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We report a case of intramural haemorrhage in the duodenum, which was diagnosed by endoscopy and clinical findings. The typical endoscopic findings are described and illustrated. Different causes of intramural haemorrhage of the gut are discussed.
A case of lymphangioma of the duodenum is reported, and the literature pertinent to its pathology reviewed. This is the eleventh case reported, and the third in which the diagnosis has been made by endoscopy. The clinical and histological characteristics are important, on account of its presentation and its penetrating character into the neighbouring structures. The characteristics of this tumor seen during endoscopy are discussed.
Report on a 42-year-old patient with extensive heterotopia of gastric mucosa within the first portion of the duodenum which formed the matrix of a hyperplasiogenic polyp.
A 64-year-old woman had gastric heterotopic of the duodenal bulb without any specific complaints. The lesion with irregular excrescence was diagnosed by means of target biopsies through endoscopy, and 3 years later, no noteworthy changes were observed in the endoscopic findings of the lesion, and it was also proved by an endoscopic Congo red test that the excrescence had a function of acid output. This is the second report of congenital heterotopic gastric mucosa of the duodenum which was confirmed not only by histological, but also functional examination.
During the period from January, 1976 to December, 1979 we performed 5000 upper gastrointestinal endoscopic examinations. Of these 650 were for gastrointestinal bleeding. In nine patients we found, endoscopically localized mucosal vascular abnormalities of the stomach and duodenum. Repeated endoscopic examinations were necessary in four cases before the correct diagnosis was made. Three telangiopathies (as we prefer to call them) were found incidentally, and in six cases endoscopy was performed because of gastrointestinal bleeding. In five of the six cases with bleeding, the telangiopathy (TAP) probably was the bleeding lesion. The treatment of choice is endoscopic, either by electrodestruction with mono-polar current, or by removal with a diathermy snare. Neither barium meal x-rays of the upper gastrointestinal tract in five cases, nor exploratory laparotomy in two cases, revealed the telangiopathies. There has been no rebleeding after the treatment, except for one case in which another TAP of the small or large bowel is implicated.
Submucosal lymphangiomas are benign tumors which rarely occur in the gastrointestinal tract. The current report describes the tenth case of a submucosal cavernous-cystic lymphangioma of the duodenum. The diagnosis was made during endoscopy and was confirmed histologically in a biopsy specimen. Following a brief review of the localization and symptoms of submucosal lymphangiomas of the gastrointestinal tract published thus far in the literature, therapeutic considerations are discussed.
Following resection of the head of the pancreas while preserving the duodenum a gastrointestinal haemorrhage was localised by red blood cells labeled in vivo with technetium-99m. The previously performed endoscopy and angiography were normal. The haemorrhage in the region of the pancreatico-jejunal anastomosis was confirmed intraoperatively. If intermittent bleedings are suspected, scintigraphy should be performed as a routine measure besides endoscopy and angiography.
The clinical and radiological features of primary adenocarcinoma of the duodenum are demonstrated by seven histologically confirmed cases. Clinically, obstruction develops following a prolonged uncharacteristic prodromal stage. The radiological findings resemble those of a carcinoma in any other part of the gastro-intestinal tract: polypoid filling defects, ulcers, mural thickening and loss of elasticity. The radiological method of choice is hypotonic duodenography. Sonography and CT are complimentary methods and are of use in postoperative follow-up.
Per-Arnt-Sim (PAS) domain-containing kinases are common in prokaryotes, but a mammalian counterpart has only recently been described. Although the PAS domain of the mammalian PAS kinase (PASK) is closely related to the bacterial oxygen sensor FixL, it is unclear whether PASK activity is changed in mammalian cells in response to nutrients and might therefore contribute to signal transduction by these or other stimuli. Here, we show that elevated glucose concentrations rapidly increase PASK activity in pancreatic islet beta cells, an event followed by the accumulation of both PASK mRNA and protein. Demonstrating a physiological role for PASK activation, comicroinjection into clonal beta cells of cDNA encoding wild-type PASK, or PASK protein itself, mimics the induction of preproinsulin promoter activity by high glucose concentrations. Conversely, anti-PASK antibodies block promoter activation by the sugar, and the silencing of PASK expression by RNA interference suppresses the up-regulation by glucose of preproinsulin and pancreatic duodenum homeobox 1 gene expression, without affecting glucose-induced changes in the levels of mRNAs encoding glucokinase or uncoupling protein 2. We conclude that PASK is an important metabolic sensor in nutrient-sensitive mammalian cells and plays an unexpected role in the regulation of key genes involved in maintaining the differentiated phenotype of pancreatic beta cells.
Exposure of islet beta-cells to elevated glucose concentrations (30 versus 3 mm) prompts enhanced preproinsulin (PPI) gene transcription and the trans-location to the nucleoplasm of pancreatic duodenum homeobox-1 (PDX-1; Rafiq, I., Kennedy, H., and Rutter, G. A. (1998) J. Biol. Chem. 273, 23241-23247). Here, we show that in MIN6 beta-cells, over-expression of p110.CAAX, a constitutively active form of phosphatidylinositol 3-kinase (PI3K) mimicked the activatory effects of glucose on PPI promoter activity, whereas Deltap85, a dominant negative form of the p85 subunit lacking the p110-binding domain, and the PI3K inhibitor LY 294002, blocked these effects. Similarly, glucose-stimulated nuclear trans-location of endogenous PDX-1 was blocked by Deltap85 expression, and wortmannin or LY 294002 blocked the trans-location from the nuclear membrane to the nucleoplasm of epitope-tagged PDX-1.c-myc. By contrast, SB 203580, an inhibitor of stress-activated protein kinase-2 (SAPK2)/p38 MAP kinase, had no effect on any of the above parameters, and PPI promoter activity and PDX-1.c-myc localization were unaffected by over-expression of the upstream kinase MKK6 (MAP kinase kinase-6) or wild-type p38/SAPK2, respectively. Furthermore, no change in the activity of extracted p38/SAPK2 could be detected after incubation of cells at either 3 or 30 mm glucose. These data suggest that stimulation of PI3K is necessary and sufficient for the effects of glucose on PPI gene transcription, acting via a downstream signaling pathway that does not involve p38/SAPK2.
Gastro-intestinal stromal tumours (GIST) are primary mesenchymal tumours arising from the gastro-intestinal tract. They are uncommon visceral tumours, preferentially located in the stomach and small intestine. The present paper will discuss the clinical presentation of GIST in a 32-year-old female (Case 1) and in a 72-year-old female (Case 2). In both cases the tumour is located in the duodenum which appears to be a rather unusual location (4%) for GIST. This work will illustrate that duodenal GIST can occur in extreme presentations, diverging from vague complaints to directly life threatening symptoms.
Intravillous, microcrater, and macroscopic invasive lesions induced in the mouse duodenum by N-ethyl-N'-nitro-N-nitrosoguanidine were examined histochemically. The cells of these neoplastic lesions and the proliferative zones of the normal crypts showed similar staining reactions in leucine aminopeptidase, alkaline and acid phosphatases, adenosine 5'-triphosphatase, and glucose-6-phosphate dehydrogenase. However, a slight decrease in succinic dehydrogenase activity and a slight increase in lactic dehydrogenase activity were observed in the intravillous and microcrater lesions compared to the activity in the proliferative zones of the crypts. The neoplastic cells of these lesions showed no mucus secretion. We discussed the origin of the neoplastic lesions using these and other findings.
Nineteen cases of villous tumors of the duodenum are reported. They have a predilection for the ampullary region, tend to present with obstructive jaundice, especially if malignancy is present, and have a high prevalence of cancer (12 of 19, or 63%). Even when biopsies are available, the diagnosis of cancer is frequently missed (5 of 9 proven cancers, 56% false-negative rate), and it may be impossible to assess the presence of carcinoma in situ or invasive carcinoma without complete excision of the lesion. The authors' experience suggests that some small benign ampullary villous adenomas or those with carcinoma in situ can be excised locally but that pancreaticoduodenectomy is preferable in the fit patient for better local control both of extensive benign lesions and cancers without distant metastases.
Five cases of villous tumors of the duodenum are reported, all of which involve the ampulla of Vater. Three of the five lesions contained either infiltrating carcinoma or carcinoma in situ. Although preoperative endoscopic biopsy was performed on all tumors no malignancy was identified. Frozen sections done at the time of operation on the three patients with carcinoma also failed to identify malignancy. One patient underwent pancreaticoduodenectomy and four patients had local excision of the tumor. Three of the patients treated with local excision developed recurrence and two subsequently had pancreaticoduodenectomy. Because of the difficulty in making an accurate diagnosis and the chance of recurrence when local excision is employed, strong consideration should be given to pancreaticoduodenectomy as the initial form of treatment of these lesions.
The evaluation of gastrointestinal hemorrhage after abdominal trauma may be both urgent and difficult. After gunshot trauma, a fistula between the duodenum and a post-traumatic, hepatic artery pseudoaneurysm presented as a gastrointestinal hemorrhage. Tc-99m labeled RBC imaging demonstrated the pseudoaneurysm but did not show it as the source of the gastrointestinal hemorrhage--a large clot had formed, occluding the fistula. Angiography further delineated the lesion as arising from the right hepatic artery and transcatheter embolization was performed.
Studies on chronic pancreatitis have focused predominantly on pain measurement, morbidity, and mortality. In this prospective follow-up study the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) was reevaluated for patients suffering from chronic pancreatitis. Pain intensity was quantified using a specially designed pain score. Twenty-five patients with chronic pancreatitis underwent duodenum-preserving pancreatic head resection. The QLQ, Spitzer's quality of life index, and the pain score were assessed twice before surgery, before discharge, and 6 and 18 months after surgery. The interscale reliability (Cronbach's coefficient alpha > or = 0.70) was confirmed for all multiitem scales except preoperative working ability. Test-retest stability for the QLQ was 94%. The QLQ correlated closely with Spitzer's quality of life index (r = 0.985, p < 0.001) and changes in body weight (r = 0.764, p < 0.001). After 18 months physical status, working ability, emotional and social functioning, and global quality of life had improved by 44, 50, 50, 60, and 67%, respectively, showing good responsiveness of the QLQ. The pain score decreased by 95% (p < 0.001). The EORTC quality of life questionnaire represents a reliable and valid measure of quality of life in patients with chronic pancreatitis.
A case of intraluminal diverticulum of the duodenum presenting with GI bleeding and associated focal diverticulitis has been added to the 39 other cases of intraluminal duodenal diverticulum previously described in the literature. The patient was treated surgically without difficulty after he was stabilized and evaluated by endoscopy and hypotonic duodenography.
Primary duodenal carcinoma is an uncommon tumor that tends to be diagnosed late in its course because of a symptom complex compatible with many benign diseases. We reviewed the cases of five patients with duodenal adenocarcinoma treated at Norfolk General Hospital from 1973 to 1983. Periampullary tumors were excluded. The most common symptom, nausea and vomiting, was present in four patients, all of whom had microcytic anemia; in three, tests showed blood in stool specimens. The upper gastrointestinal series was suggestive of carcinoma in all patients. One of the lesions was proximal to the ampulla, while the other four were in the third and fourth portions of the duodenum. Only three of the lesions could be seen on upper GI endoscopy, and in only one of the three was the biopsy specimen positive for malignancy. At laparotomy, two patients had resectable lesions, but only segmental resection was done. Three patients had unresectable disease because of liver metastases and/or involvement of the root of the small bowel mesentery. Because delay in diagnosis of duodenal carcinoma may prevent successful resection, greater awareness of the possibility of these uncommon lesions, along with aggressive diagnostic work-up, may result in a higher percentage of cures.