A 41-year-old caucasian female, with past medical history of pituitary adenoma medicated with cabergoline, presented with worsening dyspepsia and unintentional weight loss of 5%. Physical exam and laboratory results were unremarkable for pathological findings. Esophagogastroduodenoscopy revealed an oedematous and exuberant lymphangiectasia appearance in the duodenum, with no ulceration or suspected infiltration component (figure 1 - A/B). However, duodenal biopsies revealed infiltration by poorly differentiated carcinoma (figure 1 - C/D). In the meantime, infection and inflammatory/autoimmune causes were ruled out. A CT scan was performed revealing a thickened and enlarged pancreas with ill-defined limits and several intra-abdominal adenopathies, raising suspicion of pancreatic lymphoproliferative disease. EUS with FNB was performed with biopsy of the pancreas and one of the larger adenopathy. EUS also revealed an enlarged, non-nodular pancreas and a thickened duodenal wall. Mild ascites was detected. Both EUS-biopsies were concordant on the diagnosis of carcinoma with gastric or pancreatic-biliary origin, highly aggressive (Ki67>80%). Therefore, the diagnosis of pancreatic adenocarcinoma was assumed (cT4N1Mx). The patient is currently on palliative chemotherapy and remains paucisymptomatic.

Arteriovenous malformation (AVM) of the pancreas is an uncommon disease, which can cause an abdominal pain. This disease is characterized by a tangled vascular network, including the whole or part of the pancreas, resulting in portal hypertension by forming a shunt of the pancreas arteries to drain directly into the portal venous system. This study presents a case that was suspected as AVM of the pancreas by preoperative contrast-enhanced computed tomography scan (CT). A 49-year-old male patient had several episodes of abdominal discomfort associated with dyspepsia for 4 days. Magnetic resonance imaging showed enhancement of the conglomeration about 1.5 cm size in diameter in the pancreas. Selective angiography showed the proliferation of a vascular network in the pancreas and an early visualization of the portal vein during the arterial phase. Distal pancreatectomy with splenectomy was done. Histology of the pancreas showed AVM, with enzymatic fat necrosis extending to the capsule of the pancreas. The patient recovered successfully without postoperative complications. Surgical resection of pancreas is the definitive treatment for symptomatic AVM.

The authors describe 6 children with pancreas ectopy to the gastric wall. Their age was between 8 and 14 years. The main clinical and endoscopic signs were: prolonged pain, dyspepsia and a "polyp" in pyloroantral part of the stomach. In 4 of 6 children the pancreas ectopy to the gastric wall was suspected. All patients had been operated on. The indications for surgery were the following: severe pain with no effect of conservative therapy, suspicion for "polyp" malignancy and ulceration, bleeding. In one patient Bilroth-1 resection has been performed and in 2 cases sectoral dissection of the gastric wall pancreatic ectopy has been done. In 3 patients enucleation of the ectopic pancreas was performed. All patients had ineventful postoperative period. The pancreas ectopy in children is an indication for the surgery because of severe pain and possibility of severe complications. The surgery relieves pain and provides recovery.

Heterotopic pancreas (HP) is a relatively infrequent lesion most often found in the stomach. In the majority of cases, HP does not cause symptoms, but it can occasionally present as dyspepsia and upper gastrointestinal bleeding. This report describes the case of a 40-year-old man with gastric outlet obstruction resulting from HP in gastric antrum.

BACKGROUND

Cystic and neuroendocrine pancreatic neoplasms are quite rare tumors which diagnosis is often difficult due to their non specific symptomatology and limited diagnostic accuracy of conventional diagnostic instruments. Their treatment is still controversial.

METHODS

A young woman is admitted with abdominal pain and dyspepsia. Instrumental diagnosis reveals a cystic pancreatic lesion which seems to be malignant as CEA of pancreatic liquid is increased. The patient undergoes distal spleno-pancreatectomy and postoperative histological examination found IPMN associated with MCN and furthermore there was occasional diagnosis of a small neuroendocrine tumor in the pancreatic tail.

CONCLUSIONS

A correct diagnostic approach is indispensable for a correct therapeutic approach. Radical surgical treatment is indicated in all cases of main- and branch duct IPMN and in case of MCN with signs of malignant transformation. Surgical treatment is also the gold standard for pancreatic neuroendocrine tumors if they are singular and in M0 stage.

CONCLUSIONS

In case of cystic and neuroendocrine neoplasms of the pancreas the preoperative diagnostic approach is often not enough to obtain a definite diagnosis. Review of literature and this case report show that a definite diagnosis can only be done after postoperative histological examination. Recent prospective studies suggest the possibility for a follow up instead of surgical treatment for some neuroendocrine tumors.

The patient was a 63-year-old male who came to our hospital with the chief complaints of dyspepsia and abdominal fullness. Endoscopic findings showed Type 3 gastric cancer with pyloric stenosis. CT examination revealed a large amount of peritoneal fluid, invasion to the pancreas, peritoneal dissemination and paraaortic lymph node metastasis. Intraperitoneal administration of weekly CDDP 10 mg/body was in vain, and combined chemotherapy of paclitaxel and 5-fluorouracil was carried out. Ascites was significantly reduced and oral intake became possible two courses after this regimen. The tumor decreased in size after 3 courses, and the tumor markers returned to within normal limits. The patient was then discharged, and followed as an outpatient thereafter. Endoscopic examination showed improvement in narrowing of the antrum. However,tumor invasion to pancreas, peritoneal dissemination and lymph node metastasis relapsed. He died one year and one month after the onset.

BACKGROUND

The so called post-cholecystectomy syndrome is common, intractable, often progressive, causes prolonged suffering, and has no approved treatment. It usually presents with episodic biliary pains (colics), and postprandial dyspepsia (bloating and indigestion). Because treating a very recalcitrant case with lovastatin provided prolonged remission, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors were given to 12 subsequent patients with similar symptoms.

OBJECTIVE

To determine whether HMG-CoA reductase inhibitors are useful in the therapy of post-cholecystectomy biliary pain and dyspepsia.

METHODS

Open clinical trial in an internal medicine, private practice setting; data were collected from the patients' charts and from telephone interviews, five years after the index case had been treated.

RESULTS

Eight of 12 patients experienced total resolution of their symptoms after many years of suffering; response occurred slowly within the first three months of treatment. Two other patients responded, stopped their medications, relapsed, and continue to be symptomatic. One patient did not take her medication and remains symptomatic; one other patient did not respond, was diagnosed with carcinoma of the pancreas, and died from it.

CONCLUSIONS

These preliminary results suggest that HMG-CoA reductase inhibitors may be useful in relieving the symptoms of this common and intractable disorder. Controlled studies are needed.

BACKGROUND

The most common malignancy to cause gastric outlet obstruction is primary gastric adenocarcinoma and it is followed by carcinoma of the pancreas and gallbladder. Herein, we report a case of gastric outlet obstruction secondary to metastatic lobular breast carcinoma.

METHODS

Fifty-seven year old Caucasian female with recently diagnosed metastatic lobular breast carcinoma to skin was referred to gastroenterology for evaluation of dyspepsia and dysphagia. She has past medical history significant for acid reflux and Clostridium difficile colitis. Computed tomography of her abdomen showed diffused bowel wall thickening without evidence of bowel obstruction. Due to persistent abdominal pain, an upper endoscopy was performed. The upper endoscopy showed gastritis and gastric stenosis in the gastric antrum. These lesions were biopsied and dilated with a balloon dilator. The biopsy of the gastric antrum later showed a metastatic carcinoma of breast origin with typical tumor morphology and immune-phenotype.

CONCLUSIONS

Differentiating metastatic breast carcinoma from primary gastric adenocarcinoma cannot be done using histological examination alone. Immunohistochemistry is needed to differentiate the two based on staining for estrogen and progesterone receptors. The presence of gross cystic disease fluid protein 15 is also suggestive of metastatic breast carcinoma. The stomach has a significant capacity to distend (up to 2-4 L of food) and malignant gastric outlet obstruction is often undetected clinically until a high-grade obstruction develops. Our case demonstrates valuable teaching point in terms of broadening our differentials for gastric outlet obstruction. When patients present with gastric outlet obstruction, both non-malignant and malignant causes of gastric outlet obstruction should be considered. Once adenocarcinoma has been determined to be the cause of gastric outlet obstruction, further immunohistochemistry is needed to differentiate breast carcinoma from other carcinomas.

Objective In symptom-dependent diseases such as functional dyspepsia (FD), matching the pattern of epigastric symptoms, including severity, kind, and perception site, between patients and physicians is critical. Additionally, a comprehensive examination of the stomach, duodenum, and pancreas is important for evaluating the origin of such symptoms. Methods FD-specific symptoms (epigastric pain, epigastric burning, early satiety, and postprandial fullness) and other symptoms (regurgitation, nausea, belching, and abdominal bloating) as well as the perception site of the above symptoms were investigated in healthy subjects using a new questionnaire with an illustration of the human body. A total of 114 patients with treatment-resistant dyspeptic symptoms were evaluated for their pancreatic exocrine function using N-benzoyl-L-tyrosyl-p-aminobenzoic acid. Results A total of 323 subjects (men:women, 216:107; mean age, 52.1 years old) were initially enrolled. Most of the subjects felt the FD-specific symptoms at the epigastrium, while about 20% felt them at other abdominal sites. About 30% of expressed as epigastric symptoms were FD-nonspecific symptoms. At the epigastrium, epigastric pain and epigastric burning were mainly felt at the upper part, and postprandial fullness and early satiety were felt at the lower part. The prevalence of patients with pancreatic exocrine dysfunction was 71% in the postprandial fullness group, 68% in the epigastric pain group, and 82% in the diarrhea group. Conclusion We observed mismatch in the perception site and expression between the epigastric symptoms of healthy subjects and FD-specific symptoms. Postprandial symptoms were often felt at the lower part of the epigastrium, and pancreatic exocrine dysfunction may be involved in the FD symptoms, especially for treatment-resistant dyspepsia patients.

The prevalence of pancreatic diseases as the cause for dyspepsia differs in clinical materials between 0 and 25-30%. In parallel, the incidence rate of chronic pancreatitis varies between 0.7 and 10 per 100,000 inhabitants per year. The correct figures are unsettled. The main reason for the great variability in figures for frequency of chronic pancreatitis is probably the different clinical awareness and variable practice for performing morphological and functional studies of the pancreas in patients with dyspepsia. Epidemiologic data indicate, but do not prove, an increasing frequency of chronic pancreatitis at least valid for the alcoholic chronic pancreatitis. Pancreatic function and pancreatic disease are probably connected to different gastro-intestinal diseases (duodenal ulcer, inflammatory bowel diseases, malabsorption syndromes, subtotal and total gastrectomy and to some extent in patients with hepatobiliary diseases). The prevalence of chronic pancreatitis can be calculated to around 70 per 100,000 inhabitants in the Western world. Around one-third of these present with exocrine pancreatic insufficiency. The demand for enzyme substitution based on marked exocrine pancreatic insufficiency in patients with chronic pancreatitis, pancreatic cancer and mucoviscidosis can be calculated to approximately 150 patients per 1 million inhabitants. The question concerning the analgetic effect of pancreatic enzyme substitution is still unsettled.

Somatostatinomas are rare pancreatic endocrine neoplasms (PEN). We present a case of a PEN in a 63-year-old lady having diabetes mellitus, cholelithiasis, steatorrhea, weight loss, indigestion, nausea and fatigue. Ultrasonography revealed a large calcified mass occupying the liver, pancreas and emboli in the splenic vein. Fine needle aspiration cytology (FNAC) of the metastatic mass in the liver showed features of neuroendocrine tumor. Correlating the clinical picture, computed tomography and cytological findings, a diagnosis of pancreatic somatostatinoma was suggested. Serum somatostatin levels and biopsy findings confirmed the same. The patient was put on chemotherapeutic agents and octreotide and is doing well after two years of follow-up. We discuss the FNAC findings of pancreatic endocrine tumors and its differentiating features from hepatoma and other small round cell tumors.

OBJECTIVE

There are several varieties of bilioenteric fistulae. The vast majority of fistulas result from chronic cholelitiasis disease. Other relatevely common causes are chronic duodenal ulcer disease, previous instrumentation to the biliary system, chronic bowel inflammatory disease, traumatism, infections.

METHODS

The case of a 58-year-old patient is reported in whom one of the rare complications of longstanding duodenal ulcer, the cholecystoduodenal fistula, has occurred. Main symptoms were rapid weight loss (20 kg/3 months), abdominal pain, dyspepsia, vomiting. Perivisceral peritonitis developed a tumefaction (diam: 5 cm) involving duodenum, pancreas, biliary tract and gallbladder. That finding closely simulated a neoplasm evaluating it by CT scan, US scan and even in explorative laparotomy: tumefaction was impossible to isolate, so a duodenocefalopancreasectomy was performed.

OBJECTIVE

To evaluate the feasibility of laparoscopic and endoscopic cooperative partial gastrectomy,a minimally invasive surgery, in treating gastric submucosa lesion.

METHODS

We retrospectively analyzed 63 patients [34 women and 29 men, aged (52.8±18.1) years (range:14 to 78 years)] who had undergone laparoscopic and endoscopic cooperative partial gastrectomy with preserving cardia and pylorus for gastric submucosal tumor in the past 6 years. All of the patients were followed up for 2-69 months (average 35 months). The clinicopathological data, surgical approaches, and follow-up results were analyzed.

RESULTS

The surgery was successfully performed in all these 63 patients, among whom 61 were assisted by endoscopy. The most common symptom was dyspepsia. The mean distance from the lesions locating at fundus or antrum to cardia or pylorus was(2.9±1.1)cm. The minimum distance from tumor edge to cardia was 1cm. The diseases included gastrointestinal stromal tumor (n=54), carcinoid tumors (n=3), ectopic pancreas (n=2), lipoma (n=2), and leiomyoma (n=2). The tumor size ranged from 0.8 to 8.2cm, with 44 lesions (69.8%) less than 2cm. Forty-five lesions(71.4%) were located at fundus, 12 (19.0%) at body, and 6 (9.6%) at antrum. No recurrence or death was noted during follow-up.

CONCLUSIONS

Laparoscopic and endoscopic cooperative partial gastrectomy is feasible for treating gastric submucosal tumor. Endoscopy is useful for intraoperative localization and supporting, and therefore is especially helpful for preserving cardia and pylorus.

OBJECTIVE

To study the surgical management of solid-pseudopapillary tumor of the pancreas (SPTP) and its characteristics of outcome.

METHODS

Fifty-eight patients with SPTP of the pancreas admitted from January 2001 to December 2010 were retrospectively analyzed. There were 7 male and 51 female patients, with an average age of 30 years (ranging 9 to 70 years). Most patients were symptomatic before admission; the most common symptom was abdominal pain. Of the 58 patients, 21 patients underwent pancreaticoduodenectomy, 30 patients underwent distal pancreatectomy, 6 patients underwent central pancreatectomy, 1 patient underwent simple tumor enucleation, and 1 patients underwent duodenum-preserving pancreatic head resection.

RESULTS

The average length of stay in hospital was 23.8 days (ranging 12 to 64 days). Thirteen patients (22.4%) developed postoperative complications, including grade A postoperative pancreatic fistula of 8 cases, gastrointestinal tract bleeding of 1 case, pleural effusion of 2 cases, wound infection and fat liquefaction of 2 cases. Two patients underwent reoperation due to gastrointestinal tract bleeding or wound infection. There was no hospital death. Forty-four patients were followed-up for 7 to 136 months with an average of 41 months. All the 44 patients were alive, while 8 patients developed dyspepsia and 4 patients developed diabetes mellitus. There were no tumor recurrences or metastasis.

CONCLUSIONS

SPTP is found primarily in young women. Excellent prognosis would be achieved with surgical resection.

BACKGROUND

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract and occur rarely in the duodenum. Splenic angiosarcoma is an aggressive neoplasm with an extremely poor prognosis.

METHODS

We report a case of a 70-year-old man hospitalized for abdominal pain in the upper quadrants, dyspepsia and nausea, previously treated for Hodgkin lymphoma 30 years ago. Abdominal CT showed a solid nodular lesion in the third portion of the duodenum, the presence of retropancreatic, aortic and caval lymph nodes, and four nodular splenic masses. (111)In-octreotide scintigraphy revealed pathological tissue accumulation in the duodenal region, and in the retropancreatic, retroduodenal, aortic and caval lymph nodes, suggesting a nonfunctioning neuroendocrine peripancreatic tumor.

RESULTS

At exploratory laparotomy, an exophytic soft tumor was found originating from the third portion of the duodenum. Pancreas-preserving duodenectomy with duodenojejunostomy, splenectomy and lymphnodectomy of retropancreatic aortic and caval lymph nodes were performed. Pathological evaluation and immunohistochemical studies showed the presence of a duodenal gastrointestinal stromal tumor with low mitotic activity and a well-differentiated angiosarcoma localized to the spleen and invading lymph nodes.

CONCLUSIONS

We speculated that the angiosarcoma and duodenal gastrointestinal stromal tumors of this patient were due to the treatment of Hodgkin lymphoma with radiotherapy 30 years ago. Pancreas-preserving segmental duodenectomy can be used to treat non-malignant neoplasms of the duodenum and avoid extensive surgery. Splenectomy is the treatment of choice for localized angiosarcomas but a strict follow-up is mandatory because of the possibility of recurrence.

Pancreatic hydatid cyst is a rare disease found mostly in endemic regions. Having no specific clinical signs, it may present with tension related abdominal pain, dyspepsia, a palpable mass, and signs of external pressure on the surrounding organs in accordance with localization of the lesion. Pancreatic carcinoma as a neoplastic pathology with poor prognosis can have various clinical presentations changing with localization of the tumor which sometimes has cystic components. Due to the distinct nature of these pathologies, surgical approach can be fairly different. In this report, we present a case of a 70-year-old patient who had an isolated hydatid cyst in the tail of the pancreas with an incidental pancreatic carcinoma in the corpus of the pancreas. The patient was treated with a subtotal pancreatectomy, having no problems in the postoperative period leading to uncomplicated discharge.

Functional abdominal pain may often be sonographically attributed to the colon. Typically a segment of the colon is painful at direct palpation, but the wall is not thickened. The contractions between the haustra are often marked. The haustra are clearly outlined and cast acoustic shadows. If the patient also experiences spontaneous pain in this region, functional colonic pain, explained as spasms of the muscle coat, may be assumed. Clinically there are often other symptoms of the irritable bowel disease or a spastic constipation. In daily practice functional colonic pain is as frequent as dyspepsia. Differential diagnosis includes intestinal (peptic ulcer, Crohn's disease, appendicitis, diverticulitis, colon cancer) and extraintestinal diseases (e.g. of the gallbladder, pancreas and female adnexes).

BACKGROUND

Somatostatinoma is a rare, slowly growing tumor with malignity potential, most commonly located in the pancreas or duodenum. By the time its diagnosis is established, it is usually large and liver metastases are present. Increased concentrations of somatostatin, produced by pancreatic D cells or by intestinal mucosa, inihibit secretion of a number of GIT hormones, endocrine and exocrine pancreatic secretion. The clinical findings include symptoms of diabetes, dyspepsia, diarrhoea, steatorhoea, abdominal pain, hypochlorhydria, anemia. Sometimes, the finding is accidental.

UNASSIGNED

The authors present a case of somatostatinoma, detected accidentaly in a 72-year-old male. The tumor originated from the pancreatic head, partially spreading invasively into surrounding organs (duodenum), invading blood vessels and metastazing into peripancreatic lymphonodes. The tumor was asymptomatic and was detected as an accidental finding on ultrasound and CT abdominal examinations for the patient's urological disorder (vesicolithiasis). Pylorus saving hemipancreatoduodenectomy was performed and, on microscopic and subsequent immunohistochemical examination of the resecate, a well- differentiated endocrine, somatostatin- producing pancreatic carcinoma was verified.

Annular pancreas is a rare embryonal abnormality. Its manifestation in adulthood is often pinpointed with a substantial delay, which is most often attributed to pancreatitis, biliary pathology or dyspepsia. We present a case of a 28-year-old woman who had exacerbating symptoms of high bowel obstruction from 20th week of pregnancy, progressing after premature delivery. Diagnostic work-up revealed partial annular pancreas compressing the duodenum. Despite attempts of conservative treatment, her state deteriorated to such an extent that surgery was indicated and gastrojejunal bypass created. Her postoperative recovery was uneventful. In cases in which symptoms of high bowel obstruction in pregnancy persist and prostration occurs, we suggest close monitoring and a more thorough diagnostic approach. The question remains whether annular pancreas presents a cause of pathologic findings, a cofactor, or a mere accidental diagnosis in the development of superposed pathologies.

Minor degrees of pancreatic insufficiency may go unrecognized. There is a paucity of symptoms and physical findings in mild and moderate degrees of insufficiency and in such circumstances laboratory methods are necessary to determine the presence of insufficiency. The clinical picture when insufficiency is well established may be characterized by loss in weight; vague indigestion; voluminous, light-colored, glistening stools in which fat globulets may be seen; changes in the concentration of pancreatic enzymes in the blood indicative of lowered pancreatic function; diminished amounts of pancreatic enzymes in the duodenal juice, and the related poor digestion of fat and protein in the food. Lowered tolerance of carbohydrate, as found in diabetes mellitus, may or may not be present. The location and character of the disease in the pancreas causing the insufficiency may or may not be apparent.

Dyspepsia is a common symptom among patients in family medicine practice. The prevalence in adult population is about 40%. Two-thirds of patients have functional dyspepsia. Clinical assessment, diagnostic procedures and treatment of patients depend on the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impact of other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommended in patients with newly detected dyspepsia older than 50 and presenting with alarming symptoms. In persons younger than 50, the recommended strategy is ‘test and treat’. In some patients, treatment is carried out by acid suppression. In patients failing to achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantly contribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presenting with symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment of patients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits and psychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychological morbidity, as well as his efforts in healthy behavior.

This paper describes a 6-year-old Simmental bull with diabetes mellitus. The animal was referred to our clinic because of severe weight loss and chronic indigestion. Clinical examination revealed markedly disturbed general condition, impaired forestomach function and polyuria. There was aciduria, glucosuria and ketonuria. The most important biochemical findings were severe hyperglycemia, markedly increased activities of hepatic enzymes and severe metabolic acidosis. Plasma concentrations of insulin, insulin-like growth factor-I, thyroxine and 3,5,3'-triiodothyronine were lower than normal, whereas those of glucagon were higher than normal. Based on these findings, a diagnosis (secondary) diabetes mellitus was made. The bull was slaughtered and histological examination revealed mixed cell pancreatitis with severe degeneration of islet cells. Immunohistochemical examination of the pancreas showed that very few insulin-, glucagon-, somatostatin- and pancreatic polypeptide, insulin-like growth factor-I and adrenomedullin-producing islet cells were present.