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1.  Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report 
Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.
Case presentation
We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.
In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.
PMCID: PMC2997099  PMID: 21092262
2.  Reconstruction of a traumatic duodenal transection with a pedicled ileal loop: a case report 
Blunt duodenal injuries do not occur often. A patient with damage to the duodenal tissue around the pancreatic and common bile duct presents a challenge to surgeons. The choice of procedure must be tailored to the nature of the defect and the amount of tissue lost.
Case presentation
We describe the case of a 16-year-old Caucasian boy with a blunt duodenal injury after a motor vehicle accident. On admission, the patient had stable vital signs and a normal laboratory workup. Gradually his clinical condition deteriorated and a computed tomography scan showed a retroperitoneal haematoma at the level of his duodenum. A fully circumferential rupture of the second part of his duodenum was found during laparotomy, with the intact Vater's papilla lying adjacent to the defect and a superficial laceration of the head of his pancreas. The retroperitoneal haematoma was thoroughly drained and a pedicled ileal loop was interposed between the duodenal stumps to restore the continuity of the patient's duodenum. Apart from a mild postoperative pancreatitis, the patient's postoperative course evolved with no further problems. The patient was discharged on the 22nd postoperative day in excellent condition and has remained so to date (after five years).
In our case report, where the second part of the patient's duodenum was completely transected, our choices for reconstruction were limited. Important factors for the successful management of this patient were prompt surgical intervention and the accurate assessment of the nature of the duodenal and associated injuries. We believe that the technique we used was a reasonable choice because the anatomical continuity of the patient's duodenum was restored.
PMCID: PMC2987957  PMID: 20977717
3.  Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case 
Biliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case.
Seven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD.
One dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses.
In mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.
PMCID: PMC3198750  PMID: 21985492
4.  Resolving sphincter of Oddi incontinence for primary duodenal Crohn's disease with strictureplasty 
Crohn's involvement of duodenum is a rare event and may be associated to proteiform symptoms and uncommon pathological aspects which make diagnosis and treatment complex.
The peculiar aspect of this case was a suspected duodeno-biliary fistula. The patient (female, 22 years old) was affected by duodenal Crohn's disease. Magnetic resonance imaging showed a dilated common bile duct, whose final part linked to a formation containing fluid, and characterized by filling of the contrast medium in the excretory phase. Abdominal ultrasound showed intra-hepatic and intra-gallbladder aerobilia. At surgery, the duodenum was mobilized showing an inflammatory stricture and a slight dilatation of the common bile duct, with no signs of fistulas. The opened duodenum was anastomized side to side to a transmesocolic loop of the jejunum. After surgery, the general condition of the patient improved.
Only two cases of fistula between a narrow duodenal bulb and the common bile duct have been described in literature and the Authors were not be able to verify the occurrence of a duodenal biliary fistula at surgery. The association between duodenal Crohn's disease and Sphincter of Oddi incontinence is a very rare finding with different etiology: chronic intestinal pseudo-obstruction, common bile duct stones, progressive systemic sclerosis.
The treatment to resolve Sphincter of Oddi incontinence for primary duodenal Crohn's disease is not clear. Strictureplasty could be the treatment of choice, because, resolving the stricture, the duodenal pressure is likely to decrease and the reflux through the incontinent sphincter can be avoided.
PMCID: PMC3540232  PMID: 23276753
Duodenal Crohn's disease; Sphincter of Oddi incontinence; Strictureplasty; CD, Crohn's disease; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; UGI, upper gastro intestinal; MRI, magnetic resonance imaging; CKK, cholecystokinin; SO, Sphincter of Oddi
5.  Choledochal-duodenal fistula presenting as an upper GI bleed 
BMJ Case Reports  2011;2011:bcr0520114275.
Gallstones are common and largely asymptomatic, but can result in significant morbidity in a small proportion of patients. Choledochal-enteric fistulation is one such complication with an associated mortality of 15–18%. The authors present a case of an 88-year-old man admitted to the general medical ward with an acute upper gastrointestinal bleed. Oesophagogastroduodenoscopy found a large gallstone impacted in the pylorus and CT scan revealed a choledochal-duodenal fistula. At laparotomy it was found that a 6.2 cm gallstone had fistulated into D1 and the pylorus and impacted there, causing outflow obstruction – Bouveret’s syndrome. A subtotal cholecystectomy was performed and the stone was removed by a separate gastrostomy. A radiological follow through study on day 14 showed contrast passing freely through the duodenum with no leak and the patient went on to make a slow, but uneventful recovery.
PMCID: PMC3229308  PMID: 22674938
6.  Laparoscopic treatment of an upper gastrointestinal obstruction due to Bouveret’s syndrome 
Bouveret’s syndrome is an extremely rare type of gallstone-induced ileus with atypical clinical manifestations, such as abdominal distension and pain, nausea and vomiting, fever or even gastrointestinal bleeding, which may easily be misdiagnosed. In the present case, a 55-year-old male was admitted to the hospital with upper gastrointestinal obstructive symptoms but without pain, fever, jaundice or melena. At first, gastrolithiasis and peptic ulcer combined with pyloric obstruction were suspected after gastroscopy revealed a large, hard stone in the duodenal bulb. A revised diagnosis of Bouveret’s syndrome was made following abdominal computed tomography. Subsequently, the patient exhibited a good postoperative recovery after laparoscopic duodenotomy for gallstone removal and subtotal cholecystectomy. The condition of the patient remained stable after being followed up for 6 mo. The successful application of laparoscopic therapy to treat Bouveret’s syndrome has seldom been reported. Laparoscopic enterolithotomy is safe and effective, with good patient tolerability, rapid postoperative recovery and few wound-related complications. The laparoscopic treatment of Bouveret’s syndrome is worth exploring.
PMCID: PMC3812499  PMID: 24187475
Bouveret’s syndrome; Gallstone; Gastric outlet obstruction; Laparoscopic therapy; Cholecystoenteric fistula
7.  Mirizzi syndrome type Va: A rare coexistence of double cholecysto-biliary and cholecysto-enteric fistulae 
World Journal of Radiology  2010;2(10):410-413.
Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann’s pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.
PMCID: PMC2999013  PMID: 21161027
Mirizzi syndrome; Obstructive jaundice; Gallstone; Cholecysto-enteric fistula; Endoscopic retrograde cholangiopancreatography
8.  Active bleeding from a periampullary duodenal diverticulum that was difficult to diagnose but successfully treated using hemostatic forceps: a case report 
Although duodenal diverticula are common, periampullary duodenal diverticula are rare. Periampullary duodenal diverticula are usually asymptomatic and may be difficult to diagnose and treat. However, they may present with massive bleeding, requiring prompt diagnosis.
Case presentation
We report the case of a 71-year-old Asian woman with bleeding from a periampullary duodenal diverticulum. She presented with severe anemia and tarry stools. Two examinations using a forward-viewing endoscope did not identify the source of the bleeding. However, examination using a side-viewing endoscope found an exposed bleeding vessel overlying the bile duct within a periampullary diverticulum of the descending part of the duodenum. The bleeding was successfully controlled by using hemostatic forceps.
Bleeding periampullary duodenal diverticula are rare, and a bleeding point in the mucosa overlying the bile duct within a large periampullary duodenal diverticulum is very rare. Identification of a bleeding point within a duodenal diverticulum often requires repeated examination and may require the use of a side-viewing endoscope. Use of hemostatic forceps to control bleeding from a periampullary duodenal diverticulum is very rare but, for bleeding lesions overlying the bile duct within a periampullary duodenal diverticulum, is the best way to prevent obstructive jaundice.
PMCID: PMC3485119  PMID: 23101939
Bleeding periampullary duodenal diverticulum; Side-viewing endoscopy; Hemostatic forceps; Obscure gastrointestinal bleeding
Closed duodenal loops may be made in dogs by ligatures placed just below the pancreatic duct and just beyond the duodenojejunal junction, together with a posterior gastro-enterostomy. These closed duodenal loop dogs die with symptoms like those of patients suffering from volvulus or high intestinal obstruction. This duodenal loop may simulate closely a volvulus in which there has been no vascular disturbance. Dogs with closed duodenal loops which have been washed out carefully survive a little longer on the average than animals with unwashed loops. The duration of life in the first instance is one to three days, with an average of about forty-eight hours. The dogs usually lose considerable fluid by vomiting and diarrhea. A weak pulse, low blood pressure and temperature are usually conspicuous in the last stages. Autopsy shows more or less splanchnic congestion which may be most marked in the mucosa of the upper small intestine. The peritoneum is usually clear and the closed loop may be distended with thin fluid, or collapsed, and contain only a small amount of pasty brown material. The mucosa of the loop may show ulceration and even perforation, but in the majority of cases it is intact and exhibits only a moderate congestion. Simple intestinal obstruction added to a closed duodenal loop does not modify the result in any manner, but it may hasten the fatal outcome. The liver plays no essential role as a protective agent against this poison, for a dog with an Eck fistula may live three days with a closed loop. A normal dog reacts to intraportal injection and to intravenous injection of the toxic substance in an identical manner. Drainage of this loop under certain conditions may not interfere with the general health over a period of weeks or months. Excision of the part of the duodenum included in this loop causes no disturbance. The material from the closed duodenal loops contains no bile, pancreatic juice, gastric juice, or split products from the food. It can be formed in no other way than by the activity of the intestinal mucosa and the growth of the intestinal bacteria. This material after dilution, autolysis, sterilization, and filtration produces a characteristic effect when introduced intravenously. When in toxic doses it causes a profound drop in blood pressure, general collapse, drop in temperature, salivation, vomiting, and profuse diarrhea, which is often blood-stained. Splanchnic congestion is the conspicuous feature at autopsy and shows especially in the villi of the duodenal and jejunal mucosæ. Adrenalin, during this period of low blood pressure and splanchnic congestion, will cause the usual reaction when given intravenously, but applied locally or given intravenously it causes no bleaching of the engorged intestinal mucosa. Secretin is not found in the duodenal loop fluid, and the loop material does not influence the pancreatic secretion. Intraportal injection of the toxic material gives a reaction similar to intravenous injection. Intraperitoneal and subcutaneous injections produce a relatively slow reaction which closely resembles the picture seen in the closed duodenal loop dog. In both cases there is a relatively slow absorption, but the splanchnic congestion and other findings, though less intense, are present in both groups. There seems, therefore, to be no escape from the conclusion that a poisonous substance is formed in this closed duodenal loop which is absorbed from it and causes intoxication and death. Injection of this toxic substance into a normal dog gives intoxication and a reaction more intense but similar to that developing in a closed-loop dog.
PMCID: PMC2125034  PMID: 19867644
10.  The composition of hepatic and gallbladder bile in patients with gallstones 
Gut  1972;13(10):759-762.
Bile specimens were obtained from 17 patients with gallstones and 21 patients with duodenal ulcer. The specimens were obtained from the former by needle aspiration of the gallbladder and common bile duct at operation and from the latter by duodenal intubation. The concentrations of bile salt, phospholipid, and cholesterol were measured. Gallbladder bile from gallstone patients contained significantly more cholesterol than did `duodenal' bile from duodenal ulcer patients. Hepatic bile from gallstone patients contained significantly more cholesterol than did gallbladder bile from the same patients. When the data were plotted on triangular coordinates the relative composition lay within the zone of cholesterol solubility in all 21 ulcer patients. The relative composition of hepatic bile lay outside the zone of cholesterol solubility in five gallstone patients, at the limits of cholesterol solubility in a further three, and within the micellar zone in the remaining nine patients. This suggests that supersaturation of hepatic bile with cholesterol is not the sine qua non for the production of cholesterol gallstones.
PMCID: PMC1412476  PMID: 5087065
11.  Acute cholecystitis with massive upper gastrointestinal bleed: A case report and review of the literature 
BMC Gastroenterology  2007;7:12.
Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone.
Case presentation
We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done.
This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.
PMCID: PMC1851966  PMID: 17386110
12.  Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment 
BMC Gastroenterology  2007;7:26.
Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.
The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.
A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).
The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.
PMCID: PMC1933541  PMID: 17610747
13.  Ectopic papilla of Vater in the pylorus 
The major papilla of Vater is usually located in the second portion of the duodenum, to the posterior medial wall. Sometimes the mouth of the biliary duct is located in other areas. Drainage of the common bile duct into the pylorus is extremely rare. A 73-year old man, with a history of duodenal ulcer, was admitted to hospital with the diagnosis of cholangitis. Dilatation of the extrahepatic biliary duct was observed by abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. No area suggesting the presence of the papilla of Vater was found within the second duodenal portion. Finally the major papilla was located in the theoretical pyloric duct. Cholangiography was performed and choledocholithiasis was found in the biliary tree. The patient underwent dilatation of the papilla with a balloon tyre and removal of a 7 mm stone using a Dormia basket, which solved the problem without further complications. This anomaly increased the difficulty of performing therapeutic interventions during ERCP. This alteration in anatomy may increase the risk of complications during papillotomy, with a theoretically higher risk of perforation. Dilatation using a balloon was the chosen therapeutic technique both in our case and in the literature, due to its low rate of complications.
PMCID: PMC2773904  PMID: 19891024
Ectopic common bile duct; Endoscopic dilatation; Endoscopic retrograde cholangiopancreatography; Papilla of Vater; Papillotomy; Pyloric drainage
14.  Regulation of the fasting enterohepatic circulation of bile acids by the migrating myoelectric complex in dogs. 
Journal of Clinical Investigation  1983;71(3):644-654.
The purpose of this study was to correlate the fasting enterohepatic circulation (EHC) of bile acids with the migrating myoelectric complex. Four dogs were surgically provided with a functional cholecystectomy, a duodenal cannula for direct vision cannulation of the common bile duct, and 12 bipolar electrodes implanted from stomach to terminal ileum. Bile was collected in equal-volume, timed aliquots over 6 to 10 h. Aliquots were sampled and either returned to the duodenum for study of the intact EHC, or collected and retained in order to study the time course of the bile acid pool washout. In the washout experiments boluses of radiolabeled taurocholic acid were instilled into the duodenum before and after duodenal phase III of the migrating motor or myoelectric complex (MMC). In another group of experiments the bile acid pool was washed out and during a continuous duodenal infusion of taurocholic acid bile was collected to study the pattern of hepatic secretion. Results: (a) In all experiments, a single broad peak of bile flow and bile acid secretion occurred at 35-55% of the MMC migration time. At this time the MMC had migrated to a point 70-85% of the distance along the small intestine. (b) During bile acid pool washout the peak of bile flow and bile acid secretion occurred with the distal migration of the first MMC and then bile flow and bile acid secretion rates decreased to a minimum and stabilized. (c) In bile acid pool washout experiments the radiolabeled bile acids instilled into the duodenum prior to duodenal phase III were secreted and peaked with peak endogenous bile acid secretion. The secretion of radiolabeled bile acids instilled into the duodenum after duodenal phase III was delayed until the subsequent cycle of the MMC. 88% of the bile acid pool collected over 6 h was secreted during the distal migration of the first MMC (2.4 +/- 0.4 h). (d) After bile acid pool washout and during continuous duodenal infusion of taurocholic acid, hepatic bile flow and bile acid secretion continued to fluctuate with the same pattern observed with the EHC intact. Conclusions: (a) In the fasting state, the transport of intestinal bile acids to the liver is pulsatile rather than continuous and is determined by the MMC. Maximum hepatic secretion occurs when phase III of the MMC propels the intraluminal bile acid pool to its site of absorption in the distal small bowel. (b) The "housekeeping" action of the MMC is very efficient and clears 88% of the 6-h washout bile acid pool in one pass.
PMCID: PMC436914  PMID: 6826728
15.  Distribution and photodynamic effect of disulphonated aluminium phthalocyanine in the pancreas and adjacent tissues in the Syrian golden hamster. 
British Journal of Cancer  1991;64(6):1108-1115.
Necrosis of small volumes of tumour tissue with photodynamic therapy (PDT) can be achieved relatively easily. For this to be clinically relevant, it is essential to know what the same treatment parameters do to adjacent normal tissues into which the tumour has spread. For pancreatic cancers, local spread to vital structures is common. We have studied chemical extraction, microscopic fluorescence kinetics and photodynamic effects of disulphonated aluminum phthalocyanine (AlS2Pc) in normal pancreas and adjacent tissues in hamsters. Chemical extraction exhibited a peak duodenal concentration of AlS2Pc 48 h after sensitisation, with levels much higher than in stomach and pancreas. With microscopic fluorescence photometry highest levels were seen in duodenal submucosa and bile duct walls 48 h after photosensitisation. Pancreatic ducts, duodenal mucosa and gastric mucosa and submucosa exhibited intermediate fluorescence with relatively weak fluorescence in pancreatic acinar tissue and the muscle layer of the stomach. As expected, on the basis of fluorescence intensity and chemical extraction studies, the duodenal and bile duct wall were the most vulnerable tissues to photodynamic therapy. When the dose of 5 mumol kg-1 of sensitiser was used, duodenal perforations, gastric ulcers and transudation of bile from the bile duct occurred. However, the lesions in the stomach and bile duct healed without perforation or obstruction, so only the duodenum was at risk of serious, irreversible damage. Using a lower dose of photosensitiser markedly reduced damage.
PMCID: PMC1977869  PMID: 1764374
16.  A modified Rendezvous ERCP technique in duodenal diverticulum 
AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs.
METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast.
RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%.
CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.
PMCID: PMC3831199  PMID: 24255749
Endoscopic retrograde cholangiopancreatography; Retained stones; Antegrade cannulation; Intradiverticular papilla; T-tube
17.  Gastric epithelium in the duodenum: its association with Helicobacter pylori and inflammation. 
Journal of Clinical Pathology  1990;43(12):981-986.
Duodenal biopsy specimens from 471 adults and 47 children were examined to determine the prevalence and distribution of gastric epithelium in the duodenal bulb in relation to age, gender, gastroduodenal inflammation, smoking, alcohol and consumption of nonsteroidal anti-inflammatory drugs (NSAID). Gastric metaplasia was present in the anterior wall duodenal biopsy specimen in 31%, was significantly less common in patients under 17 than in adults, and was more common in males than females. In sixty two adults who underwent multiple radial duodenal biopsy gastric metaplasia was randomly distributed around the duodenal circumference; sixty three per cent of the patients with gastric metaplasia found on multiple biopsy were detected by just the anterior biopsy. Gastric metaplasia was not obviously associated with alcohol, cigarette, or NSAID consumption. While the presence of gastric metaplasia was associated with adulthood, male sex, and low fasting gastric juice pH, its extent was associated with active duodenitis and Helicobacter-associated gastritis. On logistic regression, gastric metaplasia in the duodenum and gastric Helicobacter pylori were independent predictors of active duodenitis, but were not significantly associated with inactive duodenal inflammation. H pylori was observed in duodenal biopsy specimens from 32 patients, all with active duodenitis; bacteria were present only on foci of gastric metaplasia, and were more likely to be seen when the metaplasia was extensive. It is proposed that inflammatory injury to the duodenal mucosa by H pylori may stimulate the development of further gastric metaplasia, and that the area of duodenum susceptible to colonisation with H pylori may therefore increase progressively until mucosal integrity is compromised and ulceration supervenes.
PMCID: PMC502969  PMID: 2266184
18.  Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report 
•Duodenal stump disruption is not a surgical anachronism, because it still remains one of the most dreadful postgastrectomy complications.•Postgastrectomy duodenal stump disruption poses an overwhelming therapeutic challenge.•Historical surgical sense and familiarity with the various well established methods for the treatment of duodenal stump disruption can provide to the surgical team the ability to successfully manage this devastating complication.
Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge.
The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum.
Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment.
Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.
PMCID: PMC4275811  PMID: 25437683
Duodenal stump blow out; Duodenal stump leakage; Difficult duodenum; Gastrectomy; Tube duodenostomy
19.  The clinical presentations of ectopic biliary drainage into duodenal bulbus and stomach with a thorough review of the current literature 
BMC Gastroenterology  2010;10:2.
Ectopic biliary drainage is a rare congenital anomaly on which we have scarce data in the current literature.
The data were collected from the records of 400 endoscopic retrograde cholangio-pancreatography (ERCP). In this report, we present 10 cases (male/female: 9/1, mean age 54 years, range 38-74) with ectopic biliary openings into the duodenum and/or stomach diagnosed by endoscopic retrograde cholangio-pancreatography (ERCP).
In our series, the frequency of ectopic biliary drainage is 2% (10 out of 400 ERCPs). Recurrent attacks of cholangitis and complicated ulcer formation in the distal stomach and bulbar duodenum were the most common signs in the present series. The sites of ectopic biliary drainage were the stomach in 1 case, the duodenum bulbus in 7 cases and the postbulbar duodenum in 2 cases. Bulbar ulcer, deformed pylorus and bulbus were present in 7 cases, apical bulbar stricture in 2, gastric ulcer in 1, pyloroplasty and/or gastroenterostomy in 3 cases. One case had had previous bleeding episode. Some of them had undergone previous surgeries for gall-stone disease (cholecystectomy in 5 cases, bile duct operation in 3 cases) and ulcer complications (pyloroplasty/gastroenterostomy in 3 cases). ERCP revealed dilatation of the biliary tree and hook shaped distal choledochus in all cases, choledocholithiasis in 7 and Mirizzi syndrome in 1. Endoscopic balloon dilatations for gastric outlet obstruction, extraction of bile stones after balloon dilating the ectopic site, surgery for difficult cases with large bile duct stones or with gastric outlet obstruction were preferred methods in this series of patients.
With this report, we have to remind that ectopic biliary drainage must be considered in the differential diagnosis when the clinician faces cases with gastric outlet obstruction due to peptic ulcer formation accompanied by cholangitis/cholestasis.
PMCID: PMC2881112  PMID: 20064279
20.  Operative choledochoscopy in common bile duct surgery. 
Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC2499558  PMID: 4051422
21.  Pancreas divisum and duodenal diverticula as two causes of acute or chronic pancreatitis that should not be overlooked: a case report 
Pancreas divisum is a congenital anatomical anomaly characterized by the lack of fusion of the ventral and dorsal parts of the pancreas during the eighth week of fetal development. This condition is found in 5% to 14% of the general population. In pancreas divisum, the increased incidence of acute and chronic pancreatitis is caused by inadequate drainage of secretions from the body, tail and part of the pancreatic head through an orifice that is too small. The incidence of diverticula in the second part of the duodenum is found in approximately 20% of the population. Compression of the duodenal diverticula at the end of the common bile duct leads to the formation of biliary lithiasis (a principal cause of acute pancreatitis), pain associated with biliary lithiasis owing to compression of the common bile duct (at times with jaundice), and compression of the last part of Wirsung's duct or the hepatopancreatic ampulla (ampulla of Vater) that may lead to both acute and chronic pancreatitis.
Case presentation
We describe the radiological findings of the case of a 75-year-old man with recurrent acute pancreatitis due to a combination of pancreas divisum and duodenal diverticula.
Magnetic resonance cholangiopancreatography is advisable in patients with recurrent pancreatitis (both acute and chronic) since it is the most appropriate noninvasive treatment for the study of the pancreatic system (and the eventual presence of pancreas divisum) and the biliary systems (eventual presence of biliary microlithiasis). Moreover, it can lead to the diagnostic suspicion of duodenal diverticula, which can be confirmed through duodenography with X-ray or computed tomography scan with a radio-opaque contrast agent administered orally.
PMCID: PMC2413259  PMID: 18489738
22.  Development of bile duct bezoars following cholecystectomy caused by choledochoduodenal fistula formation: a case report 
The formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding.
Case presentation
We present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar.
Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously.
PMCID: PMC1351192  PMID: 16396681
23.  Peritonitis secondary to traumatic duodenal laceration in the presence of a large pancreatic pseudocyst: a case report 
A pancreatic pseudocyst is a common sequela of severe acute pancreatitis. Commonly, it presents with abdominal pain and a mass in the epigastrium several weeks after the acute episode and can be managed conservatively, endoscopically or surgically. We report a patient with a pancreatic pseudocyst awaiting endoscopic therapy who developed a life-threatening complication following a rather innocuous trauma to the abdomen.
Case presentation
A 23-year-old Asian male student presented as an emergency with an acute abdomen a week after a minor trauma to his upper abdomen. The injury occurred when he was innocently punched in the abdomen by a friend. He experienced only moderate discomfort briefly at the time. His past medical history included coeliac disease and an admission four months previously with severe acute pancreatitis. He was hospitalized for 15 days; his pancreatitis was thought to be due to alcohol binge drinking on weekends. Ultrasound scanning showed no evidence of gallstone disease. Five days after the trauma, he became anorexic, lethargic and feverish and started vomiting bilious content. Seven days post-trauma, he presented to our emergency department with severe abdominal pain. An emergency laparotomy was performed where a transverse linear duodenal laceration was found at the junction of the first and second part of his duodenum, with generalized peritonitis. His stomach and duodenum were stretched over a large pancreatic pseudocyst posterior to his stomach. It was postulated that an incomplete duodenal injury (possibly a serosal tear) occurred following the initial minor trauma, which was followed by local tissue necrosis at the injury site resulting in a delayed presentation of generalized peritonitis.
This is the first reported case of a traumatic duodenal laceration following minor blunt trauma in the presence of a large pancreatic pseudocyst. Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury. In the presence of a large pseudocyst, however, the stretching of the duodenum over the pseudocyst had probably predisposed the duodenum to this injury. Patients awaiting therapeutic interventions for their pancreatic pseudocysts should be warned about this unusual but life-threatening risk following minor blunt abdominal trauma.
PMCID: PMC3215995  PMID: 22029762
24.  Effects of vitamin C and melatonin on cysteamine-induced duodenal ulcer in a cholestatic rat model: A controlled experimental study 
Background: Superoxide dismutase (SOD) is one of the defense mechanisms against free radicals. Cysteamine is a cytotoxic agent, acting through generation of reactive oxygen species (ROS) such as hydrogen peroxide, hydroxyl radical, and superoxide, and may decrease defense activity of SOD against ROS and induce duodenal ulcer. Melatonin is a suicidal antioxidant that has a protective effect against ROS and cytoprotective effect through inhibition of the decrease in SOD activity.
Objectives: The primary aim of this study was to assess the effects of pretreatment with vitamin C and melatonin on cysteamine-induced duodenal ulcer. Secondary aims were to compare the ulcerogenic effect of cysteamine and the antiulcer effects of vitamin C and melatonin.
Methods: This study was performed in male Wistar rats (200–250 g) in 3 groups of equal size (n = 24): bile duct ligation-induced cholestasis (test), sham, and control groups. In the test and sham groups, laparotomy was performed under general anesthesia and the common bile duct was identified; in sham rats, the common bile duct was left in situ, but in test rats, the common bile duct was isolated and doubly ligated to induce cholestasis. Animals in each group were also divided into 4 equal subgroups (n = 6). These subgroups were treated with vitamin C plus cysteamine, melatonin plus cysteamine, cysteamine alone, and saline, respectively. All animals were euthanized via overdose of ether anesthesia 24 hours after the last injection of cysteamine or saline, and 0.5 mL of blood was collected from the heart ventricle. The duodenum was cut open, washed with saline, fixed, and prepared for calculation of ulcer index (Szabo method) and histopathologic assessment. SOD activity was measured using a branded enzyme kit.
Results: In all 3 groups, animals treated with cysteamine had significantly increased mean (SE) ulcer index (test, 4.00 [0.10] vs 1.17 [0.30]; sham, 3.83 [0.16] vs 0.50 [0.22]; control, 3.67 [0.21] vs 0 [0]) and decreased SOD activity (test, 146.41 [2.16] vs 299.83 [1.94] U/mL; sham, 154.75 [2.02] vs 303.08 [0.35] U/mL; control, 157.08 [1.67] vs 314.50 [1.14] U/mL) compared with saline-treated rats (all, P < 0.001). In the test rats, ulcer index was significantly increased and SOD activity was significantly decreased compared with the sham and control groups (both, P < 0.001). Pretreatment with vitamin C and melatonin was associated with attenuation of ulcer index and increased SOD activity compared with rats treated with cysteamine alone (P < 0.001). There were no significant differences in ulcer index or SOD activity between groups administered vitamin C or melatonin.
Conclusions: In this experimental study, pretreatment with melatonin or vitamin C in all rats produced significant attenuation of the ulcer index and enhanced SOD activity. Cysteamine-induced duodenal mucosal damage was greater in cholestatic rats compared with sham and control rats.
PMCID: PMC3969597  PMID: 24688152
cysteamine-induced duodenal ulcer; cholestasis; melatonin; superoxide dismutase; vitamin C; rats
25.  Bouveret's syndrome: revisiting gallstone obstruction of the duodenum. 
Bouveret's Syndrome is obstruction of the duodenum secondary to an impacted gallstone, usually without the presence of pneumobilia. With the steadily increasing life expectancy, greater numbers of these cases are being seen. Gallstones enter the gastrointestinal tract following fistula formation between the gallbladder and an adjacent hollow viscus and may cause obstruction at any point along the intestinal tract. Duodenal obstruction is the least common and represents only a very small percentage of cases. The presenting signs of nausea vomiting, abdominal cramping, and the absence of abdominal distension should alert the clinician to pathology in the proximal small bowel. The purpose of this report is to heighten the awareness of the primary care physicians, emergency room doctors, and surgeons to this diagnosis in elderly patients so that it can be included in the differential with the usual causes of gastric outlet obstruction--including ulcer disease; neoplasm; gastric volvulus; and other enteroliths, such as bezoars. Early diagnosis is critical, as these cases require urgent surgical intervention. Early resuscitation, diagnosis, and treatment are essential for a successful outcome.
PMCID: PMC2594488  PMID: 14620710

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