BackgroundMeckel’s diverticulum is a congenital anomaly of the gastrointestinal tract. About 98% of affected patients are asymptomatic. Small intestinal examination has become easier since the development of double-balloon enteroscopy. The present case series describes 10 patients with Meckel’s diverticulum in whom double-balloon enteroscopy was useful for diagnosis.Case presentationTen patients (8 men, 2 women) with Meckel’s diverticulum underwent double-balloon enteroscopy at Kobe City Medical Center General Hospital from May 2004 through May 2013. Their median age was 31.5 years (range, 14–83 years). Ten retrograde and two anterograde double-balloon enteroscopy procedures were performed. Double-balloon enteroscopy showed Meckel’s diverticulum in nine patients, but an inverted Meckel’s diverticulum was diagnosed as a lipoma in one patient. Meckel’s diverticulum was detected by iodinated contrast medium during anterograde double-balloon enteroscopy in one of the two patients who underwent this procedure. Meckel’s diverticulum was suspected using capsule endoscopy in one of two patients who underwent this procedure. Abdominal computed tomography was performed in all patients and revealed abnormalities in six, but Meckel’s diverticulum was suspected in only two. Technetium-99 m pertechnetate scintigraphy and a small bowel series were carried out in six patients, revealing Meckel’s diverticulum in one and three patients, respectively. Surgery was performed in eight patients, and endoscopic resection was carried out in one; the remaining patient was transferred to another hospital. Ulcer formation was found in or near Meckel’s diverticulum in eight patients.ConclusionCompared with other modalities, double-balloon enteroscopy is excellent for the diagnosis of Meckel’s diverticulum because direct observation of both Meckel’s diverticulum and ulceration is possible. Double-balloon enteroscopy should be used complementarily to other less invasive examinations when needed to confirm or establish the diagnosis.
Gastrinomas mainly occur in the duodenum and pancreas. Primary hepatic gastrinoma is rare and difficult to diagnose because the liver is a frequent site of metastatic gastrinomas. Clinical factors were assessed in a 28-year-old man with diarrhea and heartburn who was hospitalized for recurrent duodenal ulcers. Abdominal ultrasound, endoscopic ultrasound and computed tomography (CT) could not detect a tumor in the duodenum or pancreas. His gastrin level was 846 pg/mL and magnetic resonance imaging showed a mass 12 mm in diameter in the right robe of the liver. A selective intra-arterial calcium injection (SACI) test and 68-gallium edotreotide positron emission tomography CT (Ga-DOTATOC PET-CT) were therefore performed. Calcium gluconate injection into the proper hepatic artery resulted in a marked increase in serum gastrin concentration in the right hepatic vein, with Ga-DOTATOC PET-CT showing uptake only by the liver mass. Following a diagnosis of primary hepatic gastrinoma, the tumor was resected. A histopathological examination indicated gastrinoma. Six months postoperatively, he has no symptoms, is not taking proton-pump inhibitors and his gastrin level remains within the normal range. The SACI test and the clinical course of this patient strongly suggest that the tumor was a primary hepatic gastrinoma. The SACI test is helpful in the diagnosis of primary hepatic gastrinoma.
Background
Methotrexate-associated lymphoproliferative disorder (MTX-LPD) can present as a benign lymphoid proliferation or a malignant lymphoma in patients taking MTX. Almost 50% of MTX-LPD cases show spontaneous remission after withdrawal of MTX treatment. Studies have suggested that the hyper-immune state of rheumatoid arthritis, the immunosuppressive state associated with MTX, and the carcinogenicity of the Epstein-Barr virus might contribute to MTX-LPD development. Although most cases of MTX-LPD occur at extranodal sites, few cases of MTX-LPD affecting the stomach and duodenum have been reported. To our knowledge, no other study has reported on the endoscopic observations of dramatic withdrawal and appearance of multiple digestive tract lesions in a short period of time. Herein, we report the clinical course and imaging findings of our case, which may be useful for understanding the pathological condition of MTX-LPD.
Case presentation
We describe the case of a 70-year-old woman with MTX-LPD of the stomach and duodenum. Disease regression was temporarily achieved after cessation of MTX treatment; however, it subsequently recurred, and complete response was only achieved after six cycles of rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (R-CHOP) chemotherapy.
Conclusions
The first-choice therapy for patients taking MTX who develop suspected MTX-LPD should be the withdrawal of MTX treatment. Even after remission is achieved, patients should be kept under careful observation, and if the disease recurs, chemotherapy should be commenced promptly.
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