Endoscopic Management of Symptomatic Duodenal Duplication Cysts: Two Case Reports

<b><i>Background:</i></b> Duodenal duplication cysts (DDCs) are rare congenital anomalies typically manifesting during childhood. Clinical manifestations are uncommon in adulthood. DDCs were classically treated surgically, but endoscopic treatment has been increasingly reported. Endoscopic cyst marsupialization establishes a communication between the cyst cavity and the duodenal lumen so that the cystic content can be drained continuously into the duodenum. We herein describe two cases of symptomatic DDCs diagnosed in adulthood and submitted to endoscopic marsupialization using different techniques and devices. <b><i>Case Summary:</i></b> Case 1: A 23-year-old female patient was admitted with the diagnosis of acute pancreatitis. Endoscopic ultrasound revealed a 35-mm duodenal subepithelial lesion whose proximal limit was immediately distal to the ampulla of Vater and filled with fluid and calcifications. Using a duodenoscope, deroofing of the lesion was made with a diathermic snare. Pathology confirmed the diagnosis of DDC. Case 2: A 41-year-old female, submitted to laparoscopic cholecystectomy 1 month earlier due to suspected lithiasic acute pancreatitis, was admitted due to suspicion of iatrogenic biliary fistula. An endoscopic retrograde cholangiopancreatography was performed and the bile leak was treated. Immediately distal to the papillary orifice, a 20-mm subepithelial lesion was also detected. A biopsy forceps was used to fenestrate its wall, allowing the exit of mucous fluid and stones, and a sphincterotome was used to expand the incision. No recurrence was documented in both cases. <b><i>Conclusion:</i></b> These cases highlight DDC as a potential cause for acute pancreatitis in adults and endoscopy as an easy treatment option.

Protruded duodenal tumor arising from Santorini’s duct of the pancreas: a rare case of intraductal papillary mucinous neoplasm mimicking a duodenal polypoid tumor

Background We experienced a rare case of intraductal papillary mucinous neoplasm arising from Santorini’s duct (SD) forming a tumor protruding into the duodenum . Case presentation A 71-year-old woman was incidentally diagnosed with a 3 cm type Isp polypoid tumor in the second portion of the duodenum at another hospital. Enhanced CT and endoscopic ultrasound revealed that the origin of this protruding tumor was arising from SD and that the tumor mimicked a pedunculated duodenal tumor. Our preoperative diagnosis was a malignant pancreatic tumor arising from SD with invasion into the duodenum. She underwent a subtotal stomach-preserving pancreaticoduodenectomy, and the resected specimen showed a 25 mm tumor protruding into the duodenum with a villous surface. The pathological findings revealed that the tumor was intraductal papillary mucinous adenoma (IPMA) arising from SD. Conclusions To the best of our knowledge, this is the first case of IPMA protruding into the duodenal lumen from SD, although most of the tumors arising from SD have been reported to be malignant.

A rare cause of gastric outlet obstruction

Gastric outlet obstruction is the clinical and pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying. It may be acute from inflammatory swelling and peristaltic dysfunction or chronic from cicatrix. Chronic inflammation of the duodenum may lead to recurrent episodes of healing followed by repair and scarring ultimately leading to fibrosis and stenosis of the duodenal lumen. We would like to present a unique case of an elderly lady presenting with intractable vomiting over 3 months, gradually progressive which aggravated on consuming solids initially to consuming liquids later. After thorough investigations a provisional diagnosis of chronic duodenal ulcer with gastric outlet obstruction probably due to cicatrix was made. On laparotomy there was a chronic scarred duodenal ulcer following a previously contained perforation which was causing the gastric outlet obstruction. Cholecystectomy, duodenoplasty and loop gastrojejunostomy was performed with no complications post-operatively. This is a rare case of previous contained duodenal perforation causing gastric outlet obstruction.

Multiorganism sepsis secondary to enteric aorto-iliac graft fistulation

A woman in her early 70s with a history of infrarenal aortic endarterectomy and aorto-bi-iliac Dacron grafting 4 years before presented with recurrent septicaemias, occasionally polymicrobial and caused by a wide variety of organisms. After treatment for her sixth bacteraemia, enteroscopy showed a small area of ulceration with synthetic graft material protruding into the distal duodenal lumen. This was followed by positron emission tomography/CT, which showed mild increase in tracer uptake in the same region localised by a previously placed haemoclip. Despite urgent vascular surgery to repair the duodenal fistulas and replace the grafts, the patient passed away. Our patient posed a diagnostic challenge due to repeated imaging studies of different modalities and routine endoscopy failing to show a source of sepsis. It is unique due to the variety of organisms cultured as a result of the enteric fistula.

Endoscopic resection of a giant symptomatic Brunner’s gland hamartoma of duodenal bulb

Brunner's gland hamartoma is a very rare benign tumor arising from the Brunner’s gland of duodenum and is usually asymptomatic, but may present with the symptom of duodenal obstruction or upper gastrointestinal bleeding due to ulceration from the tumor, requiring endoscopic or surgical resection. In our study, we report the case of a 57 year-old male who presented with pain over epigastrium, recurrent vomiting, black stool and dizziness with a lowering of hemoglobin up to 7.5 gm/dl. The blood transfusion was done to raise the hemoglobin. The upper gastrointestinal endoscopy revealed a giant submucosal polypoidal mass with a thick short stalk in duodenal bulb causing almost complete obstruction of the lumen of duodenum and there was a superficial ulceration on the under-surface of the mass. The endoscopic ultrasound revealed a submucosal lesion arising from the echo layer three. The computed tomography of abdomen showed that the polypoidal mass was confined to the duodenal lumen with no significant lumphadenopathy and normal biliary and pancreas. The endoscopic polypectomy was attempted, but the lesion was too large to grab the polyp as a whole with the conventional snare. Hence, the repeated partial snare polypectomies were done, followed by submucosal dissection to ensure the complete removal of the mass. There were no complications after the procedure. The histopathology examination of the duodenal mass confirmed the diagnosis of Brunner’s gland hamartoma and showed the presence of Helicobacter pylori as well. The endoscopic treatment of giant Brunner’s gland hamartoma avoided the need of unnecessary more invasive surgical procedure.

Gastric Outlet Obstruction due to Intramural Duodenal Hematoma after Endoscopic Biopsy: Possible Therapeutic Role of Endoscopic Dilation

Intramural duodenal hematoma (IDH) is an extremely rare complication after endoscopic biopsy. It typically presents with symptoms due to duodenal obstruction, which include abdominal pain and bilious vomiting. The hematoma may also expand and cause ampullary compression leading to pancreatitis and cholestasis. Computed tomography scan and abdominal ultrasound are the most common diagnostic modalities. Treatment is usually conservative, with bowel rest, nasogastric suctioning and total parenteral nutrition. Refractory cases have been described, requiring endoscopic therapy or surgical drainage. We describe a 28-year-old healthy male who presented with acute abdominal pain a few hours after a routine esophagogastrodudenoscopy with biopsies was performed. Following an otherwise uneventful endoscopy, he developed a gastric outlet obstruction and pancreatitis secondary to an IDH. The patient was managed conservatively. Resolution of his gastric outlet obstruction occurred immediately after gentle passage of the endoscope through the narrowed duodenal lumen.

Bovine pancreatolithiasis: case report and review of the literature

An 8-y-old lactating Holstein cow was presented to the herd veterinarian with a history of acute ataxia, and because of poor prognosis, the animal was euthanized and submitted for postmortem examination. A lumbar vertebra was incompletely fractured and had an adjacent subdural hematoma. The pancreas had a hard texture with exaggerated nodular appearance, and on cut surface, the pancreatic ducts appeared fibrotic and contained scores of round-to-faceted pancreatoliths of 0.5–2.0 mm diameter. These calculi extended from the major ducts to the pancreatic duct, sphincter, and into the duodenal lumen. Microscopically, the pancreas had severe acinar atrophy and dissecting glandular fibrosis. The major pancreatic ducts were ulcerated with fibrosis and inflammation. In humans, chronic pancreatitis has been linked to osteoporosis and increased risk of bone fractures. Manual evaluation of ribs at the time of autopsy did not reveal abnormalities in bone pliability or fragility in our cow.