Hemobilia

BACKGROUND

Laparoscopic procedures are safe and effective treatment methods in experienced hands. However, complications have been reported for laparoscopic procedures. One of the complications of laparoscopic cholecystectomy is vascular injuries. Hepatic and cystic artery injuries may occur alone or in association with bile duct injury. Bleeding from arterial injury may be seen during operation or in the late postoperative period. One of the most significant pathologies leading to this rare phenomenon is hemobilia.

METHODS

We present a case of a 62-year-old woman who underwent routine laparoscopic cholecystectomy for cholelithiasis at another hospital. She presented 6 months later with the clinical feature of upper gastrointestinal bleeding.

RESULTS

There was a 42 x 40 x 11 mm anechoic lesion and an echoic pattern compatible with a metallic object was found in the subhepatic region using abdominal ultrasonography. In the endoscopic examination, fresh blood was found in the stomach. The source of hemorrhage could not be identified. Bulbus duodeni was normal but a fresh clot on the papilla of Vateri was seen on gastroduodenoscopic examination. Laparotomy was performed and the provisional diagnosis of hemobilia was reached. The injured hepatic artery and pseudoaneurysmatic structure were repaired.

CONCLUSION

Hemobilia is a late complication of laparoscopic cholecystectomy. We believe that it is important to take into consideration that bile duct injuries may be accompanied by arterial pathology.

The prevalence of hepatitis G virus in cancer patients

Hepatitis G virus (HGV) is transfusion-transmissible and has a global distribution. However, its frequency and clinical impact have not been well established in extrahepatic cancer patients. In this study, we determined the prevalence of HGV RNA positivity, and its relationship with history of transfusion, amount of transfusion, age and sex in patients with hematological and solid malignancies in Southeastern Turkey. Sixty-one patients (35 males and 26 females) followed up for various malignancies and 60 healthy subjects were included in the study. HGV RNA was investigated by the reverse transcription polymerase chain reaction. HGV RNA was detected in none of the patients with cancer (0%) and only one person (1.6%) in the control group. There was no difference between the groups. This observation indicates that the prevalence of HGV is very low in cancer patients and healthy people in our geographical area. In addition, the role of HGV in the pathogenesis of extrahepatic malignancies seems insignificant.

The effect of continuous ambulatory peritoneal dialysis on serum CA-125 levels

Malignant and non-malignant serosal fluids were found to be associated with high serum levels of CA-125, suggesting that the presence of fluid in the serosal cavities may stimulate its release. In this study, we investigated the relationship between serum CA-125 levels and peritoneal irritation during continuous ambulatory peritoneal dialysis (CAPD). We performed a clinical study in 24 stable patients (15 amenstrual females and 9 males), aged 46 +/- 14 years on CAPD. The control group consisted of 32 healthy volunteers (20 females, 12 males) aged 44 +/- 12 years. CA-125 levels were determined prior to the CAPD dwell (without dialysate in abdomen) and during the CAPD dwell (dialysate in abdomen 4 hours after). As a result, serum CA-125 levels were found to be 14.86 +/- 5.98 U/ml and 15.23 +/- 6.05 U/ml respectively, whereas it was 8.32 +/- 5.54 U/ml in the control group. Serum CA-125 levels were found to be significantly elevated in CAPD patients when compared with healthy volunteers. However, serum CA-125 levels detected prior to and after CAPD did not differ between the groups. Interestingly, all of the patients in our study group were detected to have normal serum CA-125 levels (< 35 U/ml). We concluded that CAPD-induced abdominal artificial ascites did not affect serum levels of CA-125. Moreover, short and non-inflammatory mechanical pressures in the CAPD procedure do not have any effect on serum CA-125 levels.

Neoadjuvant chemotherapy in ovarian cancer

Patients with advanced ovarian cancer have a chance of less than 50% after radical debulking surgery. In spite of the currently more effective combination chemotherapy agents that have become available as adjuvant therapy in the last decade, the prognosis of patients with residual tumor mass larger than 1 cm in diameter following surgery is still poor. Neoadjuvant or primary chemotherapy has been suggested as an alternative approach to primary laparotomy of the bulky ovarian cancer. The advantages and available data on neoadjuvant chemotherapy are discussed in this review.

Ruptured granulosa cell tumor of the left ovary and mature cystic teratoma of the right ovary: a case report of unusual acute abdominal syndrome

Although granulosa cell tumor combined with a dermoid cyst in the same ovary is rarely seen, adult granulosa cell tumor of the ovary with contralateral teratoma has not been reported to date. In this report we present the first case in the English language literature of a ruptured granulosa cell tumor of the left ovary and mature cystic teratoma of the right ovary presenting as acute abdominal syndrome. The patient underwent total abdominal hysterectomy, bilateral-ophorectomy, and multiple pelvic lymph node sampling and infracolic omentectomy. She received combined chemotherapy consisting of bleomycin, etoposide. and cisplatin for six cycles. Subsequent follow-up and workups have revealed no evidence of disease. At 19 months after initial diagnosis, she is disease-free.

Early multimodal therapy in adult Wilms' tumor: case report

Wilms' tumor occurs rarely in adults, especially after the third decade. In adults, the prognosis of Wilms' tumor is worse than in children. In this case report, we present a 48-year old patient who relapsed with advanced stage shortly after primary surgery. A definitive treatment plan has not been established because of the rarity of this tumor in adults. After surgical removal, multimodal therapy should be begun immediately for long-lasting, complete remission.

The prevalence of TT virus in cancer patients

Transfusion-transmitted virus (TTV) is a recently discovered transfusion-transmissible DNA virus. Its frequency and clinical impact has not been established in cancer patients in Turkey. In this study, we determined the prevalence of TTV DNA positivity, and its relationship with history of transfusion, amount of transfusion, age and sex in patients with hematological and solid malignancies. Sixty-one patients (35 male and 26 female) followed up for various malignancies and 45 healthy subjects were included in the study. ITV DNA was assayed by the polymerase chain reaction (PCR). TTV DNA was detected in 18 of 61 patients (29.5%) and in 5 of 45 control subjects (11.1%). In cancer patients, the prevalence of TTV DNA positivity was higher to comparison with control group. In addition, the prevalence of TTV DNA positivity was significantly higher in 22 patients who had a history of blood transfusion in the last 6 months than 39 patients who had no current or past history of transfusion (40.9% vs 23.0% respectively). These results suggest that the prevalence of TTV DNA is high and the parenteral route is an important mode of transmission for TTV in cancer patients. In addition, the high prevalence and persistence of TTV in cancer patients with parenteral risk exposure could be related to the immunodeficiency due to cancer and high viral loads by parenteral route.

Bernard-Soulier syndrome in a Turkish family

This report describes the first Turkish family to be diagnosed with Bernard-Soulier syndrome. The family consists of nine members (two parents, three sons and four daughters). The parents were first cousins. The index case, a 22 year-old-man, had a history of haemorrhagic diathesis with thrombocytopenia, giant platelets in the peripheral blood smear and a prolonged bleeding time. Refractory idiopathic thrombocytopenic purpura had been diagnosed elsewhere and a splenectomy had been performed six months previously. Ristocetin agglutination of platelets was defective and flow cytometry analysis of platelet membrane glycoprotein showed markedly reduced expression of glycoprotein lb (2.1%). Bernard-Soulier syndrome was diagnosed. Increased mean platelet volume was found in both parents, one son and three daughters. The other son and daughter were normal.

Plasma lipid peroxidation products and antioxidant enzyme activities in patients with type 2 diabetes mellitus

Diabetes is associated with a significant increase in thiobarbituric acid reactive substances (TBARS) which are considered as an index of endogenous lipid peroxidation. The human body has a complex antioxidant defense system that prevents the initiation of free radical chain reactions. We measured plasma TBARS levels, superoxide dismutase (SOD) and catalase (CAT) activities and compared their relation to the metabolic control of diabetes and diabetic microangiopathy. Sixty-four patients (19 men), aged 52.35+/-9.31 years with type 2 diabetes mellitus were included in the study. Thirty-six healthy subjects (12 men), aged 51.02+/-7.01 years formed the control group. TBARS levels and SOD activity were elevated in the diabetic group when compared with the control group ( p<0.001 and p<0.00001, respectively). However CAT activity was significantly decreased in the diabetic group when compared with the control group ( p<0.00001). Patients with diabetic nephropathy and retinopathy, but not neuropathy, had elevated TBARS levels but there was no statistically significant difference when compared with diabetic patients without microangiopathy ( p>0.05). There was a positive correlation between plasma TBARS levels and SOD activity (r=0.770, p=0.0001) and a negative correlation between plasma TBARS levels and CAT activity (r=0.482, p=0.0001). There was also a negative correlation between SOD and CAT activities (r=-0.609, p=0.0001). We found significantly elevated TBARS levels in diabetic patients. We did not observe any correlation between TBARS levels and blood glucose and HbA(1c) levels. Elevated TBARS levels and SOD activity and decreased CAT activity may be due to a compensation mechanism of the body.

Bilateral primary squamous cell carcinoma of the ovary: a case report of isolated metastasis to the lateral pelvic wall

Primary squamous cell carcinoma of the ovary is rare. The majority of cases arise most commonly from the lining of a dermoid cyst, and less often in endometriosis or a Brenner tumor. A 40-year-old woman underwent exploratory laparotomy and was found to have a right ovarian tumor adherent to the lateral pelvic wall with no ascites. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, infracolic omentectomy, appendectomy, and right nephrectomy for bilateral primary squamous cell carcinoma of the ovary. She was started on multiagent chemotherapy. On follow-up after two years the patient had died of cerebral metastases. To our knowledge in this report we present the first case in the English literature of bilateral pure squamous cell carcinoma of the ovary.

Superior vena cava syndrome caused by chemotherapy-induced fibrosis

We report a case of a 51-year old man with small cell lung cancer who developed superior vena cava syndrome due to obstruction of the superior vena cava at the junction of the brachiocephalic vein by a fibrotic band, 2 months after completing six cycles of chemotherapy with cisplatin and etoposid. Superior vena cava syndrome caused by chemotherapy-induced pulmonary fibrosis should be kept in mind during follow-up.

Acute effect of haemodialysis on serum markers of myocardial damage

Cardiac markers are more likely to be elevated in dialysis patients than in patients with renal failure not on dialysis. In this study, 31 patients (20 males, 11 females) undergoing chronic haemodialysis were enrolled. The effect of haemodialysis on cardiac troponin T (cTnT), I (cTnI), creatine kinase MB (CKMB) mass, CKMB activity and myoglobin assays was assessed by comparing pre- and post-haemodialysis determinations. After correcting for haemoconcentration, significant differences were observed (mean +/- SEM, pre- vs post-dialysis) for myoglobin (178.9 +/- 19.3 vs 225.0 +/- 28.4 ng/ml; p=0.006) for cTnT (0.111 +/- 0.028 vs 0.148 +/- 0.037 ng/ml; p=0.004), for CKMB mass (2.75 +/- 0.37 vs 2.59 +/- 0.37 ng/ml; p=0.000) and CKMB activity (14.8 +/- 0.9 vs 13.1 +/- 0.9 U/l; p=0.000) assays. Our study questions the reliability of cardiac markers in dialysis patients and suggests that the clinical threshold value and diagnostic efficiency of each assay needs to be validated. Although these differences exceeded clinical threshold values in only a few patients, serum markers of myocardial damage in dialysis patients should be interpreted with caution.

Non-invasive imaging methods before fine-needle aspiration in the diagnosis of cervical masses

A carotid body tumour is a vascular tumour usually located at or around the bifurcation of the carotid artery and originating from the tunica adventitia. Carotid body tumours, which are generally non-functional and asymptomatic, grow slowly, which is why diagnosis can be delayed. Because of the vascular structures, fine-needle aspiration biopsy may be dangerous and impractical. Efficient and reliable methods of diagnosis, such as colour Doppler ultrasound, magnetic resonance imaging, computerised tomography and arteriography, can be useful. We report on a 58-year-old woman with diarrhoea, flushing and a cervical, hard, non-tender, fixed mass. An unsuccessful diagnostic fine-needle aspiration biopsy was performed after palpation of the cervical mass. A carotid body tumour was finally diagnosed. We concluded that non-invasive imaging methods should be evaluated before fine-needle aspiration in cervical masses. It should also be kept in mind that asymptomatic cervical masses may be related to non-local symptoms.

The efficacy of acetazolamide on visual functions in a patient with choroid metastasis of breast carcinoma

Breast carcinoma is the most frequent cancer in women and is the second leading cause of death. Choroid metastasis of breast carcinoma can be found either at presentation or in remission. It is frequently encountered in disseminated breast cancer with multiple organ metastasis. It has been proposed that the oedema-reducing effect of acetazolamide is due to stimulated ion and fluid removal from the retina to the choroid. A 40-year-old female patient on adjuvant chemotherapy for breast cancer was found to have an isolated choroid metastasis. Clinical and radiological remission was achieved after orbital radiotherapy, chemotherapy and acetazolamide treatment. In this case report, we emphasise the possible beneficial effect of acetazolamide in patients with choroid metastasis.

Dacarbazine-induced carotid artery and deep venous thrombosis in a patient with leiomyosarcoma: case report

Thromboembolic events are a common and important cause of morbidity and mortality in cancer patients that require early diagnosis and treatment. Reports have suggested that chemotherapeutic agents may contribute to this risk. In this case report, a 60-year-old male patient on chemotherapy (dacarbazine and doxorubicin) for leiomyosarcoma with no previous history of thromboembolism developed left carotid artery thrombosis 3 days after the first cycle of chemotherapy. A low molecular weight heparin was started for a possible cerebrovascular accident-related thrombosis. In the second cycle, he developed right femoral vein thrombosis only 2 days after initiating the chemotherapy. The chemotherapy protocol was changed and the patient did not develop any thrombosis during the 1-year follow-up. In the literature, no thrombotic complications have previously been reported due to either dacarbazine or doxorubicin. In conclusion, elderly patients on chemotherapy should be carefully monitored for thromboembolic complications and, in case of thrombosis, the chemotherapy protocol should be changed.

The epidemiology of elevated blood pressure as an estimate for hypertension in Aydin, Turkey

BACKGROUND

Hypertension is an important public health problem, with some variability of its epidemiological properties in different populations.

OBJECTIVES

The purpose of this study was to estimate the prevalence of hypertension and to determine the hypertension awareness, treatment and control rates in Aydin, a Turkish province.

METHODS

Of 1600 coincidentally selected people aged over 18 years in Aydin, 1480 (92.5%) had their blood pressure (BP) measured and answered a standard questionnaire in 1995.

RESULTS

Estimates of the prevalence of hypertension and its control were computed using two different criteria to define hypertension: BP > or =140/90 mm Hg or on treatment and BP > or =160/95 mm Hg or on treatment. Overall, the estimated prevalence of hypertension was 29.6% (for BP > or =140/90 mm Hg or on treatment). Hypertension prevalence increased progressively with age, from 9% in 18- to 29-year-olds to 70.6% in those 70-79 years of age. Women had a significantly higher prevalence than men (34.1% vs 26.0% respectively). Overall, 57.9% of hypertensive individuals were aware that they had high BP, and 82.1% of aware hypertensives were being treated with antihypertensive medications, but only 19.8% of treated hypertensives were under control (systolic pressure <140 mm Hg and diastolic pressure <90 mm Hg). In addition, housewives, unemployed, and the less educated individuals had greater mean systolic and diastolic BP.

CONCLUSIONS

Our results indicate that hypertension is highly prevalent in Aydin, Turkey, and the detection and control of hypertension is unsatisfactory.