Increased prevalence of abdominal aortic aneurysm in patients undergoing inguinal hernia repair compared with patients without hernia receiving aneurysm screening

BACKGROUND

The introduction of screening programs for abdominal aortic aneurysm (AAA) is being contemplated by health services in several countries. The correlation between aortic aneurysm and abdominal wall hernias is well reported, and inguinal hernia has been identified as a risk factor for aortic aneurysm. However, the prevalence of AAA in patients with inguinal hernia has not been adequately documented. This study evaluated whether patients with inguinal hernia are at increased risk of having an AAA compared with patients without hernia receiving aneurysm screening.

METHODS

Men aged >55 undergoing primary inguinal hernia repair underwent ultrasound imaging of the abdominal aorta to screen for aneurysm. A reference group was selected from men without clinical evidence of inguinal hernia participating in an AAA screening program. Prevalence and odds ratios of AAA in the two groups were calculated.

RESULTS

The study cohort comprised 235 patients with inguinal hernia and 203 controls. The mean ± SD aortic diameter was 22 ± 9 mm in patients with inguinal hernia vs 20 ± 6 mm for controls (P = .045). The prevalence of AAA was 8.1% in the hernia group and 3.9% in the control group (adjusted odds ratio, 3.9; 95% confidence interval, 1.6-9.5; P = .039). For aneurysms >4 cm, the prevalence was 5.1% in those with an inguinal hernia and 1.5% in those without an inguinal hernia (adjusted odds ratio, 4.7; 95% confidence interval, 1.2-18.5, P = .025).

CONCLUSIONS

Inguinal hernia was a significant risk factor for AAA. Entry into a screening program of men aged >55 admitted for inguinal hernia repair should be considered.

Diagnosis and laparoscopic management of a rudimentary uterine horn in a teenage girl, presenting with haematometra and severe endometriosis: our experience and review of literature

A unicornuate uterus is a rare congenital malformation of the female genital tract, which appears in about 1/1000 women and is characterized by significant anatomic variability. In the most common type, a noncommunicating rudimentary horn coexists with the unicornuate uterus. The diagnosis of this anomaly is usually delayed, as it remains asymptomatic until adolescence and its initial symptoms are atypical. As a result, it is often diagnosed after the appearance of severe complications, such as haematometra, endometriosis, infertility and ectopic pregnancy. We report a case of a teenage girl presenting with dysmenorrhoea, endometriosis and haematometra secondary to a noncommunicating rudimentary horn. The diagnosis of the anomaly was based on magnetic resonance imaging (MRI) and laparoscopy. The excision of the symptomatic rudimentary horn and the ipsilateral fallopian tube was also performed laparoscopically. A review of the literature follows, focusing mainly on the diagnosis and laparoscopic management of a unicornuate uterus and its complications in adolescence. Laparoscopy is an accurate diagnostic tool, which also carries significant advantages in effective surgical management of congenital uterine anomalies, especially in young women.

Achilles tendon volume in type 2 diabetic patients with or without peripheral neuropathy: MRI study

The aim of this study was to evaluate Achilles tendon (AT) in type 2 diabetic patients with vs. without peripheral neuropathy using Magnetic Resonance Imaging (MRI). The study included 19 patients (group A, mean age 63.9+/-7.4 years) with peripheral neuropathy and 19 patients (group B, mean age 63.6+/-6.1 years) without peripheral neuropathy, as well as 16 healthy controls (group C, mean age 61.6+/-8.4 years). Neuropathy was diagnosed by the Diabetic Neuropathy Index (DNI). The maximum AT thickness and AT volume were measured on sagittal T (1) weighted MRI images. AT volume was calculated by the sum of the tendon surface area of all contiguous sections multiplied by the slice thickness. Diabetic patients had significantly (p<0.001) greater AT volume than controls (9742.0+/-2034.9 mm(3) vs. 7323.8+/-1918.2 mm(3)). This difference was observed both in men (p=0.030) and in women (p<0.001). AT volume was significantly greater in group A vs. C (p=0.003) and in group B vs. C (p<0.001), but there was no difference between groups A and B (p=0.469). Finally, in group A increased AT volume was significantly (p=0.041) associated with clinical severity of neuropathy. CONCLUSIONS Type 2 diabetic patients have increased AT volume as compared to controls. There is no difference in AT volume between patients with and without neuropathy. However, in neuropathic patients increased AT volume is associated with severity of neuropathy.

Ultrasonographic diagnosis of pregnancy in rats

The purpose of the present study was to describe the technique for and findings of ultrasonographic examination of the rat uterus for diagnosis of early and midterm pregnancy. The uterus of anesthetized Wistar rats was examined between days 9 and 16 post coitum by transabdominal real-time ultrasonography by using a 12-MHz linear transducer. Pulsed-waved color Doppler sonography was used to measure the embryonic heart rate. The embryonic vesicles were detected with 25% false-negative diagnosis on day 9, 8% on day 10, and 0% thereafter. By day 12, the embryos were detected with measurable crown-rump length and heart rate. Ultrasonographic evidence of pregnancy in the rat was present by day 9 post coitum. Diagnosis of pregnancy was confirmed by detection of the embryo heart beat by day 12. Embryo characteristics were ultrasonographically measurable between days 9 and 16.

Groove pancreatitis: a diagnostic challenge

Groove pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area between the head of the pancreas, the duodenum and the common bile duct. It is manifested on imaging by a sheet-like mass in the groove area near the minor papilla. Thickening of the duodenal wall and cystic transformation in the duodenal wall also represent common imaging features. Pathogenesis is still unclear, and clinical presentation is not specific. Endoscopic ultrasonography (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate imaging findings consistent with the disease in typical cases, but specific diagnosis is challenging in a number of patients where biopsy is required. The disease may mimic pancreatic, common bile duct or duodenal wall cancer that requires prompt and excessive surgical intervention, as opposed to groove pancreatitis where initial conservative treatment is suggested. The clinical, histopathological and radiological features on cross-sectional imaging of this entity are discussed in this review, and differential diagnostic clues are given.

Apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing helical computed tomography pulmonary angiography

Respiratory motion artifact in intubated and mechanically ventilated patients often reduces the quality of helical computed tomography pulmonary angiography (CTPA). Apneic oxygenation is a well established intra-operative technique that allows adequate oxygenation for short periods (up to 10 min) in sedated and paralyzed patients. We describe the use of the apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing CTPA.

Double gall-bladder--two pathologies: a case report

True gall-bladder duplication is a rare biliary anomaly, which is usually discovered as an incidental finding. There are reports of double gall-bladders missed during the first operation. We present the case of a double gall-bladder which, albeit suspected during the operation, was confirmed post-operatively. The patient underwent successful laparoscopic cholecystectomy and the examination of the resected gall-bladder revealed two chambers, only one containing stones. Predisposing factors for the development of gall-stones in one gall-bladder only, as well as surgical options, are briefly discussed.

Differentiation of MEG activity in multiple sclerosis patients with the use of nonlinear analysis

The aim of this study is to investigate if there is any nonlinearity in the magnetoencephalographic recordings of patients with multiple sclerosis in comparison with controls in order to find out the differences in the mechanisms underlying their brain waves. Five multiple sclerosis patients and five controls were included in this study. Chaotic activity of multiple sclerosis patients is lower than in the normal brain. Nonlinear analysis may offer fertile perspectives for understanding the features of patients with multiple sclerosis.

EVALUATION OF AN INTRACRANIAL ARACHNOID CYST WITH MEG AFTER MAGNETIC STIMULATION

A 34-year-old male diagnosed of an intracranial arachnoid cyst arising in the left-sided temporal-parietal area, by computed tomography (CT), underwent evaluation by means of MEG. Biomagnetic waveform recordings were obtained from the target area and the Fourier analysis of these measurements was carried out. External magnetic stimulation in the order of pico Tesla was applied with proper field characteristics (intensity: 1-7.5 pT, frequency: 8-13 Hz), which were obtained prior to the application and the emitted MEG activity was recorded again. The cortical area adjacent to the borders of the arachnoid cyst emitted biomagnetic waveforms with high values. The application of magnetic stimulation resulted in a rapid attenuation of the high MEG activity in the target area. MEG may provide useful information in the diagnostic evaluation of arachnoid cyst patients and could be a supplement to other imaging modalities.

MEG evaluation of Parkinson's diseased patients after external magnetic stimulation

Magnetoencephalographic (MEG) recordings of Parkinson's diseased (PD) patients were obtained using a whole-head 122-channel magnetometer and analyzed with Fourier statistical analysis. External transcranial magnetic stimulation (TMS) in the order of pico Tesla was applied on the above patients with proper field characteristics (magnetic amplitude : 1-7.5 pT, frequency : the alpha-rhythm of the patient: 8-13 Hz) which were obtained prior to TMS. The MEG recordings after the application of TMS showed a rapid attenuation of the high abnormal activity followed by an increase of the low frequency components toward the patients' alpha-rhythm. The patients responded to the TMS with a feeling of relaxation and partial or complete disappearance of tremor, muscular ache and levodopa induced dyskinesias as well as rapid reversed visuospatial impairment, which were followed by a corresponding improvement and normalization of the MEG.

Inferior epigastric artery false aneurysms: review of the literature and case report

A case report is presented of a IEA false aneurysm successfully embolized in a 50-year old man following a blunt abdominal injury. A literature review revealed another 15 cases. Most cases were iatrogenic (13/16) complicating abdominal wall procedures. Treatment options included open surgery (8 cases), percutaneous coil embolization (6), ultrasound guided thrombin injection or ultrasound guided compression (2). The selected treatment (surgical or non-surgical) was not affected by the size of the aneurysm (p=0.6) and was successful in all patients. However two of the non-surgically removed lesions (25%) remained unchanged in size for a long time causing discomfort. IEA false aneurysms represent an uncommon entity. Open surgery for IEA false aneurysms is easy and cheap. Endovascular approaches can lead to a long delay in resolution of the problem.

Low-Frequency MEG Activity and MRI Evaluation in Parkinson's Disease

BACKGROUND

Low - frequency activity has been reported in Parkinson disease (PD). We investigated the magnetoencephalographic (MEG) recordings from PD patients and healthy volunteers in the frequency domain.

METHODS

The MEG recordings were carried out in a magnetically shielded room with a whole-head 122-channel gradiometer. Nine patients suffering from PD and 9 age and gender matched healthy subjects were included in the study. MRI with T1-w and T2-w images, was available in patients' records.

RESULTS

Frequency analysis may be usefully combined in the analysis of data sets, which contain oscillatory components. Prominent low frequencies can be seen in the spectrum obtained from the PD patients whereas in the control group the frequency range was 6Hz in the majority of channels. MRI did not disclose specific findings in any case.

CONCLUSIONS

It is suggested that the MEG could be a complementary method in the diagnostic evaluation of PD using spatial distribution of the raw data in the frequency domain.

Bile leakage presenting as acute abdomen due to a stone created around a migrated surgical clip

BACKGROUND

Surgical clips may migrate into the common bile duct after surgery for cholecystolithiasis leading to usually early or middle-term complications.

CASE REPORT

A 31-year-old woman, 6 years after laparoscopic cholecystectomy, developed acute abdomen and choloperitoneum after rupture of a secondary bile duct and bile leakage. This complication was due to a solitary common bile duct stone. The stone was formed around a surgical clip that had migrated from the cystic duct remnant to the common bile duct. The patient underwent investigative laparotomy and, subsequently, an ERCP with stone extraction and clearance of the common bile duct. She was perfectly well at the follow-up after 14 months.

CONCLUSIONS

Rupture of a bile duct and biliary peritonitis may be a delayed complication of laparoscopic cholecystectomy due to surgical clip migration and formation of a stone. Definitive treatment of the condition may be achieved through ERCP. Surgeons, gastroenterologists and radiologists should be aware of this late complication of laparoscopic cholecystectomy in cases of acute abdomen.

Bilateral metastatic rhabdomyosarcoma to the breast in an adolescent female: touch imprint cytology and implication of MyoD1 nuclear antigen

BACKGROUND

Rhabdomyosarcoma accounts for approximately 4% of all childhood malignancies. Breast metastases from rhabdomyosarcoma are uncommon with an incidence of 6%.

CASE REPORT

We present a patient who developed bilateral mammary metastases from rhabdomyosarcoma arising in the right lower extremity. An 11-year-old female with a 20-month history of rhabdomyosarcoma was referred to our department because of bilateral breast enlargement. A needle core biopsy was performed and touch imprint slides were obtained. Cytology determined the masses to be metastases of rhabdomyosarcoma. MyoD1 immunostain and RT-PCR analysis confirmed the diagnosis.

CONCLUSIONS

Cytomorphology with ancillary methods is essential in the diagnosis of metastatic breast deposits in order to avoid unnecessary mastectomy and to employ systemic treatment.

Intrahepatic extramedullary hematopoietic tumor mimicking metastatic carcinoma from a colonic primary

BACKGROUND

Extramedullary hematopoiesis (EMH) is associated with a number of diseases in which the normal function of the bone marrow is disturbed. While organs with hemopoietic capacity like the liver and spleen are most commonly involved, EMH has also occasionally been found in other organs like the adrenal gland, lymph nodes, breast, thymus, small bowel and central nervous system. However, presentation of a myeloproliferative disorder, such as EMH in these organs is a rare event.

CASE REPORT

We report clinical and fine-needle aspiration (FNA) findings in a patient who presented with intrahepatic EMH which mimicked metastatic carcinoma from a colonic primary.

RESULTS

Ultrasound-guided FNA of the intrahepatic mass revealed megakaryocytes and myelocytes thus establishing the diagnosis of EMH.

CONCLUSIONS

EMH is an unusual condition that can mimic other solid masses of the liver. Because radiologic findings are not specific, EMH should be considered in the differential diagnosis, especially in patients with a myeloproliferative disorder. FNA and subsequent cytopathological interpretation of the aspirates enables avoidance of unnecessary potentially hazardous surgery.

Fine-needle aspiration cytology of a para-aortical solitary plasma-cell tumor

Extramedullary plasma-cell tumor (EMP) is a very rare disease and mainly arises in the head and neck area. An EMP arising in the paraaortical space was diagnosed by fine needle aspiration cytology and immunocytochemistry, in a 48-year-old male. Smears were cellular and showed dissociated monomorphic plasma cells. Immunocytochemistry demonstrated monoclonal expression of kappa-light immunoglobulin chain and CD38 positivity. Cytomorphology and immunocytochemical profile allowed a definitive diagnosis of plasmacytoma.

Optimization of a contrast medium suitable for conventional enteroclysis, MR enteroclysis, and virtual MR enteroscopy

BACKGROUND

The purpose of the current study was to optimize a gadolinium-barium sulfate solution suitable for performing conventional and MR enteroclysis examinations in the same session.

METHODS

Eighteen vials of 20% barium sulfate and various gadolinium concentrations (lower 0 ml/lt, higher 45 ml/lt) were prepared and placed in the magnet. The imaging protocol was consisted of the following sequences: true FISP, HASTE with fat saturation and 3d FLASH with fat saturation in various flip angles. Ten patients underwent conventional enteroclysis with 1.2 lt of 20% barium sulfate enema and 18 ml of gadolinium. MR enteroclysis was performed afterwards using true FISP, fat suppressed 3d FLASH and fat suppressed HASTE sequences.

RESULTS

The lowest gadolinium concentration in the barium sulfate solution generating low intraluminal signal on HASTE and high intraluminal signal on true FISP and 3d FLASH sequences was 15 ml/lt. The presence of gadolinium did not influence the lumen opacification in conventional enteroclysis examination. In all patients the proposed contrast medium acted as positive in 3d FLASH (T1w), true FISP (T2/T1 w) and as a negative in HASTE (T2w). Bowel wall conspicuity, lumen opacification and distention were ranked as very good to excellent on MR enteroclysis images while artifacts level did not downgraded the overall image quality. High quality virtual MR endoluminal views of the small bowel, based on 3d FLASH images, were obtained in all cases.

CONCLUSION

A 20% barium sulfate enema with 15 ml/lt gadolinium is appropriate for conventional and MR enteroclysis examinations.