Duodenal variceal bleeding in patients with portal hypertension due to cirrhosis or other causes is uncommon. We report on a case of a 55-year-old male with an ectopic variceal rupture at the distal fourth part of the duodenum who presented with massive hematochezia and shock. Shortly after achievement of hemodynamic stability, due to the limitation of an endoscopic procedure, we initially attempted to find the bleeding focus by abdominal computed tomography, which showed tortuous duodenal varices that drained into the left gonadal vein. He was treated with first-line balloon-occluded retrograde transvenous obliteration (BRTO), resulting in a favorable long-term outcome without rebleeding three years later. This case suggests that BRTO may be a first-line therapeutic option for control of ruptured duodenal varices, especially at a distal location.
Balloon Occlusion ; Duodenal Diseases/*diagnosis/radiography/therapy ; Embolization, Therapeutic ; Gastrointestinal Hemorrhage/therapy ; Humans ; Male ; Middle Aged ; Tomography, X-Ray Computed

Complicating intramural hematoma is an interesting, relatively unusual condition. Various etiologic factors have been described, with the most common being blunt trauma, anticoagulant therapy, Henoch-Sch nlein purpura and blood dyscrasias. Most intramural hematomas resolve spontaneously with conservative treatment, and the prognosis is good. However, if the abdominal pain or obstruction does not resolve with medical management over seven to ten days, complications such as infarction or peritonitis may occur, and surgical intervention might be required. We report a case of intramural hematoma of duodenum treated with percutaneous drainage and embolization of bleeding focus which was complicated with acute pancreatitis after anticoagulation treatment in a patient with recurrent history of deep vein thrombosis. In addition, we reviewed reports of intramural hematoma of the duodenum and treatment strategies.
Adult ; Anticoagulants/therapeutic use ; Catheterization ; *Drainage ; Duodenal Diseases/*diagnosis/*therapy ; Fluoroscopy ; Hematoma/*diagnosis/*therapy ; Humans ; Male ; Thrombolytic Therapy ; Tomography, X-Ray Computed

Intramural duodenal hematoma is an uncommon condition, which usually develops after blunt abdominal trauma. It is also reported as a complication of anticoagulant therapy, blood dyscrasia, pancreatic disease, and diagnostic and therapeutic endoscopy. The typical clinical pictures of intramural duodenal hematoma consist of upper abdominal pain, vomiting, fever, and hematochezia, and it is rarely accompanied by intestinal obstruction, peritonitis, and pancreatitis as its complication. We report a case of intramural duodenal hematoma extended to peritoneal cavity, and accompanied by acute pancreatitis following therapeutic endoscopy for duodenal ulcer bleeding in a 32-year-old man who was on maintenance of anti-coagulation therapy after valvular heart surgery.
Acute Disease ; Adult ; Diagnosis, Differential ; Duodenal Diseases/*diagnosis/pathology/surgery ; Duodenal Ulcer/*complications ; Hematoma/*diagnosis/pathology/surgery ; *Hemostasis, Endoscopic ; Humans ; Male ; Pancreatitis/complications/*diagnosis ; Peptic Ulcer Hemorrhage/*therapy ; Postoperative Complications ; Tomography, X-Ray Computed

OBJECTIVETo summarize the experience with duodenal perforations to determine a systematic management approach.

METHODSA total of 11 250 patients who received endoscopic retrograde cholangiopancreatography(ERCP) in The First People's Hospital of Hangzhou from January 2005 to December 2011 and 15(0.13%) patients developed duodenal perforation. The clinical data of these 15 cases were analyzed.

RESULTSThere were 6 males and 9 females. The age ranged from 45 to 87 years. Seven patients developed perforation after sphincterotomy of the duodenal papilla. Five patients perforated due to the endoscope, and 3 due to guide wire and net basket. All the patients presented varying degree of abdominal pain and distention. CT scan of the upper abdomen showed peripancreatic and retroperitoneal air or fluid. Diagnosis was confirmed in 7 patients using abdominal X-ray. Eight patients developed postoperative abdominal pain and distention, subcutaneous emphysema, and fever 3 hours to 5 days after surgery, and diagnosis was confirmed using plain abdominal X-ray or upper abdominal CT scan. Nine patients were managed conservatively, 4 of whom were diagnosed within 3 hours after perforation and were managed by endoscopic metal clip and nasobiliary drainage and no abdominal abscesses developed. The length of hospital stay ranged from 10 to 15 days. Five patients were diagnosed 10 hour to 5 days after perforation, of whom 2 had intestinal fistula, 4 had abscess, and one died, the length of hospital stay ranged from 15 to 105 days. Six patients were managed surgically, 4 received surgery within 4 to 8 hours after perforation and no abscess developed, and the length of hospital stay ranged from 18 to 21 days. The other 2 patients were operated at 24 hours and 30 hours after perforation respectively, one of whom had recurrent intra-abdominal bleeding after surgery and one died from intra-abdominal abscess and multiple organ failure.

CONCLUSIONSFor duodenal perforations related to ERCP, early diagnosis can be made by prompt intraoperative identification and postoperative CT scan. Endoscopic metal clip and nasobiliary drainage should be considered aside from surgical intervention.

Aged ; Aged, 80 and over ; Cholangiopancreatography, Endoscopic Retrograde ; adverse effects ; Duodenal Diseases ; diagnosis ; etiology ; therapy ; Female ; Humans ; Intestinal Perforation ; diagnosis ; etiology ; therapy ; Male ; Middle Aged ; Retrospective Studies

Endoscopic retrograde biliary drainage (ERBD) is useful for the palliative decompression of biliary obstruction. However, the complications of ERBD include cholangitis, hemorrhage, acute pancreatitis, obstruction of the stent, and duodenal perforation. Pressure necrosis on the duodenal mucosa by the stent may contribute to perforation. Although duodenal perforation following ERBD is very rare compared to other complications, it can result in a fatal outcome. Recent reports describe nonsurgical treatment for small gastrointestinal perforation with localized peritonitis and suggest that endoclipping may be appropriate in the management of a well selected group of patients with iatrogenic perforation. We describe a case of duodenal perforation secondary to ERBD that was successfully treated with approximating using endoclip and detachable snare.
Bile Ducts, Extrahepatic ; Biliary Tract Diseases/complications/surgery ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenal Diseases/*diagnosis/etiology/therapy ; Female ; Gallbladder Neoplasms/diagnosis ; Humans ; Intestinal Perforation/*diagnosis/etiology/therapy ; Middle Aged ; Plastics ; Stents/*adverse effects ; Tomography, X-Ray Computed

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10X5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.
Drainage ; Duodenal Diseases/*diagnosis/pathology/surgery ; Endoscopy, Digestive System ; Female ; Gastrointestinal Hemorrhage/*etiology/therapy ; Hematoma/*diagnosis/pathology/surgery ; Humans ; Intestinal Obstruction/*etiology/therapy ; Middle Aged ; Tomography, X-Ray Computed

A human Echinostoma hortense infection was diagnosed by gastroduodenoscopy. An 81-year-old Korean male, living in Yeongcheon-shi, Gyeongsangbuk-do and with epigastric discomfort of several days duration, was subjected to upper gastrointestinal endoscopy. He was in the habit of eating fresh water fish. Two live worms were found in the duodenal bulb area and were removed using an endoscopic forcep. Based on their morphological characteristics, the worms were identified as E. hortense. The patient was treated with praziquantel 10 mg/kg as a single dose. The source of the infection in this case remains unclear, but the fresh water fish consumed, including the loach, may have been the source. This is the second case of E. hortense infection diagnosed by endoscopy in Korea.
Aged ; Aged, 80 and over ; Animals ; Duodenal Diseases/*diagnosis/drug therapy/parasitology ; Echinostoma/*growth & development ; Echinostomiasis/*diagnosis/drug therapy/parasitology ; Endoscopy, Gastrointestinal ; Female ; Fishes/parasitology ; Food Parasitology ; Human ; Korea ; Male ; Praziquantel/therapeutic use

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.
Cyanoacrylates/therapeutic use ; Duodenal Diseases/diagnosis/etiology/*therapy ; Duodenum/*blood supply ; Endoscopy, Gastrointestinal ; Gastrointestinal Hemorrhage/etiology/*therapy ; Humans ; Male ; Middle Aged ; Portal Vein ; Rupture ; Sclerosing Solutions/therapeutic use ; *Sclerotherapy ; Tomography, X-Ray Computed ; Varicose Veins/complications/*therapy

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.
Abdominal Pain ; Aged, 80 and over ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangiopancreatography, Magnetic Resonance ; Cholangitis/complications ; Diverticulum ; Duodenal Diseases/complications/*diagnosis ; Female ; Fluoroscopy ; Gallstones/diagnosis/therapy ; Humans ; Jaundice, Obstructive/*complications ; Tomography, X-Ray Computed

BACKGROUND/AIMS: Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment. METHODS: We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed. RESULTS: PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9+/-11.1 years. Mean diameter of the stones was 14.8+/-6.0 mm and mean diameter of CBD was 21.6+/-7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (> or =15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups. CONCLUSIONS: PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.
Age Factors ; Aged ; Aged, 80 and over ; *Balloon Dilation ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct/anatomy & histology ; Diverticulum/*diagnosis ; Duodenal Diseases/*diagnosis ; Female ; Gallstones/surgery/*therapy ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome