A case of enteric hemorrhage presenting as repeated melena

Introduction We report a case of acute renal failure and severe uremia presenting as gastrointestinal bleeding in an 11-year-old girl with VATER syndrome. Case Report The patient is an 11 year old girl with CKD II secondary to solitary kidney with grade 5 reflux, re-implanted at 2 years and mild persistent RTA. The patient had been clinically well apart from a 1-year history of dysuria and ultrasound evidence of a non-obstructing renal cyst. She was being monitored as an outpatient. She presented to her local emergency department with three days of hematemesis, melena, and weakness. …

Objective This work is a prospective study to emphasize the prognostic value of AIMS65 score in chronic liver disease patients presenting with upper gastrointestinal bleeding (UGIB). Background To optimize the management of UGIB, multiple clinical prediction models have been proposed as a tool to identify patients at risk for poor outcome. Patients and methods This prospective study involved 90 adult patients with chronic liver disease presenting with UGIB, selected from patients admitted in Tropical Medicine Department, Faculty of Medicine, Menoufiya University, Shebeen El-Kom, Menoufiya Governorate, Egypt, during the period from November 2015 to July 2016. Eighty-four of them were male and six were female; their ages ranged from 35 to 79 years. We excluded patients who had melena due to causes other than upper gastrointestinal pathology. AIMS65 score, Glasgow–Blatchford score, Rockall score, Modified Rockall score, Child–Pugh score, and Model for End-Stage Liver Disease score were calculated for each patient. Results The current study showed the following: ICU admission was accurately predicted by AIMS65 score [area under curve (AUC) was 0.946;P = 0.0001]. In this study, an AIMS65 score less than 2 excluded ICU admission. Rebleeding was accurately predicted by AIMS65 score (AUC was 0.844;P = 0.0001). In the current study, an AIMS65 score less than 1 excluded rebleeding. In-hospital mortality was accurately predicted by AIMS65 score (AUC was 0.973;P = 0.0001). AIMS65 score was superior to other scores in predicting mortality. In this study, an AIMS65 score less than 3 excluded in-hospital mortality. Conclusion AIMS65 is accurate, nonendoscopic score for the prediction of ICU admission, rebleeding, in-patient mortality, and cost of hospital stay. Its easy clinical application makes the AIMS65 a good option for some of the clinical outcomes to be predicted in clinical practice.

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

Objective To investigate the clinical effect of laparoscopic splenectomy combined with pericardial devascularization for the treatment of portal hypertension. Methods The retrospective cross-sectional study was conducted. The clinical data of 310 patients with portal hypertension who underwent laparoscopic splenectomy combined with pericardial devascularization in the Tangdu Hospital of Fourth Military Medical University between January 2012 and June 2016 were collected. All the patients underwent laparoscopic splenectomy combined with pericardial devascularization. Observation indicators: (1) surgical and postoperative situations; (2) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the gastrointestinal rebleeding and postoperative survival of patients up to January 2017. Measurement data with normal distribution and skewed distribution were respectively represented as average number (range) and M (range). Results (1) Surgical and postoperative situations: all patients underwent successful operation. Twelve patients converted to open surgery due to intractable bleeding and 298 underwent totally laparoscopic splenectomy combined with pericardial devascularization. Average operation time, average volume of intraoperative blood loss, average time of gastrointestinal function recovery and average time of postoperative abdominal drainage-tube removal of 310 patients were 192.5 minutes (range, 120.0-300.0 minutes), 402.3 mL (range, 150.0-1 200.0 mL), 2.4 days (range, 1.0-4.0 days) and 4.2 days (range, 2.0-8.0 days), respectively. Among 11 of 310 patients with postoperative complications, 1 died of acute severe hemorrhage of upper digestive tract, 5 with intra-abdominal bleeding received successful hemostasis (3 undergoing reoperation and 2 undergoing conservative treatment), 2 with pleural effusion were improved by thoracentesis and drainage, 2 with pancreatic leakage and 1 with pulmonary infection were cured by conservative treatment. Other 299 patients didn′t have postoperative complications. Duration of postoperative hospital stay of 310 patients was 6.4 days (range, 5.0-9.0 days). (2) Follow-up situations: 260 of 309 patients were followed up for 6-60 months, with a median time of 26 months. During the follow-up, 1 patient died of acute portal vein thrombosis at 1 month postoperatively; 15 with gastrointestinal rebleeding and melena were cured by conservative treatment; other patients had survival. Conclusion Laparoscopic splenectomy combined with pericardial devascularization for the treatment of portal hypertension is safe and effective. Key words: Portal hypertension; Liver cirrhosis; Splenectomy; Pericardial devascularization; Laparoscopy

To investigate the clinicopathological characteristics, diagnosis, treatment and prognosis of gastric hepatoid adenocarcinoma(HAS). Retrospective analysis of clinicopathological data of 24 cases with gastric HAS diagnosed by surgery and pathology in Chinese PLA General Hospital from January 2013 to May 2016 were carried out. All the patients underwent preoperative serum alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), endoscopy and imaging examination (CT or B-mode ultrasonography), and those with elevated AFP were excluded from liver cancer, cirrhosis, endodermal sinus tumor and other diseases. The follow-up ended in June 2016 or the death of the patient. The survival was from the operation to the death of the patient or the end of follow-up. There were a total of 24 cases with gastic HAS, accounting for 1.03%(24/2 326) of the total number of patients with gastric cancer diagnosed at the same time in our center. There were 19 males and 5 females, the ratio of male to female was 3.8:1.0, the mean age of the patients was 55.9 (31 to 72) years, and 2 of them had liver metastasis. The first symptom in 50% (12/24) patients was epigastric pain, in 25%(6/24) was abdominal distension with vomiting, and the rest included dysphagia (12.5%, 3/24), hematemesis (8.3%, 2/24) and melena (4.2%, 1/24). Preoperative serum levels of AFP and CEA were elevated in 10 (41.7%) and 5 patients (20.8%) respectively. All the patients underwent surgical treatment, including 23 cases with D2 radical resection of gastric cancer and R0 resection, and the other of palliative gastrojejunostomy. Lesions of HAS located in gastric antrum in 11 cases (45.8%), in cardia in 7 cases (29.2%), and in gastric body in 6 cases (25%). Tumor maximum diameter of 10 cases was larger than 5 cm, and the average diameter was 5.7(1.0 to 12.0) cm. Postoperative pathological TNM staging: stage I(b was in 1 cases, stage II( in 7 cases, stage III( in 14 cases, stage IIII( in 2 cases; lymph node metastasis in stage N1-3 in 20 cases (83.3%). Poorly-differentiated tumors were found in 21 cases (87.5%), and no well-differentiated tumors were found. There were 11 cases (45.8%) with formation of intravascular tumor thrombi. In immunohistochemistry, AFP positive expression was found in 11 cases(45.8%). Seventeen HAS cases (70.8%, 17/24) received postoperative SOX(oxaliplatin + S-1) or XELOX (oxaliplatin + capecitabine) as adjuvant chemotherapy, 5 cases postoperative immune therapy, and 2 cases postoperative traditional Chinese medicine. All the patients were followed up for 0.7 to 42.0 months (median 8 months). A total of 9 patients died, of whom, 1 case underwent gastrojejunostomy because of liver and peritoneal metastasis before operation, and died 20 days after surgery; 4 cases died of multiple liver metastases after 1.5 to 12.0 months with survival of 3 to 18 months; 3 cases presented local recurrence after 2 to 17 months with survival of 6 to 22 months; 1 cases had peritoneal metastasis after 12 month with survival of 26 months. HAS is a rare type of gastric cancer with poor prognosis. The diagnosis is mainly based on histopathology, and radical resection is the mainstay treatment.

Small intestinal hemangioma is a rare condition that can be divided histologically into capillary, cavernous or mixed types, among which the cavernous type is the most common. Here we report a case of small intestinal cavernous hemangioma with chronic hemorrhage in 44-year-old man. The patient complained of weakness and dizziness for 2 years that aggravated 1 month before admission accompanied by intermittent melena. Laboratory tests suggest severe anemia, and computed tomography, gastroscopy and colonoscopy all revealed signs of anemia. Capsule endoscopy detected small intestinal erosions, bleeding lesions and prominent neoplasms. An exploratory laparotomy was performed, in which the segment of the jejunum with lesions was resected. Pathological examination of the resected jejunum identified the neoplasm as cavernous hemangioma of the small intestine, which was the cause of severe anemia.

Objective To explore the clinical characters, treatment and prognosis of gastrointestinal Dieulafoy lesion in China. Methods Dieulafoy was used as search term, the literatures about Chinese patients with Dieulafoy lesions from January 1998 to October 2016 were retrieved in the Chinese literature library including China National Knowledge Infrastructure, VIP network, Wanfang database and China Biology Medicine disc, and a total of 515 literatures, 5 145 patients were enrolled and analyzed. The gender, age, geographical distribution, location of the lesion, treatment and prognosis of the disease were summarized. Results Among the 5 145 patients (male 3 959, female 1 186) with Dieulafoy disease, the ratio of male to female was 3.34∶1.00. The age was from 3 to 95 years, and mean age was 51 years. The lesion location was mainly in stomach (88.82%, 4 570/5 145) and second was small intestine (8.28%, 426/5 145). In stomach, the lesions were mainly located in gastric corpus, fundus and cardia. The small intestinal Dieulafoy lesions were mainly located in duodenum. The main manifests were sudden hematemesis, melena, and hematochezia. The treatments mainly was endoscopic treatment (72.56%, 3 733/5 145), and second was surgery (25.27%, 1 300/5 145) . Among the 5 145 patients with Dieulafoy disease, 5 099 patients (99.11%) were cured and 46 patients (0.89%) died. The proportions of endoscopic treatment, interventional therapy and first endoscopic treatment within 24 hours in tertiary hospitals were all higher than those of nontertiary (all P<0.01). The cure rate of tertiary hospitals (99.22%, 3 674/3 793) was significantly higher than that of nontertiary hosptials (98.54%, 1 421/1 442) (χ2=0.89, P<0.05) and the mortality was significantly lower than that of nontertiary hospitals (P<0.05). Conclusions The male is more susceptible to Dieulafoy lesion which occurred at any age than the female in China. The predilection sites of Dieulafoy lesion were stomach and duodenum. The primary treatments were endoscopic treatment and surgery, and the disease usually had a good prognosis. Key words: Dieulafoy lesion; China; Clinical cases; Literature; Gastrointestinal tract

Objective To investigate the diagnosis and treatment value of digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE) for post pancreatectomy hemorrhage (PPH), and influencing factors of severity of PPH. Methods The retrospective case-control study was conducted. The clinicopathological data of 20 patients with PPH who were admitted to the Zhongshan Hospital of Fudan University from August 2009 to November 2016 were collected. Patients with PPH in the early stage underwent reoperations for hemostasis; patients with PPH in the later stage received conservative treatment, and then DSA and TAE were considered when patients had the stable vital signs. Observation indicators: (1) DSA situations: overall times, positive rate and bleeding sites; (2) TAE situations: successful rate of hemostasis, operating time and postoperative complications; (3) follow-up situations; (4) influencing factors analysis of severity of PPH. Follow-up using outpatient examination and telephone interview was performed to detect occurrence of complications after discharging from hospital up to April 2017. Measurement data with skewed distribution were described as M (range). Count data were evaluated by the ratio and proportion. The univariate analysis was done using the Fisher exact probability. Results (1) DSA situations: all the 20 patients underwent DSA, with overall times of 27. The direct sign was 18 times extravasation of the contrast medium, with a positive rate of 66.7% (18/27). Of 18 times positive DSA, clear bleeding sites were located in 5 times gastroduodenal artery (3 times with pseudoaneurysm of gastroduodenal artery stump), in 4 times common hepatic artery (3 times with pseudoaneurysm of common hepatic artery), in 3 times superior mesenteric artery, in 2 times splenic artery, in 1 time left gastric artery, in 1 time right gastric artery, in 1 time left hepatic artery (pseudoaneurysm of left hepatic artery) and in 1 time inferior mesenteric artery. (2) TAE situations: of patients with 18 times positive DSA, patients with 15 times positive DSA received TAE, with a successful rate of hemostasis of 13/15, and patients with 5 times positive DSA received successful hemostasis by reoperation. A median operating time of TAE for patients with 15 times positive DSA was 30 minutes. There was no occurrence of adverse reaction, including fever, abdominal pain, melena, elevated aminotransferase and liver abscess. One patient complicated with splenic abscess after transcatheter splenic arterial embolization underwent puncture drainage and then had a good recovery. Of patients with 9 times negative DSA, patients with 8 times negative DSA were cured by conservative treatment and patient with 1 time negative DSA received successful hemostasis by operation. All the 20 patients were cured and then discharged from hospital. (3) Follow-up situations: 20 patients were followed up for 4-92 months, with a median time of 24 months. During the follow-up, 20 patients recovered well, without long-term complications. (4) Influencing factors analysis of severity of PPH: the results of univariate analysis showed that gender, age, preoperative blood sugar, preoperative combined jaundice, preoperative albumin (Alb), preoperative prothrombin time (PT) extended, preserving pylorus, pancreatic duct stent placement, pancreatic operation time, volume of intraoperative blood loss, intraoperative blood transfusion, property of tumor, postoperative pancreatic fistula and time of PPH were not factors affecting the severity of PPH (P>0.05). Conclusion DSA is minimal-invasive in the diagnosis for PPH, and TAE is safe and effective for patients with positive DSA. Key words: Post pancreatectomy hemorrhage; Digital subtraction angiography; Transcatheter arterial embolization; Outcomes

Objective To explore the clinical efficacy of the gap above the splenic pedicle in laparoscopic splenectomy (LS). Methods The retrospective cohort study was conducted. The clinical data of 189 patients who underwent LS in the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between August 2012 and March 2015 were collected. Among 189 patients receiving splenic pedicle division, 42 without the application of the gap above the splenic pedicle were allocated into the group A and 147 with the application of the gap above the splenic pedicle were allocated into the group B. Observation indicators included: (1) operation situations: combined operation, operation time (excluding combined operation time), volume of intraoperative blood loss (excluding blood volume of spleen), cases with conversion to open surgery; (2) postoperative situations: time to initial anal exsufflation, time for fluid diet intake, occurrence of postoperative complications and duration of hospital stay; (3) follow-up. Patients were followed up by telephone interview and outpatient examination up to August 2016. Follow-up included routine blood test, coagulation function, liver function, with or without long-term complications. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparisons of count data were analyzed by the chi-square test. Results (1) Operation situations: of 189 patients undergoing LS, 136 combined with laparoscopic pericardial devascularization, 13 combined with laparoscopic cholecys-tectomy, 9 combined with laparoscopic radio frequency ablation (RFA) of liver tumors and 26 combined with pathological examination using laparoscopic liver tissues sampling. Operation time, volume of intraoperative blood loss and cases with conversion to open surgery were (118±31)minutes, (80±38)mL, 2 in the group A and (70±22)minutes, (50±28)mL, 1 in the group B, respectively, with statistically significant differences between the 2 groups (t=12.579, -8.516, χ2=4.912, P 0.05), and a statistically significant difference in number of patients with postoperative complications between the 2 groups (χ2=7.259, P 0.05). Patients with postoperative complications were cured by symptomatic treatment. (3) Follow-up: 156 of 189 patients (33 in the group A and 123 in the group B) were followed up for 1-18 months, with an average time of 12 months. During the follow-up, 13 patients had recurrent hematemesis and melena, including 3 in the group A and 10 in the group B. Eight patients stopped bleeding after conservative treatment, 3 stopped bleeding after proxial gastrectomy and 2 died of excessive bleeding and organ failure. Conclusion Splenic pedicle division using Endo-GIA through the gap above the splenic pedicle in LS can reduce operation time, volume of intraoperative blood loss, rate of conversion to open surgery and postoperative complications. Key words: Portal hypertension; Splenomegaly; Splenectomy; Laparoscopy; Gap above the splenic pedicle

Objective To investigate the type, clinical and imaging features of iatrogenic bile duct injury and the efficacy and safety of endoscopic and interventional radiology therapy. Methods A total of 48 patients with iatrogenic bile duct injury who have undergone endoscopic and/or interventional therapy from January 1st 2013 to June 30th 2016 were enrolled. Patients′ general information, causes of injury, clinical manifestations, treatment methods, efficacy and complications were retrospectively analyzed. Results The causes of iatrogenic bile duct injury were cholecystectomy(45.8%, 22/48), liver transplantation(35.4%, 17/48), transjugular intrahepatic portosystemic shunt (8.3%, 4/48), Roux-en-Y anastomosis(6.3%, 3/48) and endoscopic retrograde cholangiopancreatography(4.2%, 2/48). The most common type of iatrogenic bile duct injury was stenosis of intra/extra bile ducts(66.7%, 32/48). Other types included biliary fistula(18.8%, 9/48), hemobilia(10.4%, 5/48) and stenosis of anastomotic stoma(4.2%, 2/48). The most common clinical manifestations were jaundice(37.5%, 18/48) and abdominal pain(29.2%, 14/48). Other clinical manifestations were fever(14.6%, 7/48), hematemesis or melena (8.3%, 4/48) and abnormal drainage fluid (8.3%, 4/48). Diagnosis was confirmed by angiography, cholangiography or endoscopy. The overall effective rate of minimally invasive therapy was 91.7%(44/48) and the most common complications were fever (16.7%, 8/48) and pancreatitis (10.4%, 5/48). Other complications were hemobilia (2.1%, 1/48), cardia dilaceration(2.1%, 1/48) and biliary fistula caused by catheter shedding(2.1%, 1/48). Conclusion Iatrogenic bile duct injury could occur after upper abdominal surgeries, endoscopic or interventional procedures. Early diagnosis and treatment with endoscopic or vascular interventional methods can achieve satisfying efficacy and safety. Key words: Cholangiopancreatography, endoscopic retrograde; Portasystemic shunt, transjugular intrahepatic; Cholecystectomy; Iatrogenic bile duct injury

Two cases of ectopic varices(EV) admitted in our hospital were reported. According to literature search from Wanfang Data and China National Knowledge Infrastructure 127 cases of ectopic varices were reported in mainland China. Among 129 cases there were 93 males and 36 females, with a mean age of (54.4±7.2) years.The most common cause of EV was portal hypertension with cirrhosis (n=104, 80.6%). The common manifestations of EV were melena(35.7%)and hematemesis (18.6%). The diagnosis was confirmed by endoscopy in 100 cases(77.5%), by surgery in 16 cases(12.4%), and by angiography in 13 cases(10.1%). The sites of EV lesions included duodenum (n=52, 40.3%), rectum (n=34, 26.4%), and jejunum or ileum (n=13, 10.1%). Among 129 EV patients, 4(3.1%)died and 125(96.9%)survived. Analysis indicates that most ectopic varices are secondary to portal hypertension of cirrhosis, and ectopic varices account for a certain percentage of all gastrointestinal hemorrhage. Key words: Gastrointestinal hemorrhage; Liver cirrhosis; Varices, ectopic

Objective To investigate the clinical features of cryptogenic multifocal ulcerous stenosing enteritis(CMUSE), and to improve the diagnosis of this rare disease. Methods From 2010 to 2015, clinical data of 10 patients with CMUSE were retrospectively analyzed, including clinical features, laboratory examination, imaging examination, appearance under endoscopy, pathologic characteristics, location of lesions, treatment and prognosis. Results Among the 10 patients with CMUSE (male six, female four), the mean age was (35.1±14.8) years. The predominant clinical manifestation was melena (eight cases), abdominal pain (eight cases) and anemia (nine cases). The results of laboratory examination showed normal in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Among seven patients, hypersensitive C reactive protein (hsCRP) of two patients increased. Imaging examination showed intestinal stricture and appearance under endoscopic examination was intestinal ulcers and stenosis. Pathologic finding was superficial ulcers at mucosal and submucosal layers. Lesions mostly involved small intestine, and one case involving ileocecal valves and rectum. Among the 10 patients, seven patients received combination of surgical resection and prednisone treatment, and three patients were only administrated with medications. After treatment, seven patients remained remission and three patients relapsed after remission. Immunosuppressors and enteral nutrition was effective in two of them and glucocorticoid resistance happened in one patient. Conclusions The diagnosis of CMUSE should be considered in patients with unexplained recurrent bowel obstruction, melena, anemia and concomitant intestinal ulcer and stricture. Endoscopy plays an important role in the diagnosis. Glucocorticoid is effective but easy to relapse. Immunomodulators and enteral nutrition may be considered as second-line therapy. Key words: Cryptogenic multifocal ulcerous stenosing enteritis; Small intestinal ulcer; Intestinal stenosis; Gastrointestinal hemorrhage; Anemia

We report the case of pancreatic adenosquamous carcinoma (PASC) that had penetrated into the stomach and transverse colon. A 55-year-old male presented to our hospital with general fatigue, melena, and left flank pain. He had no relevant medical history. A laboratory analysis upon arrival revealed marked anemia with a red blood cell count of 13.3 × 10 4 /uL and a hemoglobin level of 3.6 g/dL. There was tenderness over the upper abdomen and a palpable mass on his left upper abdomen. He was admitted for further examination of his severe anemia and abdominal symptoms. Contrast-enhanced computed tomography revealed multiple liver masses and a 10 cm sized tumor in the pancreas tail involving the gastric wall and transverse colon. Upper gastroendoscopy revealed a 4 cm sized elevated tumor with a central depression in the greater curvature of the middle gastric body. Colonoscopy revealed an ulcerative tumor extending from the splenic flexure to the mid transverse colon. Endoscopic biopsied specimens revealed adenosquamous cell carcinoma. From these findings, the diagnosis of PASC in the pancreatic tail invading into the stomach and transverse colon at an advanced stage IV was established. His anemia was treated by the administration of red blood cell concentration (RCC). Although chemotherapy was planned after his malnutrition improved, his circulatory condition worsened on day 20. Despite 10 units of RCC, his anemia did not improve and he died from circulatory insufficiency on day 23. An autopsy revealed PASC in the pancreas tail measuring 14 cm that had penetrated into the gastric wall and transverse colon. A massive amount of blood was discovered in the stomach. His death was caused by massive bleeding from the invaded lesions of the stomach. Adenosquamous carcinoma, consisting of adenocarcinoma and squamous cell carcinoma, is characterized by its aggressive proliferation and poor prognosis. To date, consensuses in the management of PASC have not been established. Further accumulation of knowledge about this carcinoma is required. J Med Cases. 2017;8(1):24-28 doi: https://doi.org/10.14740/jmc2723w

Objective To study treatment of massive variceal bleeding secondary to localized pancreatitis-associated portal hypertension (MVBPAPH). Methods A retrospective study on the clinical data of patients with MVBPAPH was carried out. Of 24 patients with MVBPAPH, 20 had pancreatic pseudocysts. 12 were operated after failure of treatment with endovascular intervention for variceal bleeding (including 10 patients with splenectomy and gastric fundus-body peripheral vessels amputation and 2 patients with pancrea-tic pseudocystogastrostomy). 8 patients underwent partial splenic embolization and left gastroepiploic artery embolization. 4 patients directly underwent splenectomy and gastric fundus-body peripheral vessels amputation for variceal bleeding. Results Left pleural effusion developed in 5 patients who underwent arterial embolization. Left pleural effusion and lung infection occurred in 2 patients who underwent operation. All patients recovered well and were discharged home. During the follow-up period of 2 to 72 months, no reblee-ding occurred in these patients (including 2 patients had passed little interval melena). Gastroscopy re-exa-mination showed that variceal veins were not found in 18 patients. Variceal veins which were detected in the remaining 6 patients were obviously less severe. Conclusion Individualized treatment should be given to patients with MVBPAPH and according to the specific type of pancreatitis and the onset time of any accompanying pseudocyst. Key words: Portal hypertension, localized; Massive upper gastrointestinal hemorrhage; Pancreatitis; Pancreatic pseudocyst

Intestinal carcinoid tumors are uncommon malignancies which grow slowly and rarely cause any symptoms. Small bowel tumors can, at times, cause bowel obstruction and rarely, bleeding. We present a 52-year-old male who presented to the hospital for evaluation of melena. His endoscopy and colonoscopy came back negative and patient unfortunately failed to get capsule endoscopy as an outpatient. One year later, patient presented with excruciating abdominal pain and was found to have small bowel obstruction with multiple transition points. Patient was found to have four nodular lesions in the small intestine which were found to be carcinoid tumor. Surgical resection definitely improved his outcome and patient did not need adjuvant therapy after surgery. This patient was a diagnostic challenge due to unusual presentation and negative CT scan imaging during both presentations. Carcinoid tumors are highly infiltrating tumors; hence, high degree of suspicion should be kept for earlier detection and better outcome. J Med Cases. 2016;7(8):320-322 doi: http://dx.doi.org/10.14740/jmc2562w

Objective To explore the feasibility of using the modified continuous balloon dilatation substituting the traditional membrane-covered stent in the treatment of benign esophageal stenosis in children. Methods A retrospective analysis of the clinical data of 25 cases with esophageal stenosis from January,2012 to February,2014 was conducted. Preoperative esophageal stenosis was confirmed by angiography, and the expansion of the stenosis segment was examined after 2-4 weeks postoperatively. According to the age and the location of the esophageal stricture, 25 cases were classified into two groups. Twelve cases of group A without obvious contraindications were treated by continuous balloon dilatation, while 13 cases of group B with age of less than 3 years or upper esophageal stenosis, retrievable stent implantation was performed. All cases were followed up from 6 months to 2 years. Clinical symptoms, swallowing fluency and the degree of esophageal stricture were followed up at 1, 3, and 6 months postoperatively, and the effect of treatment was evaluated. Results Two groups of patients were successfully treated, and the stents were removed successfully after 2-4 weeks. The average diameter of the stenosis was significantly increased after treatment, swallowing was improved obviously, with no perforation, hematemesis and melena and other serious complications. The balloon moved down happened in one case, which was adjusted under perspective observation. One case in group A underwent colonic interposition for esophageal replacement because of recurrence of restenosis. The balloon dilatation was effective in 10 cases. In Group B, 5 patients had stent migration or displacement, 3 cases had recurrent esophageal stricture, and the treatment was effective in 5 cases. There was significant difference in complications between the group A and B (χ2=5.23,P<0.05). Conclusions Continuous balloon dilatation is a simple, effective procedure with fewer complications in the treatment of children with benign esophageal stenosis. In addition to stenting, it may be another ideal choice for benign esophageal stenosis in children. Key words: Esophageal stenosis; Stents; Child

To discuss the clinical characteristics of remnant gastric cancer (RGC). Clinical data of 163 patients with RGC admitted to our department from January 2005 to January 2015 were collected and reviewed. The time duration of all the RGC patients between primary gastrectomy and occurrence of RGC ranged from 9 to 46 years (median 27.5 years). Among 163 patients, 112(68.7%) patients manifested as discomfort in the upper abdominal region, 47(28.8%) patients had hematemesis and melena, 38(23.3%) had vomiting, 17(10.4%) had swallowing difficulty and 12 (7.4%) had decreased weights. In pathology, 127 (77.9%) cases were median or low grade adenocarcinoma; 114(69.8%) patients were Borrmann type III( gastric cancer under endoscope; 145 (88.9%) patients were TNM III(-IIII( gastric cancer. A total of 106 patients underwent operation, including 75(70.8%) patients of radical resection and 31(29.3%) patients of palliative resection. Patients mainly received Billroth II( anastomosis (77.4%) as digestive tract reconstruction, while 57 cases did not receive surgical operation. The overall 1-, 3-, and 5-year survival rates of the patients were 76.1%, 43.4%, 25.8% respectively. The median survival time of patients receiving radical resection and those receiving palliative resection was 34.6 months and 16.4 months respectively, whereas patients who did not receive surgical operation died 3-8 months after initial diagnosis. Regular gastroscopy is necessary for patients undergoing gastrectomy for over 10 years. Radical resection is of great importance in the treatment of remnant gastric cancer.

Objective To research whether double antiplatelet drug combined with pantoprazole can reduce digestive tract damage, or aggravate cardiovascular system side effect. Methods 270 patients diagnosed as ischemic stroke received double antiplatelet drug were randomly divided into two groups.The treatment group received pantoprazole, the control group did not took any gastric drug.The side effect of the digestive and cardiovascular system was observed. Results 268 patients were followed up for 90 days, and digestive system side effect of the treatment group(136 cases) included indigestion in 26 cases(19.11%), stool occult blood(+ ) in 11 cases(8.08%), melena in 8 cases(5.89%), hematemesis in 0 case, and the control group(132 cases) included indigestion in 42 cases(31.82%), stool occult blood(+ ) in 23 cases(17.42%), melena in 19 cases(14.39%), hematemesis in 4 cases.There were significant differences between the two groups(χ2=6.66, 4.56, 11.2 and 4.18, all P 0.05). Conclusion Double antiplatelet drug combined with pantoprazole had a positive significance in reducing the digestive tract damage of ischemic stroke patients, and didn't increase the incidence of cardiovascular system side effect. Key words: Pantoprazole; Double antiplatelet drug; Digestive tract damage; Cardiovascular system incidence; Ischemic stroke

Objective To observe the curative effect of Weifuchun combined with Shenqifuzheng pills in the treatment of chronic atrophic gastritis. Methods 85 cases patients were divided into the control group of 42 cases and the treatment group of 43 cases.The control group were treated with omeprazole enteric-coated capsules and colloidal bismmth pectin, while the treatment group were treated with Weifuchun and Shenqifuzheng pills.The course of treatment was two months.The patients were treated by endoscopy and pathological review after the treatment, then the datas were comparedwith that before treatment. Results The total effective rate of the treatment group was 67.44%, which of the control group was 40.48%, the was statistically significant difference between the two groups (χ2=6.22, P<0.05). The symptom scores of stomach tingling, stomach fullness, facial darkness, anorexia and melena in the two groups had statistically significant differences (t=6.14, P<0.05). Conclusion Weifuchun combined with Shenqifuzheng pills have good curative effect in the treatment of chronic atrophic gastritis.It should be popularized in clinic. Key words: Gastritis, atrophic; Weifuchun; Shenqi fuzheng pill