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Manian FA, Barshak MB, Lowry KP, Basnet KM, Stowell CP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 27-2016. N Engl J Med 2016; 375:981-91. [PMID: 27602671 DOI: 10.1056/nejmcpc1607091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Farrin A Manian
- From the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Massachusetts General Hospital, and the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Harvard Medical School - both in Boston
| | - Miriam B Barshak
- From the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Massachusetts General Hospital, and the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Harvard Medical School - both in Boston
| | - Kathryn P Lowry
- From the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Massachusetts General Hospital, and the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Harvard Medical School - both in Boston
| | - Kristen M Basnet
- From the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Massachusetts General Hospital, and the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Harvard Medical School - both in Boston
| | - Christopher P Stowell
- From the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Massachusetts General Hospital, and the Departments of Medicine (F.A.M., M.B.B.), Radiology (K.P.L.), and Pathology (K.M.B., C.P.S.), Harvard Medical School - both in Boston
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Silva M, Albuquerque A, Gonçalves F, Macedo G. Throw a bone here: an evil and rare consequence of foreign body passage. Int J Colorectal Dis 2016; 31:1507-8. [PMID: 26861706 DOI: 10.1007/s00384-016-2535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Marco Silva
- Department of Gastroenterology, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Andreia Albuquerque
- Department of Gastroenterology, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Frederica Gonçalves
- Department of General Surgery, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
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Abstract
Blunt and penetrating injuries to the anus and rectum are uncommon. Considerable debate remains regarding the optimal treatment of rectal injuries. Although intraperitoneal rectal injuries can be treated similarly to colonic injuries, treatment options for extraperitoneal injuries include fecal diversion with a colostomy, presacral drainage, repair of the rectal defect, and distal rectal washout. Perineal injuries resulting in anal sphincter disruption often occur with severe associated injuries. Small defects can be repaired primarily, but extensive injuries often require diversion and sphincter reconstruction.
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Affiliation(s)
- Daniel O Herzig
- Department of Surgery, Digestive Health Center & Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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Aminsharifi A, Afsar F, Jafari M, Tourchi A. Removal of an entrapped large metallic dilator from the sigmoid neovagina in a male-to-female transsexual using a laparoscopic approach. Int J Surg Case Rep 2012; 3:266-8. [PMID: 22504480 DOI: 10.1016/j.ijscr.2012.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 02/25/2012] [Accepted: 03/09/2012] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION To describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20cm in length and 3.5cm in diameter) in a case of male-to-female transsexual. PRESENTATION OF THE CASE The patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70min. DISCUSSION Up to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator. CONCLUSION Laparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.
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Affiliation(s)
- A Aminsharifi
- Department of Urology, Laparoscopic Research Center, Stem Cell and Transgenic Technology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Unruh BT, Nejad SH, Stern TW, Stern TA. Insertion of foreign bodies (polyembolokoilamania): underpinnings and management strategies. Prim Care Companion CNS Disord 2012; 14:11f01192. [PMID: 22690353 DOI: 10.4088/pcc.11f01192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/18/2011] [Indexed: 12/17/2022] Open
Abstract
The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article.
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Desai B. Visual diagnosis: Rectal foreign body: A primer for emergency physicians. Int J Emerg Med 2011; 4:73. [PMID: 22152071 PMCID: PMC3253678 DOI: 10.1186/1865-1380-4-73] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/07/2011] [Indexed: 11/20/2022] Open
Abstract
We present a case that is occasionally seen within emergency departments, namely a rectal foreign body. After presentation of the case, a discussion concerning this entity is given, with practical information on necessity of an accurate and thorough history and removal of the object for clinicians.
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Affiliation(s)
- Bobby Desai
- Department of Emergency Medicine, University of Florida, PO Box 100186, Gainesville 32610, FL, USA.
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7
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Anderson KL, Dean AJ. Foreign Bodies in the Gastrointestinal Tract and Anorectal Emergencies. Emerg Med Clin North Am 2011; 29:369-400, ix. [DOI: 10.1016/j.emc.2011.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rodríguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farrés R. Management of foreign bodies in the rectum. Colorectal Dis 2007; 9:543-8. [PMID: 17573750 DOI: 10.1111/j.1463-1318.2006.01184.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The discovery of foreign bodies (FB) in the rectum is an infrequent clinical problem. Most commonly, FB are introduced through the anal passage or reach the rectum after oral ingestion. We describe our experience in the diagnosis and treatment of FB retained in the rectum. METHOD From 1997 to 2004, data were collected prospectively in 30 patients (20 men and 10 women; median age 42.5 years). Extraction method, size and type of object, and postextraction evolution were reviewed. RESULTS The FB was introduced anally in 16 cases and by oral ingestion in 14. Principal associated factors were: mental disorder in 11, penitentiary confinement in two, and drug and alcohol intake in two. Recent sexual activity had taken place in 14 cases. The size and nature of the FB were varied. The most frequent symptom was constipation with or without pelvic or anal discomfort (n = 23, 77%). Treatment consisted of spontaneous ejection (n = 2), digital extraction with or without enemas (n = 10), digital extraction under local/regional anaesthesia after fragmentation (n = 11) and regional exploratory laparotomy under general anaesthesia (n = 7). Grade I rectal trauma was the most common (n = 23, 77%). Six patients required colostomy. Four patients (13.5%) suffered complications and none died. Only 17 patients were hospitalized, with a mean stay of 6 days. All patients recovered without sequelae. CONCLUSION The diagnosis of rectal FB should be suspected when faced with low pelvic or perianal abdominal pain and/or rectal haemorrhage within the context of an unconvincing story in patients without a history of recent instrumental rectal exploration for therapeutic or diagnostic purposes. Because of potential complications, FB in the rectum should be considered a serious condition that must be treated without delay.
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Affiliation(s)
- J I Rodríguez-Hermosa
- Department of Colorectal and General Surgery, Hospital Universitari de Girona Dr josep Trueta, Girona, Spain.
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Yacobi Y, Tsivian A, Sidi AA. Emergent and Surgical Interventions for Injuries Associated With Eroticism: a Review. ACTA ACUST UNITED AC 2007; 62:1522-30. [PMID: 17563678 DOI: 10.1097/ta.0b013e3180341f8f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To review the consequences of sexual activities that can cause severe morbidity and the current emergent and surgical measures for treating them. METHODS A computerized search of the English and non-English MEDLINE database (January 1973 to October 2005) identified the major sexual activities that caused injuries requiring emergent or surgical intervention, or both. These activities were grouped by type, pathologic findings, and sites of injury. Cause and symptoms are discussed, as are the radiologic, emergent and surgical interventions employed worldwide. RESULTS Two major groups of sexual-erotic activities, whether self-inflicted or accidental, emerged as culpable for most of the injuries. One was hetero-homosexual relations that were associated with penile fracture and Peyronie's disease. The other was related to the sequelae of autoeroticism and included penile constriction devices, anorectal, urethra-bladder, and vaginal foreign bodies as well as autoerotic asphyxiation. Injuries in both groups affected men more than women (e.g., 1.7:1 for foreign bodies in the urethra and 99:1 for anorectal). Complications were either immediate or delayed. Predisposing factors for injury are described. Emergent medical management and corrective surgical measures (usually by urologists and gynecologists for genital involvement and proctologists and general surgeons for rectal involvement) were similar worldwide and the need for them was surprisingly limited. CONCLUSIONS Most erotic activity-related injuries are medically or surgically treatable, although some sexual practices can be lethal. Dissemination of information on risk of injury is the best preventive measure.
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Affiliation(s)
- Yacov Yacobi
- Department of Urologic Surgery, Edith Wolfson Medical Center, Holon, Israel.
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Abstract
The authors describe a 14-year-old boy who presented at the emergency department after he deliberately inserted a soda can in his rectum 48 hours before presentation. The authors were able to remove the foreign body in the operating room by squeezing and twisting the upper round of the empty soda can, in this way changing the original cylinder shape into a conus-shape. Retained foreign bodies in the rectum of children are rare. The authors report our case and discuss the relevant literature.
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Affiliation(s)
- P Steenvoorde
- Department of Surgery, Leiden University Medical Centre, Leidon, The Netherlands
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Abstract
OBJECTIVE To review the biologic characteristics of, and management approaches to, intra-abdominal infection in the critically ill patient. DESIGN Narrative review. SETTING Medline review focussed on intra-abdominal infection in the critically ill patient. PATIENTS AND SUBJECTS Restricted to studies involving human subjects. INTERVENTIONS None. RESULTS Intra-abdominal infections are an important cause of morbidity and mortality in the intensive care unit (ICU). Peritonitis can be classified as primary, secondary, or tertiary, the unique pathologic features reflecting the complex nature of the endogenous gut flora and the gut-associated immune system, and the alterations of these that occur in critical illness. Outcome is dependent on timely and accurate diagnosis, vigorous resuscitation and antibiotic support, and decisive implementation of optimal source control measures, specifically the drainage of abscesses and collections of infected fluid, the debridement of necrotic infected tissue, and the use of definitive measures to prevent further contamination and to restore anatomy and function. CONCLUSIONS Optimal management of intra-abdominal infection in the critically ill patient is based on the synthesis of evidence, an understanding of biologic principles, and clinical experience. An algorithm outlining a clinical approach to the ICU patient with complex intra-abdominal infection is presented.
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Affiliation(s)
- John C Marshall
- Department of Surgery, University of Toronto and Toronto General Hospital, University Health Network, Ontario, Canada.
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12
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Abstract
Although anal trauma is rare, iatrogenic injury is not uncommon. Immediate recognition is vital to a successful outcome and may obviate the need for a diverting stoma. Evaluation must include a search for involvement of other structures and an evaluation of the anal sphincters. Foreign bodies most often do not cause significant anorectal injuries. Extraction of these diverse objects requires ingenuity. Superficial injuries may be left open or sutured closed. There are number of options for repair of anal sphincter injuries, either immediately or in a delayed fashion. A review of the clinical environment will dictate the procedure chosen.
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Affiliation(s)
- Michael D Hellinger
- Division of Colon and Rectal Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami School of Medicine, Miami, FL 33136, USA.
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Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: technique, indications, and contraindications. Med Clin North Am 2002; 86:1217-52. [PMID: 12510453 DOI: 10.1016/s0025-7125(02)00076-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy has a broad range of indications, including evaluating lower GI symptoms such as lower GI bleeding, evaluating abnormal radiographic findings, and screening and surveillance for colon cancer. Colonoscopy is increasingly being used therapeutically. Patient evaluation, patient instructions, and colonic preparation before colonoscopy are essential for safe and efficient colonoscopy. Intravenous sedation reduces patient pain and anxiety during colonoscopy, but requires monitoring by pulse oximetry and automated measurements of vital signs. An experienced colonoscopist can complete colonoscopy in 90% or more of cases, using maneuvers to maintain the colonic lumen in view, straighten the colonoscope, and avoid looping during colonic intubation.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, Department of Medicine, State University of New York, Downstate Medical School, Brooklyn, NY, USA
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15
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Abstract
The separate disease entities that are included in the general term of pelvic organ prolapse have been discussed in detail in this chapter. The focus of discussion centered on the pathophysiology and clinical presentation of these conditions. At this point, the emergency physician should be able to properly recognize, assess, initiate treatment, and obtain appropriate referral in cases of pelvic organ prolapse. Postoperative complications commonly seen after these entities are repaired have also been reviewed to help the emergency medicine physician recognize and mange common postoperative complications.
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Affiliation(s)
- B P Harrison
- Emergency Medicine Residency Program, Darnall Army Community Hospital, Fort Hood, USA
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Rodríguez Hermosa J, Codina Cazador A, Alayrach Vilella J, García Oria M, Farrés Coll R, Gironès Vilà J, Roig García J, Tuca Rodríguez F, Pont Vallés J. Cuerpos extraños en el rectosigma. Cir Esp 2001. [DOI: 10.1016/s0009-739x(01)71764-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rispoli G, Esposito C, Monachese TD, Armellino M. Removal of a foreign body from the distal colon using a combined laparoscopic and endoanal approach: report of a case. Dis Colon Rectum 2000; 43:1632-4. [PMID: 11089605 DOI: 10.1007/bf02236754] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE We describe the case of a of 53-year-old homosexual male, from whom a cigar container (22 cm in length and 3.5 cm in diameter), which was introduced into the rectum and migrated upwards to the distal colon, was successfully extracted by combining laparoscopic and anal approaches. METHODS The foreign body was mobilized laparoscopically, pushed down the rectum, and then extracted transanally with the aid of a dilator anoscope. CONCLUSIONS Combining the laparoscopic and anal approaches in selected cases of colorectal foreign bodies is useful.
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Affiliation(s)
- G Rispoli
- Division of General Surgery, San Leonardo Hospital, Castellammare di Stabia, Italy
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Saad GA, Taha AM. Restoration of continence after shotgun injury to the anus. THE JOURNAL OF TRAUMA 2000; 49:954-7. [PMID: 11086793 DOI: 10.1097/00005373-200011000-00028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- G A Saad
- Department of Surgery, American University of Beirut, New York, New York 10022-6222, USA
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Affiliation(s)
- A Ahmed
- Division of Gastroenterology, Department of Medicine, Santa Clara Valley Medical Center, San Jose, California 95128, USA
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Dams ET, Reijnen MM, Oyen WJ, Boerman OC, Laverman P, Storm G, van der Meer JW, Corstens FH, van Goor H. Imaging experimental intraabdominal abscesses with 99mTc-PEG liposomes and 99mTc-HYNIC IgG. Ann Surg 1999; 229:551-7. [PMID: 10203089 PMCID: PMC1191742 DOI: 10.1097/00000658-199904000-00015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the accuracy of technetium-99m-labeled polyethylene glycol-coated liposomes (99mTc-PEG liposomes) and technetium-99m-labeled nonspecific human immunoglobulin G (99mTc-HYNIC IgG) for the scintigraphic detection of experimental intraabdominal abscesses in comparison with that of a standard agent, gallium-67 citrate. BACKGROUND Scintigraphic imaging techniques can be very useful for the rapid and accurate localization of intraabdominal abscesses. Two newly developed radiolabeled agents, 99mTc-PEG liposomes and 99mTc-HYNIC IgG, have shown to be excellent agents for imaging experimental focal infection, but have not yet been studied in the detection of abdominal abscesses. METHODS Intraabdominal abscesses were induced in 42 rats using the cecal ligation and puncture technique. Seven days later, randomized groups of rats received 99mTc-PEG liposomes, 99mTc-HYNIC IgG, or 67Ga citrate intravenously. The rats were imaged up to 24 hours after the injection. The biodistribution of the radiolabel was determined by counting dissected tissues ex vivo. Macroscopic intraabdominal abnormalities and focal uptake on the images were independently scored on a semiquantitative scale. RESULTS 99mTc-PEG liposomes provided the earliest scintigraphic visualization of the abscess (as soon as 2 hours after the injection vs. 4 hours for the other two agents). Liposomes, IgG, and gallium all showed similarly high absolute uptake in the abscess. Focal uptake of liposomes and gallium correlated best with the extent of the macroscopic abnormalities. CONCLUSIONS 99mTc-PEG liposomes and 99mTc-HYNIC IgG performed at least as well as the standard agent, 67Ga citrate, in the detection of experimental intraabdominal abscesses, with obvious advantages such as lower radiation exposure and more favorable physical properties. Of the two technetium agents, the liposomes seemed to be superior, providing the earliest diagnostic image and the best correlation with the inflammatory abnormalities. In addition, the preferential localization of radiolabeled PEG liposomes holds promise for targeted delivery of liposome-encapsulated drugs.
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Affiliation(s)
- E T Dams
- Department of Nuclear Medicine, University Hospital Nijmegen, The Netherlands
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Abstract
A 20-year-old man presented with a rectal "oven mitt," which was removed transanally. Rigid proctosigmoidoscopy revealed no apparent perforation, but subsequent contrast enema using meglumine diatrizoate demonstrated an extraperitoneal rectal perforation, which was probably caused by a wooden stick used to forcefully introduce the glove through the patient's anus. Thus, rectal injuries may be caused not by the foreign object itself, but by another object used as an introducer.
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Affiliation(s)
- J E Losanoff
- Department of Emergency Surgery, Military Medical Academy, Sofia, Bulgaria
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Ooi BS, Ho YH, Eu KW, Nyam D, Leong A, Seow-Choen F. MANAGEMENT OF ANORECTAL FOREIGN BODIES: A CAUSE OF OBSCURE ANAL PAIN. ANZ J Surg 1998. [DOI: 10.1111/j.1445-2197.1998.tb04701.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.
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Affiliation(s)
- D M Janicke
- Department of Emergency Medicine, State University of New York at Buffalo, Millard Fillmore Hospitals, USA
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Lheureux P, Cavenaile JC, Cornil A, Nouvelle M, Sermon F, Leduc D, Askenasi R. Ingestion de corps étrangers : attitude pratique. ACTA ACUST UNITED AC 1996. [DOI: 10.1016/s1164-6756(05)80578-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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