| Postbulbar duodenal ulceration is not common, but when present is difficult to diagnose and treat. Between January 1965 and September 1971, 1,080 patients with duodenal ulcers were treated surgically at St James Hospital. Forty-one ulcers were found at operation to lie distal to the duodenal bulb. Pain was the most common indication for surgery. In six-patients it was clinically indistinguishable from biliary pain, giving rise to diagnostic difficulty. Twelve patients (29%) presented with haemorrhage, a percentage similar to the 25% of bulbar ulcers presenting with this complication over the period of this study. This is contrary to the finding in most other series, that postbulbar ulceration is more frequently complicated by haemorrhage than is bulbar ulceration. Perforation and stenosis are uncommon complications. Postbulbar ulceration is easily overlooked in conventional barium studies. Only one-third of the patients subjected to barium meal x-ray examination had their ulcers identified in the first study. In a further third the presence of an ulcer was suspected, and the remainder required multiple investigations for undiagnosed symptoms before the condition was demonstrated. duodenoscopy was not performed in a sufficient number of patients for its value to be assessed, but other reports indicate that it should be a valuable manoeuvre. The technical difficulties and potential hazards of Polya gastrectomy are discussed and special reference is made to the surgical management of bleeding postbulbar ulcers. ( info) |
2/46. dyspepsia as a somatic expression of guilt: a case report. A 58-year-old woman developed chronic, severe symptoms of heartburn, epigastric pain, and regurgitation that persisted for 2 years. She underwent a thorough evaluation and no organic cause was identified. Therefore, a diagnosis of dyspepsia was made. Her symptoms were refractory to pharmacological treatment. Upon further probing, the patient reported that the onset of her symptoms coincided with the death of her son of cancer 2 years earlier. She blamed herself for the death of her son and admitted to a need for self-punishment. A brief course of treatment using metaphors and hypnosis resulted in a complete resolution of her symptoms, which did not recur during a follow-up of 12 years. This is the first published report of the treatment of dyspepsia using hypnotic methods. ( info) |
3/46. review article: managing the dyspeptic patient--an interactive discussion. dyspepsia, a common disorder, can present some difficult clinical dilemmas. physicians should explore some of the more challenging cases of dyspepsia in a setting that fosters interactive dialogue among colleagues, as was the case at the interactive discussion reported below. A panel of experts presented and discussed three case histories. The audience was able to choose from among several options for diagnosis or treatment and recorded their votes by means of an electronic handset. The first case concerned the relationship between continued non-steroidal anti-inflammatory drug (NSAID) use and recurrent upper gastrointestinal (GI) symptoms without ulcer or helicobacter pylori infection. The second was a woman with complex upper GI symptoms including heartburn. The last featured a young man with dyspepsia and no alarm symptoms. The first case showed that a standard dose of proton pump inhibitor (PPI) is the best treatment for patients with gastritis who continue to use NSAIDs. The second case revealed that 24-h pH monitoring can be used to establish a relationship between symptoms and reflux episodes. The third case demonstrated that it can be difficult to make a definitive diagnosis based on clinical symptoms, and that patients with endoscopy-negative reflux disease usually respond well to PPI therapy. ( info) |
4/46. Panhypopituitarism due to pituitary cyst of Rathke's cleft origin--two case reports. INTRODUCTION: Rathke's cleft cysts are cystic sellar and suprasellar lesions, characteristically lined by a single layer of ciliated cuboidal or columnar epithelium. CLINICAL PICTURE: We report 2 patients who presented with gastrointestinal symptoms and were initially investigated for dyspepsia. However, attention was subsequently drawn to persistent hyponatraemia that led to the diagnosis of panhypopituitarism due to Rathke's cleft cyst. TREATMENT: Transsphenoidal surgery followed by drainage of the cyst and partial excision of the cyst wall in both patients. OUTCOME: No recurrence of the lesions over a mean follow-up of 16 months. There has been an improvement of the hypothalamo-pituitary-adrenal axis in 1 patient and the hypothalamo-pituitary-thyroid axis and visual fields in the other. CONCLUSION: Symptomatic Rathke's cleft cysts are rare and can occasionally cause panhypopituitarism. Ideal management of these cysts is unclear, but aspiration followed by partial excision of the cyst wall seems the best initial option. ( info) |
5/46. headache of gastrointestinal origin: case studies. Three patients with headache of gastrointestinal origin are described. Reflux, dyspepsia, and constipation caused the headaches, which responded promptly to treatment of the respective gastrointestinal disorders. ( info) |
6/46. Gastric lipoma presenting with dyspepsia. Gastric lipoma is one of the rare benign gastric tumors. Its preoperative diagnosis obviates the need of an extended gastrectomy. We report a case of gastric lipoma who presented with symptoms of dyspepsia and was treated by surgical gastrectomy and tumour enucleation. ( info) |
7/46. Laparoscopic treatment of Bochdalek hernia without the use of a mesh. Bochdalek hernia is a rare pathology. The preoperative diagnosis is difficult, and few reports are available regarding its treatment. Herein we report the case of a 25-year-old woman referred for symptoms of dyspepsia, dysphagia, and thoracic pain exacerbated by pregnancy. Preoperative radiography, EGD, and CT scan revealed a paraesophageal hiatal hernia. Laparoscopic exploration showed the complete thoracic migration of the stomach through a left posterolateral diaphragmatic foramen. The diagnosis of a Bochdalek hernia was then made. The diaphragmatic defect was repaired without inserting a prosthesis, using five separate non-reabsorbable stitches (Rieder technique). The procedure was completed with a Nissen-Rossetti fundoplication. The duration of the procedure was 150 min. Hospital stay was 12 days. There were no complications. Postoperative Gastrografin radiography of the esophagus and stomach showed a normal-shaped fundoplication and confirmed the subdiaphragmatic location of the stomach. We conclude that the laparoscopic approach represents the gold standard for the diagnosis and treatment of Bochdalek hernia and any associated complications. ( info) |
8/46. Symptomatic CMV duodenitis. An important clinical problem in AIDS. Duodenal disease resulting from cytomegalovirus (CMV) infection is unusual in the absence of other gastrointestinal disease. We report two cases of CMV infection symptomatically isolated to the duodenum. One patient presented with ulcer-type dyspepsia, and the other with severe gastrointestinal bleeding. ganciclovir therapy resulted in both a clinical and endoscopic remission. The importance of endoscopic evaluation is discussed given the necessity of mucosal biopsy for diagnosis and the availability of specific and effective therapy. ( info) |
9/46. Primary benign ulcer of the gall bladder. It is sometimes impossible to come to a final diagnosis in patients with dyspepsia and upper abdominal pain in spite of extensive investigation. Such patients are usually given vague diagnoses like "non-ulcer dyspepsia" and they represent an important diagnostic challenge. ( info) |
10/46. Morgagni's hernia. Congenital diaphragmatic hernias, including Morgagni s hernia, usually present in early childhood and are treated by surgical repair. This case report is about an unusual Morgagni s hernia, presenting with dyspepsia and chest pain, at the age of 45 years. For many years the diagnosis remained a dilemma because patient s chest x-ray was not done and she was treated for "angina " and "dyspepsia". diagnosis was obvious once a chest x-ray was done, however, barium studies were performed for further confirmation. ( info) |