Barium Studies Research Articles

Neurovascular antropylorus perineal transposition using inferior rectal nerve anastomosis for total anorectal reconstruction: preliminary report in humans

Technical feasibility of inferior rectal nerve anastomosis to the anterior vagus branch of the perineally transposed antropyloric valve for total anorectal reconstruction has been previously demonstrated in cadavers. To the best of our knowledge, the present study is the first report of using this procedure in humans. Eight patients [mean age 35.5years (range 15-55years); (male/female=7:1)] underwent the procedure. The antropyloric valve with its anterior vagus branch was mobilized based on the left gastroepiploic arterial pedicle. The antral end was anastomosed to the distal colon. The anterior vagus nerve was anastomosed by epineural technique to the inferior rectal nerve in the perineum. A diverting proximal colostomy was maintained for 6months. Anatomical integrity of the graft (on magnetic resonance imaging scans), its arterial pedicle (on computed tomography angiogram) and neural continuity (on ultrasound and pyloric electromyography) were assessed. Functional assessment was performed using barium retention studies, endoscopy, manometry and fecal incontinence scores. Tension-free end-to-end anastomosis of the anterior vagus nerve to the right (n=7) and left (n=1) inferior rectal nerve was achieved. An intact left gastroepiploic pedicle, a healthy graft and neural continuity were visualized on perineal ultrasound. Electromyographic activity was noticed on neural stimulation. Endoscopy and barium studies showed voluntary antral contraction and contrast retention, respectively, in all patients. The mean resting and squeeze pressures were 26.25mmHg (range 16-62mmHg) and 50.25mmHg (range 16-113mmHg), respectively. St. Mark's incontinence scores varied between 7 and 12. There were no major surgical complications. Pudendal (inferior rectal) innervation of the perineally transposed antropylorus in total anorectal reconstruction is feasible and may improve outcomes in selected patients with end-stage fecal incontinence.

Small Bowel Volvulus Following Upper Gastrointestinal Barium Radiography

Introduction: Small bowel volvulus is extremely rare in adults. Barium has been associated with obstructive symptoms related to baroliths, but these take several days to weeks to form. Small bowel volvulus has never been reported immediately following a barium study. Case: The patient is a 49-year-old man who presented with persistent gastroesophageal reflux despite treatment with dexlansoprazole. An upper GI series was performed to evaluate for hiatal hernia. The study revealed mid-esophageal reflux with small hiatal hernia and one area of nonspecific proximal small bowel prominence. One hour after the study, he ate lunch, and fifteen minutes later developed nausea, vomiting and diffuse abdominal pain. The pain progressed and his vomiting persisted requiring hospital admission. His past medical history includes bipolar disorder, hypertension and obstructive sleep apnea. He had no prior abdominal surgeries. His medications include depakote, trileptal, seroquel, lisinopril and dexlansoprazole. Exam revealed hypoactive bowel sounds and tenderness in the epigastrium and bilateral upper quadrants. Laboratories were notable for only mild neutrophilia. Abdominal computed topography (CT) scan showed small bowel volvulus and closed loop obstruction without free air. Contrast from the prior day was present in dilated proximal small bowel loops. Nasogastric tube was placed. Repeat abdominal x-ray showed persistent obstruction without any contrast in the colon. Given lack of improvement, laparoscopy was pursued. It revealed torsion of the jejunal mesentery that was corrected. No ischemic changes were noted. His symptoms resolved and he was discharged home without any further issues. Five months later, CT enterography with gastrograffin showed no evidence of intraluminal lesion or mesenteric pathology. Discussion: Small bowel volvulus is generally described in neonates with embryologic malrotation of the midgut. The etiology in this patient is a mystery. Contributing factors may have been slowing of colonic transit as side effect of bipolar medications as evidenced by excessive stool on CT. A large bolus of barium in setting of mild ileus may have caused the jejunal volvulus.

A Case of Cascade Stomach

Purpose: We present a 47-year-old female with history of Grave's disease, history of longstanding dysphagia in the setting upper esophageal Killian Jaimeson diverticulum that later underwent open neck surgical procedure (diverticulopexy), who developed new persistent symptoms of severe dysphagia. Upon further investigation of dysphagia, via upper gastrointestinal series, patient was incidentally found to have findings consistent with cascade stomach. Upper gastrointestinal series under fluoroscopy showed aerophagia with significant swallowed air in the esophagus, stomach, and duodenum, with slight delay in barium transit but no obstruction or stricture. The stomach was found to be rotated in its long axis with initial pooling of barium in the retroflexed gastric fundus followed by slight delayed emptying in to the body. Findings were consistent with cascade stomach. Cascade stomach is diagnosed from the characteristic appearance of the stomach on barium studies. The cascade stomach consists of a biloculation of the gastric cavity into a ventral and dorsal recess and is a rare cause of upper abdominal symptoms. The causes of gastric cascade described in the literature are manifold, some of which include reflux symptoms, dyspepsia symptoms, or epigastralgia symptoms. This disorder is often difficult to diagnose or is not recognized, therefore, its true incidence is currently not known. We summarize and highlight a case of cascade stomach incidentally found in a patient who was being evaluated for dysphagia.Figure

Fibrovascular Polyp: A Rare Cause of Dysphagia

Introduction: Fibrovascular polyps of the esophagus are rare benign esophageal tumors. They are pedunculated, often arise from the upper esophagus, and are very rare causes of dysphagia. We present a case of fibrovascular polyp causing dysphagia. Case Presentation: A 55-year-old woman with history of gastroesophageal reflux (GERD) was referred for dysphagia. She complained of initial solid food dysphagia which progressed to liquids associated with a 28-pound weight loss. She also stated that she was coughing up a sausageshaped mass occasionally which was visible in her mouth but could not be vomited out and she had to swallow it back. Esophagogastroduodenoscopy (EGD) was performed to evaluate her dysphagia. The esophagus showed a mobile sausage like structure with a pedunculated stalk extending below the upper esophageal sphincter (UES) to the proximal esophagus. She was referred to ENT for removal of this lesion due to the proximity to UES and difficult endoscopic removal. Patient was taken to the operating room and esophagoscopy was performed followed by snare cautery removal of this mass in its entirety through the esophagus, pharynx, and oral cavity. Postoperative pathology showed benign fibrovascular polyp with chronic inflammation. Discussion: Fibrovascular polyps of the esophagus are rare causes of dysphagia. They often arise from the upper esophagus or hypopharynx near the level of the cricopharyngeus at the pharyngoesophageal junction. This area is known as Laimer's triangle. The pathogenesis of these polyps is thought to originate from the loose and redundant submucosal tissue near the Laimer's triangle. This mobile tissue, due to lack of muscular support, through years of esophageal peristalsis, traction, and swallowing, is dragged, elongated, and enlarged intraluminally. Though fibrovascular polyps are benign, they may be lethal due to bleeding or asphyxiation if a large polyp is regurgitated. Dysphagia is the most common complaint, followed by respiratory symptoms. Diagnosis is made by history and investigations such as endoscopy, barium swallow, endoscopic ultrasound (EUS), CT, and magnetic resonance imaging (MRI). Barium studies can show a smooth intraluminal sausage-shaped mass. EUS can be a useful adjunct for assessing size, origin of the stalk, and vascularity of the polyp. The mainstay of treatment is surgical excision due to potential risk of respiratory compromise and bleeding. Surgery also serves to exclude cancer and avoid the small risk of malignant transformation. Esophagotomy via thoracotomy should be considered for good control of hemostasis and providing adequate exposure for resection of the pedicle's origin and any redundant mucosa around the pedicle.

Fournierʼs Gangrene Complicating Inflammatory Bowel Disease: Is it Ulcerative Colitis or Crohnʼs Disease?

Purpose: A 62-year-old man with history of ulcerative colitis presented with scrotal pain and swelling. Patient denied pneumaturia, abdominal pain, diarrhea, fever/chills, or overt GI bleeding. Past medical history was significant for type 2 diabetes and ulcerative colitis. He reported multiple perineal fistulas with recent Fournier gangrene requiring serial debridements over the last 2 months. He was afebrile with stable vitals. Abdominal exam was notable for suprapubic tenderness, multiple open ulcers and discharging fistulas in the perineum. Several scars from prior fistulas were noted. MRI showed horseshoe shaped perirectal abscess and multiple perineal fistulas. Colonoscopy showed anal stenosis and a fistulous opening in the rectum. Remaining colon appeared normal. Rectal biopsies showed mildly increased plasma cells and eosinophils within lamina propria with mild architectural distortion, and patchy mild acute inflammation without granulomas. Based on clinical presentation and findings, patient was diagnosed with fistulizing Crohn's perianal disease with rectal involvement. He underwent surgical debridement with suprapubic catheter placement and was started on metronidazole, ciprofloxacin and inflixmab with good response. Discussion: Perianal Crohn's disease affects 25-40% of all Crohn's patients and includes anal fissures, perianal fistulas, anorectal abscesses, and anal stenosis. Perianal fistula affects 20-30% of all Crohn's patients. Diagnostic tests include: exam under anesthesia with probing, fistulography, barium studies, CT, pelvic MRI, and anorectal EUS. Oral metronidazole for 6-12 months followed by gradual taper can be used as initial therapy for mild to moderate disease. For severe or refractory disease, anti-TNFs agents such as infliximab or adalimubab, have been shown to reduce the number of draining fistulas and even achieve complete closure. Response is rapid with median time to response of 2 weeks. Immumodulators such as 6-MP or azathioprine have also been shown to achieve complete healing or decrease discharge but response is much slower. Only three cases of IBD complicated with Fournier's gangrene have been reported in the literature. Of these two had undiagnosed Crohn's disease and one had ulcerative pancolitis who developed Fournier's gangrene after perianal surgery. Management involves serial debridements, broad spectrum antibiotics, anti-inflammatory therapy for IBD, and diversion colostomy in severe cases.

Pancreatic Metastasis from Carcinoid Midgut Tumor. A Case Report

Context Metastatic lesions to the pancreas are rare. We present a case of an ileal carcinoid tumor with a synchronous pancreatic metastasis. Case report A 68-year-old male patient was admitted to our clinic in 2008 for diarrhea and flushing. Urinary serotonin (2x upper reference limit), 5HIAA (5x upper reference limit) and chromogranin A (2.5x upper reference limit) were increased. An octreoscan scintigraphy showed a focal uptake in the pancreatic head and a slight uptake in the lower abdomen. An abdominal CT scan did not show any pancreatic lesions, but a slightly enlarged pancreatic duct in the body of the pancreas. We reviewed the CT scan imaging and we found a hypervascular ileal lesion, confirmed by small bowel barium study. The pancreatic lesion was confirmed by MRI and resulted slightly hypermetabolic with 18 FDG-PET (SUV of 2.15). In November 2008 the patient underwent a duodenum-preserving pancreatic head resection (DPPHR), a cholecystectomy, an ileal resection (about 80 cm) and ablation of small multiple peritoneal nodules. Histology showed multiple well differentiated (Ki67 <2%) ileal carcinoid tumors with lymph-node metastases and tiny peritoneal secondary lesions. The pancreatic lesion resulted to be a metastasis of the carcinoid with positive serotonin staining. The patient is still alive with diarrhea, biochemical evidence of disease and multiple pulmonary metastases 48 months after surgery. Conclusion Pancreas is an uncommon site of metastatic spread in midgut carcinoids and should be considered in case of pancreatic synchronous lesions. In the literature we found a single case report in the last 10 years.

Surgical Management of Gastric Outlet Obstruction Due to Corrosive Injury

Corrosive gastric injury is common in India due to easily available acids which are ingested mostly for suicide attempt. Resulting gastric outlet strictures need operation in majority of the patients. We review our experience of surgical management of these cases. Thirty-seven consecutive patients over the last 4years with corrosive gastric strictures were reviewed. Extent of gastric cicatrisation was assessed by endoscopy and barium study. Nutrition was maintained, if necessary by feeding jejunostomy. Early definitive operation was preferred. Outcome of surgery was assessed. Patients presented with vomiting, weight loss, and dysphagia. Twenty patients (54%) had predominant gastric corrosive injury. The oesophageal stricture in other 17 patients (46%) could be managed easily by endoscopic dilatation. Prepyloric short gastric stricture was found in 19 patients (51%). Surgical procedures included stricturoplasty for short strictures and gastrojejunostomy for more extensive distal gastric cicatrisation. Complications included wound infection in six (16%) patients and pneumonitis in four (11%) patients. All patients gained weight within 6 to 8weeks. Management of corrosive gastric injury depends on the extent of gastric involvement, associated oesophageal stricture, and general condition of the patient. Early definitive operation and avoiding gastric resection can give satisfactory outcome.

Pulsion Diverticulum of the Oesophagus: More than just an Out Pouch.

Oesophageal diverticulum is divided into two types based on the aetiology: the pulsion and the traction diverticula. Pulsion diverticulum occurs due to increased intraluminal pressure. This can be of three types based on the location along the oesophagus: the Zenker's diverticulum (ZD), the mid-oesophageal diverticulum (MD) and the epiphrenic diverticulum (ED). A PubMed search was conducted for the words 'pulsion', 'diverticulum' and 'oesophagus' for all studies published from January 1980 to March 2013 in the English language. A total of 31 studies were identified, and out of which, five were not included in the review. The pulsion diverticulum of the oesophagus is an uncommon disorder. Its aetiology is related to the motility disorders of the oesophagus. Patients usually present with chest-related symptoms or oesophageal symptoms, which are related to the underlying motility disorder. Evaluation includes barium studies, gastrointestinal endoscopy, CT scan and oesophageal manometry. Surgery is the treatment of choice for symptomatic and large diverticula, although the outcome in asymptomatic patients is unknown. The surgical options include diverticulectomy or diverticulopexy with an adequate myotomy. Most patients with ZD are now treated by using endoscopic techniques, although no randomised trial has shown its superiority over the open technique. Minimally invasive surgery has also been used for patients with MD and ED. Although isolated case series has shown good improvement in symptoms and reduction in mortality with minimally invasive techniques in patients with ED, its role in thoracic oesophageal diverticulum is debated.

Esophageal Motility Disorders after Bariatric Surgery

A 45-year-old female who underwent a Roux-en-Y gastric bypass 10 years prior was referred to our GI clinic by a pulmonologist after an extensive negative workup for chronic cough. She also had complaints of severe regurgitation that did not respond to high-dose acid suppression therapy. An esophagogastroduodenoscopy (EGD) was performed which showed evidence of a tortuous and dilated esophagus. The lower esophageal sphincter (LES) was easily traversed with no narrowing noted. A fairly large gastric pouch was seen prolapsing into the esophagus (Fig. 1a). A barium study showed dilation of the thoracic esophagus, diminished contractility, and gastric pouch distention with compression at the LES (Fig. 1b). A high-resolution esophageal manometry (HRM) revealed aperistalsis in the body of the esophagus with normal LES pressures (Fig. 1c).

Repair of Vascular Ring with Resection of Kommerell Diverticulum and Transposition of Aberrant Left Subclavian Artery

A 32-year-old female presented with dysphagia. Radiographic studies revealed external compression of esophagus by a vascular ring. The anatomy was a right-sided aortic arch with aberrant retroesophageal left subclavian artery, emanating from a large Kommerell diverticulum (KD). Traditional repair with ligamentum division and adhesiolysis leaves a large KD still adjacent to the esophagus with the potential for persistent or recurrent symptoms. The objective of this study was the modification of operative technique to minimize the potential for persistent or recurrent symptoms. The operative repair included resection of KD with transposition of the left subclavian artery into the left carotid artery, in addition to the division of the ligamentum arteriosum and mobilization of the esophagus. The patient's dysphagia resolved and postoperative barium studies showed no residual compression. There were no significant perioperative complications. Resection of KD is a potential adjunct to traditional repair of vascular rings and might offer better long-term palliation by minimizing residual vascular compression of the esophagus.

Superior mesenteric artery syndrome: a rare complication in a child with Marfan syndrome

A 14-year-old girl presented with sudden onset abdominal pain and distension with bilious vomiting. She had no significant prior history or weight loss. On examination, bowel sounds were normal. She...

Role of Preoperative Imaging with Multidetector Computed Tomography in the Management of Patients with Gastroesophageal Reflux Disease Symptoms After Laparoscopic Sleeve Gastrectomy

The aims of the study were to evaluate if multidetector computed tomography (MDCT) can be helpful and useful in the decision-making process in sleeve patients with gastroesophageal reflux disease (GERD) symptoms and to demonstrate the reproducibility and accuracy of the technique. Twenty-three patients submitted to laparoscopic sleeve gastrectomy (LSG), complaining upper gastrointestinal (GI) symptoms and/or weight regain and candidated to laparoscopic surgical revision were investigated. All patients underwent upper GI barium study, endoscopy, and MDCT for the identification of esophageal dilatation, neofundus development, thoracic sleeve migration, sleeve dilatation, and/or antrum dilatation. Selected patients underwent laparoscopic sleeve revision, cruroplasty, and/or fundectomy according to MDCT findings. Surgical findings were considered as "gold standard." Symptom persistence or resolution was investigated after 6 months with a standard clinical questionnaire. A total of 21 patients with sleeve migration or dilatation and neofundus underwent laparoscopic revision. A strong correlation between MDCT preoperative findings and intraoperative findings was observed. The presence of sleeve migration was significantly underestimated by both conventional radiology and upper GI endoscopy (sensitivity of 57.1 and 50 %, respectively). Symptom remission was observed in 19 out of 21 patients at 6 months. In two cases, surgical revision was not indicated on the basis of MDCT findings. MDCT is more accurate than the conventional radiology and endoscopy for the detection of morphological alteration causing GERD symptoms after LSG and can be considered a valid noninvasive method to guide surgery and monitoring patients following revision.

IS AVAILABILITY OF MR ENTEROGRAPHY (MRE) REDUCING AVOIDABLE USE OF IONISING RADIATION IN DIAGNOSTIC IMAGING FOR CROHN'S DISEASE?

IntroductionMRE has been increasingly adopted as the imaging modality of choice for patients with small bowel Crohn's disease, replacing barium studies and CT. MRE has similar sensitivity to CT for...

PWE-199 Diagnostic Radiation Exposure in Patients with Crohn’S Disease Treated with Infliximab

IntroductionExposure to radiation from diagnostic imaging is thought to be associated with an increase in cancer risk. Patients with Crohn’s Disease (CD) frequently require x-ray exposure throughout the course of...

PTU-054 Outcomes following Investigation and Elective Withdrawal of Anti-TNF Therapy in Crohn’S Disease: a UK Multicentre Study

IntroductionThe impact of stopping anti-TNF for patients in clinical and/or endoscopic remission in routine clinical practise setting is uncertain. We aimed to evaluate clinical outcomes in patients who discontinued anti-TNF...

G196(P) Residual Small Bowel Length Predicts Raised D-Lactate When Screening For Bacterial Overgrowth in Children with Intestinal Failure

AimsSmall bowel bacterial overgrowth (SBBO) may cause non specific symptoms in children with intestinal failure (parenteral nutrition (PN) >28days). Rapid detection of raised serum D-lactate (DL) may be a clinically...

English

Background: Eventration of diaphragm is defined as an abnormal elevation of an intact diaphragm and most often is characterized by a developmental abnormality of the diaphragm musculature. It usually remains asymptomatic in early life and presents later with respiratory and gastrointestinal complications. It is also seen in acquired conditions like phrenic nerve dysfunction in old age. Material and methods: A 64 yr man came with abdominal discomfort and fullness with nonbilous intermittent vomitings for 20days and unable to take food. Chest roentgenogram revealed an elevated left hemidiaphragm and a shift of the lower mediastinum to right. Barium study showed gastric volvulus. CT scan showed eventration of left dome of diaphragm with gastric volvulus. Results: The procedures were performed laparoscopically and follow up showed excellent results. Patient recovered well with symptomatic relief. conclusion: All cases of diaphragmatic eventration do not require surgical intervention if it is not associated with adverse symptoms. However treatment of laparoscopic mesh repair by abdominal approach is indicated if it is symptomatic. Laparoscopic approach has become an attractive alternative because of its association with less postoperative pain and better cosmesis.

PWE-190 Outcome of Investigations for Iron Deficiency Anaemia in Men under 50 Years

IntroductionIron-deficiency anaemia (IDA) occurs in 2–5% of men and postmenopausal women in the developed world. IDA is commonly due to blood loss from lesions in the gastrointestinal (GI) tract and...

PTU-184 Unload the Burden of Unnecessary Investigations and Reduce the Delay in Diagnosing Bile Acid Malabsorption (BAM)

IntroductionBAM is an often forgotten cause for chronic diarrhoea and though it is easily diagnosed by means of the SeHCAT scan, the diagnosis is often made late in the day...

A Rare Cause of Gastrointestinal Bleeding

62 Question: A 60-year-old woman presented to our emergency room with epigastric fullness and passage of tarry stool for 1 week. She also had progressive shortness of breath, dizziness, and generalized weakness. On physical examination, slight tachycardia (heart rate, 104 bpm) with anemic conjunctiva was noted. Blood tests showed low hemoglobin (6.9 g/dL). Esophagogastroduodenoscopy revealed a polypoid tumor with superficial ulcerations and hematin coatings, suggesting recent bleeding, near superior duodenal angle of duodenum (Figure A). A barium study showed a filling defect over mesenteric side of second portion of duodenum, resulting in luminal narrowing (Figure B, black arrow). Biopsy at the overlying mucosa showed inflammatory changes without neoplastic cells. Abdominal computed tomography disclosed an enhancing soft tissue mass in the second portion of the duodenum (Figure C, D, white arrow). Tumor markers (carcinoembryonic antigen and carbohydrate antigen 19-9) were within normal limits. The patient underwent pancreaticoduodenotomy with limited antrectomy to remove the tumor. What is your diagnosis of this duodenal tumor? Look on page 261 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.