Distal Duodenal Obstruction: a Surgical Enigma

Benign duodenojejunal junction stricture: a case report

Introduction

Duodenojejunal stricture is a rare entity that has been attributed to peptic stricture, malignancy, chronic pancreatitis, Crohn's disease and other benign causes.

Case presentation

The authors present a case of a 67-year-old male who presented with upper abdominal pain for 2 weeks, 2 episodes of bilious vomiting, and inability to pass stool and flatus for 1 day. He had a history of chronic upper abdominal pain over the last 40 years and pulmonary tuberculosis 50 years back.Computed tomography (CT) scan of the abdomen and pelvis showed short segment narrowing in the fourth segment of the duodenum with dilated first, second and third segment duodenal loops. Resection and end-to-end duodenojejunal anastomosis was performed and the outcome was normal.

Discussion

Benign duodenojejunal can be treated with balloon dilatation, stenting, strictureplasty and resection anastomosis. Treatment should be offered considering efficacy, availability, complications of these modalities and aetiology.

Conclusion

Anterograde push enteroscopy and CT scan can aid in preoperative diagnosis of duodenojejunal stricture. Even in older age groups without prior surgical history, benign duodenojejunal stricture can be the cause of intestinal obstruction. Resection and end-to-end duodenojejunal anastomosis can be safe and effective treatment modalities for duodenojejunal junction stricture.

Adult Distal Duodenal Obstruction: A Diagnostic and Therapeutic Challenge

Distal duodenal obstruction (DDO) can be succinctly defined as features of gastric outlet obstruction with bilious vomiting and radiological or endoscopic evidence of post-bulbar obstruction. Obstructions of the third (D3) and fourth (D4) parts of the duodenum are rare and present significant diagnostic and surgical challenges, particularly when the cause is malignant. In the following three case reports, we discuss three distinct aetiologies of this rare syndrome and highlight important considerations surrounding the early investigation and management of these individuals. The first patient is a 60-year-old lady with primary duodenal adenocarcinoma resulting in malignant stricture at D4. She underwent segmental resection of the D4 tumour with a duodeno-jejunal anastomosis. The second patient is a 17-year-old boy with superior mesenteric artery (SMA) syndrome, who was treated conservatively. The last patient is a 71-year-old lady with a caecal carcinoma invading the retroperitoneal structures and D3. The patient underwent a palliative laparoscopic gastro-jejunostomy. Although infrequently encountered in clinical practice, the individual burden of a missed or late diagnosis of DDO, malignant or otherwise, can be disastrous. This case series illustrates the varied presentation of DDO and discusses current principles of investigation and management.

Duodenal Obstruction in a Patient Previously Treated With EndoVascular Aneurysm Sealing System Repair

The Nellix® endovascular aneurysm sealing system (EVAS) is a relatively novel approach for the treatment of abdominal aortic aneurysms (AAAs). We present herein a case of duodenal obstruction (DO) which occurred following an EVAS treatment for the repair of an AAA. A 77-year old man was admitted to our hospital with acute abdominal pain and recurrent vomiting. Computed tomography (CT) revealed a retroperitoneal 66 × 59 × 90 mm (antero-posterior, AP; latero-lateral, LL; cranio-caudal: CC) solid mass located in the epigastrium, corresponding to the infrarenal abdominal aortic aneurysm sac, previously treated by EVAS. An exploratory laparotomy was performed, which revealed a retroperitoneal mass compressing the third and fourth parts of the duodenum. A gastroenteroanastomosis was performed in order to bypass the duodenal obstruction. An extensive search of biomedical literature databases was conducted to identify similar cases. To our knowledge, this is the first reported case of DO following an AAA repair with EVAS.

Spontaneous resolution of idiopathic intestinal obstruction after pneumonia: A case report

BACKGROUND

Duodenal obstruction is a common clinical scenario that can either be mechanical or a pseudo-obstruction. Clinical management of intestinal obstruction starts from localization and proceeds to histological examination of the stenotic intestine. Systemic factors and dysfunction of distant organs might contribute to the development of intestinal obstruction. Here, we report a unique case of idiopathic mechanical duodenal obstruction, which resolved spontaneously after 3 mo of conservative treatment, but was followed by intestinal pseudo-obstruction.

CASE SUMMARY

An 84-year-old woman presented with worsened postprandial vomiting accompanied by prolonged pneumonia. Thorough noninvasive investigations revealed complete circumferential stenosis in the descending duodenum without known cause. Exploratory surgery was postponed due to septic shock and possible pulmonary fungal infection. Conservative treatment for 3 mo for ileus and control of pulmonary infection resolved the intestinal obstruction completely. Unfortunately, 2 wk later, she had regurgitation and postprandial vomiting again, complicated by deteriorating wheezing and dyspnea. Computed tomography revealed a dilated stomach and proximal duodenum without new intestinal stricture or pulmonary infiltration. The patient fully recovered after combined treatment with antireflux agents, enema, prokinetics, and bronchodilators.

CONCLUSION

This complicated case highlights the inter-relationship of local and systemic contributions to ileus and gut dysfunction, which requires multidisciplinary treatment.