[Endoscopic treatment of hemorrhages in patients with ulcerative lesions of the gut]

The issues of endoscopic treatment of gastroduodenal hemorrhage, including that, occurring in the injured persons with polytrauma, were analyzed. There was shown, that endoscopic hemostasis must be considered the method of choice in diagnosis and treatment of an acute hemorrhage of the erosive-ulcer genesis. The efficacy of endoscopic hemostasis significantly depends on its timely performance, the surgeon training and experience, an adequate choice of the method in a special clinical situation.

[Duodenal pancreatic-preserving resections with common bile and pancreatic ducts replantation by cystic form of duodenal dystrophy]

Two patients with cystic dystrophy of duodenum and chronic inflammation of duodenally ectopic pancreatic tissue were successfully operated on. Both cases clinically demonstrated abdominal pain and duodenal obstruction. Absence of substantial tissue changes in "main" pancreas allowed execution of pancreas-preserving operation. Thus, subtotal duodenectomy was performed in the first patient. The second patient had resection of vertical branch of the duodenum with intestinal fragment replacement. Extensive periorganic fibrosis in both cases substantially complicated verification of anatomic structures and dissection.

The influence of laparoscopic and open surgery on the concentration and structural modifications of insulin-like growth factor binding protein 3 in the human circulation

Insulin-like growth factor binding protein 3 (IGFBP-3) is the most abundant insulin-like growth factor binding protein in the circulation. The aim of the present work was to investigate the influence of surgery (laparoscopy and open) on the concentration and carbohydrate content of IGFBP-3. The concentration of IGFBP-3 was measured using an immunoradiometric assay (IRMA), its protein profile was characterised using immunoblotting and its sialic acid content was examined by means of Sambucus nigra agglutinin (SNA) affinity chromatography. The concentration of IGFBP-3 was significantly (p < 0.001) lower in preoperative patients compared with healthy subjects. Only patients that underwent open surgery showed a further significant decrease in the concentration of IGFBP-3. Immunoblotting detected two intact IGFBP-3 isoforms, as well as proteolytic fragments. SNA-affinity chromatography showed that in patients that underwent surgery the ratio between the two IGFBP-3 glycoforms was lower than the ratio in healthy subjects. Patients with gallbladder inflammation that underwent laparoscopy had an increased percentage of specifically bound IGFBP-3 to SNA compared with healthy subjects. Our conclusion is that open surgery decreased the level of IGFBP-3 compared with laparoscopy, whereas patients with gallbladder inflammation that underwent laparoscopy had an increased content of sialic acid in IGFBP-3.

[Surgical treatment of duodenal stenosis in Crohn's disease]

Crohn's disease may involve any part of the alimentary tract, including the stomach and duodenum. We report herein the case of a 22 year-old male in whom Crohn disease was diagnosed due to weight loss in relation with a stenosis of the first and second parts of the duodenum. A gastrojejunostomy was performed with a good subsequent result. The initial management of a Crohn's disease with involvement of the duodenum is medical. When there is an indication for surgery, a gastroenterostomy is preferred, albeit with a high incidence of outlet obstruction and marginal ulceration.

[Strategies in the surgery choice in patients with hepato-pancreatic-duodenal-biliary diseases involving cardiovascular and respiratory system diseases]

Results of treatment of 38 patients, suffering nontumoral and tumoral diseases of the hepatopancreatoduodenal zone organs and concurrent diseases of cardiovascular and respiratory systems were analyzed. Septic-purulent affections, caused by the principal disease, had constituted the leading complication in occlusion-stenotic affection of cardiac coronary vessels. Due to the alternative absence the majority of the patients were operated on with lethal outcome. Basing on analysis of morphometric investigations of cardiac vessels there was suggested the expedience of coronarographic investigation conduction and, basing on its results, to perform preoperatively the balloon dilatation or stenting of cardiac coronary vessels, independently of kind of the main disease present. In presence of haemodynamically significant stenosis of the cardiac coronary vessels trunk and main branches (more than 70% of their lumen) the lethal outcome risk after performance of operative intervention is very high.

[Isolated gastroduodenal Crohn's disease: a case report]

Although it can involve any segment of the gastrointestinal tract, Crohn's disease confined to the gastroduodenum is extremely rare. We report the story of a 20-years old male patient admitted for pyloric obstruction that developed despite medical treatment. Clinical manifestations necessitated operative treatment; Polya-gastrectomy was performed. Histology identified Crohn's disease and inflammatory changes as the cause of pyloric obstruction. Postoperative recovery was uneventful. The lesson of this case is, that if duodenal Crohn's disease would have been recognized preoperatively, gastrectomy could have been avoided. We review the literature and discuss treatment options for gastroduodenal Crohn's disease.

Ulcerative duodenitis accompanying ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon of unknown etiology. There are varied manifestations in the natural course of UC. However, duodenum is not generally considered a target organ of UC. Here, we report two patients with steroid-responsive ulcerative duodenitis with colitis that was consistent with UC, but not with Crohn's disease. We also reviewed six cases of ulcerative duodenitis with UC. Duodenal lesion with UC may be a more common phenomenon, although infrequently clinically manifested under steroid therapy. Upper gastrointestinal tract inflammation in UC warrants further studies to ascertain whether the duodenum is a target organ in UC, especially in steroid-free conditions.

Helicobacter pylori infections--are these diseases relevant for surgical treatment?

Helicobacter pylori infection and its strong association with gastroduodenal diseases has revolutionized our views and treatment options in these diseases. Surgery has always been considered a mainstay in their treatment. The development of potent eradication regimes has changed indications for operative treatment. With endoscopic procedures being increasingly performed by the surgeon himself, it has become necessary that he educate himself in the diagnosis and treatment of H. pylori infection in order to be able to cope with these diseases in every day surgical practice. Treatment of H. pylori infection may not only be seen as an alternative to operative therapy, but also as an adjunct following surgical treatment of gastroduodenal disease.

Inflammatory fibroid polyp of the duodenum

Duodenal inflammatory fibroid polyps (IFP) are extemely rare lesions indistinguishable from submucosal tumors by endoscopic inspection alone. Like gastric inflammatory fibroid polyps, they can be managed by endoscopic polypectomy or mucosectomy. However, preoperative diagnosis of this benign lesion is difficult. Here we present a case of duodenal IFP causing gastrointestinal bleeding that was evaluated by endoscopic ultrasound before surgical removal. On endosonography, the duodenal IFP appeared as a coarsely heterogeneous isoechoic and hypoechoic mass circumscribed by a distinct margin and arising from the third layer of the duodenal wall. The endosonographic appearance of this lesion was in marked contrast to that previously reported for gastric IFPs, which have tended to appear as hypoechoic homogeneous lesions with indistinct margins. Endosonographic evaluation of suspected IFPs before endoscopic or surgical treatment is useful. However, the endosonographic appearances of duodenal and gastric IFPs may be significantly different, possibly because of differences in the makeup of the duodenal and gastric walls.

Duodenal involvement of Crohn's disease: three different clinicopathologic patterns

PURPOSE

This study was designed to assess clinical and pathologic features of duodenal Crohn's disease (CD) and address its management according to different patterns of disease.

METHODS

Twelve cases of duodenal involvement in CD are reported out of 336 patients treated between 1978 and 1993. They represent 3.6 percent of all cases. Three patients had a duodenal fistula, and nine had an intrinsic duodenal lesion. The duodenal fistula was in all cases a manifestation of recurrent CD involving an ileocolic anastomosis and the third portion of the duodenum.

RESULTS

Treatment consisted of resection of the fistula's source and primary closure of duodenal breach. Of nine patients with intrinsic CD, five had stenosis and the remaining four had peptic ulcer-like lesions. Duodenal stenosis was treated with strictureplasty in three cases and duodenojejunostomy in two. No patient with ulcer-like lesions underwent surgery.

CONCLUSIONS

Differences encountered in intrinsic duodenal lesions apparently reflect two different clinical patterns. Stenosis is not usually associated with multifocal disease and is often the first evidence of disease. Ulcer-like lesions are not specific; they do not evolve into stenosis as do ulcers in other sites of the disease, spontaneously disappear and relapse, and do not require surgery, except for complications. They are always associated with other locations of the disease.

Gastrojejunostomy for management of acute proximal enteritis in a horse

A 5-year-old Arabian stallion was treated medically 6 days for proximal enteritis. On the sixth day, exploratory celiotomy verified the diagnosis and ruled out other intraluminal and extraluminal gastrointestinal tract obstructions. A gastrojejunostomy was performed. The horse had trouble maintaining and gaining weight in the first year after surgery, but 8 years after surgery, the owner reported that the horse was doing well.

Chronic ischaemic gastritis: an unusual form of splanchnic vascular insufficiency

Three cases of erosive gastroduodenitis secondary to chronic splanchnic vascular insufficiency are reported. In all cases, pain failed to respond to conventional therapeutic measures for peptic ulcer disease. A patchy discolouration and erythematous mottling of the gastric mucosa, with scattered shallow aphthous ulcers, was seen on endoscopic examination. Angiography showed coeliac axis involvement in all patients, with insufficient mesenteric collateral pathways. Chronic gastritis resolved clinically and endoscopically after revascularization.

[A case of inflammatory fibroid polyp of unusual localization]

The case of an inflammatory fibroid polyp of infrequent localization is presented. Altogether 100 cases are reported by summarizing publications in the literature and only a small part of them showed duodenal localization. The patient whose case is presented was subjected to internal examination and later to operation because of acute spastic abdominal pain and loss of weight. Following the description of the case the authors analyse the etiology of this rare disease and the problems of terminology. Radical, curative operation is considered expedient in these cases. The presented case can be regarded as a special one both from the viewpoint of diagnostics and of its duodenal localization.

Crohn's disease of the small bowel

Crohn's disease is a perplexing panintestinal disease whose etiology is unknown. Symptoms and complications vary greatly from patient to patient. Despite the fact that no cure exists, thoughtful, well-planned therapy and appropriate timely intervention, where needed, can result in maintenance of a high quality of life for affected patients.

[Value and reliability of hypotonic duodenography in chronic pancreatitis]

The incidence of pathologic duodenal abnormalities in patients suffering from chronic recurrent pancreatitis is derived from a retrospective analysis of 128 hypotonic duodenographies. The value of established diagnostic criteria and the present indication for a hypotonic duodenography in chronic pancreatitis are determined.

Duodenal Crohn's disease: an analysis of 89 cases

Duodenal Crohn's disease has an estimated incidence of 1% to 2% among patients with Crohn's disease. We report 89 patients with duodenal Crohn's disease. Common symptoms were upper abdominal pain and symptoms of gastroduodenal obstruction. Contiguous disease of the gastric antrum and duodenum was present in 60% of patients. Endoscopic examination revealed abnormalities in 62 of 67 patients. Granulomas or granulomatous inflammation was found in 37 of 76 patients. Forty-nine patients treated medically were followed up for 2-25 yr (median 9.7 yr). Good to excellent results were obtained in 45 patients. Thirty-three patients required surgical intervention, usually for gastroduodenal obstruction. Reoperation was required in eight patients, seven of whom had had vagotomy with gastroenterostomy or subtotal gastrectomy. In two of these seven patients, marginal ulcers developed. Both patients had had gastroenterostomy and vagotomy. Our experience does not support the routine use of vagotomy when a bypass procedure is performed. Good to excellent results were achieved in 26 of the 30 surgically treated patients followed up for more than 1 yr (1-43 yr; median 11 yr). Measured in terms of need for surgical intervention, gastroduodenal disease generated considerably less morbidity than did distal Crohn's disease (p less than 0.001). Most patients achieved good to excellent results whether treated medically or surgically.

[Surgical treatment of duodenal diverticula]

The work generalized an experience with the treatment of 747 patients with diverticula of the duodenum. Operations were performed on 326 of them (43.6%). In 172 patients the diverticula were associated with other diseases of organs of the abdominal cavity. Such patients were subjected to associated operations. The dependence of the clinical picture of inflamed diverticula on their localization is described. The author determines the surgeons' strategy, indications and volume of the surgery in different localizations of the diverticula. A new operation of exclusion of the duodenum allowing the postoperative lethality to be decreased from 5.5% to 1% was developed and introduced into practice.

The surgical treatment of gastroduodenal Crohn's disease

Crohn's disease can affect any part of the gastrointestinal tract. Gastroduodenal involvement is uncommon and was not recognised until 1949 (1). Since then approximately 200 cases have been described in several series in the world literature. This paper describes the clinical presentation and surgical management of ten patients treated in the Birmingham General Hospital between 1970 and 1984.

Diagnosis of gastroduodenojejunitis and its surgical treatment by a temporary duodenocaecostomy

Gastroduodenojejunitis is a catarrhal inflammation of the stomach and proximal portion of the small intestine. Secondary overloading of the stomach occurs so that affected horses rapidly enter a state of hypovolaemic shock which is further complicated by the presence of toxins. The condition can occur in a mild or severe form. In mild cases, conservative treatment comprising intravenous electrolyte therapy and repeated gastric decompression is indicated and is usually successful. In severe cases surgical treatment creating duodenocaecal anastomosis has given good results. This should be carried out if conservative treatment has shown no signs of improvement 24 h after the onset of the condition.

Long-term follow-up of patients with Crohn's disease. Relationship between the clinical pattern and prognosis

In a study of 615 new patients with Crohn's disease consecutively diagnosed at the Cleveland Clinic between 1966 and 1969, 592 patients were observed (mean greater than 13 yr, minimum 7 yr), giving a follow-up rate of 96.3%. The original hypothesis was that initial anatomic involvement (the clinical pattern) bears directly on clinical course and prognosis. Disease sites were as follows: 246 ileocolic, 165 small intestine, and 181 colon/anorectal. Among patients with ileocolic disease, 225 (91.5%) had surgery. For the small intestine pattern, the operative incidence was 65.5%; for the colon/anorectal pattern, it was 58%. Operations were for specific reasons: internal fistula with abscess or intestinal obstruction for ileocolic pattern; intestinal obstruction for small intestine pattern; and severe perianal disease or toxic megacolon for colon/anorectal pattern. Complications among nonoperated patients included perianal fistulas and extraintestinal manifestations. No statistical correlation existed between type and duration of medical treatment and prognosis. Seventy-five deaths occurred (12.8%), 36 of which related directly to Crohn's disease. Even after many years, symptoms continued and quality of life tended to be suboptimal among operated patients. For nonoperated patients, the most favorable quality of life was experienced by those with segmental involvement of the colon or ileum. Poor prognosis correlated with ileocolic disease and presence of sepsis because of an internal fistula.

Duodenal Crohn's disease complicated by common bile duct obstruction: report of a case and review of the literature

A 28-year-old woman with Crohn's disease involving the duodenum and terminal ileum presented with biochemical evidence of incomplete, extrahepatic biliary obstruction. Percutaneous transhepatic cholangiography showed partial obstruction of the intramural duodenal portion of the common bile duct. Cholangiography was complicated by cholangitis. Surgical decompression of the biliary system and bypass of the affected duodenal segment were performed after intraoperative confirmation of Crohn's disease involving the ileum, duodenum, and ampulla of Vater. The patient made a complete recovery and all previously abnormal cholestatic liver function test results returned to normal.

Surgical management of Crohn's disease involving the duodenum

The experience with 25 patients who required operation for Crohn's disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohn's disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohn's disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohn's disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohn's disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohn's disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohn's colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.

[Diagnostic and therapeutic aspects of gastroduodenal Crohn disease]

The duodenum or the stomach were involved in 20 (11%) of 177 patients with Crohn's disease. Four patients had no symptoms in the upper gastrointestinal tract, in ten patients pains and gastric disorders recurred. Six patients had severe symptoms caused by stenosis of the stomach or duodenum. The endoscopical and histological findings correlated to the severity of the symptoms. Early pathological changes were identified only by gastroscopy. We have little experience of the medical treatment of Crohn's disease of the duodenum or the stomach. A bypass procedure (gastrojejunostomy combined wih proximal-gastric vagotomy (PGV)) is indicated in all cases of severe gastric or duodenal stenosis.

Duodenal patch grafting

Loss of duodenal tissue around the pancreatic and common bile ducts presents a challenge to abdominal surgeons. Available methods to correct the problem include duodenojejunostomy, diamond duodenoplasty, serosal patching, mucosal pedicle patching from the ileum or jejunum, and gastric island patching. The choice of procedure must be tailored to the nature of the defect, the amount of tissue lost and the amount of peritoneal contamination. We believe that jejunal mucosal pedicle patching is a reasonable choice in most instances.