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Adult presentation of a congenital duodenal diaphragm
Brief Reports
Abbreviation: PD, pancreatic duct.
REFERENCES 1. Neoptolemos JP, London NJM, Carr-Locke DL. Assessment of the main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. Br J Surg 1993;80:94-9. 2. Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 1991;100:1362-70. 3. Thomas H, Madanur M, Bartlett A, et al. Pancreatic traumad12-year experience from a tertiary center. Pancreas 2009;38:113-6. 4. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568-75. 5. Huckfeldt R, Agee C, Nichols WK, et al. Nonoperative treatment of traumatic pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996;41:143-4. 6. Pederzoli P, Bassi C, Falconi M, et al. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with continuous intravenous infusion of somatostatin, glucagon or calcitonin. Surg Gynecol Obstet 1986;163:428-32.
7. Lansden FT, Adams DB, Anderson MC. Treatment of external pancreatic fistulas with somatostatin. Am Surg 1989;55:695-8. 8. Garcia-Puges AM, Navarro S, Fernandez-Cruz L, et al. Oral pancreatic enzymes accelerate closure of external pancreatic fistulae. Br J Surg 1988;75:924-5. 9. Telford JL, Farrell JJ, Saltzman JR, et al. Pancreatic stent placement for ductal disruption. Gastrointest Endosc 2002;56:18-24. 10. Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of six cases. Gastrointest Endosc 2004;59:100-7.
Division of Gastroenterology, Hepatology, and Nutrition (S.T.C., J.M., K.M., A.S., M.K.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Reprint requests: Michael K. Sanders, MD, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 3708 Fifth Avenue, Pittsburgh, PA 15213. Copyright ª 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.08.017
Adult presentation of a congenital duodenal diaphragm Damien Loh, MBBS, Trevor Leese, MD, FRCS, Sven Anders Heidelberg, Victoria, Tasmania, Australia
CASE REPORT Congenital duodenal diaphragms usually present in infancy or childhood. Adult presentation is rare. We report a late presentation of duodenal diaphragm in a 43-yearold woman. Our patient presented with a 3-month history of vomiting solids. The vomiting had become more frequent. It contained no bile. She had lost 30 kg in weight and now weighed 50 kg (body mass index 19.3). Her serum albumin level was normal, and she was not dehydrated but was anemic; amenorrhea had developed. She was noted to have duodenal stenosis on a previous endoscopy. This was assumed to be secondary to peptic stricture, and she was being treated with a proton pump inhibitor. There was no evidence of Helicobacter pylori on serology or urease testing. At our hospital, repeat endoscopy revealed food debris in a dilated stomach. The first part of the duodenum was markedly dilated but was not otherwise deformed. There was no duodenitis or gastritris and no evidence of H pylori on urease testing. In the second part of the duodenum, above the level of the ampulla of Vater, a diaphragm was noted to be causing near-total duodenal obstruction. There was an eccentric 3-mm aperture in the diaphragm (Fig. 1). Laparotomy was performed through a midline incision, and the duodenum was mobilized. A dilated stomach and
first part of duodenum was confirmed with muscular hypertrophy consistent with chronic obstruction. The second and third parts of the duodenum were collapsed with normal muscle thickness. At the junction between dilated and
654 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 3 : 2010
www.giejournal.org
Figure 1. Endoscopic appearance of a duodenal diaphragm with an eccentric 3-mm aperture.
Brief Reports
nondilated duodenum, there was no palpable stricture and no fibrosis or deformity. A longitudinal duodenotomy across the area revealed a thin friable diaphragm that was easily broken down with the fingers. The duodenotomy was then closed transversely. The patient made an uneventful recovery. Vomiting ceased, and she rapidly regained the lost weight.
DISCUSSION Adult duodenal obstruction is usually secondary to peptic stricture and is most often encountered at the pylorus or in the first part of the duodenum. Other causes of duodenal obstruction are rare and include malignant obstruction caused by pancreatic or duodenal cancer or benign strictures caused by Crohn’s disease, tuberculosis, or potassium therapy. Acquired duodenal diaphragm has been reported after long-term use of nonsteroidal anti-inflammatory drugs,1 but our patient had no history of anti-inflammatory therapy. Congenital duodenal diaphragm is a rare cause of duodenal obstruction in adults.2 Congenital duodenal occlusion presenting as a neonatal emergency may be caused by a diaphragm or a complete obliteration of the duodenal lumen. Complete obliteration may result from vascular occlusion in utero. A diaphragm may represent incomplete vacuolation of the proliferating epithelial lining of the duodenum between the sixth and eighth weeks of gestation.1 If the occlusion caused by the diaphragm is complete, symptoms appear from birth. In some cases, a lumen persists in the diaphragm, and presentation is delayed. The lumen is rarely wide enough to avoid symptoms or for symptoms to be delayed until adult life. The history in adults is usually one of persistent vomiting and weight loss. Twenty adult patients with duodenal web were reported in a large series of congenital duodenal anomalies from one center in the United States.3 The onset of symptoms in adult life seems to be the effect of progressive decompensation of the peristaltic force of the stomach and proximal duodenum.
Many open or laparoscopic procedures have been used in the surgical treatment of duodenal diaphragm, but longitudinal duodenotomy with excision of the diaphragm and transverse closure of the duodenotomy is the most prevalent. If the diagnosis can be made with confidence, it may be possible to avoid surgery with endoscopic obliteration of the diaphragm by using balloon dilation or endoscopic resection of the thin membrane.4 Visualization of the second and third parts of the duodenum at endoscopy is important to avoid missing this rare but important pathology.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
REFERENCES 1. Rha SE, Lee JH, Lee SY, et al. Duodenal diaphragm associated with longterm use of nonsteroidal anti-inflammatory drugs. AJR Am J Roentgenol 2000;175:920-1. 2. No authors listed. Duodenal diverticulum. Br Med J 1972;2:482. 3. Ladd AP, Madura JA. Congenital duodenal anomalies in the adult. Arch Surg 2001;136:576-84. 4. Okamatsu T, Arai K, Yatsuzuka M, et al. Endoscopic membranectomy for congenital duodenal stenosis in an infant. J Pediatr Surg 1989; 24:367-8.
Department of General Surgery (D.L.), Austin Health, Heidelberg, Victoria, Department of General Surgery (D.L., T.L., S.A.), North West Regional Hospital, Tasmania, Australia. Reprint requests: Damien Loh, MBBS, Department of General Surgery, Austin Health, Studley Road, Heidelberg, Victoria 3084, Australia. Copyright ª 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.08.012
Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature Sameer R. Islam, MD, Mohamed N. Attaya, BS, Sreeram Parupudi, MD, Ebtesam A. Islam, PhD, Nicholas D’Cunha, MD, Safaa Labib, MD, David Hodges, MD, Kenneth Nugent, MD Lubbock, Texas, USA
Colonic plasmacytomas are a rare manifestation of a myeloma malignancy, with fewer than 25 cases reported. We report such a case occurring in the sigmoid colon mimicking symptoms of colon cancer and review the literature. Aware-
ness of this complication in patients with multiple myeloma is important in providing early diagnosis and treatment. We recommend prompt early colonoscopies for symptomatic patients with myeloma.
www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY 655
Abbreviation: PD, pancreatic duct.
REFERENCES 1. Neoptolemos JP, London NJM, Carr-Locke DL. Assessment of the main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. Br J Surg 1993;80:94-9. 2. Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 1991;100:1362-70. 3. Thomas H, Madanur M, Bartlett A, et al. Pancreatic traumad12-year experience from a tertiary center. Pancreas 2009;38:113-6. 4. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568-75. 5. Huckfeldt R, Agee C, Nichols WK, et al. Nonoperative treatment of traumatic pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996;41:143-4. 6. Pederzoli P, Bassi C, Falconi M, et al. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with continuous intravenous infusion of somatostatin, glucagon or calcitonin. Surg Gynecol Obstet 1986;163:428-32.
7. Lansden FT, Adams DB, Anderson MC. Treatment of external pancreatic fistulas with somatostatin. Am Surg 1989;55:695-8. 8. Garcia-Puges AM, Navarro S, Fernandez-Cruz L, et al. Oral pancreatic enzymes accelerate closure of external pancreatic fistulae. Br J Surg 1988;75:924-5. 9. Telford JL, Farrell JJ, Saltzman JR, et al. Pancreatic stent placement for ductal disruption. Gastrointest Endosc 2002;56:18-24. 10. Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of six cases. Gastrointest Endosc 2004;59:100-7.
Division of Gastroenterology, Hepatology, and Nutrition (S.T.C., J.M., K.M., A.S., M.K.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Reprint requests: Michael K. Sanders, MD, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 3708 Fifth Avenue, Pittsburgh, PA 15213. Copyright ª 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.08.017
Adult presentation of a congenital duodenal diaphragm Damien Loh, MBBS, Trevor Leese, MD, FRCS, Sven Anders Heidelberg, Victoria, Tasmania, Australia
CASE REPORT Congenital duodenal diaphragms usually present in infancy or childhood. Adult presentation is rare. We report a late presentation of duodenal diaphragm in a 43-yearold woman. Our patient presented with a 3-month history of vomiting solids. The vomiting had become more frequent. It contained no bile. She had lost 30 kg in weight and now weighed 50 kg (body mass index 19.3). Her serum albumin level was normal, and she was not dehydrated but was anemic; amenorrhea had developed. She was noted to have duodenal stenosis on a previous endoscopy. This was assumed to be secondary to peptic stricture, and she was being treated with a proton pump inhibitor. There was no evidence of Helicobacter pylori on serology or urease testing. At our hospital, repeat endoscopy revealed food debris in a dilated stomach. The first part of the duodenum was markedly dilated but was not otherwise deformed. There was no duodenitis or gastritris and no evidence of H pylori on urease testing. In the second part of the duodenum, above the level of the ampulla of Vater, a diaphragm was noted to be causing near-total duodenal obstruction. There was an eccentric 3-mm aperture in the diaphragm (Fig. 1). Laparotomy was performed through a midline incision, and the duodenum was mobilized. A dilated stomach and
first part of duodenum was confirmed with muscular hypertrophy consistent with chronic obstruction. The second and third parts of the duodenum were collapsed with normal muscle thickness. At the junction between dilated and
654 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 3 : 2010
www.giejournal.org
Figure 1. Endoscopic appearance of a duodenal diaphragm with an eccentric 3-mm aperture.
Brief Reports
nondilated duodenum, there was no palpable stricture and no fibrosis or deformity. A longitudinal duodenotomy across the area revealed a thin friable diaphragm that was easily broken down with the fingers. The duodenotomy was then closed transversely. The patient made an uneventful recovery. Vomiting ceased, and she rapidly regained the lost weight.
DISCUSSION Adult duodenal obstruction is usually secondary to peptic stricture and is most often encountered at the pylorus or in the first part of the duodenum. Other causes of duodenal obstruction are rare and include malignant obstruction caused by pancreatic or duodenal cancer or benign strictures caused by Crohn’s disease, tuberculosis, or potassium therapy. Acquired duodenal diaphragm has been reported after long-term use of nonsteroidal anti-inflammatory drugs,1 but our patient had no history of anti-inflammatory therapy. Congenital duodenal diaphragm is a rare cause of duodenal obstruction in adults.2 Congenital duodenal occlusion presenting as a neonatal emergency may be caused by a diaphragm or a complete obliteration of the duodenal lumen. Complete obliteration may result from vascular occlusion in utero. A diaphragm may represent incomplete vacuolation of the proliferating epithelial lining of the duodenum between the sixth and eighth weeks of gestation.1 If the occlusion caused by the diaphragm is complete, symptoms appear from birth. In some cases, a lumen persists in the diaphragm, and presentation is delayed. The lumen is rarely wide enough to avoid symptoms or for symptoms to be delayed until adult life. The history in adults is usually one of persistent vomiting and weight loss. Twenty adult patients with duodenal web were reported in a large series of congenital duodenal anomalies from one center in the United States.3 The onset of symptoms in adult life seems to be the effect of progressive decompensation of the peristaltic force of the stomach and proximal duodenum.
Many open or laparoscopic procedures have been used in the surgical treatment of duodenal diaphragm, but longitudinal duodenotomy with excision of the diaphragm and transverse closure of the duodenotomy is the most prevalent. If the diagnosis can be made with confidence, it may be possible to avoid surgery with endoscopic obliteration of the diaphragm by using balloon dilation or endoscopic resection of the thin membrane.4 Visualization of the second and third parts of the duodenum at endoscopy is important to avoid missing this rare but important pathology.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
REFERENCES 1. Rha SE, Lee JH, Lee SY, et al. Duodenal diaphragm associated with longterm use of nonsteroidal anti-inflammatory drugs. AJR Am J Roentgenol 2000;175:920-1. 2. No authors listed. Duodenal diverticulum. Br Med J 1972;2:482. 3. Ladd AP, Madura JA. Congenital duodenal anomalies in the adult. Arch Surg 2001;136:576-84. 4. Okamatsu T, Arai K, Yatsuzuka M, et al. Endoscopic membranectomy for congenital duodenal stenosis in an infant. J Pediatr Surg 1989; 24:367-8.
Department of General Surgery (D.L.), Austin Health, Heidelberg, Victoria, Department of General Surgery (D.L., T.L., S.A.), North West Regional Hospital, Tasmania, Australia. Reprint requests: Damien Loh, MBBS, Department of General Surgery, Austin Health, Studley Road, Heidelberg, Victoria 3084, Australia. Copyright ª 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.08.012
Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature Sameer R. Islam, MD, Mohamed N. Attaya, BS, Sreeram Parupudi, MD, Ebtesam A. Islam, PhD, Nicholas D’Cunha, MD, Safaa Labib, MD, David Hodges, MD, Kenneth Nugent, MD Lubbock, Texas, USA
Colonic plasmacytomas are a rare manifestation of a myeloma malignancy, with fewer than 25 cases reported. We report such a case occurring in the sigmoid colon mimicking symptoms of colon cancer and review the literature. Aware-
ness of this complication in patients with multiple myeloma is important in providing early diagnosis and treatment. We recommend prompt early colonoscopies for symptomatic patients with myeloma.
www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY 655