the distal antrum with no visible or palpable underlying induration. A standard pyloroplasty was performed. Postoperatively the patient has gained weight steadily and has experienced no recurrence of his symptoms. DISCUSSION Since Touroff6 first described a prepyloric membrane as the cause of gastric obstruction in a premature infant, there have been numerous reports ofthis clinical entity. This lesion has been otherwise referred to as an antral web, a pyloric antral mucosal diaphragm, an antral mucosal membrane or diaphragm, a prepyloric septum, a gastric antral diaphragm, and a prepyloric mucosal diaphragm. The term antral mucosal diaphragm would seem both lucid and appropriate to describe this entity. The antral mucosal diaphragm is an abnormality of gastric mucosa which encloses a membrane of submucosa. This anomaly is thought to be congenital in origin, caused by a failure of complete foregut canalization. It has also been suggested as secondary to chronic peptic ulcer disease, but there is less support for this hypothesis. The antral mucosal diaphragm projects into the lumen of the antrum, perpendicular to the antrum's longitudinal axis and is usually found 2 to 3 cm proximal to the pylorus. An aperture is located in the diaphragm and may be central or eccentric. Its diameter may vary from 1 mm to 1 cm but is usually 1 to 3 mm. This is the first report of fiberoptic gastroscopy aiding in the pre-operative diagnosis of antral mucosal diaphragm in a child. The first decade is one of the most common periods in which this entity presents,' although it is not unusual for patients with partially obstructing diaphragms to reach adulthood before significant symptoms develop. The approach to diagnosis in the pediatric age group need not be different from the diagnostic workup in adults and should include both radiographic and endoscopic techniques. Complete or high grade gastric outlet obstruction caused by antral mucosal diaphragms is easily recognized. Diaphragms causing partial obstruction, however, may not delay contrast material in the stomach and special techniques must be used to demonstrate the lesion by upper gastrointestinal radiography.3 If partial or complete obstruction is suspected, with or without confirmatory radiographs, endoscopy should be performed. The diagnosis of an antral mucosal diaphragm can be made endoscopically using the criteria originally suggested by Banks and Waye.2 These include: (1) an opening of constant size in the distal antrum; (2) the mucosa of the diaphragm surrounding the opening is smooth, devoid of folds, and essentially identical to the mucosa throughout the antrum; (3) antral peristalsis proceeds normally to and stops abruptly at the mucosal diaphragm; (4) the opening persists despite vigorous peristalsis; (5) no regurgitation of duodenal contents appears through the diaphragm; and (6) peristalsis is observed in the antrum. beyond the diaphragmatic opening. REFERENCES 1. BANKS PA, WAYE DJ, WAITMAN AM, CORNELL A: Mucosal diaphragm of the gastric antrum. Gastroenter%gy 52: 1003, 1967 2. BANKS PA, WAYE DJ: The gastroscopic appearance of antral web. Gastrointestinal Endoscopy 15:228, 1969 3. CAMPBELL DP, VAN HOUTTE JJ, SMITH EI: Partially obstructing antral weba distinct clinical entity. J Pediatr Surg 8:723, 1973 4. CONWAY N: Pyloric antral mucosal diaphragm. Br Med J 1:970, 1965 5. SOKOL EM, SHOROFSKY MA, WERTHER JL: Mucosal diaphragm of the gastric antrum. Gastrointestinal Endoscopy 12:20, 1965 6. TOUROff ASW, SUSSMAN RM: Congenital prepyloric membranous obstruction in a premature infant. Surgery 8:739,1940 7. WOOLLEY MM, GWINN JL, MARES A: Congenital partial gastric antral obstruction. Ann Surg 180:265, 1974
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Endoscopic diagnosis of intraluminal duodenal diverticulum Michael J. Knight, MS, FRCS* James S. Mousley, FRCS Rodney C. Michell, MRCP, FFR Royal Hampshire County Hospital, Winchester Hampshire, England
Intraluminal diverticula of the duodenum are rare, and their diagnosis is essentially radiological. This report describes the endoscopic appearances of the condition and the subsequent management of the patient. CASE REPORT A 61-year-old white woman presented in January 1976 because of vague indigestion for 3 years and postprandial upper abdominal distension without vomiti ng for 3 months. Clinical examination revealed no abnormality, and, in particular, there was no demonstrable gastric splash. A
Figure 1. Radiograph showing barium-filled intraluminal diverticulum of the duodenum. barium meal (Figure 1) showed no abnormality in the esophagus or stomach but suggested the presence of an intraluminal diverticulum in the duodenum. Endoscopy of the duodenum (Figure 2) revealed a mucosal covered bar across the duodenal lumen immediately below the level of the ampulla. The bar divided the duodenal lumen proper from the empty pouchlike interior of the diverticulum which was seen to alter in size with peristalsis. At operation the gallbladder was found to contain calculi and was removed. An operative cholangiogram (Figure 3A) confirmed the absence of residual stones in the common bile 'Reprint requests: Michael Knight. 5t. George's Hospital, London, S.W.1. England.
GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic drawing of the descending duodenum showing duodenal lumen and mouth of intraluminal diverticulum.
duct but again demonstrated the presence of the intraluminal diverticulum below the ampulla in the duodenum. The structure was not palpable through the duodenal wall but was readily identified after duodenotomy. Insertion ofthe tip of the index finger into the diverticulum (Figure 38) facilitated division of its attachment to the duodenal wall below the ampulla. The duodenotomy was closed and the wound drained. Apart from an early postoperative hyperamylasemia which settled in 2 days, she made an uninterrupted recovery. In the 8 months since operation there has been no recurrence of her symptoms, and she remains well. DISCUSSION Intraluminal diverticula of the duodenum are rare. Some 20 cases have been reported.' The diverticulum is thought to represent a pulsion effect on a duodenal diaphragm 2 or an exaggerated transverse mucosal fold. 3 It occurs in the region of the ampulla and is occasionally responsible for duodenal obstruction.' The radiographic appearance by barium meal is diagnostic and typically shows a filling defect in the duodenum which itself fills with contrast medium to give a "halo" effect in the duodenal lumen. This characteristic appearance depends on the filling of the diverticulum coinciding with a film exposure, and it is the rule rather than the exception that these patients are subjected to repeated negative barium examinations before the diagnosis is made. A positive endoscopic examination of the duodenum in these cases would avoid the necessity for repeated barium examinations. Endoscopy may show that the condition is more common than is realized at the present time.
REFERENCES
J: Intraluminal diverticulum of the duodenum and choledochocele. Gut 13:207, 1972 2. ZATZKIN HR, MACY lC, KVETON FW: Intraluminal duodenal diverticulum. Am J Roentgenol 82: 1036, 1959 3. PEny BW, MOUSLEY JS: Intraluminal diverticulum of the duodenum. Br J Surg 53:73, 1966 4. MEYER AC, EDGREN DC: Duodenal obstruction by an intraluminal diverticulum. Arch Surg 73: 1058, 1956 1. BRUNTON FJ, BAMFORTH
Figure 3. (A) Operative cholangiogram demonstrating the diverticulum as a filling defect in the duodenum. (B) At duodenotomy the finger tip is inserted into the intraduodenal diverticulum.
Endoscopy in the diagnosis of aortoduodenal fistula
Burton H. Baker, MD* Michael S. Baker, MD Department of Surgery U.S. Public Health Service Hospital San Francisco, California
Leo van der Reis, MD John H. Fisher, MD Division of Gastroenterology Mary's Help Hospital Daly City, California
Upper gastrointestinal hemorrhage usually occurs secondary to erosive gastric, peptic ulceration, or esophageal varices. Aortoenteric fistula is a less well recognized source of upper gastrointestinal hemorrhage, a potentially fatal source if it is not diagnosed and treated early. In the past, the premortem diagnosis of aortoenteric fistula was made by arteriography or upper gastrointestinal radiography. Recently, the peroral panendoscope has been used to identify aortoenteric fistulas. These cases illustrate use of endoscopy for early diagnosis. VOLUME 24, NO.1, 1977
CASE REPORTS Case 1. A 49-year-old woman was brought to the emergency room in shock; blood pressure was palpable at 70 mm Hg, and she was pale, cool, and diaphoretic. Her hematocrit was 15.8%, hemoglobin 5.1 gm. After resuscitation she related that she had undergone an aortofemoral bypass graft 6 months previously. She had noted melena and had had 1 episode of hematemesis the previous week. Endoscopy, upper gastrointestinal series, and chest radiographs were -Reprint requests: Dr. M. Baker, Department of Surgery, U.S. Public Health Service Hospital, San Francisco, California 94118.
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34
Endoscopic diagnosis of intraluminal duodenal diverticulum Michael J. Knight, MS, FRCS* James S. Mousley, FRCS Rodney C. Michell, MRCP, FFR Royal Hampshire County Hospital, Winchester Hampshire, England
Intraluminal diverticula of the duodenum are rare, and their diagnosis is essentially radiological. This report describes the endoscopic appearances of the condition and the subsequent management of the patient. CASE REPORT A 61-year-old white woman presented in January 1976 because of vague indigestion for 3 years and postprandial upper abdominal distension without vomiti ng for 3 months. Clinical examination revealed no abnormality, and, in particular, there was no demonstrable gastric splash. A
Figure 1. Radiograph showing barium-filled intraluminal diverticulum of the duodenum. barium meal (Figure 1) showed no abnormality in the esophagus or stomach but suggested the presence of an intraluminal diverticulum in the duodenum. Endoscopy of the duodenum (Figure 2) revealed a mucosal covered bar across the duodenal lumen immediately below the level of the ampulla. The bar divided the duodenal lumen proper from the empty pouchlike interior of the diverticulum which was seen to alter in size with peristalsis. At operation the gallbladder was found to contain calculi and was removed. An operative cholangiogram (Figure 3A) confirmed the absence of residual stones in the common bile 'Reprint requests: Michael Knight. 5t. George's Hospital, London, S.W.1. England.
GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic drawing of the descending duodenum showing duodenal lumen and mouth of intraluminal diverticulum.
duct but again demonstrated the presence of the intraluminal diverticulum below the ampulla in the duodenum. The structure was not palpable through the duodenal wall but was readily identified after duodenotomy. Insertion ofthe tip of the index finger into the diverticulum (Figure 38) facilitated division of its attachment to the duodenal wall below the ampulla. The duodenotomy was closed and the wound drained. Apart from an early postoperative hyperamylasemia which settled in 2 days, she made an uninterrupted recovery. In the 8 months since operation there has been no recurrence of her symptoms, and she remains well. DISCUSSION Intraluminal diverticula of the duodenum are rare. Some 20 cases have been reported.' The diverticulum is thought to represent a pulsion effect on a duodenal diaphragm 2 or an exaggerated transverse mucosal fold. 3 It occurs in the region of the ampulla and is occasionally responsible for duodenal obstruction.' The radiographic appearance by barium meal is diagnostic and typically shows a filling defect in the duodenum which itself fills with contrast medium to give a "halo" effect in the duodenal lumen. This characteristic appearance depends on the filling of the diverticulum coinciding with a film exposure, and it is the rule rather than the exception that these patients are subjected to repeated negative barium examinations before the diagnosis is made. A positive endoscopic examination of the duodenum in these cases would avoid the necessity for repeated barium examinations. Endoscopy may show that the condition is more common than is realized at the present time.
REFERENCES
J: Intraluminal diverticulum of the duodenum and choledochocele. Gut 13:207, 1972 2. ZATZKIN HR, MACY lC, KVETON FW: Intraluminal duodenal diverticulum. Am J Roentgenol 82: 1036, 1959 3. PEny BW, MOUSLEY JS: Intraluminal diverticulum of the duodenum. Br J Surg 53:73, 1966 4. MEYER AC, EDGREN DC: Duodenal obstruction by an intraluminal diverticulum. Arch Surg 73: 1058, 1956 1. BRUNTON FJ, BAMFORTH
Figure 3. (A) Operative cholangiogram demonstrating the diverticulum as a filling defect in the duodenum. (B) At duodenotomy the finger tip is inserted into the intraduodenal diverticulum.
Endoscopy in the diagnosis of aortoduodenal fistula
Burton H. Baker, MD* Michael S. Baker, MD Department of Surgery U.S. Public Health Service Hospital San Francisco, California
Leo van der Reis, MD John H. Fisher, MD Division of Gastroenterology Mary's Help Hospital Daly City, California
Upper gastrointestinal hemorrhage usually occurs secondary to erosive gastric, peptic ulceration, or esophageal varices. Aortoenteric fistula is a less well recognized source of upper gastrointestinal hemorrhage, a potentially fatal source if it is not diagnosed and treated early. In the past, the premortem diagnosis of aortoenteric fistula was made by arteriography or upper gastrointestinal radiography. Recently, the peroral panendoscope has been used to identify aortoenteric fistulas. These cases illustrate use of endoscopy for early diagnosis. VOLUME 24, NO.1, 1977
CASE REPORTS Case 1. A 49-year-old woman was brought to the emergency room in shock; blood pressure was palpable at 70 mm Hg, and she was pale, cool, and diaphoretic. Her hematocrit was 15.8%, hemoglobin 5.1 gm. After resuscitation she related that she had undergone an aortofemoral bypass graft 6 months previously. She had noted melena and had had 1 episode of hematemesis the previous week. Endoscopy, upper gastrointestinal series, and chest radiographs were -Reprint requests: Dr. M. Baker, Department of Surgery, U.S. Public Health Service Hospital, San Francisco, California 94118.
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![[Intraluminal duodenal diverticulum].](/assets/img/hold.png)
