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Hemangiopericytoma: an unusual cause of upper gastrointestinal hemorrhage.
Hemangiopericytomas, first described in 1942, are rare, highly vascular neoplasms that arise from capillary pericytes. They are seen most commonly as a painless mass arising from the lower extremity but can also originate in the pelvic retroperitoneum and on the head, neck, chest, and abdomen. An unusual case is reported here of a patient presenting with recurrent massive upper gastrointestinal (GI) bleeding in whom a large hemangiopericytoma was found arising in the perisplenic soft tissues. Precedence exists in the literature for the association of hemangiopericytoma with GI bleeding. In prior reports, however, a mural origin of the tumor and subsequent bleeding into the GI lumen was demonstrated. In the case presented here, marked dilatation of the gastric and splenic vessels was noted, but there was no direct pathologic involvement of the stomach wall. It is proposed that superficial gastric erosions combined with the tumor-associated increased vascularity within the stomach wall led to recurrent major bleeding. Diagnosis of these tumors roentgenographically is nonspecific, but angiography is helpful. Morphological characteristics allow accurate histopathological diagnosis and provide prognostic information. The treatment of choice remains wide surgical excision, with the addition of radiation or chemotherapy in selected cases.
Peroral prostheses for palliating malignant esophageal and gastric obstruction.
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[Anastomotic stenoses correlated with the use of mechanical staplers in the surgery of esophageal cancer].
From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.
[Reflux esophagitis and cicatricial stenosis of the muff-like esophageal-small intestine anastomosis after performing a gastrectomy for stomach cancer].
In the late follow-up period after gastrectomy conduction for gastric cancer using antireflux muff-like esophago-jejunal anastomosis 587 patients were examined. Mild reflux esophagitis was revealed in 29 (4.9%), moderate--in 9 (1.5%) of patients. Cicatricial stenosis of anastomosis have occurred in 127 (8.5%) of patients, including an early one--in 70.1% and the late--in 29.9%. The dilation using tubular bougies, passed along the guide, proved effective in the treatment of early stenosis. The stenosed part was cut through the endoscope with subsequent bougienage for the late stenosis.
[Gastric rupture secondary to barotrauma in the framework of a diving accident. Apropos of a case report and literature review].
Gastric perforation secondary to barotrauma is rare. The case of a diver suffering from gastric rupture due to a decompression accident is presented here. This rupture was a linear one, localized on the lesser curvature and responsible for a large pneumoperitoneum. Rupture occurs with an excluded stomach, a condition implying cardio-pyloric occlusion. The expansion of intra-gastric air, further worsened by accelerated surfacing provokes excessive gastric dilatation leading to partial or complete rupture (by virtue of the Boyle-Mariotte law: Pressure x Volume = constant). The lesion is always on the lesser curvature. However, it is often difficult to locate, even when peroperative gastroscopy is performed.
Gastric rupture in horses: a review of 54 cases.
The historical, clinical, laboratory, surgical and necropsy findings in 54 cases of gastric rupture in horses are described. Eleven per cent of the deaths of horses undergoing exploratory coeliotomy for colic during the period of the study were a result of gastric rupture. Comparison with all horses which had exploratory coeliotomies for colic over an eight year period did not show that horses with gastric rupture were different from these reference horses regarding age, breed or season. There were fewer stallions than expected in the gastric rupture group. Horses with histories of both acute and chronic (more than 36 h) colic were susceptible to gastric rupture. Primary and idiopathic causes of gastric dilation and rupture accounted for about one-third of the horses. All but one of these cases resulting from secondary causes fell into three aetiologically-related groups: obstructive, peritoneal and enteric, with approximately equal numbers of horses in each group. Most of the ruptures occurred along the greater curvature of the stomach. At least six horses ruptured their stomachs postoperatively in the presence of an indwelling nasogastric tube. The presence or absence of gastric reflux following nasogastric intubation was not a reliable indicator, on its own, of gastric dilation. Horses that later died from gastric rupture had markedly elevated heart rate, hypochloraemia, peritoneal exudative effusion (particularly with evidence of sepsis), pre- and/or postoperative gastric reflux and small or large intestinal disease. However, no distinctive feature of these horses was shown to place them at risk of gastric rupture.
Diffuse leiomyomatosis of the esophagus: a case report and review of the literature.
A case of diffuse leiomyomatosis of the esophagus in a 21-year-old woman with a 5-year history of dysphagia is presented. The radiological appearance was that of achalasia, but at esophagoscopy, a diagnosis of an organic stricture of the lower end of the esophagus was made. During the operation a diffuse tumor involving the lower end of the esophagus, cardia, upper portion of the stomach, and the tail of the pancreas was found. The histological diagnosis was diffuse leiomyomatosis of the esophagus. The individual characteristics of the microscopic picture are described. Distal esophagectomy and total gastrectomy resulted in complete recovery of the patient. This is a very rare condition; only a dozen similar cases have been published before. The data of these patients are presented.
Study on the role of gastric Helicobacter infection in gross pathological and histological lesions of the stomach in finishing pigs.
The prevalence of gastric Helicobacter infection in finishing pigs and the influence of this infection on gastric lesions was studied. Stomachs of 89 finishing pigs from 27 randomly selected herds were sampled at the slaughterhouse. Forty cases (Group A) were selected based upon the presence of gross pathological lesions in the pars oesophagea, and further 49 cases were obtained at random (Group B). Three samples of gastric tissue (junction of pars oesophagea and pars cardiaca, fundic area, and pyloric area) were collected from each stomach for histological and immunohistochemical examination. Helicobacter antigen was detected in 76 cases (85.4%). No association was found between the presence of Helicobacter in the stomach and the occurrence of gross pathological lesions in the pars oesophagea or gastritis detected on histological examination. However, a significant association was found between the occurrence of Helicobacter in the pyloric area and the presence of erosions/ulcers in the pars oesophagea (OR: 7.01, p = 0.022) in Group B. A significant association was also evident between the presence of Helicobacter and glandular lesions (dilatation of the glands + glandular abscess + degeneration of glandular epithelial cells). In conclusion, Helicobacter infection seems to be a contributing factor to pathological changes in the stomach of finishing pigs.
[A case of gastric hamartomatous inverted polyp (submucosal tumor type) accompanied by gastric cancer].
Endoscopic examination of a 39-year-old woman revealed a flat-elevated submucosal tumor (SMT) in the upper third area of the stomach and a IIc lesion in the anterior wall of the lower third of the stomach. Endoscopic ultrasonography findings suggested an aberrant pancreas. Both lesions were resected by distal gastrectomy. Histological examination of the SMT revealed the dilated glands with cyst formation and proliferation of smooth muscle bundles in the submucosal layer, and it was diagnosed as a gastric hamartomatous inverted polyp. The IIc lesion was a signet ring cell carcinoma. Cases of gastric hamartomatous inverted polyps coexistent with gastric cancer have been rarely reported in Japan.
Gastric hypomotility in Duchenne's muscular dystrophy.
In Duchenne's muscular dystrophy, functional impairment of smooth muscle in the gastrointestinal tract can cause acute gastric dilatation and intestinal pseudo-obstruction that may be fatal. We describe a patient with this syndrome who at autopsy had smooth-muscle degeneration of the stomach. To provide objective evidence of functional smooth-muscle impairment in Duchenne's dystrophy, we performed gastric-emptying studies in 11 patients and 11 normal controls, using technetium-99m radionuclide scintigraphy in a test meal of oatmeal. The patients with Duchenne's dystrophy had delayed gastric-emptying times (118.18 +/- 32.21 minutes [mean +/- SEM]) as compared with controls (42.5 +/- 3.4 minutes, P less than 0.01). The cause of the pathological and functional abnormalities we describe in smooth muscle is unknown but may be a deficiency of dystrophin, the recently identified gene product of the Duchenne's muscular dystrophy locus.
Total gastric transposition: an alternative to esophageal replacement in children.
Total gastric transposition was performed in 21 children as an alternative procedure for esophageal replacement. The age at the operation ranged from 15 months to 11 years. Half of the children were less than 2 years old. Fifteen patients had esophageal atresia. The stomach was passed toward the neck either through the esophageal bed (6 cases, with concomitant blunt esophagectomy without thoracotomy) or the retrosternal route (15 cases). There was one death in the early postoperative period secondary to an anastomotic leak and acute mediastinitis in a case of pharyngogastric anastomosis. Three other patients developed cervical leak with spontaneous closure but this ultimately led to a late anastomotic stricture (more than 6 months) requiring endoscopic dilatation. Only one child needed more than three attempts of endoscopic dilatation. None of these patients required surgical revision. The mean follow-up was 60 months (range, 10 to 122 months). Despite bulky atonic intrathoracic stomach occurring in some children, only two patients developed regurgitation and symptoms of poor gastric emptying. There were neither early nor late respiratory problems. Excellent and good functional outcome were achieved in 85% and 15% of the patients, respectively. Two patients have not undergone a weight catch-up phase. The majority of the children have been between the 20th and 80th percentile for weight. Five children remain below the 20th and two below the 5th percentile. The remarkably low morbidity and mortality combined with satisfactory functional results indicate that the total gastric transposition is a safe and easy alternative surgical procedure for esophageal replacement in children.
Mechanisms for regulation of gastrin and somatostatin release from isolated rat stomach during gastric distention.
AIM: To investigate the intragastric mechanisms for regulation of gastric neuroendocrine functions during gastric distention in isolated vascularly perfused rat stomach. METHODS: Isolated vascularly perfused rat stomach was prepared, then the gastric lumen was distended with either 5,10 or 15 ml pH7 isotonic saline during a period of 20 min. During the distention, the axonal blocker tetrodotoxin (TTX), the cholinergic antagonist atropine, or the putative somatostatin-antagonist cyclo (7-aminoheptanoyl-Phe-D-Trp-Lys-Thr(Bzl)) were applied by vascular perfusion. The releases of gastrin and somatostatin were then examined by radioimmunoassay. RESULTS: The graded gastric distention caused a significant volume-dependent decrease in gastrin secretion (-183+/-75 (5 ml), -385+/-86 (10 ml) and -440+/-85 (15 ml) pg/20 min) and a significant increase of somatostatin secretion (260+/-102 (5 ml), 608+/-148 (10 ml) and 943+/-316 (15 ml) pg/20 min). In response to 10 ml distention, the infusion of either axonal blocker TTX (10(-6) M) or cholinergic blocker atropine (10(-7) M) had a similar affect. They both attenuated the decrease of gastrin release by approximately 50 %, and attenuated the increase of somatostatin release by approximately 40 %. The infusion of somatostatin-antagonist cyclo (7-aminoheptanoyl-Phe-D-Trp-Lys-Thr (Bzl)) (10(-6)M) attenuated the decrease of gastrin release by about 60 %. Furthermore, combined infusion of the somatostatin-antagonist and atropine completely abolished distention-induced inhibition of gastrin release. CONCLUSION: The present data suggest that distention of isolated rat stomach stimulates somatostatin release via cholinergic and non-cholinergic TTX-insensitive pathways. Both somatostatin and intrinsic cholinergic pathways are responsible for distention-induced inhibition of gastrin release.
Unusual gastric polyp showing submucosal proliferation of glands: case report and literature review.
We report an unusual pedunculated polyp in the stomach in a 41-year-old woman. She was hospitalized because of epigastric discomfort. Endoscopy revealed a polyp with a long stalk in the fundus of the stomach. The polypectomyzed polyp measured 23 x 18 x 9 mm and was characterized by submucosal proliferation of glands and cystic dilatation. The surface of the polyp was covered with gastric mucosa of fundic or pyloric gland type. The glandular structures consisted of various types of lining cells, including pyloric or mucous-neck cell type, surface mucous (foveolar) cell type, parietal-like cells, and somatostatin-positive cells. The submucosal glandular or cystic elements were connected with the overlying gastric mucosa through a defect of the muscularis mucosa, suggesting that this polyp may have been formed by the heterotopic inverted downgrowth of mucous glands into the submucosa. We discuss the histogenesis of this rare polyp and present a review of the literature.
Anastomotic stenoses occurring after circular stapling in esophageal cancer surgery.
BACKGROUND: Circular staplers have reduced the incidence of anastomotic leaks in esophagovisceral anastomosis. However, the prevalence of stenosis is greater with staplers than with manual suturing. The aim of this study was to analyze potential risk factors for the onset of anastomotic stenoses and to evaluate their treatment and final outcome. METHODS: Between 1990 and 1995, 187 patients underwent esophagectomy and esophagogastrostomy with anastomosis performed inside the chest using a circular stapler. RESULTS: Twenty-three patients (12.3%) developed an anastomotic stenosis. The incidence of strictures was inversely related to the diameter of the stapler. Concomitant cardiovascular diseases; morphofunctional disorders of the tubulized stomach, such as those related to duodenogastric reflux; and neoadjuvant chemotherapy were also recognized as significant risk factors. Endoscopic dilatations proved safe and were effective in the treatment of most anastomotic stenoses. CONCLUSIONS: To reduce the risk of anastomotic stenosis after stapled intrathoracic esophagogastrostomy, adequate vascularization of the viscera being anastomized should be maintained, and it is mandatory to use the largest circular stapler suitable. Furthermore, it is essential to reduce the negative inflammation-inducing effects of duodenogastroesophageal reflux to a minimum. Endoscopic dilatations are safe and effective in curing the great majority of anastomotic stenoses.
Esophageal food bolus obstruction: evaluation of extraction and modified push techniques in 75 cases.
BACKGROUND AND STUDY AIMS: Endoscopic extraction is the standard method of treating esophageal food bolus obstructions. The efficacy, efficiency, and safety of various techniques used over a 12-year period were evaluated. PATIENTS AND METHODS: Seventy-five procedures with soft food bolus obstruction were analyzed. If endoscopic extraction failed, or it was determined that alternative techniques would be effective, food was pushed into the stomach by: a) the endoscope tip, with or without a guide wire; or b) the wire-guided Savary dilators. The duration of the procedures included therapeutic Savary dilation (in 61 of 75 cases). RESULTS: Food bolus obstruction was associated with peptic strictures (69%), Schatzki's rings (19%), and tight fundoplications (3 %). No narrowing was seen in 9%. Extraction, scope push and Savary push methods were successful in seven of 16, 48 of 48, and 20 of 20 attempts, respectively. The mean duration, including stricture dilation (+/- 1 standard deviation), for the extraction, scope push and Savary push procedures were 32 (+/- 17), 18 (+/- 14) and 27 (+/- 15) mm, respectively. No cases of perforation, hemorrhage, oxygen desaturation, aspiration, or pneumonia occurred. CONCLUSIONS: Management of esophageal food bolus obstructions by modified push methods and esophageal dilation in the same session appears to be effective, efficient and safe. The methods employed should be individualized for each patient. Push methods require experience and judgment.
[MRI of an afferent loop syndrome presenting as obstructive icterus].
The afferent loop syndrome corresponds to an acute or chronic obstruction of the afferent loop following a partial gastrectomy with Billroth II gastro-jejunal anastomosis. We describe the case of a 77-year-old man with history of partial gastrectomy for peptic ulcer disease performed 31 years ago and currently admitted for jaundice and poor general status. MR imaging showed dilatation of biliary and pancreatic ducts and showed a soft tissue mass between the afferent loop and the residual stomach. Endoscopy showed complete obstruction of the afferent loop by a biopsy-proven adenocarcinoma. The patient died of sepsis shortly after endoscopy of septicemia.
Esophagitis, peptic ulcer and early stricture; non-surgical management.
In the management of esophagitis, peptic ulcer and early stricture, a basic medical program, including correction of dietary abuse, administration of antispasmodics and antacids, and treatment of existing oral infections, should be started promptly. Elevation of the head of the bed approximately six to eight inches helps to prevent acid regurgitation from the stomach, especially at night. In cases of early organic stricture of the lower esophageal segment, gentle, gradual and frequent dilatation of the esophagus may prove helpful. The dilatation should be carried out gradually over a period of weeks. One of the methods for this procedure is the use of bougies graduating in size. By following such a program of medical management and gentle dilatation until the disease entity remains quiescent and stationary, satisfactory results are obtained in a majority of cases and radical (and often disappointing) surgical procedures can be avoided.