Duodenal Localization Research Articles

Limited Wedge Resection of a Duodenal Gist in a Patient with Intermittent Melena

Gastrointestinal Stromal Tumors account for 1% - 2% of all gastrointestinal (GI) tract tumors. Among GISTs, duodenal localization occurs in less than 5% and usually presents with upper GI bleeding. A 45-year-old man presented in the outpatient department with complaints of epigastric discomfort, intermittent melena and undocumented weight loss for the preceding 3 months. Initial upper GI endoscopy showed mild duodenitis and no other upper GI pathology. For unexplained symptoms, a CT Scan was performed which demonstrated a well-defined solid lesion along the second part of the duodenum. An endoscopic ultrasound (EUS)-guided biopsy of a subepithelial lesion at D2 was performed. Immunohistochemistry findings were suggestive of GIST. Wedge resection of the duodenal mass was done. Duodenal GIST should be considered as a differential in cases of GI bleeding when other differentials have been ruled out. Limited resection of duodenal GIST should be considered over pancreaticoduodenectomy, in case of small size tumors.

2557 Duodenal Duplication Cyst—A Rare Congenital Anomaly

INTRODUCTION: Enteric duplication cysts are uncommon congenital abnormalities of the gastrointestinal tract that arise from a disruption in the normal recanalization of the developing gut. Most frequently they are located in the jejunum or ileum, rarely will an enteric duplication cyst present in the duodenum. Here we present a rare case of an enteric duplication cyst in the duodenum. CASE DESCRIPTION/METHODS: Patient is a 48 year old male with a medical history of alcohol abuse who presented to our emergency department (ED) complaining of severe epigastric pain and non-bloody vomiting for 1 day. The patient reported drinking 3 beers daily and had one previous episode of similar symptoms one year prior. Notable workup in the ED included an elevated Lipase of 6443 U/L. A computed tomography (CT) scan of the abdomen without contrast was also done and showed inflammatory changes surrounding the pancreas and an ovoid hyperdense object adjacent to the junction between the duodenum and jejunum. The patient was then admitted under the impression of acute pancreatitis. Given the findings of the CT scan a repeat scan was done with oral and intravenous contrast. This showed the same ovoid soft tissue abnormality with findings suggestive of mildly complex enteric duplication cyst (Figures 1 and 2). During his hospital stay the patient was managed with morphine for pain control, intravenous fluids and was discharged two days later with follow up appointments scheduled. DISCUSSION: Several mechanisms have been proposed to explain the pathogenesis of enteric duplication cysts but no clear cause has been elucidated. The cystic structure is composed of a smooth muscle outer wall and internal epithelium that may be stratified, ciliated, or columnar. The majority of cases are diagnosed during the perinatal period and early childhood with rare cases being diagnosed during adulthood. It can be discovered either as an incidental finding during routine imaging such as CT scan, endoscopy, or laparotomy. When symptoms are present, they widely vary depending on the size and the location. Symptomatic disease can present in the form of gastrointestinal bleeding, gastric outlet obstruction, pancreatitis, dysphagia, intussusception, volvulus or obstruction of the biliary tree. Duodenal localization of duplication cysts is rare but may have significant clinical and therapeutic importance due to the nearby anatomic structures that can be disrupted by the abnormality.

Assessment of the external validity of the AJCC 8th staging system for small intestinal adenocarcinoma: a time to reconsider the role of tumor location?

The current study evaluates the validity and performance of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for small intestinal adenocarcinoma patients. Surveillance, Epidemiology and End Results (SEER) database [2004-2015] was explored and AJCC 6th, 7th, and 8th versions were assigned for each patient. Through Kaplan-Meier estimates, overall survival analyses were conducted. Cox regression analysis (adjusted for age, race, gender, sub-site, grade and surgical treatment) was conducted for cancer-specific survival and additionally, pairwise hazard ratio comparisons were performed. A total of 2,997 small intestinal adenocarcinoma patients were eligible and included in the analysis. Overall survival was compared according to the three AJCC staging systems. For the three versions, the P value for the trend in overall survival was significant (P<0.0001). Cancer-specific Cox regression hazard was calculated for the three staging systems. Pairwise hazard ratio comparisons between different AJCC 6th stages were conducted and all P values for comparisons were significant (P<0.0001). Pairwise hazard ratio comparisons between different AJCC 7th and 8th stages were also performed, and all comparisons were significant (P<0.05) except for stage IIB vs. IIIA. C-statistic (using death from small intestinal adenocarcinoma as the dependent variable) for AJCC 6th staging system was: 0.645 [standard error (SE): 0.011; 95% CI: 0.623-0.668]; for c-statistic for AJCC 7th staging system was 0.658 (SE: 0.011; 95% CI: 0.637-0.680); while c-statistic for AJCC 8th staging system was 0.660 (SE: 0.011; 95% CI: 0.638-0.682). Multivariate analysis of factors affecting cancer-specific survival suggested that older age (P=0.005), higher lymph node ratio (P<0.0001) and duodenal localization of the primary are associated with worse outcomes (P=0.008). There is no evidence that AJCC 8th system provided better prognostic characterization compared to previous AJCC staging systems for small intestinal adenocarcinoma. Subsite-specific staging paradigms should be explored in future editions of the staging system.

Helicobacter pylori, úlcera péptica y cáncer gástrico

Introducción. Por lo general, se ha descrito que la localización duodenal de la úlcera es más frecuente que la localización gástrica; sin embargo, en áreas con alta incidencia de cáncer gástrico la úlcera péptica parece tener una distribución anatómica distinta, existiendo predominio de la localización gástrica.Objetivo. Realizar una revisión narrativa de la literatura acerca de la distribución anatómica de la úlcera péptica en áreas con alta y baja incidencia de cáncer gástrico.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip, SciELO y Cochrane Library con los términos “Peptic ulcer” AND “stomach neoplasm”; la búsqueda se hizo en inglés con sus equivalentes en español y se limitó a estudios observacionales, cohortes y casos y controles.Resultados. Se encontraron alrededor de 50 artículos con información relevante para la presente revisión.Conclusión. La literatura disponible sugiere que la úlcera péptica predomina en áreas donde el cáncer gástrico tiene alta incidencia, mientras que en zonas donde la incidencia de la neoplasia es baja predomina la localización duodenal.

Duodenal localization is a negative predictor of survival after small bowel adenocarcinoma resection: A population-based, propensity score-matched analysis.

This study assessed the influence of tumor localization of small bowel adenocarcinoma on survival after surgical resection. Patients with resected small bowel adenocarcinoma, ACJJ stage I-III, were identified from the Surveillance, Epidemiology, and End Results database from 2004 to 2013. The impact of tumor localization on overall and cancer-specific survival was assessed using Cox proportional hazard regression models with and without risk-adjustment and propensity score methods. Adenocarcinoma was localized to the duodenum in 549 of 1025 patients (53.6%). There was no time trend for duodenal localization (P = 0.514). The 5-year cancer-specific survival rate was 48.2% (95%CI: 43.3-53.7%) for patients with duodenal carcinoma and 66.6% (95%CI: 61.6-72.1%) for patients with cancer located in the jejunum or ileum. Duodenal localization was associated with worse overall and cancer-specific survival in univariable (HR = 1.73; HR = 1.81, respectively; both P < 0.001), multivariable (HR = 1.52; HR = 1.65; both P < 0.001), and propensity score-adjusted analyses (HR = 1.33, P = 0.012; HR = 1.50, P = 0.002). Furthermore, young age, retrieval of more than 12 regional lymph nodes, less advanced stage, and married matrimonial status were positive, independent prognostic factors. Duodenal localization is an independent risk factor for poor survival after resection of adenocarcinoma.

Peroxisome proliferator-activated receptor-γ and thymic stromal lymphopoietin are involved in the pathophysiology of childhood coeliac disease.

Celiac disease (CD) is a chronic autoimmune enteropathy caused by exposure to dietary gluten in genetically predisposed individuals. The transcription factor peroxisome proliferator-activated receptor gamma (PPARγ) was shown to exert protective effects in several immune-mediated disorders. Activation of PPARγ suppressed the expression of thymic stromal lymphopoietin (TSLP), an inducer of proinflammatory cytokines. Since the role of TSLP in gluten-sensitive enteropathy is completely unknown, we investigated the involvement of TSLP and its regulator PPARγ in childhood CD. We collected duodenal biopsy specimens from 19 children with newly diagnosed CD, 6 children with treated CD (gluten-free diet, GFD), and 10 controls. Expression of mRNA and protein levels of PPARγ, TSLP, and TSLP receptor were determined by real-time RT-PCR and Western blot, respectively. Duodenal localization of PPARγ and TSLP was studied by immunohistochemistry. In duodenal mucosa of children with CD, the amount of PPARγ was significantly lower and simultaneously that of TSLP significantly higher compared to controls (p < 0.05). In GFD-treated patients, the levels of PPARγ mRNA and protein were significantly higher while that of TSLP markedly lower compared to newly diagnosed CD (p < 0.05). Immunohistochemistry revealed PPARγ and TSLP expression in lamina propria immune cells and in enterocytes. Low expression of PPARγ and high expression of TSLP in the duodenal mucosa of children with newly diagnosed CD suggest that they are involved in the pathophysiology of CD. We hypothesize that PPARγ may be an inhibitory regulator of TSLP-stimulated inflammatory processes in CD.

A Large-Sized Phytobezoar Located on the Rare Site of the Gastrointestinal Tract

Bezoars are concretions of undigested material and are most often observed in the stomach. They can occur at any site in the gastrointestinal tract; however, duodenal localization is very rare. We report the case of a 71-year-old male who had undergone subtotal gastrectomy with gastroduodenostomy and experienced severe epigastric discomfort, abdominal pain, and vomiting for a few days. An approximately 7×8 cm-sized mass was found on an abdominal computed tomography scan. On following endoscopy, a large bezoar was revealed in the duodenum and was removed using an endoscopic removal technique, assisted by a large amount of Coca-Cola infusion.

Symptomatic duodenal Crohn's disease: Is strictureplasty the right choice?

Primary duodenal localization of Crohn's disease (CD) is rare. Medical therapy can control symptoms, but surgery is required when progressive obstructive symptoms occur. Surgical options include bypass, resection, or strictureplasty, but it is still not clear which should be the treatment of choice. Reviewing the medical records of 1253 patients undergoing surgery for CD between January 1986 and December 2011 at the Digestive Surgery Unit of the Department of Clinical Physiopathology of the University of Florence, 10 patients (6 males and 4 females) underwent operations for duodenal CD. Four patients had only a duodenal localization, 6 patients had synchronous involvement of other intestinal tracts. Strictures were distributed in all the duodenal portions: in 7 patients there were single lesions, in 3 patients there were multiple lesions. Eight patients were treated with strictureplasty: 5 with the Heineke–Mikulicz technique, 2 with Jaboulay, and 1 with a pedunculated jejunal patch. Two patients were treated with resection: one with a B2 gastro-duodenal resection, and 1 with a duodenal–jejunal resection and an end to side duodeno-jejunal anastomosis. Follow up of the patients was from 2 to 18years. No recurrence of duodenal CD was observed in the 2 patients treated with resection, while 2 of the 8 patients treated with strictureplasty had a recurrence. In our experience, strictureplasty is indicated when less than 2 strictures are present in the 2nd or 3rd duodenal portion. In cases with multiple strictures localized in the 1st or the distal duodenal portion, resection is preferable.

Laparoscopic approach for duodenal carcinoid.

Carcinoids are a heterogeneous group of neuroendocrine tumours. Duodenal localization is associated with relatively benign behaviour of the tumour, slow progression, low metastatic potential, and absence of endocrine activity. Type and extent of surgery depend on size and staging of the tumour. In this article, we present a case study of a 27-year-old female patient with well-differentiated carcinoid in the second part of the duodenum. The tumour of a size 5 mm × 3 mm × 2 mm manifested with abdominal symptomatology and did not invade the muscularis propria. Scintigraphy did not demonstrate other pathological deposits of somatostatin receptors. The wedge resection of the duodenal wall was performed laparoscopically with perioperative endoscopic localization and marking of the tumour. Uneventful operation and postoperative course presents a contribution of miniinvasive surgery of specific duodenal lesions.

Crohn’s disease of the duodenum. Clinical signs, diagnosis, conservative and surgical treatment

Duodenal localization of Crohn's disease is rare, accounting for only 0.5-4% of all cases. Most common complaints are gastric outlet obstruction and weight loss. Histologic findings of endoscopic biopsy are frequently not definitive, making differentiation from other, benign structures complicated. There are also no standard guidelines regarding indications for surgical management. We reviewed the cases of three surgically managed patients with duodenal Crohn's disease at the 1st Department of Surgery, Semmelweis University of Medicine, Budapest, during a 5-year period (2002-2007). All three patients had persistent symptoms of stomach emptying disorder despite medical therapy and had severe weight loss (13-30 kg). In two cases resection of the stenotic duodenum was performed successfully using Billroth II method. Gastro-jejunal bypass was performed in one case, where the descendent duodenum was inflamed. All patients have been asymptomatic since surgery (9-45 months of follow-up) and recovered their earlier bodyweight. The postoperative period was uneventful. There is indication of surgery in cases of stenosing duodenal Crohn's disease, when medical therapy is not successful, but long-standing malnutrition should be treated preoperatively. We found perioperative morbidity to be similar in patients with duodenal Crohn's and in those with Crohn's disease of other intestinal locations.

Les pancréas aberrants : à propos de cinq cas

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

Impact de l’infection à Helicobacter pylori sur le risque de complications gastro-duodénales des traitements anti-inflammatoires non stéroïdiens

The interaction of Helicobacter pylori (H. pylori) and non steroidal anti-inflammatory drugs (NSAIDs) on the development of gastro-duodenal ulcers and their complications is complex and controversial. From a clinical point of view, the question is whether or not H. pylori infection should be tested and eradicated in patients treated or about to be treated by NSAIDs or low-dose aspirin. Contradictory results have been reported in epidemiological studies. Recent data suggest that H. pylori-NSAID interaction may be different depending on the type of treatment, non aspirin NSAIDs or low-dose aspirin, the gastric or duodenal localization of ulcer and the strains of H. pylori. Controlled randomized studies suggest that eradication of H. pylori may be beneficial in NSAID-naïve patients but not in those already on long term NSAID therapy. Recommendations are proposed for different subgroups of patients. In NSAID users presenting with gastro-duodenal ulcer or complications, H. pylori screening and eradication are indicated. In patients treated or about to be treated by NSAIDs, the "test and treat" H. pylori strategy is recommended if there is a history of gastroduodenal ulcer or complications. Whether this strategy should be generalized preventively in patients without ulcer history is still controversial and deserves further studies.

Co-localization of the mammalian hemochromatosis gene product (HFE) and a newly identified transferrin receptor (TfR2) in intestinal tissue and cells.

Mutations in the HFE gene and a newly identified second transferrin receptor gene, TfR2, cause hemochromatosis. The cognate proteins, HFE and TfR2, are therefore of key importance in human iron homeostasis. HFE is expressed in small intestinal crypt cells where transferrin-iron entry may determine subsequent iron absorption by mature enterocytes, but the physiological function of TfR2 is unknown. Using specific peptide antisera, we examined the duodenal localization of HFE and TfR2 in humans and mice, with and without HFE deficiency, by confocal microscopy. We also investigated potential interactions of these proteins in human intestinal cells in situ. Duodenal expression of HFE and TfR2 (but not TfR1) in wild-type mice and humans was restricted to crypt cells, in which they co-localized. HFE deficiency disrupted this interaction, altering the cellular distribution of TfR2 in human crypts. In human Caco-2 cells, HFE and TfR2 co-localized to a distinct CD63-negative vesicular compartment showing marked signal enhancement on exposure to iron-saturated transferrin ligand, indicating that HFE preferentially interacts with TfR2 in a specialized early endosomal transport pathway for transferrin-iron. This interaction occurs specifically in small intestinal crypt cells that differentiate to become iron-absorbing enterocytes. Our immunohistochemical findings provide evidence for a novel mechanism for the regulation of iron balance in mammals.

Helicobacter pylori Infection in Children and Adults: A Single Pathogen But a Different Pathology

The aims of this retrospective study were to ascertain in large series of children and adults: the relationship of the infecting strain to gastric mucosal lesions; and the relationship of the infecting strain to its duodenal localization. We studied 307 and 604 consecutive children and adults. In gastric mucosal samples H. pylori was cultured, genotyped and histologically assessed, while inflammation, activity and intestinal metaplasia were graded. In a subset of 171 patients H. pylori ureaseA (ureA) and cagA genes were amplified (PCR) using mucosal biopsies from the duodenum. H. pylori infection was diagnosed in 40 children and 308 adults. cagA was identified in 50% and 65.5% of infected children and adults. Antral activity was associated with the density of infecting bacteria (p <.001) and with cagA (p <.01). Intestinal metaplasia was correlated with cagA (p <.001). The ureA gene was found in 56 duodenal samples from 82 H. pylori positive patients. Duodenal H. pylori ureA was significantly more frequent in patients with duodenal diseases than in those without (p <.01), cagA positive strains being mainly involved in the infection of this anatomical area (p <.01). A severe H. pylori-associated gastritis is more prevalent when the density of infecting bacteria is high and when cagA positive strains cause the infection. The most virulent cagA positive H. pylori colonizes not only the gastric, but also the duodenal mucosa, which can be directly damaged by the bacteria itself or by its products.