Benign ulcer of the small bowel.
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Humans↗
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A rational treatment of ruptured peptic ulcer.
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Humans↗
Splenic abscess: a diagnostic pitfall in the ED.
Splenic abscess, with its rare incidence and various misleading clinical manifestations, usually is a diagnostic pitfall in the modern emergency department. The most frequently seen symptoms and signs are fever, abdominal pain and tenderness over left upper quadrant, splenomegaly, leucocytosis, and left lower chest abnormalities. Four cases were collected during the past five years. On admission, one patient manifested symptoms mimicking a perforated peptic ulcer and the other three patients presented clinical and roentgenographic signs suggestive, but non-specific, for splenic abscess. In two cases, the diagnosis was based on sonography followed by computed tomography (CT). In one case, the splenic abscess was only visualized by CT. They all survived after splenectomy and appropriate antibiotic therapy. Culturing disclosed the offending organisms to be Escherichia coli, Pseudomonas aeruginosa, a Salmonella species, and Streptococcus viridans. These nonspecific clinical pictures should be thoroughly investigated, and CT, the most sensitive diagnostic tool, should be used whenever splenic abscess is suspected. Early diagnosis and timely treatment reduce the morbidity and mortality associated with splenic abscess.
Abdominal Pain↗
Imaging and intervention in patients with acute right lower quadrant disease.
US using graded compression plays a central role in the diagnostic work-up of acute right lower quadrant disease, but its results should always be integrated with clinical data and results of other possible radiological examinations. Direct US visualization of an inflamed appendix is solid proof of appendicitis. Pitfalls are secondary enlargement in perforated peptic ulcer, caecal carcinoma or Crohn's disease. If a normal appendix is visualized in its full length, appendicitis can be excluded. However, this is rarely the case. In practice, the only means to exclude appendicitis is to demonstrate an alternative condition, which in most cases is possible by US alone. Concomitant adynamic ileus is a valuable US finding. Abscesses related to appendicitis, Crohn's disease and colonic carcinoma respond well to percutaneous drainage, which is technically possible in 95% of cases. Some of these abscesses evacuate spontaneously to neighbouring bowel. For abscesses due to caecal diverticulitis spontaneous evacuation to the caecal lumen is the rule. For indication and drainage strategy, integration of US, CT and clinical data are indispensable. The use of US in right lower quadrant disease will not only lead to a strong improvement of diagnostic accuracy, but also to better understanding of the incidence and natural course of various conditions such as abortive appendicitis, appendiceal abscess, caecal diverticulitis, bacterial ileocaecitis and right-sided segmental infarction of the omentum.
Acute Disease↗
Extending the limits of lung cancer resection.
Patients with locally advanced bronchogenic carcinoma are often considered to have unresectable disease because of invasion into vital structures, or they undergo resection with questionable or involved margins, which results in local recurrence later. Brachytherapy (direct application of radioactive sources to the tumor bed) offers the potential to provide tumoricidal doses of radiation to the target area with minimal toxicity to surrounding structures. In this study, one of two different techniques of brachytherapy was utilized to treat 15 highly selected patients with histologically positive (n = 8) or suspicious (n = 7) margins after resection. The techniques were easy to apply and were not associated with any complications directly related to their use. One postoperative death resulted from a perforated peptic ulcer. In the remaining 14 patients, at a mean follow-up of 38 months, local control was complete in 12 (86%) patients, and 8 patients are alive, with 7 free of disease. Thoracic brachytherapy may offer the potential for cure to patients whose disease would otherwise be considered inoperable.
Brachytherapy↗
Ultrasonography of the acute abdomen: gastrointestinal conditions.
Although multislice, helical CT is increasingly replacing ultrasonography for the evaluation of patients with acute abdominal pain, ultrasound does have certain specific advantages over CT. This article discusses the advantages of ultrasound in imaging of the acute abdomen, exploring such areas as appendicitis, ileocecal Crohn's disease, infectious ileocolitis and infectious ileocecitis, mesenteric lymphadenitis, cecal carcinoma, sigmoid diverticulitis, right-sided colonic diverticulitis, and perforated peptic ulcer.
Abdomen, Acute↗
Blood pressure cuff compression injury of the radial nerve.
We describe a 19-year-old man who underwent emergency laparotomy for perforated peptic ulcer. He was otherwise healthy before this admission with no history of diabetes mellitus or neuropathy. A standard-size adult blood pressure cuff connected to a Dinamap monitor, set to cycle automatically every 3 minutes was affixed to his left upper extremity during surgery. One day after the operation he complained of numbness over the dorsum of the left hand and wrist drop. Physical examination revealed 0/5 muscle power of the left wrist and finger extensor muscles with reduced sensation on the radial aspect of the dorsum of the same hand. A diagnosis of acute radial nerve injury was made and rehabilitation was started. The wrist numbness and sensation improved with physical therapy, and he was discharged 9 days after the operation with an active wrist splint. He continued with rehabilitation on an out-patient basis. The muscle power of the wrist extensors gradually improved after three months of physical therapy and reverted to completely normal one month later. Locating the cuff higher on the arm, away from the elbow joint, to avoid the most superficial portion of radial nerve, may prevent this type of compression injury especially in asthenic patients.
Adult↗
Accuracy of magnetic resonance imaging in determining cause of sudden death in adults: comparison with conventional autopsy.
AIM: To determine the accuracy and define the limitations of post mortem magnetic resonance imaging (MRI) in determining the cause of sudden death in adults. METHODS AND RESULTS: Sudden unexpected adult deaths in the community, reported to the Coroner (n = 10), excluding suspicious, violent or potentially drug-related deaths, were submitted to whole body MRI, followed by full invasive autopsy. The MRI scans were reported independently by four radiologists, blinded to the autopsy findings; two had previous experience of post mortem MRI. An abnormality that related to the cause of death as identified at autopsy, was identified by at least one radiologist in eight cases. These were pulmonary consolidation (autopsy finding pneumonia) (n = 1), pneumoperitoneum (autopsy finding perforated peptic ulcer) (n = 2), left ventricular failure (autopsy finding ischaemic heart disease) (n = 4), and disseminated bronchial carcinoma (n = 1). However, in only one case were all radiologists able to provide a confident cause of death (disseminated bronchial carcinoma). In two cases, in which death occurred 2-6 days and 3-6 days before MRI, early decomposition prevented interpretation of the images. Severe coronary artery atheroma was detected at autopsy in 7/10, but these lesions were not detected by MRI. Previous experience in reporting post mortem MRI, without autopsy comparison, did not result in more accurate interpretation of the images. CONCLUSIONS: This pilot study suggests that post mortem MRI can identify some abnormalities relating to the common causes of sudden death in adults, but there is a need for greater experience in correlating MRI with autopsy findings before a reliable cause of death can be made by MRI alone. Inability to image coronary artery lesions, differentiating thrombus from clot and pulmonary oedema from pneumonic exudates, are specific problems that may be corrected with greater experience and higher resolution scans.
Adult↗
Laparoscopic renal biopsy: a 9-year experience.
OBJECTIVES: To present our experience and outcome of consecutive laparoscopic renal biopsy over a 9-year period, as renal biopsy remains an important diagnostic procedure for evaluating proteinuria, haematuria and renal failure, but when percutaneous biopsy is contraindicated, a laparoscopic biopsy is an attractive option because it is minimally invasive. PATIENTS AND METHODS: Seventy-four patients (29 male, 45 female, mean age 45 years, range 3-79) had a laparoscopic renal biopsy taken for various indications, e.g. morbid obesity, solitary kidney, coagulopathy, failed percutaneous biopsy, high location of the kidney and poor visualization with ultrasonography. The kidney was approached via a laparoscopic retroperitoneal route using a two-port technique, with the patient in the flank position. After identifying the kidney, one to five cortical biopsies were obtained with cup-biopsy forceps. RESULTS: Adequate tissue was obtained in 96% of the patients; the mean (range) operative duration was 123 (9-261) min and the estimated blood loss 67 (5-2000) mL. Forty-three patients were discharged within 24 h. Complications occurred in 10 patients, with significant bleeding in three. One patient died after surgery, secondary to a perforated peptic ulcer while on high-dose steroid therapy. CONCLUSION: Laparoscopic renal biopsy is a safe and effective alternative to open renal biopsy for patients in whom percutaneous biopsy is not feasible. It offers the advantage of obtaining cortical biopsies and achieving haemostasis under direct vision. Adequate renal tissue is obtained in most cases. Recovery and convalescence are short for most patients.
Adolescent↗
Laparoscopic renal biopsy.
BACKGROUND: Renal biopsy continues to be a pivotal tool and frequently indispensable diagnostic procedure in the clinical assessment of proteinuria and or unexplained renal disease. Laparoscopic renal biopsy has recently been reported as an alternative to open renal biopsy. METHODS: Thirty-two patients who had proteinuria and/or renal insufficiency underwent laparoscopic renal biopsy at our center. The indications for biopsy included failed percutaneous biopsy (N = 3), morbid obesity (14), solitary kidney (5), chronic anticoagulation/coagulopathy (6), religious consideration (refusal of potential blood transfusion) (2), multiple bilateral renal cysts and body habitus (1 case each). The kidney was approached via a laparoscopic retroperitoneal route (retroperitoneoscopy) using a two port technique. The lower pole of the kidney was localized using blunt dissection, laparoscopic cup biopsies were performed, and hemostasis was achieved using standard techniques. RESULTS: All biopsies were successfully completed laparoscopically with sufficient tissue obtained for histopathological diagnosis in all cases. Mean estimated blood loss was 25.9 ml (range 5 to 100). None of the patients required parenteral narcotics during the perioperative period. Operative time ranged from 0.8 to 3.0 hours (mean 1.5). Mean hospital stay was 1.7 days (range 0 to 7). Sixteen patients were treated as outpatients. Patients returned to normal activity at a mean of 1.7 weeks (range 0.3 to 3.0) postoperatively. In one patient, the spleen was inadvertently biopsied without consequence. An additional patient developed a postoperative 300 cc perinephric hematoma that resolved without the need for intervention. One postoperative mortality occurred on postoperative day seven secondary to a perforated peptic ulcer in a patient undergoing high-dose steroid therapy for lupus nephritis. CONCLUSION: Laparoscopic renal biopsy is a safe, reliable, minimally invasive alternative to open renal biopsy for patients in whom a closed percutaneous approach is either a relative or absolute contraindication, which can be performed on an outpatient basis.
Adolescent↗
Surgeons and infectious disease specialists: different attitudes towards antibiotic treatment and prophylaxis in common abdominal surgical infections.
BACKGROUND: The role of medical infectious disease (ID) specialists in the treatment of surgical infections is increasing but no information is available regarding the therapeutic perception held by these non-surgeons treating surgical infections. The purpose of this study was to assess the attitude of the ID specialists towards antibiotic treatment and prophylaxis of common abdominal surgical infections and to compare it with that of surgeons "interested" in this field. METHODS: A questionnaire, polling opinions regarding the management of common surgical infections, was sent to 396 medical ID specialists (New York State) and 515 surgeon members of the Surgical Infection Society (SIS). The questions covered areas involving choice of antibiotics, and timing and duration of treatment in given clinical scenarios, including elective and emergent colorectal surgery, perforated peptic ulcer, and appendicitis. RESULTS: Response rates for the medical and surgical groups were 10.1% and 15.6%, respectively. Regarding prophylactic use of antimicrobials, the pattern of administration was similar for the two groups. Regarding therapeutic use, on average medical ID specialists used antibiotics twice as long as the surgical group. The main reason identified was the failure of medical ID specialists to understand the conceptual difference between contamination and infection. CONCLUSIONS: Medical ID specialists may overtreat common surgical infections with antibiotics. Surgical infections should be treated by surgeons.
Abdomen↗
Cefmetazole treatment of intra-abdominal infection.
Seventy-nine patients were enrolled in a study comparing cefmetazole and cefoxitin as single agent antibiotic therapy for intra-abdominal infection. Thirty-seven patients had appendicitis, 16 patients had perforated peptic ulcer while 26 patients had a variety of other infectious processes. The clinical response to both antibiotics was good and tolerance was equivalent. Four patients with Pseudomonas aeruginosa isolated from the initial culture experienced microbiological failure. Three patients treated with cefmetazole had prolongation of the prothrombin time.
Abdomen↗
Giant horseshoe intra-abdominal abscess.
A study of 12 patients with giant horseshoe abscess of the abdominal and pelvic cavities seen at the Surgical Services of the University of Cincinnati Medical Center has emphasized the complexity and bizarre nature of these lesions. These infections represented a huge abscess or series of communicating abscesses extending from one subphrenic space along the corresponding paracolic gutter into the pelvis, up and along the opposite paracolic space, and into the other subphrenic space. Since these lesions occurred infrequently, they were often not recognized until they had become far advanced and had produced profound effects on the patients. The diagnosis was difficult and obscured by various factors including the postoperative state after laparotomy for complex diseases or serious injuries of the biliary tract, the genitourinary tract, or the alimentary tract. An important etiologic component of the formation of these giant abscesses was the continuing escape and collection of large volumes of fluid resulting from lesions of the biliary tract, postoperative hemorrhage, or an unrecognized large perforated peptic ulcer. Nine patients were treated successfully and 3 died. The many diagnostic and therapeutic problems presented by the patients with this interesting and complex lesion have emphasized the importance of earlier and more accurate diagnosis, early and adequate surgical drainage, intelligently applied antibiotic therapy and appropriate supportive treatment. Failure to recognize and drain effectively each of the component sections of this lesion led to continuing sepsis with prolonged morbidity, progressive debility, and death.
Abdomen↗
Orthotopic transplantation during early infancy as therapy for incurable congenital heart disease.
Since November 1985, 14 neonates and young infants have undergone orthotopic heart transplantation at Loma Linda University Medical Center (LLUMC) as therapy for hypoplastic aortic tract complex. Eleven (78%) survived surgery and are living and well today. Three perioperative deaths resulted: one due to perforated peptic ulcer, one due to necrotizing pneumonitis, and one due to graft failure unrelated to rejection. No late deaths occurred in the 1-29 months of follow-up, during which time noninvasive surveillance techniques were used. Immunosuppression was accomplished using cyclosporine and azathioprine. Steroids and antithymocyte globulin were used for identified rejection episodes only. Ordinary childhood infections were tolerated well. All survivors were normotensive. There was no late renal dysfunction. Although inadequate donor resources remain a significant limiting factor for transplantation therapy during early life, these results suggest that cardiac transplantation is effective therapy for selected neonates and young infants with incurable congenital heart disease.
Heart Defects, Congenital↗
Zollinger-Ellison syndrome. Clinical presentation in 261 patients.
We prospectively evaluated the initial presenting symptoms in 261 patients with Zollinger-Ellison syndrome (ZES) over a 25-year period. Twenty-two percent of the patients had multiple endocrine neoplasia-type 1 (MEN-1) with ZES. Mean age at onset was 41.1 +/- 0.7 years, with MEN-1 patients presenting at a younger age than those with sporadic ZES (p < 0.0001). Three percent of the patients had onset of the disease < age 20 years, and 7% > 60 years. A mean delay to diagnosis of 5.2 +/- 0.4 years occurred in all patients. A shorter duration of symptoms was noted in female patients and in patients with liver metastases. Abdominal pain and diarrhea were the most common symptoms, present in 75% and 73% of patients, respectively. Heartburn and weight loss, which were uncommonly reported in early series, were present in 44% and 17% of patients, respectively. Gastrointestinal bleeding was the initial presentation in a quarter of the patients. Patients rarely presented with only 1 symptom (11%); pain and diarrhea was the most frequent combination, occurring in 55% of patients. An important presenting sign that should suggest ZES is prominent gastric body folds, which were noted on endoscopy in 94% of patients; however, esophageal stricture and duodenal or pyloric scarring, reported in numerous case reports, were noted in only 4%-10%. Patients with MEN-1 presented less frequently with pain and bleeding and more frequently with nephrolithiasis. Comparing the clinical presentation before the introduction of histamine H2-receptor antagonists (pre-1980, n = 36), after the introduction of histamine H2-receptor antagonists (1981-1989, n = 118), and after the introduction of proton pump inhibitors (PPIs) (> 1990, n = 106) demonstrates no change in age of onset; delay in diagnosis; frequency of pain, diarrhea, weight loss; or frequency of complications of severe peptic disease (bleeding, perforations, esophageal strictures, pyloric scarring). Since the introduction of histamine H2-receptor antagonists, fewer patients had a previous history of gastric acid-reducing surgery or total gastrectomy. Only 1 patient evaluated after 1980 had a total gastrectomy, and this was done in 1977. The location of the primary tumor in general had a minimal effect on the clinical presentation, causing no effect on the age at presentation, delay in diagnosis, frequency of nephrolithiasis, or severity of disease (strictures, perforations, peptic ulcers, pyloric scarring). Disease extent had a minimal effect on symptoms, with only bleeding being more frequent in patients with localized disease. Patients with advanced disease presented at a later age and with a shorter disease history (p = 0.001), were less likely to have MEN-1 (p = 0.0087), and tended to have diarrhea more frequently (p = 0.079). A correct diagnosis of ZES was made by the referring physician initially in only 3% of the patients. The most common misdiagnosis made were idiopathic peptic ulcer disease (71%), idiopathic gastroesophageal reflux disease (GERD) (7%), and chronic idiopathic diarrhea (7%). Other less common misdiagnosis were Crohn disease (2%) and various diarrhea diseases (celiac sprue [3%], irritable bowel syndrome [3%], infectious diarrhea [2%], and lactose intolerance [1%]). Other medical disorders were present in 55% of all patients; patients with sporadic disease had fewer other medical disorders than patients with MEN-1 (45% versus 90%, p < 0.00001). Hyperparathyroidism and a previous history of kidney stones were significantly more frequent in patients with MEN-1 than in those with sporadic ZES. Pulmonary disorders and other malignancies were also more common in patients with MEN-1. These results demonstrate that abdominal pain, diarrhea, and heartburn are the most common presenting symptoms in ZES and that heartburn and diarrhea are more common than previously reported. The presence of weight loss especially with abdominal pain, diarrhea, or heartburn is an important clue suggesting the presence of gastrinoma. The presence of prominent gastric body folds, a clinical sign that has not been appreciated, is another important clue to the diagnosis of ZES. Patients with MEN-1 presented at an earlier age; however, in general, the initial symptoms were similar to patients without MEN-1. Gastrinoma extent and location have minimal effects on the clinical presentation. Overall, neither the introduction of successful antisecretory therapy nor widespread publication about ZES, attempting to increase awareness, has shortened the delay in diagnosis or reduced the incidence of patients presenting with peptic complications. The introduction of successful antisecretory therapy, however, has dramatically decreased the rate of surgery in controlling the acid secretion and likely led to patients presenting with less severe symptoms and fewer complications. (ABSTRACT TRUNCATED)
Abdominal Pain↗
Late-onset idiopathic hypoparathyroidism as a cause of diarrhoea.
A 62-year-old man presented with a 20-month history of intermittent watery diarrhoea and hypocalcaemia. At age 43 he had undergone partial gastrectomy with Billroth II anastomosis for perforated peptic ulcer and at age 57 developed megaloblastic anaemia with low serum cobalamin and folate levels. Exhaustive gastrointestinal studies performed to ascertain the cause of the diarrhoea were all negative. Plasma parathyroid hormone levels were undetectable and late-onset idiopathic hypoparathyroidism was diagnosed. Normalization of hypocalcaemia promptly corrected the bowel habit. Idiopathic hypoparathyroidism is an unusual cause of diarrhoea that should, however, be considered in patients with hypocalcaemia and associated diarrhoea without evidence of primary intestinal disease.
Diarrhea↗
Pyoderma gangrenosum outside the context of inflammatory bowel disease treated successfully with infliximab.
A 63-year-old man with chronic lymphocytic leukaemia developed pyoderma gangrenosum following minor trauma to the leg. He required intensive inpatient management with a multitude of treatments including larval therapy, surgical debridement, ciclosporin, methotrexate, thalidomide, pulsed intravenous methylprednisolone and high-dose intravenous immunoglobulin, clofazamine and high dose oral corticosteroids, none of which were helpful. Treatment complications included steroid-induced diabetes, Cushing's syndrome and perforated peptic ulcer. The pyoderma remained refractory to treatment and continued to extend until he received intravenous infliximab 5 mg/kg at weeks 0, 2 and 6.
Antibodies, Monoclonal↗