Western blotting in the diagnosis of duodenal-biliary and pancreaticobiliary refluxes in biliary diseases

BACKGROUND: Currently adopted diagnostic methods for duodenal-biliary and pancreaticobiliary refluxes carry many flaws, so the incidence of the two refluxes demands further larger sample size studies. This study aimed to evaluate Western blotting for the diagnosis of refluxes in biliary diseases. METHODS: An oral radionuclide (99)mTc-DTPA test (radionuclide, RN) was conducted for the observation of duodenal-biliary reflux prior to measuring bile radioactivity and Western blotting for detecting bile enterokinase (EK). Pancreaticobiliary reflux was assessed by biochemical and Western blotting tests for biliary amylase activity and trypsin-1, respectively. In accordance with bile sample origin, our samples were classified into ductal bile and gall bile groups; based on each individual biliary disease, we further classified the ductal bile group into five subgroups, and the gall bile group into four sub-groups. Western blotting was conducted to assess the two refluxes in biliary diseases. RESULTS: Consistencies were noted between EK and RN tests when diagnosing duodenal-biliary reflux (P<0.001). The amylase and trypsin-1 tests also showed consistency in diagnosing pancreaticobiliary reflux (P<0.001). Amylase and lipase levels within gall and ductal bile were strongly correlated (P<0.05). In the common bile duct pigment stone group, the EK and trypsin-1 positive rates were found to be insignificant (P>0.05); in the common bile duct cyst group, the EK positive rate was significantly lower than the trypsin-1 positive rate (P<0.05). CONCLUSIONS: Western blotting can accurately reflect duodenal-biliary and pancreaticobiliary refluxes. EK has greater sensitivity than RN for duodenal-biliary reflux. The majority of biliary amylase and lipase comes from the pancreas in all biliary diseases; pancreaticobiliary reflux is the predominant source in the common bile duct cyst group and duodenal-biliary reflux is responsible for the ductal pigment stone group.

Spontaneous intramural duodenal hematoma in type 2B von Willebrand disease

Intramural duodenal hematoma is a rare cause of a proximal gastrointestinal tract obstruction.Presentation of intramural duodenal hematoma most often occurs following blunt abdominal trauma in children,but spontaneous non-traumatic cases have been linked to anticoagulant therapy,pancreatitis,malignancy,vasculitis and endoscopy.We report an unusual case of spontaneous intramural duodenal hematoma presenting as an intestinal obstruction associated with acute pancreatitis in a patient with established von Willebrand disease,type 2B.The patient presented with abrupt onset of abdominal pain,nausea,and vomiting.Computed tomography imaging identified an intramural duodenal mass consistent with blood measuring 4.7 cm×8.7 cm in the second portion of the duodenum abutting on the head of the pancreas.Serum lipase was 3828 units/L.Patient was managed conservatively with bowel rest,continuous nasogastric decompression,total parenteral nutrition,recombinant factorⅧ(humateP)and transfusion.Symptoms resolved over the course of the hospitalization.This case highlights an important complication of an inherited coagulopathy.

Usefulness of duodenal biopsy during routine upper gastrointestinal endoscopy for diagnosis of celiac disease

瞄准：在一张成年西班牙的人口在平淡的上面的胃肠的内视镜检查法期间在十二指肠的活体检视性能描述趋势，并且在临床的实践为乳糜泻的诊断分析它的值。方法：在当承担上面的胃肠的内视镜检查法时，执行的十二指肠的活体检视的 15 年趋势(1990 ～ 2004 ) 被学习。我们与贫血症或长期的腹泻在全面的组，并且在亚群分析了乳糜泻的流行。结果：十二指肠的活体检视在 13 678 上面的胃肠的内视镜检查法(7.6%) 中的 1033 个被执行；这的使用的增加在学习时期上被观察(1.9% 在 1990-1994， 5% 在 1995-1999 并且 12.8% 在 2000-2004 ) 。乳糜泻在 22 个病人(2.2%) 被诊断，这比在男人在女人是更经常的(3% 和 1% 分别地) 。十四从 514 (2.7%) 有贫血症的病人， 12 从 141 (8.5%) 与长期的腹泻并且 8 (19%) 从 42，与贫血症，正长期的腹泻有乳糜泻。一个古典临床的演讲在 55% 盒子中被观察， 23% 病人联系了疱疹样皮炎和 64% 介绍贫血症；9% 被家庭屏蔽诊断并且 5% 由秘密成员基因 hypertransaminasaemia。结论：在成年人在平淡的上面的胃肠的内视镜检查法期间承担的十二指肠的活体检视，逐渐地被合并了到临床的实践，并且是为在象有贫血症或长期的腹泻的那些那样的高风险组的乳糜泻的诊断的一个有用工具。

Acute duodenal Crohn's disease successfully managed with low-speed elemental diet infusion via nasogastric tube:A case report

十二指肠的 Crohn 的疾病是稀罕的，并且没有阻塞的病人是对待的医学上。我们此处报导谁的一个案例十二指肠的 Crohn 的疾病成功地通过一个 nasogastric 试管与低速度的元素的食谱注入被管理。28 岁的女性得了尖锐十二指肠的 Crohn 的疾病。上面的官方补给的放射线学、内视镜的考试在十二指肠冠显示出苛评。用十二指肠的活体检视标本，粘膜 cytokine 层次被测量；interleukin (IL )-1beta, IL-6， IL-8，和肿瘤坏死 factor-alpha 层次显著地被提高。为起始 2 wk，粉状的 mesalazine 口头上地被给，但是它不是有效的。为下一 2 wk，她用商业地可得到的 Elental (TM ) 与低速度的元素的食谱治疗被对待，它用注入泵通过一个 nasogastric 试管连续地被灌输。nasogastric 试管的尖端被放在幽门的一个立即的口头的方面。注入速度是 10 mL/h (平常的速度， 100 mL/h ) 。在 2-wk 治疗以后，她的症状非常被改进，并且内视镜的联盟者，十二指肠的苛评和发炎改善了。十二指肠的粘膜 cytokine 层次显著地在处理前与那些相比减少了。尽管我们的经验是有限的，通过一个 nasogastric 试管的低速度的元素的食谱注入可以是为尖锐十二指肠的 Crohn 的疾病的一个有用处理。

Duodenitis in Systemic Autoimmune Diseases: Pathologist Perspective

Aims: To study the histomorphology of duodenitis associated with systemic autoimmune diseases with clinicopathologic correlation. Patients and Methods: This is a descriptive prospective study. Fifteen patients of autoimmune diseases with duodenitis were included. Informed consent was taken. Histomorphological parameters studied were villous architecture, crypt architecture, intraepithelial lymphocyte (IEL) count per 100 enterocytes, villous tip IEL count per 20 enterocytes were counted, inflammatory cells in lamina propria—lymphocytes, neutrophils, eosinophils, epithelioid cells. Statistical analysis was done using IBM-SPSS software version 21. Results: Fifteen cases of duodenitis associated with autoimmune diseases included 6 patients of systemic lupus erythematosus (SLE), 5 of rheumatoid arthritis, one each of ankylosing spondylitis, systemic sclerosis, dermatomyositis and seronegative reactive arthritis. All these cases were serologically proven. Only 3 (20%) patients had mild villous blunting. Six patients (46.7%) had increased IEL counts. The range of IELs was 8 - 30, mean ± SD was 14 ± 7.6. Range of villous tip IELs was 0 - 8 with mean ± SD of 3.45 ± 2.56. Six patients (46.7%) had increased IEL counts but only 3 patients (20%) had increased villous tip IELs. All patients had moderate increase in lymphoplasmacytic infiltrate in lamina propria. Eosinophils in lamina propria were increased in 46.7% cases.? Conclusion: One of the causes for malabsorptive conditions in adult population in South India is found to be duodenitis associated with autoimmune conditions. We conclude that a combination of clinical, serological, endoscopic and histopathologic features is crucial in arriving at a correct diagnosis.

Application of Percutaneous Endoscopic Gastrojejunostomy in Duodenal Crohn’s Disease-Associated Strictures

Background Duodenal Crohn’s disease(CD)-associated strictures are related to a high risk of malnutrition,and effective methods of enteral nutrition(EN)are needed to support these patients.The purpose of this study was to evaluate the efficacy and safety of percutaneous endoscopic gastrojejunostomy(PEG-J)for the treatment of duodenal CD-associated strictures.Methods Patients with strictures associated with duodenal CD were recruited.The clinical data,stricture characteristics,nutritional status,duration of PEG-J tube placement,complications,and follow up periods were recorded.Results A total of 24 patients with duodenal CD-associated strictures underwent PEG-J tube placement.The PEG-J tubes were successfully placed in 100%of the patients within an average of 19.04±2.94 minutes.There were no procedure-related complications.There were no major complications after PEG-J tube placement,and only two minor complications(8.33%)occurred.PEG-J was well tolerated in all patients.The mean Karnofsky score was 67.50±7.94 points and 83.33±7.02 points(P=0.000),the mean body mass index was 17.02±1.85 kg/m^(2)and 18.10±1.78 kg/m^(2)(P=0.045),and the mean Alb level was 35.28±5.35 g/dl and 38.68±5.10 g/dl(P=0.029)before PEG-J and 3 months after PEG-J,respectively.The median CD Activity Index(CDAI score)was 144(range 87-280)and the median C-reactive protein(CRP)was 1.90 mg/L(0.5-67.9 mg/L)after PEG-J,which were significantly lower than the respective 196 mg/L(range 114-331 mg/L)(P=0.044)and 3.75 mg/L(range 0.5-67 mg/L)(P=0.033)before PEG-J.Conclusion PEG-J was a safe,well-tolerated and effective method for the treatment of duodenal CD-associated strictures.PEG-J improved the patient’s nutritional status and reduced disease CD activity.These findings suggest that PEG-J is an option for EN in patients with duodenal CD-associated strictures.

Evolution of nonspecific duodenal lymphocytosis over 2 years of follow-up

AIM: To assess the evolution of duodenal lymphocytosis(DL), a condition characterized by increased intraepithelial lymphocytes(IELs), over 2 years of follow-up.METHODS: Consecutive patients undergoing upper endoscopy/histology for abdominal pain, diarrhea, weight loss, weakness or other extraintestinal features compatible with celiac disease(CD) were included. Evaluation of IELs infiltrate in duodenal biopsy sampleswas carried out by CD3-immunohistochemistry and expressed as number of positive cells/100 enterocytes. Diagnostic agreement on the IELs count was tested by calculating the weighted k coefficient. All patients underwent serological detection of autoantibodies associated with CD: Ig G and Ig A anti-tissue transglutaminase and endomysium. Each patient underwent further investigations to clarify the origin of DL at baseline and/or in the course of 2 years of follow-up every six months. Autoimmune thyroiditis, intestinal infections, parasitic diseases, bacterial intestinal overgrowth, hypolactasia and wheat allergy were detected. Colonoscopy and enteric magnetic resonance i m a g i n g w e r e p e r f o r m e d w h e n n e c e s s a r y. R i s k factors affecting the final diagnosis were detected by multinomial logistic regression and expressed as OR.RESULTS: Eighty-five patients(16 males, 69 females, aged 34.1 ± 12.5 years) were followed up for a mean period of 21.7 ± 11.7 mo. At baseline, endoscopy/duodenal biopsy, CD3 immunohistochemistry revealed: > 25 IELs/100 enterocytes in 22 subjects, 15-25 IELs in 37 and < 15 IELs in 26. They all had negative serum anti-transglutaminase and anti-endomysium, whilst 5 showed Ig G anti-gliadin positivity. In the course of follow-up, 23 developed CD seropositivity and gluten sensitivity(GS) was identified in 19. Other diagnoses were: 5 Helicobacter pylori infections, 4 jejunal Crohn's disease, 1 lymphocytic colitis and 1 systemic sclerosis. The disease in the remaining 32 patients was classified as irritable bowel syndrome because of the lack of diagnostic evidence. At multivariate analysis, the evolution towards CD was associated with an IELs infiltrate > 25(OR = 1640.4) or 15-25(OR = 16.95), human leukocyte antigen(HLA) DQ2/8(OR = 140.85) or DQA1*0501(OR = 15.36), diarrhea(OR = 5.56) and weakness(OR = 11.57). GS was associated with IELs 15-25(OR = 28.59), autoimmune thyroiditis(OR = 87.63), folate deficiency(OR = 48.53) and diarrhea(OR = 54.87).CONCLUSION: DL may have a multifactorial origin but the IELs infiltrate and HLA are strong predictive factors for CD development and a clinical diagnosis of GS.

EUS mini probes in diagnosis of cystic dystrophy of duodenal wall in heterotopic pancreas:A case report

Cystic dystrophy of the duodenal wall is a rare condition characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal wall. A 38-year-old man was admitted to the hospital for abdominal pain and vomiting after food intake. The diagnosis of acute pancreatitis was initially suspected. Abdominal ultrasound examination revealed thickening of the second portion of duodenal wall within which, small cysts (diameter, less than 1 cm) were present in the vicinity of pancreatic head.The head of pancreas appeared enlarged (63 mm×42 mm)and hypoechoic. Upper endoscopy and barium X-ray series were performed revealing a severe circumferential deformation, as well as 4 cm long stenosis of the second portion of the duodenum. CT examination revealed multiple cysts located in an enlarged, thickened duodenal wall with moderate to strong post-contrast enhancement. We suspected that patient had cystic dystrophy of duodenal wall developed in the heterotopic pancreas and diagnosis was confirmed by endoscopic ultrasound (EUS). Endoscopi cutrasound (EUS) revealed drcular stenosis from the duodenal bulb onwards. A twenty megaHertz mini-probe examination further showed diffuse (intramural) infiltration of duodenal wall limited to the submucosa and muscularis propria of the second portion of duodenum with multiple microcysts within the thickened mucosa and submucosa, a. Patient was successfully surgically treated and pancreatoduodenectomy was performed. The pathological examination confirmed a diagnosis of cystic dystrophy of a heterotopic pancreas.Endoscopic ultrasonography features allow preoperative diagnosis of cystic dystrophy of a heterotopic pancreas in duodenal wall, with inb'alumina120 MHz mini probe sonography being more efficient in cases of luminal stenosis.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

Background:There are no clearly defined indications for pancreas-preserving duodenectomy.The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreaspreserving duodenectomy.Methods:Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included.We divided the series according to indication:scenario 1,primary duodenal tumors;scenario 2,tumors of another origin with duodenal involvement;and scenario 3,emergency duodenectomy.Results:We included 35 patients.Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis,limited duodenectomy in 7,and third+fourth duodenal portion resection in 27.The indications for scenario 1 were gastrointestinal stromal tumor(n=13),adenocarcinoma(n=4),neuroendocrine tumor(n=3),duodenal adenoma(n=1),and adenomatous duodenal polyposis(n=1);scenario 2:retroperitoneal desmoid tumor(n=2),recurrence of liposarcoma(n=2),retroperitoneal paraganglioma(n=1),neuroendocrine tumor in pancreatic uncinate process(n=1),and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage(n=1);and scenario 3:aortoenteric fistula(n=3),duodenal trauma(n=1),erosive duodenitis(n=1),and biliopancreatic limb ischemia(n=1).Severe complications(Clavien-Dindo≥IIIb)developed in 14%(5/35),and postoperative mortality was 3%(1/35).Conclusions:Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors,and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

Endoscopic management of intramural spontaneous duodenal hematoma:A case report

BACKGROUND Intramural duodenal hematoma is a rare condition described for the first time in 1838.This condition is usually associated with blunt abdominal trauma in children.Other non-traumatic risk factors for spontaneous duodenal haematoma include several pancreatic diseases,coagulation disorders,malignancy,collagenosis,peptic ulcers,vasculitis and upper endoscopy procedures.In adults the most common risk factor reported is anticoagulation therapy.The clinical presentation may vary from mild abdominal pain to acute abdomen and intestinal obstruction or gastrointestinal bleeding.CASE SUMMARY The aim of this case summary is to show a case of intramural spontaneous hematoma with symptoms of intestinal obstruction that was properly drained endoscopically by an innovative system lumen-apposing metal stent Hot AXIOS™stent(Boston Scientific Corp.,Marlborough,MA,United States).CONCLUSION Endoscopic lumen-apposing metal stent Hot AXIOS™stent is a safe and feasible treatment of duodenal intramural hematoma in our case.

1例环状胰腺合并十二指肠膜式狭窄超声表现

患儿男,14个月,间断性餐后呕吐胃内容物1年;产前检查无明显异常,外院诊断为“牛奶蛋白过敏”,更换奶粉后症状稍缓解;半年前添加辅食后呕吐加重,伴便秘、腹胀。查体:腹部膨隆,叩诊呈鼓音。实验室检查未见明显异常。

突发重大传染病事件背景下过负荷医院管理研究的范围综述

背景过负荷医院在突发重大传染病事件中发挥重要作用。与其他情况相比,过负荷医院在突发重大传染病事件背景下的管理与运营具有特异性,管理模式的漏洞会造成严重后果,目前尚无相关研究的梳理与总结。目的对突发重大传染病事件背景下过负荷医院管理的研究进行范围审查,以分析医院管理的要素及研究现状,为未来该领域的研究提供指导。方法以Arksey和O’Malley报告的框架和原则及相关学者提供的进一步建议构建方法学框架,检索Pubmed、Embase、Cochrane Library、中国生物医学文献数据库中相关研究,检索时限为建库至2022-06-17。对纳入文献进行汇总和分析。结果纳入25篇文献,均来自于新型冠状病毒感染疫情期间中国方舱医院与定点医院的研究,过负荷医院管理的要素涵盖应急准备、人员管理、运营管理和服务管理。结论对于过负荷医院管理的研究数量增加、研究领域广泛,但研究质量不佳、缺乏统一的评价指标与反馈工具。今后应提高与过负荷医院相关研究质量,制定标准化管理流程,完善评价指标的构建和落实,为临床护理实践提供更多指导。

化学注浆在引汉济渭秦岭输水隧洞施工过程中的应用研究

水工隧洞开挖施工过程中遇到的地下水和松软岩层工程病害问题的治理是输水隧洞工程施工中的主要难题之一。因此,以引汉济渭秦岭输水隧洞工程为背景,针对该隧洞K68+835~K68+851段开挖掌子面及边墙涌水问题,提出采用化学注浆技术进行涌水堵漏处理。首先,对节理密集带2m宽初支进行凿除,准确揭示密集带。其次,给出了涌水堵漏处理区域划分方法、区域注浆堵漏处理顺序以及拱顶、边墙、底板注浆堵漏处理顺序。最后,通过化学注浆技术在引汉济渭秦岭输水隧洞开挖掌子面及边墙涌水问题处理中的成功应用,说明该技术可以做到用于指导化学注浆在输水隧洞施工过程中涌水堵漏处理,为今后类似输水隧洞工程中的涌水堵漏处理提供借鉴。

Effect of the timing of gluten introduction on the development of celiac disease

Celiac disease(CD) is a permanent auto-immune enteropathy,triggered in genetically predisposed individuals by the ingestion of dietary gluten.Gluten is the alcohol-soluble protein component of the cereals wheat,rye and barley.CD is a multifactorial condition,originating from the interplay of genetic and environmental factors.The necessary environmental trigger is gluten,while the genetic predisposition has been identified in the major histocompatibility complex region on chromosome 6p21,with over 90% of CD patients expressing HLA DQ2 and the remaining celiac patients express DQ8.The fact that only about 4% of DQ2/8positive individuals exposed to gluten develop CD,has led to the recognition that other genetic and environmental factors are also necessary.In the last few years,several epidemiological studies have suggested that the timing of the introduction of gluten,as well as the pattern of breastfeeding,may play an important role in the subsequent development of CD.Here,we present and review the most recent evidences regarding the effect of timing of gluten introduction during weaning,the amount of gluten introduced and simultaneous breastfeeding,on the development of CD.

Different risk factors influence peptic ulcer disease development in a Brazilian population

AIM: To investigate age, sex, histopathology and Helicobacter pylori (H. pylori) status, as risk factors for gastroduodenal disease outcome in Brazilian dyspeptic patients.tients submitted to upper gastroscopy at Hospital das Clinicas of Marilia, antral biopsy specimens were obtained and subjected to histopathology and H. pylori diagnosis. All patients presenting chronic gastritis (CG) and peptic ulcer (PU) disease localized in the stomach, gastric ulcer (GU) and/or duodenal ulcer (DU) were included in the study. Gastric biopsies (n = 668) positive for H. pylori by rapid urease test were investigated for vacuolating cytotoxin A (vacA ) medium (m) region mosaicism by polymerase chain reaction. Logistic regression analysis was performed to verify the association of age, sex, histopathologic alterations, H. pylori diagnosis and vacA m region mosaicism with the incidence of DU, GU and CG in patients. RESULTS: Of 1466 patients submitted to endoscopy, 1060 (72.3%) presented CG [male/female = 506/554; mean age (year) ± SD = 51.2 ± 17.81], 88 (6.0%) presented DU [male/female = 54/34; mean age (year) ± SD = 51.4 ± 17.14], and 75 (5.1%) presented GU [male/female = 54/21; mean age (year) ± SD = 51.3 ± 17.12] and were included in the comparative analysis. Sex and age showed no detectable effect on CG incidence (overall c 2 = 2.1, P = 0.3423). Sex [Odds ratios (OR) = 1.8631, P = 0.0058] but not age (OR = 0.9929, P = 0.2699) was associated with DU and both parameters had a highly significant effect on GU (overall c 2 = 30.5, P < 0.0001). The histopathological results showed a significant contribution of ageing for both atrophy (OR = 1.0297, P < 0.0001) and intestinal metaplasia (OR = 1.0520, P < 0.0001). Presence of H. pylori was significantly associated with decreasing age (OR = 0.9827, P < 0.0001) and with the incidence of DU (OR = 3.6077, P < 0.0001). The prevalence of m1 in DU was statistically significant (OR = 2.3563, P = 0.0018) but not in CG (OR = 2.678, P = 0.0863) and GU (OR = 1.520, P = 0.2863). CONCLUSION: In our population, male gender was a risk factor for PU; ageing for GU, atrophy and metapla-sia; and H. pylori of vacA m1 genotype for DU.

Chronic ulcerative gastroduodenitis as a first gastrointestinal manifestation of Hermansky-Pudlak syndrome in a 10-year-old child

A 10-year-old Chinese boy who had a history of congenital thrombocytopathy presented with severe iron deficiency anemia secondary to chronic gastric inflammation and duodenal ulcerations. Subtle oculocutaneous albinism led to the finding of diminished dense bodies in the platelets under electron microscopy, hence the diagnosis of Hermansky-Pudlak syndrome (HPS). Biopsies from the stomach and duodenum revealed a lymphocytic infiltration in the submucosa, but H pylori infection was absent. The gastroduodenitis responded to the treatment with omeprazole while iron deficiency anemia was corrected by oral iron therapy. HPS is a rare cause of congenital bleeding disorder with multisystemic manifestations. Upper gastrointestinal involvement is rare and should be distinguished from a mere manifestation of the bleeding diathesis.

A comparative study of biliary trace elements and clinical phenotypes in Wilson disease

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Study on relationship between acute gastrointestinal disease and Helicobacter pylori infections

Objective: To assess the relation between acute gastrointestinal disease and Helicobacter pylori (H. pylori) infections. Methods: Over the 18-month period, a total of 323 patients referred to three hospitals in Babol (north of Iran) were enrolled in this cross-sectional study. H. pylori status (rapid urease test), endoscopic findings in the patients, personal habits (smoking or alcohol intake) and administration of drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs) were analyzed using standard Chi-square test and multinomial logistic regression analysis. Results: Results showed that acute gastric ulcer patients had a significant association with alcohol (P=0.001, OR=6.183), opium (P=0.022, OR=2.823), smoking (P=0.016, OR=2.579) and NSAIDs (P=0.046, OR=2.071). However, patients with in acute duodenal ulcer have a significant association with opium (P=0.023, OR=2.326) and alcohol (P=0.003, OR=3.888). As well as, gastric cancer had significant association with alcohol (P<0.05, OR=6.937), smoking (P=0.012, OR=2.738), family history (P=0.005, OR=4.380) and gender (P≤0.05, OR=5.103). Conclusions: Current investigation shows that H. pylori infection, alcoholism, male gender, age and family history have an additive impact on the incidence of gastric cancer. In addition, alcoholism, opium usage, NSAIDs and family history have more impact on the incidence of acute gastric ulcer and acute duodenal ulcer in patients.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

AIM To investigate the range of pathologies treated by pancreas preserving distal duodenectomy(PPDD) and present the outcome of follow-up.METHODS Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenumwas transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodenojejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed. RESULTS Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy(PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma(n = 6), adenomas(n = 5), gastrointestinal stromal tumours(n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression(n = 1 each). Median postoperative length of stay(LOS) was 8 d and morbidity was low [pain and nausea/vomiting(n = 2), anastomotic stricture(n = 1), pneumonia(n = 1), and overwhelming postsplenectomy sepsis(n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8(6-14) d vs PD 11(10-16) d, median(IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease(at 2 mo and at 8 years respectively).CONCLUSION PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

以十二指肠溃疡为突出表现的IgG4相关性疾病1例

报告1例以十二指肠溃疡为主要表现的IgG4相关性疾病,以提高对IgG4相关性疾病的认识。患者为70岁男性,因间断皮肤瘙痒、腹痛4年,伴黑便2月余入院。患者4年前因全身瘙痒、腹痛就诊外院,检查血IgG43.09 g/L(参考值0~1.35 g/L)、谷丙转氨酶554 U/L(参考值9~40 U/L)、谷草转氨酶288 U/L(参考值5~40 U/L)、总胆红素54.16μmol/L(参考值2~21μmol/L)、直接胆红素29.64μmol(参考值1.7~8.1μmol/L),均明显升高。腹部CT和磁共振胰胆管造影检查显示胰头及胰尾肿胀,胆总管狭窄,肝内外胆管扩张。诊断IgG4相关性疾病,予醋酸泼尼松40 mg,每日1次。治疗后患者皮肤瘙痒及黄疸消退,后患者停药。2个月前患者出现黑便,血常规提示重度贫血,诊断消化道出血。在外院治疗未见好转来北京医院急诊,胃镜显示十二指肠球部1.5 cm溃疡,给予奥美拉唑治疗后复查仍便潜血阳性。检查正电子发射计算机断层扫描(positron emission tomography-CT,PET-CT)提示十二指肠壁的代谢活性未见明确异常,未发现肿瘤病变,考虑IgG4相关性疾病,为进一步诊治收入北京医院风湿免疫科。患者既往有右侧颌下腺肿物切除术及糖尿病。入院后检查血IgG45.44 g/L(参考值0.03~2.01 g/L),腹部增强CT可见胰腺轻度肿胀及异常强化,自身免疫性胰腺炎可能;肝内外胆管略扩张,肠系膜上血管周围软组织影,考虑腹膜后纤维化可能。十二指肠球部溃疡活检组织病理可见纤维组织增生及多量淋巴细胞浸润,每高倍镜视野IgG4阳性浆细胞约20~30个,IgG4阳性浆细胞占IgG阳性浆细胞的比例超过40%。诊断为IgG4相关性疾病,给予甲泼尼龙琥珀酸钠40 mg静脉滴注,每日1次,持续2周,后改为口服醋酸泼尼松50 mg,每日1次,逐渐减量至醋酸泼尼松5 mg维持,同时联合环磷酰胺0.4 g,静脉滴注,每2周1次,复查患者十二指肠溃疡愈合。IgG4相关性疾病是一种较罕见的免疫介导的慢性炎症伴纤维化疾病,可累及全身多个器官和系统,临床表现复杂多样。IgG4相关性疾病的消化系统表现多为急性胰腺炎和胆管炎,罕见表现为消化道溃疡。该病例证实IgG4相关性疾病可以表现为十二指肠溃疡,是十二指肠溃疡的罕见原因之一。