title: Bleeding from duodenal ulcer in a patient with bilio-pancreatic diversion.
abstract: Scopinaro's bilio-pancreatic diversion is considered as an acceptable malabsorptive surgical approach for the treatment of morbid obesity. We describe a case of acute recurrent gastro-intestinal bleeding in a patient with a previous Scopinaro's bilio-pancreatic diversion. At the first admission in our department, gastroscopy, colonoscopy, contrast-enhanced computerized tomography and angiography resulted negative for active bleeding. Hypovolemic shock indicated laparotomy and an intraoperative enteroscopy performed through a small enterotomy showed an ulcerative perforation sourced in an ischemic portion of a distended duodenal stump, with a bleeding branch of gastro-duodenal artery at the bottom. Hemorrhage was stopped with stitches. Two years later a new episode of duodenal bleeding associated with severe malnutrition occurred. A covered chronic ischemic perforation sustained by duodenal distension due to biliopancreatic limb sub-obstruction appeared to be the most probable etiology of the recurrent duodenal bleeding. The patient underwent again to laparotomy and adhesiolysis; hemorrhage was stopped by means of ligation of gastroduodenal artery and bilio-pancreatic diversion was converted into a standard Roux-en-Y gastroenterostomy with an entero-entero anastomosis 40 cm from the Treitz ligament in order to restore an anatomo-functional condition guaranteeing normal absorption and intestinal transit. After Scopinaro's bilio-pancreatic diversion duodenal bleeding can represent a rare serious presentation of biliopancreatic limb obstruction; because of the complex anatomical reconstruction performed during this intervention, the duodenum results unavailable during upper gastro-intestinal endoscopy, and if a duodenal bleeding is suspected laparotomy followed by enteroscopy represents an effective diagnostic approach.
authors: Reparto di Chirurgia Generale, Ospedale San Gerardo, Università di Milano-Bicocca, via Pergolesi 33, 20052, Monza, Italy. mattia_garancini@yahoo.it
authors: Mattia
authors: M
authors: Garancini
authors: Margherita
authors: M
authors: Luperto
authors: Alberto
authors: A
authors: Delitala
authors: Matteo
authors: M
authors: Maternini
authors: Franco
authors: F
authors: Uggeri
mesh_terms: D001158:Arteries / Q000601:surgery; D015904:Biliopancreatic Diversion; D004381:Duodenal Ulcer / Q000150:complications*; D004386:Duodenum / Q000098:blood supply; D005763:Gastroenterostomy; D006801:Humans; D008026:Ligation; D008297:Male; D044342:Malnutrition / Q000209:etiology / Q000601:surgery; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000209:etiology / Q000601:surgery*; D013270:Stomach / Q000098:blood supply