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• W2891661920 abstract "Question: A 77-year-old man presented with a 2-day history of abdominal fullness and progressively increasing severe epigastric pain associated with nausea and vomiting. The patient had no previous history of symptoms related to his gastrointestinal tract. He did not smoke or drink. Physical examination revealed moderate epigastric tenderness. Laboratory tests showed the following significant results: white blood cell count, 17,200/μL; aspartate aminotransferase level, 183 U/L; alanine aminotransferase level, 81 U/L; bilirubin level, 3.60 mg/dL; and amylase level, 3686 U/L. Abdominal computed tomography scan with contrast material showed a well-defined mass in the second portion of the duodenum. The pancreas was enlarged with fluid, and the main pancreatic duct was slightly dilated (Figure A, B). Esophagogastroduodenoscopy showed a large tumor originating in the antrum that had prolapsed through the pylorus into the duodenum (Figure C, endoscopic view in gastric antrum; Figure D, endoscopic view in duodenum). What is the most likely diagnosis? How should be the patient be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Computed tomography scan showed the characteristic features of gastroduodenal intussusception, with the head of the intussusceptum reaching the second portion of the duodenum. This led to the compression of the ampulla of Vater and was associated with acute pancreatitis and biliary obstruction. The tumor was moved back into the stomach with a through-the-scope balloon catheter (Figure E, F), and the patient’s symptoms immediately resolved. After the normalization of the liver enzymes and pancreatic enzymes, the patient underwent endoscopic submucosal dissection, and en bloc resection was performed for the tumor (4.5 × 4.0 cm in diameter; Figure G). Histologic examination revealed a moderately differentiated adenocarcinoma restricted to the mucosal layer, without vessel invasion or lymph node involvement (Figure H). Endoscopic retrograde cholangiopancreatography revealed no abnormalities in the pancreaticobiliary ducts. His post-treatment course was uneventful. Until 11 years thereafter, there has been no evidence of recurrence or metastasis. Gastroduodenal intussusception, also known as ball valve syndrome, is a rare occurrence, frequently resulting from the prolapse of an underlying pedunculated gastric wall lesion into the duodenum. This rare presentation is documented to be caused by both benign and malignant lesions, including hyperplastic and adenomatous polyp, adenocarcinoma, lipoma, leiomyoma, leiomyosarcoma, Brunner's gland hamartoma, and gastrointestinal stromal tumors.1Yildiz M.S. Doğan A. Koparan I.H. et al.Acute pancreatitis and gastroduodenal intussusception induced by an underlying gastric gastrointestinal stromal tumor: a case report.J Gastric Cancer. 2016; 16: 54-57Crossref PubMed Scopus (11) Google Scholar Gastroduodenal intussusception induced by gastric tumor tends to arise in the distal part of the stomach, mainly in the antrum, and is less commonly seen in the body, fundus, and anastomosis.1Yildiz M.S. Doğan A. Koparan I.H. et al.Acute pancreatitis and gastroduodenal intussusception induced by an underlying gastric gastrointestinal stromal tumor: a case report.J Gastric Cancer. 2016; 16: 54-57Crossref PubMed Scopus (11) Google Scholar Downward traction of the duodenal wall by the intussusceptum may have distorted and obstructed the ampulla of Vater. The compression and obstruction of the ampulla of Vater can cause pancreatitis,2Yilmaz M. Ibarra J. Musher B.L. Prolapsed gastric gastrointestinal stromal tumor: a rare cause of biliary obstruction and acute pancreatitis.Clin Gastroenterol Hepatol. 2015; 13: e35-e36Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar as observed in the present case. Endoscopic management is the preferred therapeutic modality for the management of gastric polyps. However, in cases where this is not feasible, for example in patients with large lesions, laparoscopic or open surgery approaches must be used.3Chahla E. Kim M.A. Beal B.T. et al.Gastroduodenal intussusception, intermittent biliary obstruction and biochemical pancreatitis due to a gastric hyperplastic polyp.Case Rep Gastroenterol. 2014; 8: 371-376Crossref PubMed Scopus (9) Google Scholar" @default.
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• W2891661920 date "2018-12-01" @default.
• W2891661920 modified "2023-09-23" @default.
• W2891661920 title "A Rare Cause of Acute Pancreatitis" @default.
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• W2891661920 doi "https://doi.org/10.1053/j.gastro.2018.07.050" @default.
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