A novel 125I seeds fixed on gastric tube for treatment of inoperable esophageal carcinoma: A case report

To explore the treatment benefit of 125I seeds fixed on a gastric tube in the early inoperable esophageal carcinoma (EC).Three senile patients with early inoperable EC who were treated with brachytherapy between October 2017 and February 2019 were included in this study. 125I seeds were fixed on the gastric tube, which was then inserted on the surface of the EC. One patient suffered from severe pulmonary insufficiency; 1 patient underwent colon cancer surgery one week before treatment and suffered from liver dysfunction and esophageal varices; 1 patient suffered from venous embolism of lower extremities and pulmonary artery embolism.All three patients were successfully operated and completed treatment. During the operation, no displacement and shedding of 125I seed gastric tube occurred. After surgery, the discomfort while swallowing and pain after eating were significantly improved. Moreover, dysphagia was relieved in patient 3. In addition, no complications, such as perforation or bleeding, occurred. Local lesions were effectively controlled.Gastric tube with 125I seeds provides a new treatment protocol for inoperable EC and malignant obstruction of esophageal carcinoma.     

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report

BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously. Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach. Traditionally, this necessitates surgical intervention. Recently, however, the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension, nausea, and melena of two days duration. His imaging illustrated a massively distended stomach. A nasogastric tube did not result in drainage of fluid or decompression of his abdomen. His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended "fluid"-filled gastric remnant. An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant. Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. The patient underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of symptoms. Healing superficial gastric ulcers were visualized on a follow-up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound-directed transgastric intervention.     

Efficacy of neodymium:YAG laser therapy for gastric antral vascular ectasia (GAVE) following hematopoietic cell transplant

We determined the incidence of severe bleeding from gastric antral vascular ectasia (GAVE) after myeloablative hematopoietic cell transplant and the outcomes after treatment with endoscopic neodymium:YAG laser photocoagulation. From 1992 to 2005, the incidence of severe bleeding from GAVE was 6/4491 (0.13%). All patients had received oral busulfan and four had sinusoidal obstruction syndrome. Gastrointestinal bleeding began a median of 53 days after transplant (range 15-2952). After GAVE was diagnosed by endoscopic and histologic findings, a median of three (range 2-7) sessions of laser therapy were required to control the bleeding with a median of 2737 J (range 1117-6160 J) per session. A median of 16 units (range 4-44) had been transfused prior to laser therapy and a median of four additional units (range 0-113) were transfused until bleeding was controlled. All patients were followed for at least 70 days after the last laser therapy session, with no further episodes of bleeding. Complications were mild and included abdominal pain and asymptomatic ulceration; however, one patient required gastrectomy due to gastric necrosis following transarterial embolizations. In summary, severe bleeding from GAVE is rare following hematopoietic cell transplant. Treatment with endoscopic therapy using the Nd:YAG laser is safe and effective.     

Gastrointestinal bleeding during liver transplantation--report of two cases

A few authors have reported, especially as intraoperative complications, gastrointestinal hemorrhage related to liver transplantation. The aim of this study was to show two cases of gastrointestinal hemorrhage, which occurred during surgery. The first patient was male, 46 years old, with viral hepatic cirrhosis. He had previously presented two episodes of digestive bleeding. Upper digestive endoscopy showed esophageal gastric varices. During the hepatectomy there was bleeding inside the nasogastric tube associated with severe hemodynamics instability without other sources of bleeding. Intraoperative endoscopy evidenced bleeding gastric varices. Gastrectomy was carried out and the varices were tied. The piggyback technique was used in the liver transplantation. The surgery was concluded without problems and in the following four and a half years his condition has evolved well. In the second case, the patient was aged 17, female, with autoimmune hepatic cirrhosis. She had previously presented one episode of digestive bleeding. Intraoperative endoscopy showed median esophageal varices. During the anesthetic induction she presented an episode of hematemesis. A Sengstaken-Blakemore balloon was introduced. The transplant was performed without further problems. Her case has been followed for 14 months in the outpatients' clinic with a good postoperative course. To sum up, gastrointestinal hemorrhage can be due to portal hypertension during the liver transplantation and must be treated quickly. In these cases the surgery must be ongoing.     

Gastric antral vascular ectasia (watermelon stomach) in patients with systemic sclerosis

This report describes 5 patients with systemic sclerosis (SSc) who developed severe, recurrent upper gastrointestinal (GI) bleeding due to gastric antral vascular ectasia (GAVE). The clinical records, the endoscopic findings, and the histologic appearance of biopsy specimens and surgically resected gastric tissue from the patients were reviewed. All 5 patients developed severe and recurrent episodes of upper GI bleeding leading to severe anemia requiring multiple transfusions. The cutaneous involvement was diffuse in 3 patients and limited in 2. All but 1 had cutaneous telangiectasias. The diagnosis of GAVE was established by endoscopy within 3 years of the diagnosis of SSc in all cases. One patient required heater probe cautery, 2 required laser coagulation, and 2 underwent surgical resection of the gastric antrum for control of the GI bleeding. The possibility of GAVE should be considered in SSc patients who have recurrent upper GI bleeding. It is suggested that the antral vascular lesions in these patients may represent a component of the spectrum of vascular alterations of SSc.     

Endoscopic injection sclerosis in bleeding gastric varices

Ninety-two consecutive, nonrandomized patients with bleeding varices were prospectively studied using sclerotherapy to control and prevent rebleeding. During this study, nine patients with gastric variceal bleeding were identified. A gastric variceal subset is defined and represents a 10% incidence in this series. All patients presented with indexed gastric bleeding varices that subsequently accounted for 34 bleeding sessions. The units of blood per rebleeding episode, hospital days, cost, and outcome were markedly different from the esophageal variceal groups. Initial management of indexed bleeding episodes by sclerotherapy and Sengstaken-Blakemore tubes were comparable; however, the number of rebleeding episodes was much higher. There was poor control of rebleeding with an associated higher rebleeding mortality and complications secondary to repeated sclerotherapy and Sengstaken-Blakemore tube use. In 37% of the patients, rebleeding was the direct result of gastric ulcerations at the endoscopic injection sclerotherapy site. The survival curve of this group was much lower than esophageal variceal bleeders. Endoscopic injection sclerotherapy in patients with bleeding gastric varices offers only temporary control of bleeding, and the high incidence of severe early rebleeding requires consideration of alternative methods for management or modified sclerotherapy techniques.     

胃出口、十二指肠和近端小肠恶性梗阻的内镜治疗

目的 探讨经内镜金属支架置入术治疗胃出口、十二指肠和近端小肠恶性梗阻的临床价值.方法 对1999年3月至2005年3月经内镜放置金属支架治疗的21例胃出口、十二指肠和近端小肠恶性梗阻患者的临床资料进行回顾性分析.结果 21例中20例放置支架成功,成功率为95.2%,其中4例采取经内镜钳道（TTS）方式释放支架,16例为经导丝直接释放支架.19例支架放置后1-3d梗阻症状得到缓解或消除,临床有效率为90.5%,平均生存期4.5个月.1例术后出血,予保守治疗而愈.1例术后1个月支架移位,1例术后2个月肿瘤向支架内浸润生长,导致梗阻复发,均予放置第2根支架后缓解.结论 经内镜放置金属支架治疗胃出口、十二指肠和近端小肠恶性梗阻是一种简单可行、安全有效的方法.     

Ectopic pancreas: usual and unusual features

Nine patients with ectopic pancreas in the stomach (8 patients) and duodenum (1 patient) were studied both radiographically and endoscopically. Correct diagnosis was made by radiography in six cases and by endoscopy in seven cases. Masses radiographically larger than 3 cm in diameter were seen in three patients. The incorrect radiographic diagnoses were related to the presence of a large mass in one patient and to the complications of severe bleeding and gastric outlet obstruction in the other two. Endoscopy and radiography are complementary modalities in the diagnosis of ectopic pancreas.     

Videolaparoscopy gastrectomy for complicated peptic ulcer: technique and case report

Since the introduction of H2 receptor antagonists and inhibitors of the acid pump, the indications for the surgical management of peptic disease have decreased significantly. However some patients presenting bleeding, perforation, gastric outlet obstruction and intractable peptic ulcer still need surgical treatment. The first laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world. The aim of this study was to present a case of totally laparoscopic Billroth II gastrectomy and to describe an alternative technique using endoscopic stapling devices. We present a case of a 48-year-old man, complaining of severe epigastralgia, who had a 20-year history of peptic ulcer. Gastroscopy had revealed a duodenal ulcer and a deformity of the bulbus. A diagnosis of intractable peptic ulcer was made, and the patient underwent laparoscopic Billroth II gastrectomy with side-to-side intracorporeal gastrojejunostomy using endoscopic stapling devices. On postoperative day 1, he was able to walk. On postoperative day 3, he started on a clear liquid diet and was discharged on postoperative day 6. During his postoperative recovery, the patient experienced little pain and did not request narcotic analgesia. Laparoscopic gastric resection is an alternative to open procedure in well selected cases.     

Hemoperitoneum secondary to spontaneous rupture of metastatic gastric leiomyosarcoma of the liver: Report of a case.

Hepatic rupture with resulting hemoperitoneum due to metastatic cancer is uncommon. Reports in the literature have described a wide variety of neoplasms causing this usually fatal phenomenon. We describe a rare case of spontaneous rupture of hepatic metastases from gastric leiomyosarcoma. A 72-year-old male patient with sudden onset severe epigastric pain was rushed into emergency service. After examination, the patient underwent urgent operation withe possible diagnosis of perforated gastric or duodenal ulcer. During exploration, we determined bleeding mass on the diaphragmatic side of the left lobe of the liver and a mass on the posterior wall of the stomach. Hemostasis was provided.     

Splenic Vein Thrombosis as a Consequence of Chronic Pancreatitis: A Study of Three Cases

Splenic vein obstruction was found in three patients with chronic pancreatitis. All had suffered epigastric pain, but no specific findings which suggested obstruction of the splenic vein were evident on physical or laboratory examinations. Enlarged pancreatic contour with calculi and pseudocyst formation were observed by CAT scan in all three cases. Gastric varices were found in two patients who had episodes of gastric bleeding. The splenic vein was shown to be occluded in two patients in the venous phase of celiac angiography and was entirely nonvisualized by percutaneous portography in the third case. The first patient underwent elective surgery, while the second patient had emergency surgery due to intraabdominal abscess formation with gastric bleeding. The surgical procedure in both patients was splenectomy coupled with distal pancreatectomy. Thrombus formation was confirmed by venous dissection at surgery.     

Hemorrhagic radiation gastritis after chemoradiation therapy for peritoneal lymph node metastasis of esophageal carcinoma successfully treated with repeated intraarterial steroid infusions

Although intraarterial steroid infusion therapy has previously been shown to be effective for inflammatory bowel disease, it has not yet been applied for the treatment of hemorrhagic radiation gastritis. We report herein a case of hemorrhagic radiation gastritis of gastric tube that occurred after chemoradiation therapy for postoperative peritoneal lymph node metastasis in a patient with esophageal carcinoma who had a history of esophagectomy reconstructed with a gastric tube. The hemorrhagic gastritis that occurred in the gastric tube was successfully treated with repeated intraarterial steroid infusions through the regional vessels to the reconstructed gastric tube. A 70-year-old Japanese woman received chemoradiation therapy for metastatic lymph nodes of the celiac axis. Four weeks after completion of chemoradiation therapy, acute persistent bleeding occurred in the gastric mucosa of the reconstructed gastric tube in the irradiated area. Despite application of available therapeutic modalities, her persistent bleeding was intractable, and a total of 50 units of blood transfusion was required to improve progressive anemia. Finally, intraarterial steroid infusion therapy was applied through the right gastroepiploic artery supplying the main blood flow to the gastric tube. Three repeated intraarterial steroid infusions through the right gastroepiploic artery were effective, and hemostasis was finally completed soon after the last dose of intraarterial steroid was given. This case highlights the clinical importance and significance of hemorrhagic radiation gastritis of the reconstructed gastric tube with posterior mediastinal route occurring after chemoradiation therapy. Repeated intraarterial steroid infusion could be one option that appears clinically useful to treat intractable bleeding from radiation gastritis.     

Impact of unusual gastrointestinal problems on the treatment of tricyclic antidepressant overdose

We report the cases of two patients with tricyclic antidepressant overdose in which the use of charcoal was hampered by gastrointestinal abnormalities. In the first patient, a previous gastric bypass procedure impeded the placement of an orogastric tube and subsequent charcoal administration, while potentially facilitating rapid absorption of the drug--factors that may have contributed to her death. In the second patient, severe esophageal spasm delayed therapy until IV nitroglycerin relieved the functional obstruction. Both circumstances are previously unreported complications associated with tricyclic antidepressant overdose. Potentially corrective measures are proposed.     

Severe paraneoplastic gastroparesis associated with anti-Hu antibodies preceding the manifestation of small-cell lung cancer

Gastroparesis is a common but challenging disorder which can be idiopathic or induced by a variety of underlying diseases, most frequently by diabetes, or post-surgical conditions of the upper abdomen. Clinicians must also consider rare causes of gastric motor dysfunction, such as collagen vascular disorders and paraneoplastic syndromes. Here we present the case of a patient with severe gastroparesis, who was admitted to our hospital for vomiting and weight loss of 25 kg within four months. Endoscopy showed a dilated fluid-filled stomach without peristalsis but no obstruction. High titres of anti-Hu antibodies were detected in patient's serum, supporting the diagnosis of severe paraneoplastic gastroparesis with chronic intestinal pseudo-obstruction. Fine-needle aspiration of suspicious mediastinal lymph nodes guided by endoscopic ultrasound revealed lymphatic metastases of a small-cell lung carcinoma. Jejunal tube feeding and chemotherapy with carboplatin and etoposide were initiated. Paraneoplastic gastrointestinal dysmotility is rare, however, clinicians should consider this differential diagnosis in otherwise unexplained gastrointestinal motor dysfunction. The pathophysiology of paraneoplastic gastroparesis, the diagnostic relevance of anti-Hu antibodies as well as therapeutic options are discussed.     

A critical appraisal of indications for endoscopic placement of nasojejunal feeding tubes

BACKGROUND: Postpyloric feeding is indicated whenever nutritional intake is compromised because of impaired gastric emptying. Although guidelines concerning this feeding modality are available it remains unclear whether these are applied in clinical practice. We therefore evaluated the indications provided by applicants for endoscopic placement of nasojejunal feeding tubes at our centre. METHODS: A prospective study was conducted in patients who were referred for endoscopic nasojejunal-feeding tube placement in a 950-bed Dutch university hospital. State-of-the-art criteria for nasojejunal tube placement comprised severe gastro-oesophageal reflux, gastroparesis leading to aspiration, gastric stasis not responding to prokinetics, gastroduodenal obstruction or proximal enteric fistulae. The study endpoint was met if the feeding tube was no longer needed or had to be replaced, or if the patient was discharged from the hospital or died. RESULTS: During a four-month observation period, 131 patients were enrolled, of whom 57% came from intensive care units. Tube placement only met at least one of the mentioned criteria in the hospital protocol in 59% of all cases, while in intensive care patients a lower proportion was observed (50%, p. <0.05). In the latter group, in 35% of all cases no increased gastric residues had been measured at all. CONCLUSION: Although directives are at hand that provide clear indications for endoscopic placement of nasojejunal feeding tubes, our data show that these guidelines are frequently not followed in clinical practice. These findings suggest that supervised implementation of established guidelines might reduce the strain on both patients and the hospital's resources.     

重型脑损伤上消化道溃疡出血的防治

目的 探讨应用氢氧化铝凝胶与山莨菪碱注射剂等混合后早期鼻饲，防治重型颅脑损伤患者上消化道出血的疗效。方法 重型颅脑损伤患者1113例分为3组。对照组410例，伤后72d内无任何预防上消化道出血措施；A组540例使用胸脉或管喂甲氰咪胍，雷尼替丁，奥美拉唑；B组163例，管喂氢氧化铝凝胶和山莨菪碱混合剂163例。比较3组上消化道出血的发生率。结果 B组上消化道出血的发生率为1．25％，与A组和对照组比较（P＜0．01）均明显降低，需输血治疗例数及其用血量和死亡率也有同步下降。全组未发现管喂药物后所导致的胃肠返流。结论 氢氧化铝疑胶与山莨菪碱注射剂等混合后早期鼻饲对防治重型颅脑损伤消化道出血具有重要临床应用价值。     

CLINICAL INVESTIGATION OF UPPER GASTROINTESTINAL HEMORRHAGE AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background: Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG. Patients and Methods: We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement. Results: Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement‐related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement‐related hemorrhage and one patient each with reflux esophagitis and gastric ulcer. Conclusions: Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.     

Massive postoperative hemorrhage from hepatic artery erosion.

A 66-year-old male patient who had undergone repeated operations for peptic ulcer disease involving the right upper abdominal quadrant, developed cholecystitis with calculous obstruction of the common bile duct. The gallbladder was removed. Later, an operation was performed for removal of a residual stone from the common duct. At this time an anomalous arterial structure was noted about the duct. Hemorrhage occurred ten days postoperatively, and the anomalous hepatic artery was found to be eroded. The bleeding was controlled. During the succeeding two weeks there were four episodes of bleeding (involving erosion of the hepatic artery and adjacent tissues), three of which were controlled. The fourth episode ended in the death of the patient from exsanguination secondary to bleeding from stress ulcers in the gastric remnant. At no time did the laboratory data unequivocally indicate an abnormality of blood coagulation. Erosion of the anomalous cystic artery apparently precipitated the fatal chain of events.     

Treatment of bleeding from portal hypertensive gastropathy by portacaval shunt

Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submucosal veins without inflammation. During 1988 to 1993,12 patients with biopsy-proven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding from severe portal hypertensive gastropathy. Eleven patients had been hospitalized for bleeding three to nine times previously, and one was bleeding uncontrollably for the first time. Requirement for blood transfusions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertensive gastropathy. Admission findings were ascites in 9 patients, jaundice in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had previously received repetitive endoscopic sclerotherapy for esophageal varices, which has been reported to precipitate portal hypertensive gastropathy. Eight patients had failed propranolol therapy for bleeding. Portacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean portal vein—inferior vena cava pressure gradient from 251 to 16 mm saline. There were no operative deaths, and two unrelated late deaths after 13 and 24 months. During 1 to 6.75 years of follow-up, all shunts remained patent by ultrasonography, the gastric mucosa reverted to normal on serial endoscopy, and there was no gastrointestinal bleeding. Recurrent portal-systemic encephalopathy developed in only 8% of patients. Quality of life was generally good. It is concluded that portacaval shunt provides definitive treatment of bleeding portal hypertensive gastropathy by eliminating the underlying cause, and makes possible prolonged survival with an acceptable quality of life.     

Prolapse of Foley Catheter Gastrostomy Tube Causing Obstructive Jaundice

A patient with Foley catheter tube gastrostomy was seen with vomiting and jaundice resulting from the prolapse of the tube into the jejunum. Repositioning of the catheter resulted in complete resolution of symptoms. Migration of the inflated balloon of a Foley gastrostomy tube, causing high intestinal obstruction and gastrointestinal bleeding, has been reported. Obstructive jaundice is another rare but reversible complication.