Intrathoracic drainage of a perforated prepyloric gastric ulcer with a type II paraoesophageal hernia

BACKGROUND: With an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum. CASE PRESENTATION: A 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well. CONCLUSION: Type II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge

Results of 244 consecutive patients with hemorrhoids treated with Doppler-guided hemorrhoidal artery ligation

Abstract AIM: This study was designed to determine the effect of treating hemorrhoids with the Doppler-guided hemorrhoidal artery ligation (DG-HAL) procedure. METHODS: From June 2005 to March 2008, 244 consecutive hemorrhoidal patients underwent hemorroidal artery ligation performed with the DG-HAL system from AMI. All patients were evaluated postoperatively with a proctologic examination and interview. Further follow-up was performed by telephone with a standardized questionnaire. When indicated, patients revisited the clinic for further examination and treatment. RESULTS: 244 patients were treated with DG-HAL. The mean follow-up time was 18.4 months (range 1.4-37.2). Sixty-seven percent of the patients had an improvement of symptoms after one treatment. Fifty-three patients (22%) underwent a second procedure because of persisting symptoms. Thirteen patients (25%) underwent a second DG-HAL and 40 (75%) underwent rubber band ligation. In total, 69% of the patients had a good response using the DG-HAL technique. Multivariate logistic regression analysis revealed prolapse to be an independent risk factor for persistent symptoms (OR = 2.38, 95% CI 1.10-5.15). Patients with grades 3 and 4 hemorrhoids had a higher risk of developing recurrent disease (OR = 4.94, 95% CI 0.67-36.42). CONCLUSION: DG-HAL seems to be an effective procedure for treating low-grade hemorrhoids. A resection procedure should be the treatment for patients with recurrent disease