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Megaduodenum Associated with Gastric Strongyloidiasis

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Megaduodenum Associated with Gastric Strongyloidiasis CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 11 (2015) 71–74 View metadata, citation and similar papers at core.ac.uk brought to you by CORE Contents lists available at ScienceDirect provided by Elsevier - Publisher Connector International Journal of Surgery Case Reports journal homepage: www.casereports.com Megaduodenum associated with gastric strongyloidiasis Amanda Pinter Carvalheiro da Silva a,c, Yuri Longatto Boteon a,c, Valdir Tercioti Jr b,c, Luiz Roberto Lopes a,c, João de Souza Coelho Neto a,c, Nelson Adami Andreollo a,c,∗ a Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, Faculty of Medical Sciences, UNICAMP, SP, Brazil b Digestive System Diseases Discipline and Gastrocenter, Department of Surgery, Faculty of Medical Sciences, UNICAMP, SP, Brazil c Department of Surgery, Digestive Diseases Surgical Unit and Gastrocenter, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Rua Tessália Vieira de Camargo, 126 - Cidade Universitária Zeferino Vaz, 13083-887 Campinas, SP, Brazil article info abstract Article history: Gastric strongyloidiasis and megaduodenum are rare diseases. Gastrointestinal (GI) strongyloidiasis has Received 4 October 2014 many clinical features. One of them is megaduodenum. We describe a case of a 32-years-old man who Received in revised form has come to us from an endemic area for Strongyloides stercoralis. He had had megaduodenum diagnosed 19 November 2014 in his childhood. We submitted him to two surgeries. He has recovered just after the second surgery, a Accepted 25 November 2014 Roux-en-Y partial gastrectomy. After that, his follow-up was uneventful and the patient has gained 10 kg Available online 28 November 2014 in weight. Histopathology confirmed gastric strongyloidiasis. In conclusion, if patients arrive from an endemic area of S. stercoralis and if they present GI symptoms or a previous diagnosis of megaduodenum, Keywords: Megaduodenum they must be considered for a histological evaluation for gastric strongyloidiasis. Strongyloidiasis © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open Gastrectomy access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). 1. Introduction and gas elimination, and vomiting. Also, he has mentioned previ- ous episodes of melena and hematemesis. As personal background, Dilatation of the duodenum, called megaduodenum, is a rare the patient had had a prior abdominal surgery that was performed condition. Its clinical appearance is characterized by chronic in his childhood due to gastroduodenal ulcer disease. This first duodenal stasis, dilatation, hypertrophy, and elongation of the surgery had been performed in Haiti and we have never had access duodenum.1 Thompson et al.2 described megaduodenum as an to his medical records from there. We have to address that he was endoscopic finding linked to strongyloidiasis. This disease is caused treated initially by the Neurology Specialty, not by the authors’ by the nematode (roundworm) Strongyloides stercoralis (S. sterco- staff. This initial work-up has included blood tests (human immun- ralis). It is most common in the tropical, subtropical, and in warm odeficiency virus (HIV) serology, Chagas’ disease serology, B and temperate regions of the world. C hepatitis serologies, syphilis serology, cytomegalovirus (CMV) This paper aims to report a clinical case of a patient with serology, iron dosage, and B12 vitamin dosage). All these tests have megaduodenum associated with gastric strongyloidiasis. He has resulted negative or within the normal limits. Besides, an upper GI been submitted two surgeries by the authors. We have not found a endoscopy was performed as well. It has shown a jejunal ulcer in similar case in the medical literature. the side-to-side gastroenteroanastomosis, a megaduodenum, and a duodenal stenosis located at thirty centimeters downstream the pylorus (third portion of the duodenum). Although there was a jeju- 2. Case report nal ulcer in the side-to-side gastroenteroanastomosis in this first exam, this bypass has been without signs of obstruction at that B.G., 32-years-old black man, has born in Haiti. He has lived moment. Moreover, in this upper GI endoscopy, biopsies were per- there until he was grown-up. Then, he has come to Brazil to study formed at the anterior wall of the pyloric antrum. Histopathology and he was enrolled in September 2010 at The State University of has diagnosed chronic gastritis in this first examination and Heli- Campinas (UNICAMP) as a postgraduate student. At the very begin- cobacter pylori (H. pylori) infection has resulted negative. According ning, he has had complaints of lower limbs weakness and impaired to the medical records, the Neurology Specialty diagnosed him with walking. Moreover, he has complained about difficulties in stool a sensory and motor diffuse polyradiculitis. Surprisingly, there was not further investigation concerning his GI symptoms at this first evaluation. ∗ Corresponding author at: Surgery Department, Faculty of Medical Sciences, PO After that, he has been followed in an outpatient ambulatory in Box 6111, State University of Campinas – UNICAMP, 13083-887, Campinas, SP, Brazil. a clinic specialized in esophageal, gastric, and duodenal diseases. Tel.: +55 19 3521 9450; fax: +55 19 3521 8043. E-mail address: [email protected] (N.A. Andreollo). http://dx.doi.org/10.1016/j.ijscr.2014.11.066 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). CASE REPORT – OPEN ACCESS 72 A.P.C. da Silva et al. / International Journal of Surgery Case Reports 11 (2015) 71–74 Fig. 1. Contrast radiographic study showing a duodenal stenosis in the third portion of the duodenum and the megaduodenum. Fig. 3. Histopathological studies showing Strongyloides stercoralis’s larvae on the gastric mucosa. Initially, he was treated with proton pump inhibitors therapy (PPI). But unfortunately, he has lost follow-up at that moment. After a gap of two years, the patient has returned with an episode making a bypass of the narrowed area of the duodenum. The patient of upper GI bleeding. Promptly, a new upper GI endoscopy has been has resumed, leaving the hospital seven days after this first surgery. made. It has shown gastric stasis, a diminished diameter in the side- However, one month afterward, he has returned with abdomi- to-side gastroenteroanastomosis, mucosal erosions in the jejunal nal pain, difficulty stool and gas elimination, vomiting, and severe of this side-to-side gastroenteroanastomosis, megaduodenum, and weight loss. Again, a new work-up was done. The upper GI mucosal erosions in the duodenum. Besides, in this exam it was endoscopy has shown a wide and previous gastroenteroanastomo- apparently observed also a side-to-side jejunal–duodenum anas- sis. A new contrast radiographic study has demonstrated a wide tomosis with some stenosis (this anastomosis would be located and permeable gastroenteroanastomosis. Nonetheless, there was between the second and third portions of the duodenum). Still, a slowed small bowel transit as well. Throughout this in-hospital a naso-enteral tube was inserted at this GI endoscopy, bypassing period, the patient has suffered persistent fever, with several this duodenal stenosis. However, he has got worse, with per- infectious outbreaks. He, initially, was treated as a framework sistent vomiting without improvement with medical treatment. of bronchopneumonia. Finally, he was admitted in the intensive Meanwhile, preoperative contrast radiographic studies have shown care unit, requiring parenteral nutritional support, and intravenous that, in fact, the patient had undergone a gastroenteroanasto- antibiotics. mosis procedure in his infancy and there was not a side-to-side Because of the maintenance of vomiting, anorexia, and malnu- jejunal–duodenum anastomosis. Actually, there was a duodenal trition, another surgery was scheduled after controlling infection. stenosis in the third portion of the duodenum (Fig. 1)–asit On this occasion, we have chosen to perform a partial gastrectomy. has been seen in the first GI endoscopy two years ago. There- We have used a Roux-en-Y reconstruction, aiming to exclude the fore, the authors have scheduled a surgery. He has undergone a duodenum from alimentary tract. Definitely, after this last surgical conversion of this gastroenteroanastomosis procedure to a Roux- procedure, the patient has resumed well, accepting oral nutrition en-Y gastroenteroanastomosis operation without any resection of and recovering weight. Lastly, he has left hospital one week after the stomach (Fig. 2). Still, we have repaired its prior anastomosis this surgery. Histopathology of the surgical specimen resulted in between stomach and efferent jejunal limb, increasing its diam- gastric (Figs. 3 and 4), duodenal (Fig. 5), and jejunal strongyloidiasis. eter. Lastly, we have made a side-to-side anastomosis between In conclusion, after this diagnosis has been reached, he was the third portion of the megaduodenum and a jejunal loop, thus treated with ivermectin, a broad-spectrum antiparasitic drug. He has overcome, gaining almost 10 kilogram in weight after six- months follow-up. Fig. 4. Histopathological studies showing S. stercoralis’s larvae on the gastric Fig. 2. Roux-en-Y gastroenteroanastomosis – first surgery. mucosa. CASE REPORT – OPEN ACCESS
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