Yoshihiro Sakashita

Usefulness of computed tomography as a preoperative diagnostic modality in a case with acute jejunogastric intussusception.

A 72-year-old man was admitted to our hospital with an acute abdomen 1 h after the abrupt onset of hematemesis and upper abdominal pain. His medical history included a distal gastrectomy for gastric cancer 15 years previously and a subsequent gastrojejunostomy with Braun’s anastomosis because of an anastomotic stricture. Physical examination at the time of admission revealed diffuse abdominal tenderness with muscular guarding and a palpable firm mass in the left upper quadrant. A plain X-ray of the abdomen showed dilatation of the small intestine, but this finding was not specific enough to lead to a diagnosis. A subsequent abdominal computed tomography (CT) showed intestinal loops intussuscepted into the patient’s severely dilated gastric remnant through the gastrojejunostomy (Fig. 1a). Contiguous CT sections identified a normal afferent loop and intussuscepted efferent loops extending into the lower abdomen (Fig. 1b, c). Together, these findings suggested that the intussusception into the stomach involved the efferent loop, indicating the presence of a type II jejunogastric intussusception (JGI). The patient was immediately taken into surgery. Surgery revealed a severely dilated stomach stump and an 80-cm-long efferent intestinal loop that had intussuscepted in a retrograde direction at the gastrojejunostomy into the remnant gastric lumen, passing over the Braun’s anastomosis, which is in agreement with the preoperative diagnosis made by CT (Fig 2). After unsuccessful efforts to reduce this invagination by Hutchinson’s procedure,partial resection of a 100-cm-long small intestine, with end-to-end anastomosis and efferent loop fixation, was subsequently performed. The resected specimen was found to be gangrenous without perforation for a distance of 10 cm below the Braun’s anastomosis. No abnormalities such as a tumor, ulcer, diverticulum, or stenosis were identified that could have acted as a leading point for the intussusception. The JGI in this case was thus considered to be a late complication of gastrojejunostomy with Braun’s anastomosis. J Gastrointest Surg (2007) 11:1078–1080 DOI 10.1007/s11605-007-0125-z

Ruptured left colic arterial aneurysm treated by transcatheter arterial embolization alone and without a subsequent laparotomy: Report of a case

We herein report the case of a 49-year-old male patient with a ruptured aneurysm originating in the left colic artery, which was successfully treated by transcatheter arterial embolization (TAE) Abdominal computed tomography revealed a large hematoma with a central small aneurysm in the left upper abdomen. Celiac and superior mesenteric arteriography showed no dye extravasation. Subsequent aortography showed an aneurysm arising from the branch of the left colic artery that was successfully treated by selective TAE. Further surgery for subsequent ischemia was not performed. In cases presenting with an unclear source of intraabdominal bleeding, an aneurysm of the inferior mesenteric arterial branch should be considered. Transcatheter arterial embolization is a plausible initial treatment option as an effective therapeutic approach because it provides a curative and less invasive alternative to other therapies. Based on our experience and a review of the literature, surgery may not necessarily be imperative, even in cases of a ruptured aneurysm of a colic arterial branch after TAE.

Dieulafoy's disease as a possible cause of gallbladder hemorrhage

To the Editor, Dieulafoy’s disease is a rare form of gastrointestinal hemorrhage, often severe, which arises from an abnormally large artery running within the submucosa. The initial case reports involved the stomach, but subsequent reports have demonstrated that Dieulafoy’s disease can occur in various locations throughout the gastrointestinal tract. We now present a case report of Dieulafoy’s disease of the gallbladder, in which the source of a massive hemorrhage appeared to be a large-caliber artery situated within a mucosal erosion of the gallbladder wall. A 56-year-old man with no history of prior abdominal intervention or prior gastrointestinal surgery was admitted to Oda Municipal Hospital with severe epigastralgia. A physical examination showed muscle guarding in the upper abdomen. Laboratory chemistry studies found moderately elevated levels of serum biliary enzymes and transaminases. A blood cell count showed leukocytosis and a hemoglobin of 9.9 g/dL. Abdominal ultrasonography revealed a distended gallbladder containing relatively high-echo material. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed, yielding a massive flow of fresh blood at the initial puncture. In light of this evidence of hemorrhage of the gallbladder, an urgent laparoscopic cholecystectomy was performed.At surgery, the gallbladder was enlarged and firm, but the surrounding tissues were only mildly inflamed. The resected specimen revealed an 8 ¥ 10-cm gallbladder filled with approximately 100 mL of fresh blood, blood clots, and a gallstone 1 cm in diameter. Fresh blood and blood clots were also found in the cystic duct. Ulceration with bleeding from an exposed vessel was observed in the neck of the gallbladder. This ulcerative lesion was distinct from the PTGBD insertion site and both edges of the resected specimen (Fig. 1a). On histological examination an ulcer with a tortuous enlarged artery was found in the submucosal layer immediately beneath an area of the gallbladder mucosa, showing inflammatory changes consistent with mild chronic cholecystitis (Fig. 1b). No vascular abnormalities were observed in any of the other gallbladder sections. The pathological diagnosis was Dieulafoy’s disease of the gallbladder. Dieulafoy’s lesions are most often found in the proximal stomach but have been reported at sites throughout the gastrointestinal tract. In the present case a massive hemorrhage in the interior of the gallbladder appeared to arise from an unusually large-caliber submucosal artery close to the mucosa, which had eroded the overlying epithelium in the absence of a primary ulcer, an appearance similar to that seen in gastrointestinal Dieulafoy’s lesions. To our knowledge, this case is the first report of Dieulafoy’s disease of the gallbladder, which in this instance was treated with laparoscopic cholecystectomy. The etiology of Dieulafoy’s disease is still unknown, and no triggering causes have been identified. Although it has been reported that most cases of Dieulafoy’s disease are not associated with a mucosal inflammatory reaction at the site of arterial rupture, mild cholecystitis was observed in the present case. Juler et al. studied a series of nine cases with gastric Dieulafoy’s disease and hypothesized that chronic gastritis predisposed to vascular dysplasia, leading to thrombosis and necrosis of the arterial wall prior to rupture. However, published study data to date are insufficient to determine whether vascular dysplasia resulting from cholecystitis could cause disruption of overlying epithelium and hemorrhage. Some reports have suggested hemorrhagic cholecystitis as a possible cause of hemobilia leading to gastrointestinal bleeding. Although this case did not present with gastrointestinal bleeding, the presence of blood in the cystic duct as well as inside the gallbladder, without ductal obstruction, raises the prospect that if the patient had delayed seeking medical attention, the disease may Figure 1 Dieulafoy’s lesion of the gallbladder. (a) The resected specimen contains a small ulcerative lesion at the neck of the gallbladder (white arrow). This lesion is distinct from the percutaneous transhepatic gallbladder drainage insertion site (black arrow). Magnified view of the ulcerative lesion (inset, white arrowhead). (b) Histological examination of the area of ulceration shows a thrombus located immediately beneath the gallbladder mucosa adjacent to a tortuous large artery in the submucosal layer (black arrow, HE, original magnification ¥40). doi:10.1111/j.1440-1746.2007.04296.x