A 75-year-old man presented to our facility with a 5-day history of hematemesis. He reported a left inguinoscrotal hernia that had been present since 1990. Physical examination demonstrated an incarcerated inguinoscrotal hernia. Abdominal computed tomography revealed the stomach, small, and large bowel in the hernia. Esophagogastroduodenoscopy revealed food and brownish liquid in the stomach. Neither the antrum nor the pylorus could be identified during the esophagogastroduodenoscopy, consistent with an incarcerated portion of the stomach. Blood was not seen in the examined portion of the gastrointestinal tract. He was emergently treated with surgical intervention.
Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures.
gastrosplenic fistulas showed similar survival of 82% in all cases of gastrosplenic fistulas. However, in recent times safety and efficacy of PCD has been well established. PCD has been attempted in prior reports with gastrosplenic fistula but required surgery for definitive management. The choice of surgery is generally open splenectomy with partial gastric resection but laparoscopic techniques have been described. [2491] Figure 1. (a) Large splenic abscess with loss of fat planes with stomach (b) Resolution of abscess with double pigtail catheters (c) Gastrosplenic fistula opening seen in body of stomach on endoscopy (d) Healed gastric wall after 6 weeks of initial presentation.
A 48-year-old man presented in a near-syncopal state with a 3-day history of melaena, anaemia and epigastric pain. His medical history was significant for chronic autoimmune sclerosing pancreatitis and three previous hospitalisations for enigmatic gastrointestinal bleeding. Symptomatic treatment for anaemia was coupled with oesophagogastroduodenoscopy, two colonoscopies and video capsule endoscopy, but all failed to identify a source of gastrointestinal bleeding. CT angiography of the abdomen revealed extravasation of contrast from a small branch of the splenic artery, later identified as a splenic artery pseudoaneurysm, which was subject to two separate failed embolisation attempts. The patient eventually required a splenectomy to abate the haemorrhaging. One-month postsplenectomy, the patient was haemodynamically stable but required readmission due to significant epigastric abdominal pain secondary to acute exacerbation of pancreatitis.
Figure 1. A. Endoscopic appearance of schwannoma as a smooth exophytic submucosal mass with central depression seen along the greater curvature of distal gastric body. B. Abdominal CT demonstrating luminal compression of the gastric body by a schwannoma with relatively homogenous attenuation and enhancement.
Esophageal bleeding has a broad differential. One rare cause of esophageal bleeding is an intercostal artery pseudoaneurysm, which usually presents as hemothorax secondary to trauma or an iatrogenic cause; we identified only 9 reported cases in the English literature. Rarer still is pseudoaneurysm of the intercostal-bronchial trunk, which has not been reported in the literature. We report a 61-year-old man with an intercostal-bronchial trunk pseudoaneurysm who presented with hematemesis and signs of upper gastrointestinal bleeding without previous history of trauma. This case report serves to broaden the differential for esophageal bleeding.
Transhiatal herniation of the pancreas is a rare phenomenon, especially after esophagectomy. We present a 66-year-old White man who developed a 15-cm transhiatal hernia containing nonobstructed small bowel and pancreas approximately 23 years after an open transhiatal esophagectomy for esophageal adenocarcinoma. He experienced frequent nausea and regurgitation and slept upright in a chair for comfort for 8 years postoperatively until subsequent workup discovered an incarcerated supraumbilical incisional hernia containing omentum, which was repaired laparoscopically. Afterward, he remained asymptomatic for 15 years until he presented to our clinic with complaints of acid reflux.Physical examination and vital signs were unremarkable aside from mild epigastric tenderness on abdominal examination. Amylase was 58 m/L, and lipase was 30 m/L. Thoracic, abdominal, and pelvic computed tomography demonstrated a hiatal hernia involving the gastric pull-through extending into the lower inferior mediastinum along with the pancreas and nonobstructed loops of small bowel Figure 1. Pancreas visualized in mediastinum inferior to gastric pull-through.
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