Vasculitis-induced colonic strictures: report of two cases

PURPOSE

The clinical presentations of gastrointestinal involvement from systemic vasculitis are diverse. Colonic involvement from systemic vasculitis is unusual. We report the first case of a symptomatic colonic stricture associated with rheumatoid vasculitis and another associated with systemic lupus erythematosus.

METHODS

The clinical, radiologic, and histologic features of two cases of symptomatic colonic strictures secondary to colonic involvement with vasculitis are described. The literature covering gastrointestinal involvement from vasculitis in these conditions is reviewed.

RESULTS

Surgical resection of the colonic strictures was required in both patients and had a satisfactory outcome.

CONCLUSIONS

These cases provide further evidence of the protean clinical presentations of intestinal involvement in systemic vasculitis. Although immunosuppression has been shown to be of value in the treatment of vasculitis affecting the gastrointestinal tract, surgical resection is required for established strictures.

Sclerosing encapsulating peritonitis after intraperitoneal use of povidone iodine

BACKGROUND

The use of intraperitoneal povidone iodine as an agent for peritoneal lavage in colorectal surgery is controversial. Although it possesses a wide range of antimicrobial activity and is rapidly lethal to dissociated colorectal cancer cells in vitro, concern about its potential toxicity remains.

METHODS

Two cases of sclerosing encapsulating peritonitis (SEP) following elective colorectal surgery are presented. In each case the peritoneal cavity was lavaged with an aqueous povidone iodine solution. The surgical literature on the intraperitoneal use of povidone iodine is reviewed.

RESULTS

Significant morbidity resulted from the postoperative development of SEP in both of our patients. In one patient an ileo-anal pouch could not be fashioned following an initial colectomy, and in the second patient a small-bowel obstruction required a laparotomy and a period of intravenous nutrition before an oral diet could be tolerated.

CONCLUSION

The use of povidone iodine for peritoneal lavage in colorectal surgery is to be cautioned against in concentrations of > 1%.

Hydrodissection: an easy way to dissect anatomical planes and complex adhesions

BACKGROUND

Sharp dissection of adherent tissues resulting from previous sepsis or surgery is frequently time-consuming and sometimes difficult.

METHODS

The introduction of saline under pressure into the plane of dissection facilitates this task.

RESULTS

Hydrodissection both creates and displays the correct plane between adherent tissues.

CONCLUSIONS

This technique increases the safety and decreases the time spent in adhesiolysis in re-operative surgery.

Are special investigations of value in the management of patients with fecal incontinence?

PURPOSE

The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone.

METHODS

Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography.

RESULTS

In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy.

CONCLUSIONS

Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.

Laparoscopic resection of the colon and rectum for cancer

BACKGROUND

Laparoscopically-assisted resection for large bowel cancer is technically feasible. Sixty-six patients who had resection of the colon or rectum for cancer have been audited prospectively.

METHODS

Clinical and pathological data were collected prospectively as part of the ongoing Concord Hospital colorectal cancer project. Patients were followed up for a median of 29 months.

RESULTS

In 57 of 66 patients in whom laparoscopic resection was attempted the operation was completed laparoscopically. Three patients died from perioperative myocardial infarction. The median postoperative stay was 14 days. There was a high incidence of postoperative respiratory and cardiac complications. One patient developed a port-site metastasis.

CONCLUSION

There was no obvious benefit from laparoscopically-assisted resection of large bowel cancer in these patients.

The clinical and radiological features of cholecystocolic fistulae

The clinical and radiological features of seven patients presenting with cholecystocolic fistulae are reviewed. The majority of the patients were elderly (age range 43-85 years, mean 70.7 years) and there was a female preponderance (6:1). The condition usually has a benign clinical course. Diarrhoea was the most common presenting symptom and the typical clinical features of gallbladder disease were absent. Cholangitis occurred in only one patient. The time between onset of symptoms and diagnosis varied from 1 week to 2 years (mean 22 weeks). In only one patient was the diagnosis of biliary-intestinal fistula suspected on the basis of the plain abdominal radiograph (Case 5). A diagnosis of cholecystocolic fistula was established by barium enema (5 cases), endoscopic retrograde cholangiopancreatography (ERCP) (1 case) and diagnostic laparotomy (1 case). The only cause identified in this series was acute or chronic cholecystitis.

Cutaneous presentation of juvenile chronic myelogenous leukemia: a diagnostic and therapeutic dilemma

Annular, erythematous, circinate plaques were the first manifestation of juvenile chronic myelogenous leukemia (JCML) in an otherwise healthy 2.5-year-old boy who had had these lesions since 6 months of age. The lesions showed an atypical hematopoietic infiltrate on biopsy. Biopsy of a bone marrow specimen and peripheral blood smear were normal six months before leukemic transformation. At 3 years of age the boy developed splenomegaly, thrombocytopenia, and petechiae, and a bone marrow aspirate and cell marker studies were regarded as consistent with, if not diagnostic of, JCML. Four previous cases of cutaneous leukemic infiltrate associated with JCML have been published. Our patient had recurring urticarial-like plaques for two years before the initial bone marrow finding of JCML. Given the poor prognosis and progressively evolving course of JCML, it may be appropriate to consider therapy before bone marrow changes, based on the presence of the cutaneous eruption with the appropriate findings on skin biopsy and an elevated fetal hemoglobin.

[Cerebrovascular accidents. Case material based on hospital records]

Perceiving that inaccuracy of clinical records is the rule rather than the exception, the author examines the data base of the Amarante Regional Hospital with particular relevance to the patients who were hospitalized with cerebral vascular accident (CVA) in the Department of Internal Medicine during 1990, 1991 and 1992. The objective is to view the existing computerised hospital database as a source of information for future studies within the clinical field and, at the same time, to be aware of the department's casuistry and to contribute to the epidemiological understanding of the population who lives in the area of influence of this hospital. In this department, 24% of all the hospitalised patients had either a recent CVA or had already had one previously. On the whole, the disease affected both sexes in an equal manner, but females later than males. The mortality rate was greater in patients with CVA (17%) than in those without CVA (9%) and was also greater in CVA-females (19%) than in CVA-males (15%). The intercurrences in the community were the cause of admission in 26% of the hospitalised patients with a CVA, and were mainly respiratory, metabolic and urinary diseases, and appeared to be more serious in males. The mortality rate in patients with intercurrences (19%) was only exceeded by that caused by hemorragic accidents (22%). The author examines and discusses the instances of error during the construction and data gathering of the database and draws his own conclusions.

Hernia uteri (correction of: uterus) inguinale associated with unilateral renal agenesis

We report a patient with a rudimentary uterine horn, fallopian tube and ovary in an inguinal hernia. Associated with this abnormality the patient had ipsilateral renal agenesis and a unicornuate uterus.

Psychological assessment of postdisaster class action and personal injury litigants: a case study

The case study method is used to describe psychological assessments undertaken with victims of a combined natural/technological disaster for litigation purposes. A class action suit was filed in which the authors determined levels of traumatic stress in 27 plaintiffs as a group and relative to each other. The process was effective--the case was settled out of court in favor of the litigants. Individual litigants were satisfied with monetary awards received.

Glycogen storage disease in adults

OBJECTIVE

To identify complications amenable to prevention in adults with glycogen storage disease (GSD) types Ia, Ib, and III and to determine the effect of the disease on social factors.

DESIGN

Case series and clinical review.

SETTING

Referral medical centers in the United States and Canada.

PATIENTS

All patients with GSD-Ia (37 patients), GSD-Ib (5 patients), and GSD-III (9 patients) who were 18 years of age or older.

MEASUREMENTS

Ultrasound or radiographic studies identified liver adenomas, nephrocalcinosis, or kidney stones. Radiographic studies identified osteopenia. Reports of the clinical examination, serum chemistry results, and social data were obtained.

RESULTS

For patients with GSD-Ia, problems included short stature (90%), hepatomegaly (100%), hepatic adenomas (75%), anemia (81%), proteinuria or microalbuminuria (67%), kidney calcifications (65%), osteopenia or fractures or both (27%), increased alkaline phosphatase (61%) and gamma-glutamyltransferase (93%) activities, and increased serum cholesterol (76%) and triglyceride (100%) levels. Hyperuricemia was frequent (89%). Patients with GSD-Ib had severe recurrent bacterial infections and gingivitis. In patients with GSD-III, 67% (6 of 9) had increased creatinine kinase activity. Four of these patients had myopathy and cardiomyopathy.

CONCLUSIONS

For GSD-Ia, hyperuricemia and pyelonephritis should be treated to prevent nephrocalcinosis and additional renal damage. For GSD-Ib, granulocyte-colony-stimulating factor may prevent bacterial infections. For GSD-III, more data are required to determine whether the myopathy and cardiomyopathy can be prevented. Most of the patients with GSD-I and GSD-III had 12 or more years of education and were either currently in school or employed.

Femoral nerve palsy following laparoscopic inguinal herniorrhaphy

Laparoscopic inguinal herniorrhaphy has undergone a rapid evolution. The technique currently favored by many laparoscopic surgeons places a prosthetic mesh over the myopectineal orifice. We describe a femoral nerve palsy after such an operation and detail the anatomy of the nerves at risk during laparoscopic inguinal herniorrhaphy. We discuss how injury to these structures and the attendant anterior thigh pain and weakness may be avoided.

Radiology of starch granulomatous peritonitis

Starch granulomatous peritonitis (SGP) is a rare complication of abdominal surgery that results, in a susceptible individual, from contamination of the peritoneal cavity with starch particles from the surgeon's gloves. It is important to make the diagnosis of SGP without recourse to re-operation as the optimal treatment is non-surgical. A case of SGP that was confirmed only after re-operation and resection of the involved tissues is reported. The first description of an abdominal computed tomography scan in this condition is presented, the significance of which was only recognized postoperatively.