Gastrointestinal X-ray Series Research Articles

P3.58: Modified Spiral Intestinal Lengthening and Tailoring for Short Bowel Syndrome

Background: The spiral intestinal lengthening and tailoring (SILT) procedure is a new surgical technique for autologous intestinal reconstruction in patients with short bowel syndrome. The aim of this work is to present a first description of a modified SILT technique by which the mucosal layer is left intact to possibly reduce the severe postoperative complications of intestinal leakage and abdominal abscess formation. Materials and methods: The modified SILT technique was performed on a 10-cm-long intestinal segment in 2 pigs to determine the technical feasibility. Thereafter, the short-term clinical feasibility was monitored clinically in 2 dogs by gastrointestinal X-ray series at postoperative day 4 and by relaparotomy postoperative day 10. Results: It was technically feasible to lengthen the intestinal segment from 10 cm to 20 cm and tailoring it from 3 cm to 1.7 cm in diameter, while leaving the intestinal mucosal layer intact. The postoperative course was uneventful for both dogs. The gastrointestinal X-ray series showed an inconspicuous intestinal transit time without any signs of stricture, perforation, or leakage. In the relaparotomy, the initially achieved lengthening and tailoring extents were preserved and the operated intestinal segment was well perfused with no early signs of necrosis, stenosis, or leakage. Conclusions: Leaving the mucosal layer intact during SILT is technically and clinically feasible in the short term in a large animal model. Further studies are needed to fully assess the impact of this technical modification on the long-term outcome of larger series.

Modified Spiral Intestinal Lengthening and Tailoring for Short Bowel Syndrome.

The spiral intestinal lengthening and tailoring (SILT) procedure is a new surgical technique for autologous intestinal reconstruction in patients with short bowel syndrome. The aim of this work is to present a first description of a modified SILT technique by which the mucosal layer is left intact to possibly reduce the severe postoperative complications of intestinal leakage and abdominal abscess formation. The modified SILT technique was performed on a 10-cm-long intestinal segment in 2 pigs to determine the technical feasibility. Thereafter, the short-term clinical feasibility was monitored clinically in 2 dogs by gastrointestinal X-ray series at postoperative day 4 and by relaparotomy postoperative day 10. It was technically feasible to lengthen the intestinal segment from 10 cm to 20 cm and tailoring it from 3 cm to 1.7 cm in diameter, while leaving the intestinal mucosal layer intact. The postoperative course was uneventful for both dogs. The gastrointestinal X-ray series showed an inconspicuous intestinal transit time without any signs of stricture, perforation, or leakage. In the relaparotomy, the initially achieved lengthening and tailoring extents were preserved and the operated intestinal segment was well perfused with no early signs of necrosis, stenosis, or leakage. Leaving the mucosal layer intact during SILT is technically and clinically feasible in the short term in a large animal model. Further studies are needed to fully assess the impact of this technical modification on the long-term outcome of larger series.

Persistent elevation of serum CA 19-9 with no evidence of malignant disease

Serum CA 19-9 is the mainstay marker for the diagnosis of biliopancreatic malignancies, though a persistent elevation can also be observed in various benign diseases. In this study, a marked increase of serum CA 19-9 was seen in 10 patients who had no evidence of malignant disease. The possible causes of this finding are discussed. Nine women and one man were studied, whose admitting diagnoses were as follows: pulmonary fibrosis in two, diabetes in two, non-ulcer dyspepsia in two, obesity in one, acute diarrhoea in one, colon diverticula in one and gastric ulcer in one. Routine blood tests, tumour marker determinations, imaging studies and endoscopy were carried out at admission. Serum CA 19-9 levels ranged from 112 to 1338 IU/ml (mean 517 IU/ml). Abdominal ultrasonography, CT-scan, upper gastrointestinal X-ray series and gastrointestinal endoscopies were negative for malignancy. During the follow-up period (range 2-7 years) serum CA 19-9 values were persistently elevated in all patients. Our study shows that persistent and significant elevation of serum CA 19-9 can be found in non-malignant and non-cholestatic disease.

Hamartomatous Inverted Polyp Successfully Treated by Endoscopic Submucosal Dissection

We report a case of gastric hamartomatous inverted polyps that are a rare histological type of gastric polyp and difficult to diagnose. Gastric submucosal tumor was detected by upper gastrointestinal X-ray series in 37-year-old man. Endoscopy revealed a submucosal tumor (SMT) , which eroded with a depression on its surface in the fornix. Endoscopic ultrasonography showed a heterogeneous tumor in the third layer. Endoscopic submucosal dissection (ESD) was performed to resect the tumor completely. The pathological diagnosis was a gastric hamartomatous inverted polyp. The patient was later discharged without any complications. Hamartomatous inverted polyps without a stalk are classified as the SMT type because the tumor is inverted down growth into the submucosal layer, otherwise polyps with a stalk are classified as the polyp type. All of the polyps were resected endoscopically, however, surgical resection was performed for those of the SMT type, because it is difficult to remove this type completely by en-block resection using conventional EMR technique. ESD method may be indicated for SMT-type hamartomatous inverted polyps.

Atypical left paraduodenal hernia

A 47-year-old man came to the hospital because acute abdominal pain and vomits. The patient had suffered from episodes of intestinal obstruction since adolescence, and has been studied by a gastroenterologist who found no abnormalities. These episodes have been solved spontaneously in nearly all occasions. However, he had come to the emergency room for the same reason twice last year. The exploration showed abdominal distension and tympanism in the epigastrium. There were neither laparotomic scars nor hernia defects in the abdominal wall. Abdominal X-rays showed air-fluid levels at the small bowel, and marked distension in the proximal and medium jejunum. Gastrointestinal X-ray series with gastrographin showed no abnormal findings. After 48-72 hours the patient persisted with the same complaints, and we decided to operate. During the operation we found a congenital malformation: an intestinal hernia of jejunum inside a peritoneal sac formed by a peritoneal flap of the left mesentery (Fig. 1), as well as an abnormal implantation of the mesentery above the rectum. We performed a resection of the peritoneal sac (Fig. 2) and the adherences inside it. The postoperative period was normal.

In the Tall Grass

In the Tall Grass

Laparoscopic Ladd Procedure for Correction of Pediatric Malrotation: Initial Experience

Introduction: Malrotation without midgut volvulus can cause chronic, intermittent symptoms and produce potentially disastrous consequences if left untreated. Upper gastrointestinal x-ray series (UGI) in such patients often suggest a rotational anomaly but may not be completely diagnostic. Methods: Thirteen children, aged 3 months to 14 years, suspected of having malrotation without volvulus based on preoperative symptoms and UGI, underwent laparoscopic exploration by a single surgeon over a 21 month period. Results: Ten of 13 (77%) were confirmed to have malrotation and underwent laparoscopic correction. Operative time ranged from 80 to 209 minutes (mean, 134 minutes) with minimal blood loss. Feedings were started within 24 hours in 6 (60%) and within 72 hours in the remaining 4 (40%). Full feedings were tolerated by postoperative day (POD) 4 in all patients. Hospital stay ranged from 1 to 4 days (mean, 2.8 days). Two of the three children with negative laparoscopies were discharged by POD 1. Followup has...

Estenose hipertrófica do piloro: caracterização clínica, radiológica e ecográfica

Estenose hipertrófica do piloro é uma condição comum em infantes com 2 - 12 semanas de idade e cuja causa permanece desconhecida. O diagnóstico clínico baseia-se na história de vômitos não-biliosos em jato, sinais de hiperperistalse gástrica e "tumor" pilórico palpável ao exame físico. Os autores ilustram os típicos achados desta alteração em seriografias do trato gastrointestinal superior e na ultra-sonografia abdominal. Critérios diagnósticos são descritos e as aplicações desses dois métodos são estabelecidos segundo a literatura vigente.

Une complication rare de l’anastomose iléoanale avec réservoir : le syndrome de la pince mésentérique

The aim of this study was to report a new case of superior mesenteric artery syndrome following total proctocolectomy and ileal pouch-anal anastomosis for chronic ulcerative colitis. Diagnosis was made following a prolonged gastric stasis and was based on upper gastro-intestinal X-ray series. Medical treatment was unefficient and gastro-jejunostomy was performed. The early outcome was good.

Endoscopic Diagnosis and Extraction of Gastric Parasites

The value of endoscopy in the diagnosis and extraction of parasites in the human digestive tract has been demonstrated (1). Worms attached to gastric mucosa are exceptional and only a small number of cases have been reported in the literature (2, 3). A 40-year-old male presented with epigastric pain of one month duration. The pain onset occurred immediately after returning from the mountains where the patient drank spring water. Physical examination and laboratory data were normal. Stool specimens were negative for parasites and culture. An abdominal ultrasound and upper gastrointestinal X-ray series were normal before consulting our hospital.

SUPERIOR MESENTERIC ARTERY SYNDROME IN A CHILD WITH BRAIN INJURY

Superior mesenteric artery syndrome is a rare cause of upper intestinal obstruction in both adults and children. This report describes an 11-yr-old boy with severe traumatic brain injury who developed superior mesenteric artery syndrome while undergoing rehabilitation. After the onset of postprandial bilious vomiting, an upper gastrointestinal x-ray series revealed abrupt obstruction of flow of barium at the third part of the duodenum with dilation of the first and second portions and antiperistaltic flow of barium. He was treated nonsurgically and feeding was accomplished using a tube passed into the jejunum. No recurrence was reported at follow-up 2 yr later. Prolonged recumbency and recent weight loss were considered as the precipitating factors.

Idiopathic gastroparesis in patients with unexplained nausea and vomiting

Nausea and vomiting are symptoms sometimes associated with motor dysfunction. We compared a group of young patients suffering from chronic nausea and/or vomiting and normal upper gastrointestinal x-ray series with a control group. The members of both groups underwent isotopic examinations of their stomachs. The aim of the study was to find a simple method of checking the stomach and proving a motor dysfunction in a group of patients with chronic, inexplicable nausea and vomiting. Patients and controls fasted for at least 6 hr were given 0.5 mCI of [99mTc] diethylene triaminopentaacetic acid orally in 150 cc milk with 50 g cornflakes. A time-activity curve was obtained and radioactivity over the stomach was recorded exponentially. The parameter of the T1/2 emptying time was used. In normal controls T1/2 emptying time ranged from 18 to 26 min. Twenty-five symptomatic patients were examined, three of whom achieved normal values, but 22 patients showed pathologic results ranging from 36 to 184 min. In patients with chronic nausea and/or vomiting an isotopic examination of the stomach may provide a simple and rapid diagnostic method of evaluation.

Clinicopathological features of elevated lesions of the duodenal bulb

We present here our findings on patients with an elevated lesion of the duodenal bulb. All these patients were treated in our clinics between the years 1984 and 1988. These lesions were present in 36 of 8,802 patients who underwent upper gastrointestinal pan-endoscopy. Two patients had a duodenal carcinoma, 2 an adenoma, and 1 a Brunner's gland adenoma. There were 15 with a hyperplastic polyp, 3 with a heterogenic gastric mucosa, 3 with Brunner's gland hyperplasia, 6 with duodenitis, and 4 with regenerative mucosa. Among these 36 lesions, only 69% (25 lesions) were evident on the upper gastrointestinal X-ray series. Adenoma and Brunner's gland adenoma were of a pedunculated form of the gross type and had an irregular surface mucosa. Both duodenal carcinomas were detected by endoscopic biopsy and were resected. Histologically, these lesions were limited to the submucosal layer and were of the non-pedunculated polypoid form, but there were no other characteristic endoscopic features, in comparison with other elevated lesions. Thus, upper gastrointestinal endoscopy with routine observations of the duodenal bulb plus endoscopic biopsy will lead to a definite diagnosis of these elevated lesions and to the early detection and treatment of this rare malignant lesion.

Diagnosis and Treatment of Dyspepsia

Dyspepsia is a common problem in ambulatory care. While many authorities recommend ordering upper gastrointestinal x-ray series (UGI) before therapy, there is evidence that clinicians frequently treat dyspepsia without diagnostic procedures. Decision analysis was performed to select optimal management based on probabilities and outcome values from the published literature. The choices evaluated were Symptomatic Therapy (low dose antacids or anticholinergics), Ulcer Therapy (high dose antacids or cimetidine), or UGI followed by further tests or therapy. Our model indicates that mortality is minimized if UGI is performed prior to selection of therapy, and if endoscopy is performed when the x ray shows gastric ulcer. Weeks of pain are minimized if Ulcer Therapy is begun immediately, but direct health care costs are minimized by beginning with Symptomatic Therapy. The marginal cost per additional life saved by performing a UGI rather than beginning with Ulcer Therapy was +1.6 million to +2.3 million, depending on whether endoscopy followed the finding of gastric ulcer. Mortality advantages of the strategies beginning with UGI were sensitive to assumptions regarding the incidence of gastric cancer and the benefits of early diagnosis. With slight reductions in these base case values, the Ulcer Therapy strategy appeared to minimize all outcomes except dollar cost.

The Use of Cimetidine in the Newborn

Although uncommon, reflux esophagitis and gastric and duodenal ulcer disease have all been reported to occur in the newborn period.1,2 Cimetidine, a competitive antagonist specific for the histamine H2-receptor, has been demonstrated effective in reducing gastric acidity in the adult. Its neonatal use has not been reported. The following cases suggest that cimetidine may be beneficial for the newborn with such disorders. CASE REPORTS Case 1 Baby L. weighed 740 gm at birth, was at 28 weeks gestation, and had prolonged, severe respiratory illness requiring ventilatory assistance. Repeated attempts at feedings, which began at 6 weeks of age, were associated with regurgitation, abdominal distention, and melenetic gastric aspirates. An upper gastrointestinal (GI) x-ray series confirmed reflux esophagitis. At 8 weeks of age cimetidine treatment was started at a dose of 10 mg/kg/day. The drug was continued for three weeks. Within one week of the initiation of cimetidine therapy, there was a significant reduction in the frequency of vomiting and abdominal distention and the upper GI bleeding disappeared. There were no neurologic abnormalities noted on serial examinations performed during cimetidine therapy. There were also no changes in renal and liver function studies, or hematologic values associated with drug use. Case 2 Baby G. was born at 27 weeks gestation and weighed 820 gm. He had severe respiratory distress and required ventilatory assistance. At 3 weeks of age, bronchopulmonary dysplasia was diagnosed by x-ray and by tracheal cytology. Because of clinical deterioration from this process, the baby was started on therapy with corticosteroids at 24 days of age.

The Upper Gastrointestinal X-ray Series for the Diagnosis of Malrotation of Intestine

The Upper Gastrointestinal X-ray Series for the Diagnosis of Malrotation of Intestine

Routine preoperative upper gastrointestinal series (UGIS) in patients with biliary tract disease: a plea for more selectivity.

Preoperative upper gastrointestinal x-ray series (UGIS) in patients with documented biliary tract disease commonly is carried out before cholecystectomy. Of 250 patients who had consecutive cholecystectomies performed in a 400-bed private hospital, 105 patients did not have UGIS prior to operation and no gastroduodenal disease was discovered at operation. Thirty-nine positive x-ray examinations were obtained among the 145 patients who had preoperative UGIS. In only three of these patients was a gastric procedure added at operation; no unexpected cancers were found. In the other 36, "positive" findings consisted of small hiatal hernias, diverticula of the esophagus, stomach, or duodenum not clinically significant or postgastrectomy anatomic abnormalities. This review suggests that routine preoperative UGIS may not be warranted in such patients and urges greater selectivity of patients having this procedure.

Multiple Phlebectasia of the Jejunum

In 1963, Rappaport and Shiffman¹reported three male patients who had a history of peptic ulcer, caviar spots of the tongue, angiokeratoma of Fordyce, and multiple phlebectasia of the jejunum. One of the three patients bled from the jejunal phlebectasia. A similar case is described below. <h3>Patient Summary</h3> This 53-year-old white man began to have cramping epigastric pain at the age of 21. Gastrointestinal x-ray series was said to disclose "spasms of the duodenum." Medical management gave only partial relief. In 1937, a gastro-intestinal x-ray series failed to disclose a peptic ulcer. In 1947, at age 35, the epigastric cramping became much more frequent lasting months and responding poorly to medical measures. Again, a gastrointestinal series was said to show "spasms of the duodenum." Intravenous pyelography and cholecystography were normal. Intensive ulcer therapy gave relief of symptoms. In 1948, he had one episode of hematemesis and several episodes of

MEDIASTINAL EMPHYSEMA AFTER RECTAL BIOPSY.

IN THE day-to-day practice of medicine, routine or frequently utilized procedures are often regarded as being devoid of danger to the patient. The following case history illustrates the occurrence of an unusual and potentially serious complication after the performance of a presumably innocuous procedure. Report of a Case A 34-year-old Caucasian man was admitted to the Rancocas Valley Hospital in Willingboro, NJ because of a three-week history of rectal bleeding during bowel movements. He was otherwise asymptomatic. The past medical history was unremarkable. Physical examination, including a digital rectal examination was normal. The hemoglobin, hematocrit, urinalysis, and fasting blood sugar values were normal. On the second hospital day, an upper gastrointestinal x-ray series was performed. A deformed duodenal bulb, attributed to scarring from previous ulceration was noted. No other abnormalities were seen. On the same day, a sigmoidoscopic examination was performed after a cleansing enema. A hypertrophied anal papilla was

ESOPHAGEAL HIATUS HERNIA. TECHNIQUE OF OPERATION AND RESULTS IN 92 PATIENTS.

The full significance of the role of esophageal hernia as a common cause of upper abdominal gastrointestinal symptoms has been realized only within the past few years. Moore and Kirklin, 1 in 1930, reported that until 1924 only 20 cases of esophageal hiatus hernia had been listed at the Mayo Clinic. Brick 2 found esophageal hiatus hernia to be the second most common abnormality reported in upper gastrointestinal x-ray series in 3,449 patients examined, following closely behind peptic ulcer. The diagnosis of an esophageal hiatus hernia is not in itself indication for surgical repair. However, patients with persistent symptoms are advised to have repair before developing such complications as ulceration, hemorrhage, stenosing esophagitis, or stricture. Symptoms The symptoms of hiatus hernia are varied and common to many upper gastrointestinal disorders, as well as to cardiac and respiratory disturbances. Pain is the most common of all symptoms and is frequently described