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PubMedDate not supplied

The significance of gallbladder trauma.

This study reviewed patients with gallbladder trauma over a 14-year period treated at Truman Medical Center to determine the complications, associated injuries, and mortality rate. Fourteen patients had gallbladder trauma, 12 penetrating and two blunt. All patients underwent cholecystectomy and 10 had 3 or more associated injuries that required operative care. There were no biliary duct injuries or postoperative biliary complications. Seven patients had postoperative wound, pulmonary, or abdominal infections. There was one mortality due to delayed splenic hematoma, myocardial infarction, and cardiac dysrhythmia. Gallbladder trauma was always associated with significant multi-organ injuries that required early operative intervention.

Adult↗
PubMed1994

Fatal pneumococcal septicemia in hemoglobin SC disease.

We retrospectively examined the medical and autopsy records of seven previously unpublished cases of fatal pneumococcal septicemia in children with hemoglobin SC disease. The earliest death occurred in a 1-year-old child who had congenital heart disease with cyanosis; the other children were aged 3 1/2 to 15 years. Only one child had received pneumococcal vaccine or prophylactic penicillin therapy. All seven children had an acute febrile illness and rapid clinical deterioration despite parenterally administered antibiotic therapy and intensive medical support. Erythrocyte pit counts in two patients were 40.3% and 41.7%, respectively (normal, < or = 3.6%). Autopsy data from five cases showed marked splenic congestion without infarction in five, splenomegaly in four, and bilateral adrenal hemorrhage in three. These cases illustrate that functional asplenia predisposes some children with hemoglobin SC disease to the development of fatal septicemia after the age of 3 years. We conclude that pneumococcal vaccine should be administered to all children with hemoglobin SC disease and that acute febrile illnesses should be investigated promptly for the possibility of septicemia. The routine use of prophylactic penicillin therapy in infants and children with hemoglobin SC disease remains controversial.

Adolescent↗
PubMed1979

Buerger's disease involving the celiac artery.

A young male with Buerger's disease who had previously required a left leg amputation died in renal failure and sepsis. Postmortem examination revealed an obliterative lesion of the celiac artery, which resulted in hepatic, splenic, and pancreatic infarctions. Celiac artery involvement represents an unusual manifestation of thromboangiitis obliterans.

Adult↗
PubMed2000

Clinical application of therapeutic erythrocytapheresis (TEA).

Therapeutic erythrocytapheresis (TEA) has been used in different diseases such as polycythemia vera (PV), secondary erythrocytosis or hemochromatosis as a process of the less cumbersome but more expensive phlebotomy. TEA is preferred in emergency conditions such as thrombocytosis or in conditions such as porphyria cutanea tarda (PCT) or erythropoietic porphyria when plasma exchange (PEX) is often combined with TEA to reduce extracellular levels of uroporphyrin which contribute to plasma hyperviscosity. TEA is often combined with drug therapy that varies from etoposide in PV to EPO and desferoxamine which are used to mobilize and reduce iron stores in hemochromatosis. Benefits from this combination may be more long lasting than expected. Nonetheless for TEA, there is no standard protocol and, clinical experience with this therapy remains highly anecdotal. Therapeutic red cell-exchange (TREX) has been used with much interest over the years, starting with the management of hemolytic disease of the newborn and later used to correct severe anemia in thalassemia patients thereby preventing iron overload. It has also been used for the management of complications of sickle cell disease such as priapism, chest syndrome, stroke, retinal, bone, splenic and hepatic infarction or in preparation for surgery by reducing HbS to less than 30%. Automated apheresis has also favored the use of TREX in conditions such as paroxysmal nocturnal hemoglobinuria and aniline poisoning, arsenic poisoning, Na chlorate intoxications and CO intoxications, hemoglobinopathies, autoimmune hemolytic anemia, reactions due to ABO incompatibility, in preparation for ABO incompatible bone marrow transplantation or for preventing anti-D immunization after the transfusion of D(+) cells to D(-) recipients. Another field of application has been in the emergency management of intraerythrocytic parasite infections such as malaria and babesiosis. Application of TREX may be wide but its real use remains limited. In our personal experience, in 16 years, only 167 TREX procedures have been carried out in a total of 13,747 therapeutic procedures. This represents only 1.21% of the total.

Anemia, Sickle Cell↗
PubMed2002

Heparin-induced thrombocytopenia: a common complication in cardiac transplant recipients.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an idiosyncratic complication of heparin therapy triggered by the development of immunoglobulin G (IgG) antibodies to platelet factor 4 heparin. It typically results in a 50% decrease in platelet count. Paradoxically, although bleeding is rare, there is a high risk of venous or arterial thrombotic events. Given that many patients awaiting transplantation are exposed to heparin for prolonged periods, we sought to determine the frequency of HIT and its consequences among patients before and after cardiac transplantation. METHODS: We reviewed retrospectively the clinical, pathologic, and laboratory databases for all patients who underwent heart transplantation at our institution between January 1, 1998, and December 31, 2000. An enzyme-linked immunoabsorption assay (ELISA) that detected IgG, IgA, and IgM antibodies directed against platelet factor 4 heparin complex confirmed the diagnosis of HIT. We analyzed bleeding and thrombotic complications and determined the influence of HIT on post-transplant outcomes. RESULTS: An assay for HIT antibody was performed before or after transplantation in 26 of 46 patients (46% of the entire cohort). In all cases, the clinical indication for testing was thrombocytopenia. Among patients screened, HIT antibody was detected in 11 patients (39%); HIT developed in 10 of 11 patients before transplantation. The mean platelet count at diagnosis was 88,000 +/- 22,000/mm(3). Heparin-induced thrombocytopenia with thrombosis syndrome developed in 5 of 11 patients (45%). Manifestations included splenic and renal infarctions, renal artery occlusion, coronary artery embolism with myocardial infarction, pulmonary embolism, and femoral and jugular venous occlusions. Alternative pre-operative anti-coagulation included lepirudin (n = 7), argatroban (n = 1), dalteparin (n = 1), and abciximab (n = 1). Two deaths occurred in the HIT-positive group; neither bleeding nor thrombosis caused either death. Actuarial 36-month survival did not differ between HIT-positive and HIT-negative cohorts (78% and 79%, respectively). CONCLUSION: Heparin-induced thrombocytopenia is a frequent complication among patients hospitalized for heart failure who are awaiting heart transplantation. Timely HIT-antibody screening and the use of alternative forms of systemic anti-coagulation may permit successful transplantation with intermediate survival rates comparable to those of HIT-negative recipients.

Adolescent↗
PubMed2002

Endovascular repair of abdominal aortic aneurysms: stent-graft fixation across the visceral arteries.

PURPOSE: Recent studies have suggested that transrenal artery fixation of endovascular stent-grafts is safe and may be a desirable means of reducing the risk of type I endoleaks, particularly those with short infrarenal necks. The close proximity of the superior mesenteric and celiac arteries to the renal arteries may commonly result in the placement of the stent struts across all the vessels of the visceral segment of the aorta. The purpose of this study was to determine the incidence and impact of transvisceral artery fixation during aortic stent-graft deployment for the treatment of abdominal aortic aneurysms (AAAs). METHODS: From January 1997 to June 1999, 192 patients (165 men, 27 women; mean age, 82 years) with AAAs were treated with an endovascular graft secured proximally to the aorta with a long (15 mm) uncovered stent segment (60 Parodi/Palmaz, 132 Talent-LPS). Preoperative and postoperative abdominal aortograms and intravenous contrast enhanced spiral computed tomography (CT) scans were performed. Follow-up CT scans were obtained at 3, 6, and 12 months and yearly thereafter as a means of determining stent position and visceral artery patency RESULTS: In 95 patients (49%), the uncovered stent was at or above the level of the superior mesenteric artery. In 23 patients (12%), the stent extended to the level of the celiac axis. In a mean follow-up period of 25 months (range, 6-44 months), serum creatinine levels remained stable, no stenoses or occlusions occurred in the celiac, superior mesenteric, or renal arteries, and no evidence of renal, hepatic, splenic, or intestinal infarction was present on contrast enhanced spiral CT scans. There were no type I endoleaks. CONCLUSION: Transvisceral fixation of the uncovered proximal aortic stent occurs frequently during deployment of devices designed for transrenal fixation and is associated with no early morbidity. Long-term follow-up is necessary to ensure that there are no late sequelae.

Aged↗
PubMed2006

Pediatric wandering spleen successfully treated by laparoscopic splenopexy.

Wandering spleen is a rare clinical condition associated with a high incidence of splenic torsion and infarction. The preferred treatment is splenopexy to reposition the spleen in the left upper quadrant of the abdomen. We report the case of a 12-year-old girl who presented with intermittent abdominal pain. An abdominal sonography was diagnostic of wandering spleen. The patient was successfully treated by laparoscopic splenopexy. The spleen was repositioned in the left upper quadrant and fixed to the posterior abdominal wall by a mesh patch attached by staples. To reinforce the splenopexy we created an additional support by plicating the phrenocolic ligament and suturing it to the lateral abdominal wall, making a pouch for the inferior pole of the spleen. The postoperative course was rapid and uneventful. A normal spleen position was verified by radionuclide scans at 3 days and 6 months postoperatively. Laparoscopic splenopexy is an excellent option for organ-preserving treatment in wandering spleen.

Child↗
PubMed1993

Abdominal complications in pediatric bone marrow transplant recipients.

Abdominal problems and catastrophes often complicate the clinical course after bone marrow transplantation (BMT) in children. These complications can be grouped into categories of infection, chemotherapy and radiation toxicity, graft-versus-host disease (GVHD), recurrent or de novo malignancy, and miscellaneous complications and can involve the hepatobiliary system, pancreas, spleen, gastrointestinal tract, and urinary tract. Infection is common after BMT: the causative organism depends on the changing immunologic state of the recipient and even on environmental factors such as recent construction, humidity, and antibiotic use. Chemotherapy and radiation therapy can cause hepatic veno-occlusive disease, pancreatitis, nephritis, and hemorrhagic cystitis. GVHD is a process in which donor lymphoid cells produce damage to recipient target organs, especially skin, liver, and intestinal mucosa. Recurrent or de novo disease or malignancies, particularly B-cell lymphomas, may develop in chronically immunocompromised children. Other problems include stone disease, splenic and renal infarction, and complications of hyperalimentation therapy. Abdominal imaging, including plain radiography, contrast material-enhanced studies of the bowel, real-time and duplex sonography, and computed tomography, is essential in diagnosing these problems and evaluating response to therapy.

Bone Marrow Transplantation↗
PubMed1984

Intravascular contrast agents suitable for magnetic resonance imaging.

Two paramagnetic chelates, chromium EDTA and gadolinium DTPA, were evaluated as potential intravenous contrast agents for magnetic resonance imaging (MR) using a 0.5-T superconducting scanner. After evaluating both agents in vitro, in vivo studies were conducted in dogs to document changes in renal appearance produced by contrast injection. Acute splenic and renal infarction were diagnosed with contrast-enhanced MR and confirmed by gamma camera imaging following administration of Tc-99m-labeled DMSA and sulfur colloid. The authors conclude that intravenous paramagnetic contrast agents presently offer the best mechanism for assessment of tissue function and changes in perfusion with MR.

Animals↗
PubMed1995

A dialysis patient with systemic calciphylaxis exhibiting rapidly progressive visceral ischemia and acral gangrene.

Systemic calciphylaxis is a rare, poorly understood syndrome of progressive peripheral ischemic necrosis and medial arterial calcification in patients with end-stage renal disease. We report a patient with this syndrome which developed following corticosteroid administration and who ultimately required amputation of the four extremities. Furthermore, cerebral, myocardial, splenic, and intestinal infarctions also developed in parallel with the increment of visceral arterial calcification. No evidence of noticeable hyperparathyroidism or elevation of serum calcium-phosphate product was observed. We speculated that, in addition to diabetes mellitus and chronic renal failure while undergoing dialysis therapy, the administration of corticosteroids might act synergistically to cause calciphylaxis.

Calciphylaxis↗
PubMed1994

[Angioimmunoblastic lymphadenopathy. Apropos a case with unusual clinical manifestations and evolution to T-cell lymphoma].

We present the case of a 67-years-old patient which, after treatment with ciprofloxacin, developed fever, exanthema, arthralgias, polyadenopathies, hepatosplenomegaly, autoimmune hemolytic anemia, hypergammaglobulinemia and severe inversion of the CD4/CD8 ratio. Latter, he developed ischemic signs in several locations (splenic and cerebral infarcts), as well as polyneuropathy and inflammatory myopathy. The diagnosis of angioimmunoblastic lymphadenopathy was established through ganglionary biopsy. The patient improved initially with the administration of corticoids, but in a few months, he developed pleomorphic T lymphoma with quick fatal evolution. We discuss the rarity of some of the clinical and laboratory manifestations in this patient and we comment on the association of ciprofloxacin and the angioimmunoblastic lymphadenopathy, which has never been previously described in the international literature.

Aged↗
PubMedDate not supplied

Nontraumatic focal lesions of the spleen: assessment of imaging and clinical evaluation.

Fifty-nine cases of nontraumatic splenic disease were reviewed to evaluate the roles of clinical findings, computed tomography, ultrasound, and radionuclide scanning in diagnosis and management. Patient groups included lymphoma (30 patients), infarct (11 patients), abscess (9 patients), cyst (5 patients), hemangioma (3 patients), and hamartoma (1 patient). In no case were clinical findings alone sufficient to diagnose a splenic lesion. Clinical and laboratory manifestations were nonspecific in all groups. Moreover, no radiologic study reliably diagnosed splenic lymphoma or leukemia. All other focal splenic lesions were consistently diagnosed noninvasively. Cross-sectional imaging was more useful than radioisotope scanning, and often provided adjunctive diagnosis of extrasplenic pathology. The superior detail, spatial resolution, and sensitivity of computed tomography made it the single most valuable diagnostic modality.

Abscess↗
PubMed1992

Splenic hematoma in acute pancreatitis. Role of coagulation disorders.

Splenic hematomas are infrequent complications of acute pancreatitis. In some cases, local factors that may play a role in the pathogenesis of the hematoma (thrombosis of the splenic artery or veins, intrasplenic pseudocysts, perisplenic adhesions, enzymatic digestion) are found. In the absence of local factors, the etiology of splenic hemorrhage remains unknown. We report two cases of splenic hematoma occurring during an acute necro-hemorrhagic pancreatitis associated with renal failure that required renal replacement therapy (hemodialysis and continuous arteriovenous hemodialysis). In both cases, more than half of splenic parenchyma was affected by multiple infarctions. No local factors responsible for the splenic abnormalities were detected in either case. Thrombosis of the splenic arterial microcirculation and a coagulation disorder consistent with disseminated intravascular coagulation was detected in one patient. In the second patient, coagulation disorders secondary to either liver disease, pancreatitis and its septic complications, or extracorporeal circuit heparinization for renal replacement therapy were present. Coagulation disorders should be considered whenever a splenic hematoma is found in a patient with acute pancreatitis. Disseminated intravascular coagulation may be the etiology of a splenic hematoma in acute pancreatitis.

Acute Disease↗
PubMed2005

Contrast enhanced sonography of focal splenic lesions with a second-generation contrast agent.

OBJECTIVE: Contrast enhanced sonography (CES) of second generation contrast media have shown a spleen-specific uptake of the microbubble contrast agent. The aim of this study was to investigate the ability of a second generation contrast agent to enhance splenic lesions. METHODS: From October 2003 to September 2004, 46 consecutive patients with focal (peri-) splenic lesions on B-mode sonography were studied by CES using a transpulmonary second-generation contrast agent (SonoVue). Data were retrospectively evaluated. Diagnosis of the patients were infarction (n = 9), lymphoma (n = 7), metastasis (n = 6), injury (n = 4), haemangioma/splenoma (n = 6), accessory spleen (n = 3), cyst (n = 2), and unknown cause (n = 9). Diagnosed of splenic lesions was confirmed by histology (n = 5), contrast enhanced computed tomography (n = 25), MRI (n = 4), scintigraphy (n = 1), and follow up (n = 38). Extent of enhancement (EE) was evaluated during the arterial phase (5-30 s) and the parenchymal phase (3-5 minutes): EE of focal splenic lesions was determined using the surrounding splenic tissue as an in vivo reference, and classified as anechoic vs. hypoechoic vs. isoechoic vs. hyperechoic vs. mixed. The contribution of CES to the final diagnosis was classified as low, helpful or highly necessary. RESULTS: In all but one patient enhancement of normal splenic tissue occurred. During the arterial and parenchymal phase, lesions were found to have anechoic 10/10, hypoechoic 12/24, isoechoic 12/7, hyperechoic 7/0 and mixed enhancement 5/5, respectively. Value of CES for final diagnosis was low n = 24 (52%) (7 lymphomas, 6 metastases, 2 cysts, 9 unknown), helpful n = 9 (20%) (4 infarctions, 2 ruptures, 3 accessory spleens) and highly necessary n = 13 (28%) (5 infarctions, 2 ruptures, 6 haemangiomas/splenomas). CONCLUSION: Contrast-enhanced sonography is of diagnostic value in subgroups of patients with (peri-)splenic lesions (48%): including splenic infarction, splenic rupture, splenic haemangioma/splenoma, and accessory spleen.

Aged↗
PubMed1995

Elevated serum antibody response to toxin A following splenic abscess due to Clostridium difficile.

Splenic abscess and segmental small-bowel infarction were documented in a patient from whose splenic culture Clostridium difficile was isolated. A week and a half after splenectomy and partial bowel resection, diarrhea developed and stool cultures yielded an isolate of C. difficile that was identical to the abscess isolate when subjected to restriction endonuclease analysis. The level of IgG antibody to toxin A was markedly higher in serum from this patient than in sera from patients with C. difficile diarrhea alone. This case illustrates a rare but serious extraintestinal manifestation of infection with C. difficile and suggests a correlation between serum levels of IgG antibody to toxin A and systemic exposure to C. difficile, a typically noninvasive enteric pathogen.

Abscess↗
PubMed1995

Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis.

OBJECTIVES: The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. METHODS: Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. RESULTS: Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). CONCLUSIONS: (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Adolescent↗
PubMed1994

Enhanced rim around infarcted, traumatized spleen on computed tomographic scans: case report.

Computed tomography is considered a reliable imaging technique when determining the extent of splenic injury. We present the case of a patient with a traumatic infarct of the spleen detected by computed tomographic scanning of the abdomen. During laparotomy there was an infarction of the spleen from a hilar injury in addition to bleeding from the splenic vein. We conclude that ongoing bleeding from the splenic hilar vessel can lead to a rim of enhancement around the spleen from contrast material. This should be taken into account when a decision is made for nonsurgical management.

Abdominal Injuries↗
PubMed1984

[Splenic involvement in infectious endocarditis. 5 clinical cases and 78 necropsies].

Splenic involvement is a classical complication of infective endocarditis (IE). Clinical manifestations are rare, 5 out of 100 IE: unexpected rupture (1 case), abscess causing reinfection (2 cases), pseudo-tumour (1 case) and terminal infarction (1 case). In addition to a review of the literature, a post mortem histological study of the spleen of 78 cases of IE was undertaken. Splenic involvement did not seem to be the direct cause of death. Three types of lesions which may or may not be associated were observed: congestive inflammatory lesions, infarction (48 p. 100), abscess (6 p. 100). Splenic infarction usually results in scarring but may progress to abscess formation. Rupture was not observed in this autopsy series. Although splenic involvement is common at post mortem it gives rise to few symptoms. Persistant pyrexia and the appearance of local signs should lead to investigation of splenic complications and eventually, to surgical ablation.

Adolescent↗