We report a case of a patient with duodenal obstruction due to retroperitoneal bleeding after the rupture of a lower pancreaticoduodenal artery aneurysm. An 80-year-old female was admitted to our hospital because of nausea and vomiting. During hospitalization, she developed hemorrhagic shock. Enhanced computed tomography revealed retroperitoneal bleeding. Abdominal angiography revealed an 8-mm aneurysm of the lower pancreaticoduodenal artery, stenosis at the trunk of the celiac artery, and increased blood flow through the pancreaticoduodenal arcades from the superior mesenteric artery. Embolization using coils was successful. On day 24, the patient presented with vomiting. Imaging modalities revealed dilatation of the stomach and duodenum. Thus, duodenal obstruction due to the retroperitoneal hematoma was suspected. After percutaneous drainage of the retroperitoneal hematoma, the patient's symptoms improved. In the present case, the formation of the lower pancreaticoduodenal artery aneurysm was related to median arcuate ligament syndrome. After transcatheter embolization of a ruptured visceral aneurysm, obstruction of the gastrointestinal tract by hematoma should be meticulously evaluated.
A 73-year-old female visited our hospital complaining of nausea and epigastric pain because of ileus. She had a history of two laparotomy procedures in her youth, interferon treatment for chronic hepatitis C, and radiation therapy for uterine cervical cancer 19 years ago. Transanal double-balloon enteroscopy demonstrated annular stenosis with ulceration of the anal side of the dilated small intestine. Therefore, surgical resection was performed, and late radiation enteritis was diagnosed on histopathological examination. We report a case of ileus due to radiation enteritis 19 years after radiotherapy.
An 88-year-old man who had been suffering from repetitive fever and abdominal pain every few months for several years was diagnosed with localized acute cholangitis and referred to our center. Various examinations, including computed tomography (CT) and endoscopic ultrasonography (EUS), revealed that the accessary hepatic duct was obstructed by clips used during laparoscopic cholecystectomy performed 7 years previously. It was not possible to approach the completely isolated duct via the transpapillary route. After obtaining fully informed consent, EUS-guided drainage of the occluded duct through the duodenal wall was performed with a self-expanding metal stent. No adverse events related to the procedure were observed, and his symptoms disappeared by the next day. EUS-guided drainage represents a therapeutic option in patients with an accessory hepatic duct, which is iatrogenically isolated by surgical clips.
A 60-year-old woman visited our hospital due to hematochezia. Colonoscopy revealed a 50-mm-diameter submucosal tumor with ulceration of the left side of the transverse colon, and magnetic resonance imaging (MRI) demonstrated the presence of small hepatic nodules. Submucosal tumor of the colon with liver metastasis was therefore diagnosed. To prevent tumor bleeding, we performed partial transverse colectomy. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma presenting as a submucosal tumor with a high frequency of vascular invasion. Computed tomography (CT) angiography revealed a 40-mm-diameter confluent multinodular-type hepatocellular carcinoma with outward spread from segment II and multiple intrahepatic metastases. Our final diagnosis was hepatocellular carcinoma with hematogenous colon metastasis.
We report a rare case of a 67-year-old man who underwent resection of carcinoma in situ and minimally invasive carcinoma of the pancreas. The patient presented with upper abdominal and back pain. No definite pancreatic mass was detected on abdominal ultrasonography, computed tomography, magnetic resonance imaging (MRI), or endoscopic ultrasonography (EUS). However, EUS and MRI demonstrated stenosis of the main pancreatic duct (MPD) in the body and post-stenotic dilatation, resulting in mild dilatation of MPD in the tail. Serial pancreatic juice aspiration cytology after endoscopic nasopancreatic drainage was suggestive of pancreatic adenocarcinoma. Examination of the distal pancreatectomy specimen demonstrated carcinoma in situ in MPD and branches, with multiple intraepithelial neoplastic lesions in the background pancreas and an additional focus of minimally invasive carcinoma.