Duodenal Obstruction Research Articles

S1531 Therapeutic Challenges in Afferent Loop Syndrome Presenting as Recurrent Pancreatitis With Ascending Cholangitis

Introduction: Afferent Loop Syndrome (ALS) is a post-surgical complication associated with multiple gastrointestinal surgeries such as partial gastric resections with Billroth II, Roux-en-Y reconstructions, and pancreaticoduodenectomies. ALS occurs from a distal obstruction of the afferent limb resulting in accumulation of bile, pancreatic fluid, or small bowel secretions. Case Description/Methods: A 59-year-old male with a history of peptic ulcer disease status post gastric antrectomy and Billroth II presented to the hospital with one day of abdominal pain. He admitted to nausea and vomiting without fevers or chills. Admission vitals were noncontributory. Physical exam demonstrated tenderness to light palpation in the epigastric region. Initial laboratory results were significant for a leukocytosis of 24.3 K/mm3, lipase of 382 IU/ml, AST of 1,285 IU/ml, ALT of 560 IU/ml, and ALP of 289 IU/ml. Blood cultures grew E. coli. Abdominal CT scan demonstrated a duodenal blind limb dilation with stones present, and MRI-MRCP demonstrated a distended duodenal stump with intraluminal stones. EGD was performed showing evidence of previous Billroth II gastroenterostomy and a stricture in the blind limb of the duodenum. Ceftriaxone was started for cholangitis with ensuing clinical improvement. Endoscopic intervention was deferred due to clinical improvement with medical management with plan for follow up with surgery for definitive management upon discharge. Discussion: The underlying mechanism for obstruction in ALS can be due to adhesions, herniations, scarring from prior ulceration, or malignancies. Abdominal CT is the gold standard for diagnosis, but treatment of ALS can be difficult. Surgery has been the therapeutic mainstay, but endoscopic intervention with lumen-apposing metal stents (LAMS) shows promising results in biliary and duodenal obstructions. LAMS are placed during endoscopic ultrasonography-biliary drainage procedures, and multiple successful approaches have been described in the literature. One technique used is the deployment of LAMS across a gastroenterostomy, bypassing the stricture. Another method is the intraluminal placement of a LAMS directly across an area of stenosis, placing a transmural stent. As our patient showed, treatment of ALS is challenging. Data describing the outcomes and adverse events of endoscopic intervention is limited. Although current evidence of LAMS use is promising, longitudinal studies are needed to better understand the risks and benefits of this procedure.

S1666 EUS Choledochoduodenostomy: A Novel Way to Treat Recurrent Malignant Biliary Obstruction in the Setting of an Existing Biliary and Duodenal Stent

Introduction: EUS-guided choledochoduodenostomy (EUS-CD) is an effective way to manage patients with malignant biliary obstruction and an inaccessible papilla. It involves creation of a fistula between the duodenal bulb and distal common biliary duct (CBD) using a lumen-apposing metal stent (LAMS). Data shows high technical and clinical success rates, with low adverse event rates and improved morbidity and mortality. Advantages of this approach include the ability to provide drainage to altered or inaccessible anatomy, and minimal invasiveness due to internalized drainage. We present a report of a patient with cholangitis due to recurrent biliary and gastric outlet obstruction (GOO) treated successfully with duodenal stenting and EUS-CD despite indwelling hardware. Case Description/Methods: A 71-year-old male with as history of locally invasive pancreatic adenocarcinoma presented with cholangitis and intolerance to oral intake. His prior course was complicated by GOO and biliary obstruction that required biliary fully covered self-expandable metal stent (FC-SEMS) and uncovered duodenal stent placement. Despite palliative chemotherapy, he presented 6 months later with cholangitis and imaging findings concerning for CBD stent occlusion, partial GOO and new ascites. Upper endoscopy showed significant stenosis within the duodenal stent that involved the major papilla, preventing conventional ERCP. The decision was made to evaluate for EUS biliary drainage. Presence of significant ascites precluded hepaticogastrostomy or gastrojejunostomy, however, there was an area superior to the indwelling biliary stent amenable to EUS-CDS. A 10mm x10mm LAMS was placed into the common hepatic duct with drainage of purulent fluid (Figure 1). Cholangiogram confirmed correct placement and excluded a leak. An uncovered duodenal stent was deployed through the indwelling duodenal stent and placement confirmed radiographically (Figure 1). The patient was discharged 2 days later with downtrending liver chemistries and tolerating oral intake. Discussion: Patients with combined malignant biliary and duodenal obstruction can be challenging to manage. Existing hardware complicates management even further. This case highlights the versatility of EUS biliary drainage allowing patient directed therapy with EUS-CDS in the setting of an existing biliary stent as an effective means of biliary drainage when ERCP was not possible.Figure 1.: A: occluded biliary stent B: LAMS with pigtail stents C: duodenal stent D: KUB showing stents in place.

S3584 Endoscopic Evaluation in a Patient with Post-Bulbar Duodenal Ulcer and Stricture

Introduction: Gastric outlet obstruction (GOO) is the least frequent complication of peptic ulcer disease (PUD) in the US after bleeding and perforation. Ulcers located in the pyloric region and duodenum are most causative of GOO. PUD has decreased since the advent of PPI and eradication of Helicobacter pylori. Although most patients have typical ulcer symptoms prior to the development of complications, asymptomatic ulcers necessitate the need for endoscopic evaluation. Early suspicion and endoscopic evaluation can assist with the prompt management of this complication. Case Description/Methods: 71 year-old white male evaluated for a 5 week history of abdominal pain, nausea, post-prandial vomiting, 35 pound weight loss. Denied the use of non-steroidal anti-inflammatory drugs. Medical history is significant for type 2 diabetes mellitus current tobacco use and hypertension. No prior history of PUD. Physical exam was notable for epigastric tenderness and muscle wasting. Contrasted Abdominopelvic CT showed questionable diverticulum in the second portion of the duodenum and no evidence of pancreatic mass. Endoscopic evaluation showed severe erosive esophagitis, a pinhole stricture in the duodenal bulb with the appearance of a benign peptic stricture. The duodenal stricture was unable to be traversed with a standard gastroscope. With fluoroscopic guidance, the stricture was dilated progressively with a balloon to 6mm, 8mm and 10mm. Biopsies were obtained and the stricture was then traversed with a pediatric scope. After endoscopic evaluation, it was determined that the duodenal stricture was not amenable to durable endoscopic intervention. Pathology, negative for Helicobacter pylori and malignancy. Patient subsequently underwent an exploratory laparotomy and gastrojejunostomy with gastro-jejunal tube placement. Patient continued to improve and was discharged to continue tube feeding at home, outpatient follow up with gastroenterology and surgery. Discussion: Endoscopy plays a critical role in the evaluation and management of patients with symptoms concerning for post bulbar duodenal ulcer, stricture and gastric outlet obstruction. Silent ulcers and complications are more prevalent in older patients. Early detection, evaluation and treatment of GOO could improve disease related morbidity and mortality. Risk modification which consists of tobacco cessation, treating post bulbar ulcers, duodenal ulcers and Helicobacter pylori infection could improve the GOO trends.Figure 1.: Severe Duodenal Stenosis.

Laparoscopic bypass surgery as palliative treatment for duodenal obstruction due to lymph node metastasis invasion of hepatocellular carcinoma

Laparoscopic bypass surgery as palliative treatment for duodenal obstruction due to lymph node metastasis invasion of hepatocellular carcinoma

S3018 Superior Mesenteric Artery Thrombosis Associated With Antiphospholipid Syndrome and COVID-19

Introduction: Mesenteric artery thrombosis and antiphospholipid syndrome (APS) is a rare combination but must be suspected in patients with high clinical suspicion. Treatment options of mesenteric ischemia include open surgical or endovascular revascularization. Medical therapy can be given in patients with incomplete duodenal obstruction, multiple comorbidities and moderate symptoms. Here we present a case of rethrombosis of superior mesenteric artery (SMA) in a patient with APS, history of SMA thrombosis with stent placement and COVID 19 while being on direct oral anticoagulant (DOAC). Case Description/Methods: 56 year old male with PMH of APS, peripheral arterial disease, deep vein thrombosis (DVT) s/p inferior vena cava filter, chronic mesenteric ischemia s/p small bowel resection complicated by SMA thrombosis treated with stent placement, left atrial thrombosis (was on xarelto) presented with intermittent abdominal pain in the lLUQ for last 2 weeks, aggravated 20 min after eating and radiated to the flanks, associated with non bloody non bilious vomiting and chills. He also tested PCR positive for COVID but was asymptomatic.. On admission, vitals were normal. Lipase was moderately elevated but criteria for pancreatitis were not met. CT scan with oral and IV contrast showed occluded superior mesenteric artery stent with distal reconstitution of the vessel via collaterals from celiac and inferior mesenteric artery suggesting chronicity of the occlusion. Invasive radiology was also consulted, but considering developed collaterals and no bowel ischemia, no intervention was attempted. Xarelto was discontinued. Patient was started on heparin drip and then bridged to warfarin before discharge. Discussion: DOAC for patients with APS can lead to increased risk of thrombotic events as per European wide review. Our patient has multiple etiologies for development of restenosis including Covid 19, APS, left atrial thrombosis and the use of direct acting anticoagulation. Our case is compelling because of rethrombosis of SMA while being on DOAC in APS and COVID 19 itself is a thrombophilic condition, which might be contributing to the cause.Figure 1.: CT Abdomen Pelvis with oral and IV contrast showing filling defect in Superior Mesenteric Artery

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction.

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

Acute duodenal obstruction is a rare complication of gallstone disease

Acute duodenal obstruction is a rare complication of gallstone disease

Congenital adhesion bands causing distal duodenal obstruction in a 6-year old child

A congenital adhesion band is a rare condition, but may induce small bowel obstruction at any age. Only a few sporadic case reports exist. We report a 6 -year- old boy with failure to thrive who presented with symptoms of high small bowel obstruction, absolute constipation of one week duration. He was managed successfully by division of congenital adhesion bands running across the third part of the duodenum. A good result can be expected in a late presentation of a congenital adhesive intestinal obstruction if early diagnosis and prompt management is pursued.

The incidence of different forms of ileus following surgery for abdominal birth defects in infants: a systematic review with a meta-analysis method.

ObjectivesIleus following surgery can arise in different forms namely as paralytic ileus, adhesive small bowel obstruction or as anastomotic stenosis. The incidences of these different forms of ileus are not well known after abdominal birth defect surgery in infants. Therefore, this review aims to estimate the incidence in general between abdominal birth defects.ContentStudies reporting on paralytic ileus, adhesive small bowel obstruction or anastomotic stenosis were considered eligible. PubMed and Embase were searched and risk of bias was assessed. Primary outcome was the incidence of complications. A meta-analysis was performed to pool the reported incidences in total and per birth defect separately.SummaryThis study represents a total of 11,617 patients described in 152 studies of which 86 (56%) had a follow-up of at least half a year. Pooled proportions were calculated as follows; paralytic ileus: 0.07 (95%-CI, 0.05–0.11; I 2=71%, p≤0.01) ranging from 0.14 (95% CI: 0.08–0.23) in gastroschisis to 0.05 (95%-CI: 0.02–0.13) in omphalocele. Adhesive small bowel obstruction: 0.06 (95%-CI: 0.05–0.07; I 2=74%, p≤0.01) ranging from 0.11 (95% CI: 0.06–0.19) in malrotation to 0.03 (95% CI: 0.02–0.06) in anorectal malformations. Anastomotic stenosis after a month 0.04 (95%-CI: 0.03–0.06; I 2=59%, p=0.30) ranging from 0.08 (95% CI: 0.04–0.14) in gastroschisis to 0.02 (95% CI: 0.01–0.04) in duodenal obstruction. Anastomotic stenosis within a month 0.03 (95%-CI 0.01–0.10; I 2=81%, p=0.02) was reviewed without separate analysis per birth defect.OutlookThis review is the first to aggregate the known literature in order approximate the incidence of different forms of ileus for different abdominal birth defects. We showed these complications are common and the distribution varies between birth defects. Knowing which birth defects are most at risk can aid clinicians in taking prompt action, such as nasogastric tube placement, when an ileus is suspected. Future research should focus on the identification of risk factors and preventative measures. The incidences provided by this review can be used in those studies as a starting point for sample size calculations.

Laparoscopic Management of Congenital Intestinal Obstruction: Duodenal Atresia and Small Bowel Atresia.

Background: Congenital intestinal obstruction occurs in ∼1:2000 live births. Congenital duodenal atresia and duodenal stenosis are frequent causes of intestinal obstruction and occur in 1 per 5000-10,000 live births. Today, duodeno-duodeno anastomosis is still the treatment of choice, and it can be performed safely by minimally invasive surgery, although duodenojejunal anastomosis is surgically simpler and has equal results. Jejunum-ileal atresia or stenosis is a major cause of neonatal intestinal obstruction; its prevalence is 1:330-1:1500 live births. Nowadays, the ability of laparoscopic assisted identification of the atresia and repair by only exteriorization of the small bowel through the umbilicus makes this technique safe and feasible in almost every new born. Methods: This article will describe the operative technique of laparoscopic management of congenital duodenal and small bowel obstruction. Results: For congenital duodenal atresia patients, mortality rate is less than 5% and the majority are secondary to associated comorbidities. There is a low rate of anastomotic leaks, anastomotic stricture, delayed gastric emptying, and bacterial overgrowth. For small bowel atresia patients, complications include anastomotic leak, adhesions, small bowel obstruction, and short bowel syndrome in less than 5% of the patients. The rate of re-operations due to small bowel obstruction in laparoscopic assisted repair patients is less compared with laparotomy patients. Conclusions: Minimally invasive surgery for duodenal and small bowel atresia is safe and feasible and reduces the complications of open surgical procedures.

Stage interventions in the treatment of patients with malignant diseases of the common bile duct terminal segment complicated by acute mechanical jaundice

Obstructive mechanical jaundice is a well-researched complication of various diseases and causes, yet considering patients` condition with malignant diseases according to the stage of the malignant process, severity of complications and etc. Selection of the most appropriate method of surgical treatment is always an option where it is essential to consider finding a way between efficiency and surgical trauma.
 The aim of the research is to optimize the results of surgical treatment of patients with malignant tumours of the common bile duct terminal segment complicated by acute mechanical jaundice.
 Materials and methods: patients over 18 y.o. with duodenal obstruction; the presence of other active cancer pathology or blood diseases.
 The research was performed on 2 different groups divided according to the use of biliary passability restoring method concluding the preferability of minimally invasive methods of bile duct decompression.
 Results: minimally invasive methods are not inferior to the effectiveness of biliary decompression comparing to open methods, have a number of advantages, such as minimal invasiveness, relative safety, low incidence of complications and mortality
 Conclusions: the introduction of the developed algorithm for surgical treatment of blastomatous mechanical jaundice with the consistent use of antegrade and open methods, as well as antegrade, retrograde and “rendezvous” techniques in surgically incurable patients allowed to reduce the number of early postoperative complications from 32.7 % to 13.3 %, the number of complications requiring surgery – from 5.8 % to 1.3 % and the level of postoperative mortality – from 11.5 % to 2.7 %.

Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction.

Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.

EUS-guided duodenojejunostomy for the nonsurgical management of duodenal obstruction in a patient with complicated postsurgical anatomy

A 62-year-old man received a diagnosis of high-grade duodenal GI stromal tumor (GIST), for which he underwent surgical resection and duodenojejunostomy. He later experienced an anastomotic stricture and bowel obstruction requiring revisional loop gastrojejunostomy (A). After revision, he soon after experienced intractable abdominal pain, nausea, and vomiting, which were attributed to duodenal obstruction and bile reflux gastritis.

Clinical management for malignant afferent loop obstruction.

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

Initial experience of endoscopic ultrasound-guided antegrade covered stent placement with long duodenal extension for malignant distal biliary obstruction (with video).

Background/PurposeThis study aimed to evaluate the feasibility of endoscopic ultrasound (EUS)‐guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal biliary obstruction (MDBO) with duodenal obstruction (DO) or surgically altered anatomy (SAA) after failed endoscopic retrograde cholangiopancreatography (ERCP).MethodsOutcomes were technical and clinical success, reintervention rate, adverse events, stent patency, and overall survival. Inverse probability of treatment weighting (IPTW) and competing‐risk analysis were performed to compare with conventional EUS‐BD.ResultsTwenty‐five patients (DO, n = 18; SAA, n = 7) were included. The technical and clinical success rates were 96% and 84%, respectively. Reintervention occurred in two patients (8.3%). Adverse events occurred in six patients (24%; two cholangitis, 16%; four mild postprocedural pancreatitis [24% (n = 4/17) in patients with non‐pancreatic cancers]). The median patency was 9.4 months, and the overall survival was 2.73 months. After IPTW adjustment, the median patency in the EASL (n = 25) and conventional EUS‐BD (n = 29) were 10.1 and 6.5 months, respectively (P = .018).ConclusionsEASL has acceptable clinical outcomes with a low reintervention rate but higher rate of postprocedural pancreatitis in patients with non‐pancreatic cancers. Randomized trials comparing EASL and conventional EUS‐BD for MDBO with pancreatic cancers and DO/SAA after failed ERCP are needed to validate our findings.

Trans-anastomotic tube feeding in the management of congenital duodenal obstruction: a systematic review and meta-analysis.

Feed intolerance is a common problem in neonates with congenital duodenal obstruction (CDO). Some surgeons insert trans-anastomotic tubes (TAT) to facilitate feed tolerance. We conducted a systematic review to evaluate the efficacy and safety of TATs in CDO. Medline, EmBase, CINAHL, and Cochrane Library were searched till July 2020. Risk of bias was assessed using ROBINS-I tool. Meta-analysis was conducted using Random Effects Model. No randomized controlled trials addressing the question were identified. In the 6 included observational studies, 96 infants underwent intraoperative TAT placement and 117 did not. Four studies reported benefits of TAT such as early attainment of full feeds and decreased need for parenteral nutrition. Two studies reported better outcomes in the no-TAT group. Accidental removal of TAT without clinical harm was reported in three studies [5/37 (14%), 4/17 (23%), and 2/4 (50%)]. Overall meta-analysis found no differences between the groups on any outcome. However, sensitivity analysis after excluding two studies with high risk of bias found that TAT tubes are associated with shorter duration of PN and shorter time to full enteral feeds. GRADE of evidence was very low for all outcomes. Evidence is limited regarding the efficacy and safety of intraoperative TAT placement in neonates with CDO. Well-designed RCTs are needed to address the issue definitively.

Case Report: Superior Mesenteric Artery Syndrome in a Healthy Adolescent

Superior mesenteric artery (SMA) or Wilkie’s syndrome is a rare clinical entity of partial or complete duodenal obstruction. The lack of awareness for this phenomenon often results in a delayed diagnosis, yet it can predispose to potentially life-threatening complications. Our case of young female presented for recurrent vomiting and weight loss, the CT scan showed narrow aortomesenteric angle resulting in external compression of the duodenum, other workup including laboratory test and endoscopy were negative. SMA syndrome should be always in the differential diagnosis of unexplained vomiting and weight loss, mainly in the young age group

Ultrasonographic Imaging of the Fetal Duodenal Tract.

To investigate whether fetal duodenal tract sections can be visualized in the prenatal ultrasonographic examination. This study was designed in cross-section. Healthy singleton pregnant women who applied to the perinatology outpatient clinic for second-level ultrasound scanning between September 2020 and February 2021 were included in the study. Demographic information of the participants was obtained and an ultrasound scan was performed. The fetal duodenal tract was evaluated in three sections, including the pylorus. The fetal duodenal tract was differentiated from adjacent organs by its anatomical location, hyperechoic nature, and presence of fluid in the lumen. A total of 278 eligible participants between 18 and 22 weeks of gestation were evaluated. While the fetal pylorus was closed in 76.6% of the participants, it was open in 23.4%. Duodenum pars superior, pars descendens, and pars inferior imaging rates were 99.3%, 98.2%, and 95.7%, respectively. It was possible to distinguish these parts from neighboring organs by 99.6%, 100%, and 100%, respectively. While the first, second, and third parts of the duodenum were observed as solid in 42.0%, 58.2%, and 52.2%, respectively, 57.9%, 41.7%, and 47.7% had fluid in the lumen. The fetal duodenal tract can be viewed with prenatal ultrasonography in pregnant women who are not in a dorsoanterior position. This may make an additional contribution to the diagnosis of duodenal obstructions, which is the most common cause of intestinal atresia in prenatal screening.

Subacute duodenal obstruction caused by Common Celiaco-Mesenteric Trunk anomaly-A case report.

Introduction and importanceThe origin of the mesenteric vasculature is highly variable. One such variation is the common celiaco-mesenteric trunk (CMT). To our knowledge, this is the first reported case of subacute duodenal obstruction caused by common CMT. The awareness of this anomaly helps keep a high index of suspicion for varied presentations, prompts appropriate investigations, timely intervention, and avoids iatrogenic injury.Patient profileA 15-year-old boy presented with a history of repeated attacks of colicky abdominal pain with bilious vomiting. Computed tomography of the abdomen with intravenous contrast revealed subacute duodenal obstruction caused by an acute angulation of common CMT with the abdominal aorta. To relieve the obstruction, the patient underwent a side-to-side duodenojejunostomy.DiscussionA common CMT, where the coeliac artery (CA) and superior mesenteric artery (SMA) have a common origin from the aorta, accounts for less than 1% of all splanchnic artery anomalies. Most CMTs are incidental findings, but aneurysm or dissection of the common trunk commonly accompany this anatomical aberrancy. Intestinal obstruction due to CMT anomaly is a rare occurrence.ConclusionThere should be a high index of suspicion concerning vascular anomalies in patients, especially children presenting with repeated episodes of subacute intestinal obstruction. This knowledge of vascular aberrations prevents disastrous iatrogenic complications.

English

BACKGROUND Chronic pancreatitis is a chronic inflammatory disease, causing complications related to the duodenum like duodenal obstruction or complications related to the biliary system like cholestasis, cholangitis, secondary biliary cirrhosis and cholangiocarcinoma. The purpose of the study was to observe the occurrence, clinical manifestations and outcome of the complications and foster a deeper understanding of the long-term prognosis of patients suffering from chronic pancreatitis. METHODS This was a prospective observational study. After taking informed consent, total 50 patients admitted in hospital with features suggestive of chronic pancreatitis with or without duodenal or biliary complications were selected and were followed up throughout the course of the disease. All demographic parameters, diabetic status, liver function test, USG findings suggestive of duodenal obstruction or biliary abnormalities, upper GI endoscopy, computed tomography of whole abdomen, MR cholangio pancreatography and barium meal were studied. RESULTS Chronic pancreatitis is more common in male and the common age of presentation is between 45 and 54 years. 12 patients were diabetics. 42 % of the total 50 patients developed transient hyperbilirubinaemia. 5 male patients and 1 female patient had persistent hyperbilirubinaemia and had persistently raised values of alkaline phosphatase. 1 male and 2 female patients also suffered from hypoproteinaemia. About 42 % of the patients of chronic pancreatitis suffered from transient rise in conjugated bilirubin and were managed conservatively. 12 % of the patients suffered from persistently raised conjugated bilirubin, indicating biliary obstruction. 22 % of patients developed cholangitis responding to conservative management. 12 % of cases, 5 males and 1 female suffered from biliary stricture, and were managed surgically with hepaticojejunostomy. No cases of cholangiocarcinoma were detected. CONCLUSIONS The most common complication in patients of chronic pancreatitis is transient biliary stasis, others being cholangitis and persistent hyperbilirubinaemia. No cases of cholangiocarcinoma were detected. KEYWORDS Billiary, Duodenal, Complications, Stricture, Cholestasis, Cholangitis, Chronic, Pancreatitis