Intermittent Obstruction Research Articles

Giant Gastric Polyp, A Rare Cause Of Gastric Outlet Obstruction

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy. Hyperplastic polyps are the most commonly encountered gastric polyps (75%). Most of gastric polyps are asymptomatic but they may present with occult bleed, obstruction or abdominal pain. We report a case of an 80-year-old woman who presented with a benign gastric polyp causing an intermittent gastric outlet obstruction, who was successfully treated with resection.

Duodenal haematoma following endoscopy as a marker of coagulopathy

Intramural duodenal haematomas (IDHs) are a rare complication of endoscopic biopsy but can cause significant morbidity and mortality, including duodenal obstruction, hospitalization and needing intravenous feeding. They are extremely uncommon in those with normal haematology. To describe the occurrence of IDHs following endoscopic biopsy in our institution. We identified three patients who developed a post biopsy IDH during an 18-month period (2010-2012) in a retrospective search of our hospital pathology and imaging databases. All three children had complex medical problems and presented with gastrointestinal symptoms including severe abdominal pain, reflux, poor feeding and abnormal gut transit time. All underwent normal upper GI endoscopy with duodenal biopsy. Following endoscopy, they presented with intermittent GI obstruction with severe abdominal pain, distension and bilious vomiting or symptoms of pancreatitis, had imaging features of IDH and were managed conservatively making a full recovery. Initial haematology including platelet counts were normal, but two children were subsequently found to have platelet dysfunction and the third to have an unclassified coagulopathy. IDHs may be the presenting factor in children with unsuspected bleeding problems. We present these findings to raise awareness of the imaging features and clinical impact of these cases because better understanding of these risk factors may help to avoid these complications in children in the future.

Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.

A Rare Cause of Intussusception in an Adult

Case: A 60-year-old female with no significant past medical history was evaluated in our clinic for persistent mid-abdominal pain, microcytic anemia and abnormal imaging. She reported a year of intermittent post-prandial abdominal discomfort. These episodes were of variable duration and often associated with nausea, vomiting and a sensation of bloat. Her previous work up included an initial CT scan which revealed an approximately 12 cm segment of ileum containing elongated “fat” in its central portion with an associated ileo-ileal intussusception, but without obstruction. Subsequent colonoscopy was notable for a prolapsed ileocecal valve, but a normal appearing ileum up to 15 to 20 cm. A small bowel follow through revealed a long, serpiginous, fixed low density lesion extending through several mid-ileal loops in the right lower quadrant. After evaluation in our clinic, she underwent a retrograde double-balloon enteroscopy. Approximately 50 to 60 cm proximal to the ileocecal valve she was found to have a polypoidal lesion with a very long, thick stalk and overlying ulceration. An endoloop was applied close to the base of the stalk and the lesion was then partially resected with snare cautery. The gross description of the resected specimen revealed a red-tan irregularly shaped polypoid mass measuring 5 x 1.8 x 1.6 cm. Microscopically, there was a mixed proliferation of smooth muscle bundles, nerves and ganglion cells, mature adipose tissue, and numerous thin and some thick walled blood vessels involving the mucosa, submucosa and smooth muscle consistent with a small bowel neuromuscular and vascular hamartoma (NVMH). Discussion: NMVH is a rare benign neoplasm occurring in the small intestine that was first described by Fernando and McGovern in 1982. From our review, there have only been 15 cases reported in the literature since its introduction. NMVH typically occurs in adults and often presents as intermittent intestinal obstruction or as occult gastrointestinal bleeding. In each of the previous cases, surgical resection has led to resolution of the patient's symptoms. From our review, this is the first case in the English literature of attempted endoscopic resection of a NMVH via double-balloon enteroscopy. Other types of small intestinal hamartomas have been reported in the literature as rare causes of intussusception, typically in children. In addition, cecal hamartomas have been reported as a rare cause of colonic intussusception. To our knowledge, there has been no previous report of image-documented intussusception caused by small intestinal NMVH in an adult or child. We would like to support its inclusion in the differential diagnosis of causes of intussusception in adults.

Giant antral inflammatory fibroid polyp causing intermittent gastric outlet obstruction and a wasting syndrome: Case report

Hyperplastic or inflammatory polyps of the gastric corpus and antrum typically develop in association with chronic gastritis and are very common benign and asymptomatic lesions of the stomach. Rarely, they cause gastric outlet by prolapsing through the pyloric channel. We report an 82-year-old woman who presented with abdominal pain, intermittent nausea, eructation, anorexia and important weight loss and iron deficiency anemia. The clinical presentation mimic malignancy. The CT scan showed the presence of large irregular and ulcerated pedunculated mass located in the duodenum conditioning delay in gastric emptying. The endoluminal caliber reduction of the antrum/pyloric transition was evident. Upper gastrointestinal endoscopy exposed a 50 mm eroded prepyloric sessile polyp, prolapsed through the duodenum. It was totally removed with a snare and diathermy technical. Microscopic examination revealed chronic gastric, intestinal metaplasia and the presence of polymorphic fusiform fibroblast cells arranged in fascicles and whom formation in an inflammatory background rich in eosinophils. Rapid urease test for Helicobacter pylori yielded a negative result. The patient recovered the wasting syndrome and has been symptom-free during nine months of follow-up. We highlight this case because of the unusual presentation of a clinical suspicion of malignant disease.

The cholinergic system may play a role in the pathophysiology of residual excessive sleepiness in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by momentary cessations in breathing during sleep due to intermittent obstruction of the upper airway. OSA has been frequently associated with a number of medical comorbidities. CPAP (continuous positive airway pressure) is the gold standard treatment and is known to improve OSA symptoms, including excessive sleepiness. However, 12–14% of CPAP-treated patients continue to complain of sleepiness despite normalization of ventilation during sleep, and 6% after exclusion of other causes of EDS. This is of great concern because EDS is strongly associated with systemic health disorders, lower work performance, and a high risk of accidents. We hypothesized that decreased central cholinergic activity plays a role in the pathophysiology of residual excessive sleepiness in patients with OSA treated with CPAP. Acetylcholine (Ach) plays a large role in wakefulness physiology, and its levels are reduced in sleepiness. Herein, we discuss the potential role of the cholinergic system in this new clinical condition.

Hypothesis for intracranial hypertension in slit ventricle syndrome: New concept of capillary absorption laziness in the hydrocephalic patients with long-term shunts

Many theories have been postulated to date regarding mechanisms involved in intracranial hypertension in patients with long-term, shunt-induced slit ventricle syndrome (SVS), but it still seems difficult to define this entity more clearly. Many hypotheses have attempted to explain the causes of SVS as chronic or intermittent catheter obstruction, brain compliance change, and ventricular herniation and distortion, but this theory does not explain clearly the reason why extraventricular pressure (EVP) is increased and intraventricular pressure (IVP) is low or frequently negative. The authors attempt to postulate a hypothesis by addressing new concept of capillary absorption laziness which results in dissociation of EVP with IVP.We, the authors, propose a concept of ‘capillary absorption laziness’, which is a tendency of the brain parenchymal extracellular fluid (ECF) not to be absorbed through the brain parenchymal capillary absorption system (BPCAS) that results from the bypass of ECF to shunt in the low or even negative ECF pressure and IVP. If this continues for a prolonged period, the tendency not to be absorbed through the BPCAS, even when the IVP and extracellular fluid pressures increases more than the intracranial pressure (ICP), may be established. This leads to situations of the brain such as parenchymal accumulation of the ECF which results in brain edema or swelling, and eventually distortion or herniation which can act as a functional obstruction and consequent dissociation between the IVP and EVP.Hypothesis of capillary absorption laziness may explain several common phenomena of the SVS such as low or even negative IVP in coexistence with high EVP and high ICP, and in these cases, we expect serious complications of SVS such as brain distortion and herniation. From this hypothesis we attempt to find new shunt management protocols to prevent long-term shunt induced complications.

Intermittent hydronephrosis in childhood

Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed. The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary. Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed. 76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed. Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.

Total Artificial Heart Support with Two Continuous-Flow Ventricular Assist Devices in a Patient with an Infiltrating Cardiac Sarcoma

Primary cardiac sarcoma is normally fatal, but cardiac replacement may provide some hope for long-term survival. A 38 year-old man with cardiac sarcoma, involving the interventricular septum and posterior wall with intermittent mitral obstruction, underwent implantation of two HeartMate II ventricular assist devices for total artificial heart support. After cardiectomy, the HeartMate sewing rings were sewn to the right neoatrium and the left atrial remnants. After the outflow grafts were sewn end to end to the pulmonary artery and aorta, the two drivelines were externalized through the abdominal wall, and perfusion started. The postoperative course was complicated by respiratory and renal dysfunction, which resolved. After 6 months of support, the patient has normal organ function and is ambulatory. Follow-up oncologic evaluation of positron emission tomography-computed tomography scan is negative.

An Unusual Cause of Recurrent Intestinal Obstruction

Question: A 56-year-old man with end-stage renal failure secondary to chronic glomerulonephritis presented with a 4-month history of symptoms suggestive of recurrent intermittent small bowel obstruction. He had previously undergone continuous ambulatory peritoneal dialysis (CAPD) between 2004 and 2011. However, this was complicated by CAPD peritonitis and the CAPD catheter was removed in September 2011. He has since been on hemodialysis via a left arm arteriovenous graft. For the past 4 months, he has experienced recurrent episodes of abdominal distension associated with bilious vomiting requiring multiple hospitalizations.

Endoscopic Treatment of a Symptomatic Ileal Lipoma with Recurrent Ileocolic Intussusceptions by Using Cap-Assisted Colonoscopy

A 73-year-old woman presented with intermittent abdominal pain and weight loss of 15 kg for 2 years. Colonoscopy revealed an erythematous polypoid tumor with a long and wide stalk in the cecum, but with air inflation, it abruptly went away through the ileocecal valve (ICV). An abdominal computed tomography showed a well-demarcated pedunculated subepithelial mass of 2.6×2.7 cm size with fat attenuation in the terminal ileum. It was an intussusceptum of the ileal lipoma through the ICV. This ileal lipoma was causing her symptoms because repeated ileocolic intussusceptions resulted in intermittent intestinal obstructions. In order to avoid surgical sequelae of ileal resection, snare polypectomy using cap-assisted colonoscopy technique was performed within the ileum without complications. The histopathology report confirmed it as a subepithelial lipoma. After endoscopic resection of the ileal lipoma, the patient has been free of symptoms and was restored to the original weight.

Acute Abdominal Pain Secondary to Chilaiditi Syndrome

Chilaiditi syndrome is a rare condition occurring in 0.025% to 0.28% of the population. In these patients, the colon is displaced and caught between the liver and the right hemidiaphragm. Patients' symptoms can range from asymptomatic to acute intermittent bowel obstruction. Diagnosis is best achieved with CT imaging. Identification of Chilaiditi syndrome is clinically significant as it can lead to many significant complications such as volvulus, perforation, and bowel obstruction. If the patient is symptomatic, treatment is usually conservative. Surgery is rarely indicated with indications including ischemia and failure of resolution with conservative management.

Hemodynamic Response to Dynamic Changes in Upper Airway Impedance?A Volunteer Study

Introduction: Intermittent airway obstruction may occurring both intubated and non-intubated critically ill patients due to endotracheal tube obstruction or kinking in the former and loss of oropharyngeal tone particularly during sedation in the latter patient group. Spontaneous breathing efforts against high airway resistance invoke shifts in intrathoracic pressure, which could potentially negatively affect cardiac performance. Previous studies utilized the Mueller Maneuver as a model for pathophysiologic changes during these episodes. However, this model only accounts for the state of maximum inspiration. To study progressive airway obstruction of various degrees, we devised an experimental setup allowing for a dynamic simulation and identification of associated short-term effects of breathing against discretely increasing airway resistance. Material and methods: 14 healthy volunteers (9 female, 5 male; mean age 27.8 ± 4.1 years, mean body mass index 26.1 ± 3.6 kg/m2) were asked to breathe through a set of endotracheal tubeswith decreasing internal diameter, while cardiovascular and hemodynamic parameters were recorded.StrokeVolume (SV) and Cardiac Index (CI) were recorded using thoracic bioreactance. Heart Rate (HR), non-invasive arterial blood pressure, oxygen saturation and spirometry parameters were also recorded. Results: Baseline SV, HR and CI averaged 99.8 ml, 69.5/min and 4.01 l/min/m2. During respiration through tubes with decreasing diameters, SV, HR and CI decreased significantly. At maximum airway resistance, SV, HR and CI averaged 90.7 ml, 65.0/min and 3.38 l/min/m2, representing mean percent changes from baseline of -9.1% (p=0.0041), -6.5% (p<0.0001) and -15.7% (p<0.0001). Strong inverse Pearson correlations were detectible between calculated additional airway resistance (Hagen-Poiseuille) and SV (R=-0.143, p=0.013), and CI (R=-0.147, p=0.011), respectively. Blood pressure, arterial oxygen saturation and spirometry parameters did not differ significantly. Conclusions: Increases in airway resistance were dynamically associated with significant hemodynamic deterioration. Ensuring the maintenance of airway patency is therefore an important factor to consider in hemodynamically unstable patients.

Sleep-disordered breathing in 15-year-old boy with arterial hypertension

Obstructive sleep apnea/hypopnea syndrome (OSA/HS) is the basis of the spectrum of sleep-disordered breathing (SDB) and is a condition characterized by the presence of snoring, repetitive partial upper airway obstruction (hypopnea) and/or intermittent complete obstruction (apnea), long enough to cause reduce the level of oxygen in the blood (desaturation), fragmented sleep and excessive daytime sleepiness. It is known that OSA/HS in the middle and older age predisposes to arterial hypertension (AH). We discuss a case of 15-year-old boy with AH and OSA/HS. He was treated on nasal continuous positive pressure in the upper airway (nasal CPAP) with good results.

Abdominal cocoon syndrome: Preoperative diagnostic criteria, good clinical outcome with medical treatment and review of the literature

Sclerosing encapsulating peritonitis, or abdominal cocoon syndrome, was described firstly in young adolescent girls. It is characterized by a thick fibrotic peritoneum that wraps the bowel in a concertina-like fashion with some adhesions. We report a man with intermittent intestinal obstruction and an abdominal cocoon encasing the small bowel. Our patient had no history of peritonitisor tuberculosis. We think he had primary abdominal cocoon syndrome. To the best of our knowledge, very few male patients have been reported in the medical literature as developing this condition. We treated the patient with drug therapy, including steroidand mycophenolate mofetil, and a liquid diet program, without surgical operation. He was symptom-free on follow-up over a period of 11 months.

Nasopharyngeal branchial cleft cyst

Second branchial cleft cysts are almost always located in the neck; thus, their presence in the nasopharynx is extremely rare. A 44-year-old man was referred to our department because a cystic mass was fortuitously found in the right lateral nasopharyngeal wall during transnasal esophagogastroscopy. He had suffered from intermittent right-sided nasal obstruction since childhood. T1- and T2-weighted magnetic resonance imaging revealed hyperintense signals. Marsupialization was performed by diode laser via an endoscopy-guided approach. No immediate postoperative complications occurred, and there was no recurrence 6 months following surgery. When a cystic lesion presents in the lateral nasopharynx, branchial cleft cyst should be considered in the differential diagnosis. In our experience, marsupialization by diode laser via an endoscopy approach is a safe and straightforward method of treating nasopharyngeal branchial cleft cyst, with no adverse effects.

Endoscopic Treatment of Intermittent Gastric Outlet Obstruction Caused by a Prolapsing Gastric Antral Polyp

Purpose: Gastric outlet obstruction often presents with nausea and vomiting and usually develops over weeks to months. The most common causes of gastric outlet obstruction are peptic ulcers, malignancy, bezoars, foreign bodies, and pyloric stenosis. Methods: We report a case of intermittent gastric obstruction caused by a prolapsing hyperplastic gastric antral polyp. Results: A healthy 44-year-old female presented with 3 months of intermittent dull mid abdominal pain, nausea and intermittent non-bloody, non-bilious vomiting. She also described early satiety and a weight loss of 8 pounds over the 3 months. She was otherwise healthy and took no medications. On physical exam she had normal bowel sounds, and mild tenderness over the epigastric region. She had a negative Murphy's sign, and the spleen and liver were normal. Her complete blood count was normal, with no anemia. Upper endoscopy was recommended to further investigate the patient's pain, nausea, vomiting and weight loss. On upper endoscopy, a 3 cm pedunculated, prolapsing, polyp was found arising in the gastric antrum and causing ball-valve effect within the pylorus and near complete obstruction of the pyloric channel. The polyp was observed to cause intermittent gastric outlet obstruction. The polyp was completely resected by a monopolar polypectomy using a large snare and sent for pathology. Pathology showed a hyperplastic polyp without evidence of metaplasia, dysplasia or malignancy. Random gastric biopsies showed chronic inactive gastritis and no evidence of Helicobacter pylori. At the follow-up 12 months after the polypectomy, the patient remained symptom free. Conclusion: We report the case of a patient with intermittent symptomatic gastric outlet obstruction caused by a benign prolapsing gastric polyp treated by endoscopic snare resection. There are 39 previously reported cases of gastric polyps leading to gastric outlet obstruction. Gastric polyps causing gastric outlet obstruction are more common in females (23 cases) with median age of onset of 72 years in females. Previously reported polyps arise from the antrum and have a median size of 5 cm (1.5-8 cm). They can be managed surgically with excision, or endoscopically with snare polypectomy or endoscopic mucosal resection (EMR) of sessile polyps. The median size of endoscopically removed polyps is 3 cm, with largest reported in the literature being 8 cm. Complications of endoscopic management include bleeding and perforation. Gastric polyps should be considered in the differential diagnosis of a patient who present with intermittent gastric outlet obstruction. Endoscopic management with snare resection is a good option if technically feasible and can result in a long term response.

Endoscopic Removal of Brunnerʼs Gland Hamartomas with the Aid of Endoscopic Ultrasound: A Case Series

Purpose: Case 1: 36-year-old man presented with 8 months of intermittent nausea, vomiting, epigastric pain and a 30-pound weight loss. EGD revealed a large, sessile lipoma-like mass in the duodenal bulb. EUS was not useful due to movement of the mass back and forth within the distal duodenum. The mass was injected with epinephrine and removed with a hot snare; Roth basket was used for retrieval. Two clips were placed at the resection site with no evidence of bleeding or perforation. Pathology revealed a Brunner's Gland hamartoma (BGH) that measured 2.6 cm in greatest dimension. Case 2: 59-year-old woman presented with a long history of intermittent epigastric pain, postprandial nausea and a 15-pound weight loss over several months. EGD with EUS revealed a 4 cm heterogeneous, pedunculated mass in the duodenal bulb arising from both deep mucosa and submucosa. The mass ball-valved into the antrum, intermittently obstructing the pylorus. The mass was injected with epinephrine and removed with a hot snare; Roth basket was used for retrieval. The site was clipped without complication. Pathology was diagnostic and revealed a BGH measuring 4 cm. Case 3: 43-year-old man presented with 7 months of reflux without nausea or vomiting and intermittent melena after treatment for H. pylori. He had a 40-pound weight gain. EGD/EUS revealed a lobulated, pedunculated polypoid mass in the apex of the duodenal bulb which originated from the submucosa. Ulceration was noted on the underside of the lipoma-like mass, and it was removed with a hot snare. A clip was placed for minimal oozing after resection. Pathology revealed a 3 cm BGH. Discussion: A number of reports describing the removal of BGH by endoscopy have been published. We report the second series of endoscopic resection of BGH with EUS. Brunner's Glands are in highest concentration in the duodenal bulb and secrete alkaline substances in response to acid. Adenomas arising from these glands are referred to as Brunner's Gland hamartoma, Brunner's Gland hyperplasia or Brunneroma. Larger lesions can cause abdominal pain, bleeding and intermittent obstruction with nausea, vomiting or bloating. Options for removal include surgical resection or endoscopic polypectomy. Biopsies taken during EGD are often normal because normal mucosa overlies the hyperplasia. More recently, EUS has been used to differentiate BGH from other similarly appearing tumors of the duodenum. Traditionally felt to require surgical resection, large Brunner's Gland hamartomas can be safely and effectively removed by endoscopic resection, particularly with the aid of EUS. Endoscopic removal should be considered as first-line therapy if technically possible.

Rhinosporidiosis.

Rhinosporidiosis is chronic granulomatous parasitic infection caused by Rhinosporidium seeberi. The organism is now classified under mesomycetozoa as a parasite. It predominantly affects mucous membrane of nose and nasopharynx but other sites are also involved. It is non-contagious sporadic disease which is notorious for its high rate of recurrence and vascularity. We report a 32 years old Indian male who presented in outpatient department of Rafha Central Hospital with complaint of recurrent epistaxis, intermittent left nasal obstruction and pedunculated fragile mass coming out from left nostril after forceful blowing of nose. Diagnosis was established by histopathology of partially excised lesion with high index of suspicion for rhinosporidiosis due to strawberry-like appearance of fragile polypoidal mass. The treatment involved total surgical excision of the lesion with electrocoagulation of the base using rigid nasal endoscope. This case is reported due to its rarity and high recurrence after surgical excision.

Double-chambered right ventricle presenting significant outflow tract obstruction only in the right decubitus position.

A 75-year-old man was referred to our echocardiography laboratory for presurgical evaluation. His past history included ventricular septal defect closure. He reported chest discomfort in the right decubitus position. Two-dimensional and Doppler echocardiography revealed an anomalous muscle bundle with accelerated blood flow in the right ventricle. The peak flow velocity of the flow increased from 1.4m/s in the left decubitus position to 2.9m/s in the right decubitus position. Double-chamber right ventricle with intermittent mid-ventricular obstruction during the right decubitus position was confirmed by transesophageal echocardiography.