is correlated with the lesion size. Thirdly, patients with duodenal papilla adenomas have a risk of progression into adenocarcinoma, thereby requiring close follow-up.

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Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated lymphatic vessels in the gastrointestinal tract, leading to protein-losing enteropathy (PLE). We report the case of a 43-year-old male presenting with refractory PLE, characterized by generalized edema, chronic diarrhea, and significant weight loss over four months. Despite multiple consultations and treatments for presumed inflammatory bowel disease, his symptoms persisted, and his condition worsened. An upper endoscopy was performed, revealing white villi in the duodenum. Histopathological examination of duodenal biopsies confirmed the presence of markedly dilated lymphatic vessels in the lamina propria, consistent with PIL. The patient was managed with a high-protein, low-fat diet supplemented with medium-chain triglycerides (MCTs) and octreotide therapy. This treatment regimen led to significant clinical improvement, including reduced edema, normalization of albumin levels, and resolution of gastrointestinal symptoms. This case underscores the importance of considering PIL in adults with refractory PLE.

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Abdominal tuberculosis presents with nonspecific clinical and radiological features, often leading to diagnostic and therapeutic delays. Retroperitoneal pseudo-tumoral tuberculosis is a rare radio-clinical entity, characterized by its atypical and confusing symptomatology. We present the case of a 48-year-old male patient with no significant medical history, who was admitted to our department with a right retroperitoneal tumor presented as right renal colic due to compression of the lumbar ureter. Initially misdiagnosed as a gastrointestinal stromal tumor (GIST) of the lower duodenal angle, the patient underwent duodenal wedge resection, right hemicolectomy, and resection of the right lumbar ureter. Pathological examination of the surgical specimen confirmed follicular tuberculosis. The patient was subsequently treated with antitubercular drugs for 6 months with a good follow-up. Retroperitoneal pseudo-tumoral tuberculosis exhibits a polymorphic and nonspecific clinical presentation in our setting, highlighting the importance of early endoscopic or image-guided biopsies to prevent unnecessary surgical interventions.

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OBJECTIVE: We present an unusual case of a small para-aortic lymphocele causing duodenal stenosis after lymphadenectomy and discuss its treatment. CASE REPORT: Our case involved a 57-year-old woman with endometrial cancer who underwent surgery, including para-aortic lymphadenectomy. On postoperative day 7, projectile vomiting occurred. Computed tomography (CT) revealed a small lymphocele in the dorsal duodenum, causing duodenal stenosis. Transpercutaneous and transduodenal puncture or surgical procedures were difficult because the cyst was too small. Per endoscopic and gastrointestinal series findings on the postoperative day 22, a liquid diet was presumed to be able to pass through the narrow portion. Hence, concentrated liquid food was administered orally; no vomiting occurred. At 2 months postoperatively, CT showed no lymphocele. CONCLUSION: Conservative treatment involving waiting for spontaneous lymphocele reduction with a concentrated fluid diet may be considered in such cases if fluid passage is confirmed with endoscopy and gastrointestinal series.

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This case report describes a 28-year-old man with erythropoietic porphyria (EPP). After receiving an intravenous iron infusion, he experienced a significant acute aggravation of his condition. The patient had a vesicular rash on the face and arms with severe itching and burning feelings in addition to nausea, vomiting, and black-colored vomit. Abnormal liver function tests and anemia were found in the lab tests. Quick diagnosis and multidisciplinary care from dermatology, gastrointestinal, and hematology experts were essential. Strict light avoidance, symptom management techniques, and cessation of intravenous iron were all part of the treatment plan. The patient's symptoms subsided over a period of 12 months, and he resumed his regular activities. In managing EPP, key learning points stress the importance of vigilance in spotting trigger variables, prompt diagnosis, light avoidance, consistent follow-up, and genetic counseling.

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The single anastomosis duodeno-ileostomy with sleeve gastrectomy/single anastomosis duodenal switch (SADI-S/SADS) has gained attention as an alternative to the traditional biliopancreatic diversion with duodenal switch (BPD-DS). In 2021, IFSO endorsed SADI-S/SADS as a safe and effective procedure, underscoring the necessity for long-term multidisciplinary care and randomized controlled trials (RCTs). A task force was established to conduct a systematic review of current evidence on SADI-S/SADS to guide clinical practice. A systematic review was conducted across three databases, focusing on studies examining SADI-S/SADS and its outcomes. A total of 93 studies were analyzed. SADI-S/SADS demonstrated efficacy in weight loss and medium-to-long-term control of type 2 diabetes mellitus (T2DM), along with positive outcomes regarding hypertension and hyperlipidemia. However, its impact on other comorbidities remains inconclusive. Frequent nutritional deficiencies were identified, particularly in fat-soluble vitamins, anemia, and hypoalbuminemia. Despite significant efforts, high-quality evidence on SADI-S/SADS remains scarce, prompting IFSO to advocate for increased registry participation, publication of long-term studies, and more RCTs. Lifelong supplementation and monitoring for nutritional deficiencies are recommended. The current position statement will be reviewed in 2 years.

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Although bleeding is the most common complication of peptic ulcer disease, bleeding from the proper hepatic artery is unusual. We report on the case of an 87-year-old woman who presented with melena. An upper endoscopy was performed for a bleeding duodenal ulcer; however, the bleeding could not be controlled. A careful assessment using contrast-enhanced computed tomography (CT) demonstrated that the bleeding source was the proper hepatic artery. Transcatheter arterial embolization of the proper hepatic artery was successfully performed. This case highlights the importance of careful assessment using contrast-enhanced CT to identify the source of bleeding. Endovascular treatment is the first choice of treatment for patients with bleeding from large arteries.