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Matsushima T, Mitsunari K, Maekawa N, Yamada S, Ito H, Kurata H, Nakamura Y, Matsuo T, Ohba K, Imamura R. Partial penectomy for severe penile ulceration caused by cholesterol crystal embolization. IJU Case Rep 2023; 6:394-397. [PMID: 37928290 PMCID: PMC10622217 DOI: 10.1002/iju5.12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/19/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Cholesterol crystal embolism is a rare microembolic disease caused by cholesterol crystals that can present with various symptoms after vascular surgery, catheterization, or anticoagulation therapy. We report a case of penile ulceration caused by cholesterol crystal embolism. Case presentation A 72-year-old man undergoing maintenance dialysis for end-stage renal failure presented with penile pain and a black glans ulcer. Despite low-density lipoprotein apheresis, he was referred to our hospital because of lack of improvement. Based on his medical history and clinical presentation, including artificial vascular replacement and right toe amputation, cholesterol crystal embolism was suspected and partial penectomy was performed, thus confirming the diagnosis. Penile pain resolved after surgery, and he was discharged on Day 10. Unfortunately, he died after small bowel perforation developed 2 months after surgery. Conclusion Penile ulcers caused by cholesterol crystal embolism may indicate the severity and progression of disease and typically require surgical intervention.
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Affiliation(s)
- Toshiki Matsushima
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kensuke Mitsunari
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Nobuhide Maekawa
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Shota Yamada
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hidenori Ito
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hiroki Kurata
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Yuichiro Nakamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiro Matsuo
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kojiro Ohba
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryoichi Imamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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2
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Mahtani AU, Tahir MK, Padda I, Haider M, Ebrahimi F, Otterbeck P, Nfonoyim J. Spontaneous Cholesterol Embolism Leading to Small Bowel Obstruction and Perforation. JACC Case Rep 2023; 13:101780. [PMID: 37153475 PMCID: PMC10157106 DOI: 10.1016/j.jaccas.2023.101780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/04/2023] [Accepted: 01/19/2023] [Indexed: 05/09/2023]
Abstract
A spontaneous occurrence of cholesterol embolization syndrome causing small bowel obstruction and perforation is a highly scarce event. In this article, we report a case of spontaneous cholesterol embolism resulting in small bowel obstruction and perforation in a 52-year-old male with multiple cardiovascular and medical comorbidities. In our patient, the source was an eccentric left lateral atherosclerotic plaque from the abdominal aorta that was identified using computed tomography. A distal occlusion in numerous small intestinal arteries due to cholesterol embolism was confirmed on biopsy after surgical resection. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Arun Umesh Mahtani
- Department of Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
- Address for correspondence: Dr Arun Umesh Mahtani, 1059, 7 Navy Pier Court, Staten Island, New York 10304, USA.
| | - Muhammad Khalid Tahir
- Department of Nephrology, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Inderbir Padda
- Department of Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Muhammad Haider
- Department of Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Farhang Ebrahimi
- Department of Nephrology, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Philip Otterbeck
- Department of Endocrinology, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
| | - Jay Nfonoyim
- Department of Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, New York, USA
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3
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Sakamoto T, Yamakawa T, Hirano K, Kobayashi A, Kasai M, Koizumi K, Yokoo T, Komatsumoto S, Murohisa T, Shimizu T. The systemic immune response due to cholesterol crystal embolization syndrome: a case report. BMC Nephrol 2022; 23:314. [PMID: 36123635 PMCID: PMC9487086 DOI: 10.1186/s12882-022-02939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cholesterol crystal embolization syndrome (CES) occurs when an atherosclerotic plaque causes small-vessel embolization, resulting in multi-organ damage. Although CES is pathologically characterized by an infiltration of eosinophils, the implication of the systemic inflammatory response represented by hypereosinophilia is unclear in clinical practice. Herein we present the case of a patient diagnosed with CES who developed multiple allergic organ injuries, including daptomycin-related dermatitis and later vancomycin-induced acute tubulointerstitial nephritis, which was successfully treated by the withdrawal of each medicine with or without corticosteroid therapy, one by one. Case presentation A 76-year-old Japanese man diagnosed with thoracic aneurysm rupture underwent total arch replacement through the open stent graft technique. Postoperatively, he developed methicillin-resistant Staphylococcus epidermidis bacteremia, which was treated with daptomycin. Subsequently, he presented with palpable purpura on both dorsal feet, erythema around his body, and hypereosinophilia. Daptomycin was replaced with vancomycin due to suspicion of drug-induced erythema. The erythema gradually faded. On nine days after vancomycin therapy, the systemic erythema rapidly reappeared followed by acute renal failure. The renal function decline prompted hemodialysis. A skin biopsy revealed cholesterol embolization, whereas a kidney biopsy revealed acute tubulointerstitial nephritis. After vancomycin discontinuation and initiation of systemic corticosteroid treatment, his kidney function was restored to the baseline level. Conclusions The present case highlights cholesterol embolization can cause allergic complications in addition to direct organ damage.
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Affiliation(s)
- Tetsu Sakamoto
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan.,Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu-cho, Simotsuga-gun, Tochigi, Japan
| | - Takafumi Yamakawa
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan.,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Keita Hirano
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan. .,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
| | - Arisa Kobayashi
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan.,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Mio Kasai
- Department of Cardiovascular Surgery, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan
| | - Kiyoshi Koizumi
- Department of Cardiovascular Surgery, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Satoru Komatsumoto
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan
| | - Toshimitsu Murohisa
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Yobe-cho 284-1, Ashikaga, Tochigi, 326-0843, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu-cho, Simotsuga-gun, Tochigi, Japan
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4
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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5
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Sato Y, Okamoto K, Fukuda M, Oyama Y, Kondo Y, Nishida H, Daa T, Togo K, Sonoda A, Fukuda K, Matsunari O, Ogawa R, Honda K, Mizukami K, Okimoto T, Kodama M, Murakami K. An Autopsy Case of Acute Pancreatitis Caused by Cholesterol Crystal Embolization. Intern Med 2021; 60:839-845. [PMID: 33055480 PMCID: PMC8024961 DOI: 10.2169/internalmedicine.5524-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cholesterol crystal embolization (CCE) shows a poor prognosis and it can cause ischemic organ damage due to a cholesterol embolism from atherosclerotic lesions in large blood vessels. Such an embolism mainly affects the kidneys and skin, although cases involving digestive organs have also been reported. We encountered an autopsy case of CCE with damage mainly to the digestive organs, including the pancreas. The patient had non-specific abdominal symptoms or image findings. Symptomatic therapy failed to save him. CCE can involve the digestive organs, and so must be differentiated from abdominal pathologies. Moreover, conventional treatments may be ineffective, and new treatments might thus be necessary.
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Affiliation(s)
- Yuto Sato
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazuhisa Okamoto
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Masahide Fukuda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Yuzo Oyama
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Yoshihiko Kondo
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Haruto Nishida
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Kazumi Togo
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Akira Sonoda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kensuke Fukuda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Osamu Matsunari
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Koichi Honda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazuhiro Mizukami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Tadayoshi Okimoto
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Masaaki Kodama
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
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6
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Affiliation(s)
- Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Japan
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Japan
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7
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Hamura R, Haruki K, Iwase R, Furukawa K, Shirai Y, Onda S, Gocho T, Ikegami T. Ischemic small bowel perforation caused by cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent hepatocellular carcinoma: a case report. Surg Case Rep 2021; 7:45. [PMID: 33566211 PMCID: PMC7876172 DOI: 10.1186/s40792-021-01116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Cholesterol crystal embolism (CCE) following transcatheter arterial chemoembolization (TACE) is rare. Case presentation A 71-year-old man underwent TACE for recurrence of hepatocellular carcinoma (HCC). On postoperative day (POD) 5, he developed abdominal pain and fever. Computed tomography revealed intraperitoneal free air. The patient was diagnosed with gastrointestinal perforation with peritonitis, for which partial intestinal resection and covering ileostomy were performed. Histological examination revealed perforation of the small intestine caused by CCE. The patient made a satisfactory recovery and was discharged on POD 30. The patient showed no recurrence of cholesterol crystal embolism or HCC for 2 years after surgery. Conclusion We reported a successfully treated case of ischemic small bowel perforation due to cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent HCC.
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Affiliation(s)
- Ryoga Hamura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Koichiro Haruki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryota Iwase
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenei Furukawa
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Shirai
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shinji Onda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takeshi Gocho
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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8
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Chapelle N, Mosnier JF, Coron E. Bleeding Ulcers of the Right Colon. Gastroenterology 2020; 159:449-450. [PMID: 32205171 DOI: 10.1053/j.gastro.2020.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/12/2020] [Accepted: 03/16/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Nicolas Chapelle
- Institut des Maladies de l'Appareil Digestif, Service de Gastroenterologie, Oncologie digestive et Assistance Nutritionnelle, CHU de Nantes, Nantes; INSERM UMR 1235 The Enteric Nervous System in Gut and Brain Disorders, Faculté de Médecine, Nantes; Université de Nantes, Nantes.
| | - Jean-François Mosnier
- Université de Nantes, Nantes; Service d'Anatomo-cytopathologie, CHU de Nantes, Nantes
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, Service de Gastroenterologie, Oncologie digestive et Assistance Nutritionnelle, CHU de Nantes, Nantes; INSERM UMR 1235 The Enteric Nervous System in Gut and Brain Disorders, Faculté de Médecine, Nantes; Université de Nantes, Nantes
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9
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Shibata J, Yoshihara M, Kato T. Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report. BMC Surg 2020; 20:54. [PMID: 32192489 PMCID: PMC7082983 DOI: 10.1186/s12893-020-00716-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization. Case presentation A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired. Conclusions Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.
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Affiliation(s)
- Jumpei Shibata
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan.
| | - Motoi Yoshihara
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
| | - Takehito Kato
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
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10
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Denis Le Seve J, Gourraud Vercel C, Connault J, Artifoni M. [Update on cholesterol crystal embolism]. Rev Med Interne 2020; 41:250-257. [PMID: 32088097 DOI: 10.1016/j.revmed.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 12/19/2019] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a systemic pathology associated with diffuse atherosclerosis. Pathophysiology corresponds to tissue necro-inflammation secondary to arteriolar occlusion associated with microembolism from atherosclerotic plaques of large diameter arteries. The clinical presentation is heterogeneous and polymorphic. Multiple organs may be the targets, but preferential damage is skin, kidneys and digestive system. It is a serious pathology, underdiagnosed, with a poor prognosis. The risk factors for developing the disease remain the same risk factors as atheroma. The factors favouring migration of microembolism remain mainly vascular interventional procedures; easy to diagnose, they oppose spontaneous embolic migrations or secondary to the introduction of antithrombotic treatment, whose diagnosis is more difficult and the prognosis more severe. The diagnosis of the disease remains mostly a diagnosis of elimination and often refers to a bundle of clinical, biological, morphological and histologic arguments. The treatment is poorly codified and the subject of few publications. It will favour both symptomatic treatment (and mainly that of pain) and complications (high blood pressure, renal insufficiency). The aetiological support remains less consensual. The treatment of atherosclerotic plaques consists, of course, in the correction of classical cardiovascular risk factors, the introduction of a statin. It will be discussed in the implementation of surgery or angioplasty to exclude potentially responsible atherosclerotic lesions. Eviction of antithrombotic therapy should be considered in terms of the benefit-risk balance, but often in favour of maintaining it. Finally, other treatments may be proposed in a case-by-case basis, such as oral or intravenous corticosteroid therapy, colchicine or LDL aphaeresis.
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Affiliation(s)
- J Denis Le Seve
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Gourraud Vercel
- Service de néphrologie et immunologie clinique, centre hospitalier universitaire de Nantes, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Connault
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Artifoni
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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11
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Zaveri S, Price LZ, Tupper H, Tadros RO. Atheroembolism to the Breast. Ann Vasc Surg 2019; 64:411.e17-411.e20. [PMID: 31669478 DOI: 10.1016/j.avsg.2019.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/26/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
We report the case of a woman presenting with livedo reticularis of the breast who was found to have atheroembolism to the breast following upper extremity percutaneous access. Atheroembolism is the embolization of cholesterol crystals off an atherosclerotic plaque that can occur spontaneously or as a result of vascular intervention. This is a unique presentation of an otherwise well-described complication of vascular catheterization, and we propose that livedo reticularis of the breast can be interpreted as a sign of atheroembolism in the appropriate clinical context.
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Affiliation(s)
- Shruti Zaveri
- Division of General Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Lucyna Z Price
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Haley Tupper
- Icahn School of Medicine, The Mount Sinai Hospital, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY.
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12
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Ozkok A. Cholesterol-embolization syndrome: current perspectives. Vasc Health Risk Manag 2019; 15:209-220. [PMID: 31371977 PMCID: PMC6626893 DOI: 10.2147/vhrm.s175150] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022] Open
Abstract
Cholesterol-embolization syndrome (CES) is a multisystemic disease with various clinical manifestations. CES is caused by embolization of cholesterol crystals (CCs) from atherosclerotic plaques located in the major arteries, and is induced mostly iatrogenically by interventional and surgical procedures; however, it may also occur spontaneously. Embolized CCs lead to both ischemic and inflammatory damage to the target organ. Therefore, anti-inflammatory agents, such as corticosteroids and cyclophosphamide, have been investigated as treatment for CES in several studies, with conflicting results. Recent research has revealed that CES is actually a kind of autoinflammatory disease in which inflammasome pathways, such as NLRP3 and IL1, are induced by CCs. These recent findings may have clinical implications such that colchicine and IL1 inhibitors, namely canakinumab, may be beneficial in the early stages of CES.
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Affiliation(s)
- Abdullah Ozkok
- Department of Internal Medicine and Nephrology, Memorial Şişli Hospital, Istanbul, Turkey
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13
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Kumakura S, Nakamichi T, Suzuki N, Yamakage S, Ishikawa A, Fujikura E, Sato S, Aoki T, Musha H, Kikuchi K, Nagasawa T, Sato H, Ito S, Miyazaki M. A Catastrophic Case of Idiopathic Cholesterol Crystal Embolism with Multiple Lethal Complications: A Labyrinth Underneath the Diagnosis of Skin Ulcers in Chronic Kidney Disease Patients. Intern Med 2019; 58:1753-1758. [PMID: 30713332 PMCID: PMC6630139 DOI: 10.2169/internalmedicine.2378-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 66-year-old man was admitted to our hospital because of multiple refractory skin ulcers. Based on his severe systemic arterial calcification and severe calcium-phosphate imbalance due to severe kidney dysfunction, we initially considered calciphylaxis. However, a skin biopsy provided a diagnosis of cholesterol crystal embolization. Although we initiated hemodialysis, steroid treatment, and low-density lipoprotein-cholesterol apheresis, he died of multiple intestinal perforation. An autopsy showed cholesterol crystals occluding multiple organ arterioles. This case suggests that skin ulcers in patients with chronic kidney disease may be an important diagnostic hallmark and may be associated with several serious diseases.
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Affiliation(s)
- Satoshi Kumakura
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Blood Purification, Tohoku University Hospital, Japan
| | - Takashi Nakamichi
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Nonoka Suzuki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Shu Yamakage
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Ayako Ishikawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Emi Fujikura
- Division of Blood Purification, Tohoku University Hospital, Japan
| | - Satoko Sato
- Department of Pathology, Tohoku University Hospital, Japan
| | - Takeshi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Hiroaki Musha
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Katsuko Kikuchi
- Department of Dermatology, Tohoku University Graduate School of Medicine, Japan
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Sato
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Blood Purification, Tohoku University Hospital, Japan
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14
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Tian M, Matsukuma KE. Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case. AUTOPSY AND CASE REPORTS 2019; 9:e2018082. [PMID: 31086777 PMCID: PMC6455701 DOI: 10.4322/acr.2018.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
Cholesterol crystal embolism is a rare and easily overlooked cause of colonic ischemia. The gastrointestinal tract is the third most common organ system affected by cholesterol emboli, second only to kidney and skin. Here we present a catastrophic case of gastrointestinal cholesterol crystal embolism leading to extensive post-operative bowel infarction and ultimately death. For a practicing pathologist, careful attention to the vessels of any ischemic bowel and recognition of the subtle but distinct angular imprint of cholesterol crystals facilitates prompt identification of the atheroemboli. In some cases, early identification may help mitigate further tissue damage. In more acute and severe cases, identification of the cholesterol crystal emboli may be important primarily for documentation of procedural complications.
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Affiliation(s)
- Miao Tian
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine. Sacramento, CA, USA
| | - Karen E Matsukuma
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine. Sacramento, CA, USA
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Cholesterol Crystal Embolization to the Kidney and to a Duodenal Leiomyoma. ACG Case Rep J 2018; 5:e62. [PMID: 30214911 PMCID: PMC6119206 DOI: 10.14309/crj.2018.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/25/2018] [Indexed: 11/21/2022] Open
Abstract
Cholesterol crystal embolism can be spontaneous or iatrogenic, and it can involve any organ of the gastrointestinal tract, presenting with common gastrointestinal symptoms such as bleeding, perforation, obstruction, and inflammation. It is therefore considered the “great masquerader,” requiring a high level of suspicion because the condition is associated with increased morbidity and mortality. We present a 69-year-old man who presented with gastrointestinal bleeding and azotemia. He was found to have cholesterol crystal embolization in the kidney and a duodenal leiomyoma, the latter being an uncommon site to embolize.
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Murono K, Kawai K, Hata K, Emoto S, Kaneko M, Sasaki K, Nishikawa T, Otani K, Tanaka T, Ikemura M, Nozawa H. A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism. Surg Case Rep 2018; 4:29. [PMID: 29619591 PMCID: PMC5884749 DOI: 10.1186/s40792-018-0442-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/28/2018] [Indexed: 03/04/2023] Open
Abstract
Background Cholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis. Case presentation A 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake. Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE. Conclusion This appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.
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Affiliation(s)
- Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masako Ikemura
- Department of Pathology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Park SG, Chung CH, Park CY. Colon Perforation during Sorafenib Therapy for Advanced Hepatocelluar Carcinoma. A Case Report. TUMORI JOURNAL 2018; 97:794-9. [DOI: 10.1177/030089161109700618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There are no effective conventional systemic cytotoxic therapies for patients with unresectable or advanced hepatocellar carcinoma (HCC). Sorafenib, an oral multi-targeted tyrosine kinase inhibitor, was recently approved for the treatment of patients with HCC. Sorafenib is generally well tolerated and has an acceptable toxicity profile. Gastrointestinal perforation is a rare adverse event. We present a case of transverse colon perforation during sorafenib therapy for advanced HCC. A 68-year-old woman with advanced HCC was treated with sorafenib. Eight weeks later the patient presented with the sudden onset of sharp abdominal pain. Emergency surgery was performed for panperitonitis and a perforation involving the transverse colon.
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Affiliation(s)
- Sang-Gon Park
- Department of Internal Medicine, Hemato-oncology, Chosun University Hospital, Gwangju, Korea
| | - Choon-Hae Chung
- Department of Internal Medicine, Hemato-oncology, Chosun University Hospital, Gwangju, Korea
| | - Chi-Young Park
- Department of Internal Medicine, Hemato-oncology, Chosun University Hospital, Gwangju, Korea
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Ghanem F, Vodnala D, K Kalavakunta J, Durga S, Thormeier N, Subramaniyam P, Abela S, S Abela G. Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features. J Biomed Res 2017; 31:82-94. [PMID: 28808190 PMCID: PMC5445211 DOI: 10.7555/jbr.31.20160100] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cholesterol crystal embolic (CCE) syndrome is often a clinically challenging condition that has a poor prognostic implication. It is a result of plaque rupture with release of cholesterol crystals into the circulation that embolize into various tissue organs. Plaque rupture seems to be triggered by an expanding necrotic core during cholesterol crystallization forming sharp tipped crystals that perforate and tear the fibrous cap. Embolizing cholesterol crystals then initiate both local and systemic inflammation that eventually lead to vascular fibrosis and obstruction causing symptoms that can mimic other vasculitic conditions. In fact, animal studies have demonstrated that cholesterol crystals can trigger an inflammatory response via NLRP3 inflammasome similar to that seen with gout. The diagnosis of CCE syndrome often requires a high suspicion of the condition. Serum inflammation biomarkers including elevated sedimentation rate, abnormal renal function tests and eosinophilia are useful but non-specific. Common target organ involvement includes the skin, kidney, and brain. Various testing including fundoscopic eye examination and other non-invasive procedures such as trans-esophageal echocardiography and magnetic resonance imaging may be helpful in identifying the embolic source. Treatment includes aspirin and clopidogrel, high dose statin and possibly steroids. In rare cases, mechanical intervention using covered stents may help isolate the ruptured plaque. Anticoagulation with warfarin is not recommended and might even be harmful. Overall, CCE syndrome is usually a harbinger of extensive and unstable atherosclerotic disease that is often associated with acute cardiovascular events.
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Affiliation(s)
- Firas Ghanem
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA; Wheaton Franciscan Health, Brookfield, WI, USA
| | - Deepthi Vodnala
- University of Missouri, St. Luke's Health System, Kansas City, MO 48824, USA
| | - Jagadeesh K Kalavakunta
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA.,Borgess Hospital, Kalamazoo, MI, USA
| | - Sridevi Durga
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Noah Thormeier
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Prem Subramaniyam
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Scott Abela
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - George S Abela
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA.,Department of Physiology, Division of Pathology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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Abstract
Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.
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Affiliation(s)
- Yin Ping Liew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Grassia R, Manotti L, Pasin F. An Unusual Storm Within the Gastroduodenal Tract. Gastroenterology 2016; 151:243-4. [PMID: 27376513 DOI: 10.1053/j.gastro.2016.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Roberto Grassia
- Digestive Endoscopy and Gastroenterology Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Laura Manotti
- Pathology Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Federico Pasin
- Internal Medicine Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zhao F, Pang LC, Zhao YF, Zhang ZH, Mao K. Clinical effect of use of Bhutto butorphanol combined with propofol in painless colonoscopy: An analysis of 70. Shijie Huaren Xiaohua Zazhi 2013; 21:1996-1999. [DOI: 10.11569/wcjd.v21.i20.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the application of Bhutto butorphanol combined with propofol in painless colonoscopy.
METHODS: One hundred and forty patients treated by painless colonoscopy were randomly and equally divided into either a control group or an observation group. The control group was intravenously injected with remifentanil 1 μg/kg and propofol 2 mg/kg, while the observation group was intravenously injected with Bhutto butorphanol 15 μg/kg and propofol 2 mg/kg. Analgesic effects were compared between the two groups before anesthesia, intraoperatively and postoperatively. Changes in mean arterial pressure (MAP), venous oxygen saturation (SPO2) and heart rate (HR) were monitored, and postoperative recovery time and adverse reactions such as respiratory disorder, abdominal pain, dizziness, and vomiting were recorded.
RESULTS: MAP, SPO2 and HR showed no significant differences in the two groups between before and after operation (observation group: 88 times/min vs 86 times/min; control group: 88 times/min vs 82 times/min). Postoperative awake time was significantly shorter in the observation group than in the control group (7.5 min ± 1.5 min, 12.5 min ± 3.5 min, P < 0.01). VAS pain score was significantly lower in the observation group than in the control group (2.57 ± 0.83, 3.32 ± 1.25, P < 0.01). The incidence of adverse reactions was also lower in the observation group than in the control group.
CONCLUSION: The use of Bhutto butorphanol combined with propofol in painless colonoscopy is associated with good analgesic effect, short postoperative recovery time and few adverse reactions.
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Li YJ, Qi CH, Tian J, Wu XL. Use of propofol versus propofol combined with fentanyl during painless gastroscopy in elderly patients. Shijie Huaren Xiaohua Zazhi 2013; 21:690-693. [DOI: 10.11569/wcjd.v21.i8.690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the advantages and disadvantages of two intravenous anesthesia strategies used for painless gastroscopy in elderly patients.
METHODS: Sixty elderly patients who underwent gastroscopy at our hospital from May 2008 to February 2011 were included. The patients were randomly and equally divided into two groups (A and B) and underwent treatment with either intravenous propofol or propofol combined with fentanyl. The OAAS criteria were adopted, and a score < 2 was used as the critical value. Those who did not reach the critical value were additionally given propofol 10-30 mg. The time required for reaching the critical value, recovery time, and orientation recovery time were compared. Using the time point at 20 min prior to anesthesia as the basic point, the heart rate (HR), blood pressure (BP), respiratory rate (RR), and SPO2 at 5 min after anesthesia were compared.
RESULTS: All the 60 patients felt asleep and completed gastroscopy. 46 cases waked up 1-5 min after gastroscopy, and 14 cases became completely conscious in 15 min. Both the time of reaching the critical value and analepsia in group A were significantly lower than those in group B (19.5 min ± 2.6 min vs 14.9 min ± 3.1 min, 17.5 min ± 2.2 min vs 11.1 min ± 1.7 min, both P < 0.01). The orientation recovery time did not significantly differed between the two groups (P > 0.05). HR, BP, RR, and SPO2 were all decreased to some extent in both groups in the first 5 min. The decreasing amplitude of HR in group A was significantly higher than that in group B (-9.9 time/min ± 5.1 time/min vs -13.2 time/min ± 4.7 time/min, P < 0.05), but the decreasing amplitude of systolic pressure was significantly lower in group A than in group B (P < 0.01). The decreasing amplitude of RR and SPO2 showed no significant difference between the two groups (both P > 0.05).
CONCLUSION: Intravenous propofol combined with fentanyl is an effective and safe anesthesia method in painless endoscopy in elderly patients, with less stimulation of pharyngeal reflex and less effect on the circulatory and respiratory systems.
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Biedermann L, Gaspert A, Gubler C. The way to a man's stomach is through his heart. Gastroenterology 2012; 142:212, 413. [PMID: 22192435 DOI: 10.1053/j.gastro.2011.02.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 02/08/2011] [Accepted: 02/11/2011] [Indexed: 12/02/2022]
Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
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Miyamoto S, Matsushita M, Shimatani M, Kato K, Okazaki K. Double-balloon enteroscopy for multiple ischemic stenoses in the jejunum caused by cholesterol crystal embolisms. Gastrointest Endosc 2011; 73:1060-2. [PMID: 21035799 DOI: 10.1016/j.gie.2010.08.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 08/29/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Sachi Miyamoto
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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Di Tullio MR, Homma S. Atherosclerotic Disease of the Proximal Aorta. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Konstantinidis IT, Warshaw AL, Deshpande V, Sahani D, Berger D, Fernandez-del Castillo C, Ferrone CR. Cholesterol crystal embolization presenting as either solid or cystic pancreatic lesion. J Surg Oncol 2010; 102:706-8. [PMID: 20976733 DOI: 10.1002/jso.21521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cholesterol crystal embolization (CCE) can result in end-organ ischemia. Retrospective review of clinicopathologic data. The first patient was anticoagulated with coumadin for chronic atrial fibrillation and presented subacutely with a solid mass. The second patient suffered from coronary artery disease post-angioplasty/stenting and presented with acute pancreatitis and pancreatic cystification. CCE should be considered in patients with significant vascular disease, arrhythmias or vascular manipulation who present with a pancreatic mass.
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Abstract
Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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Park DH, Kwon TH, Cho HD, Park JH, Lee SH, Park SH, Kim HS, Kim SJ. Pancreatic infarction resulting from cholesterol crystal embolism mimicking a solid pancreatic tumor. Gastrointest Endosc 2008; 67:176-8. [PMID: 17945231 DOI: 10.1016/j.gie.2007.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 04/30/2007] [Indexed: 02/08/2023]
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Jucgla A, Moreso F, Muniesa C, Moreno A, Vidaller A. Cholesterol embolism: Still an unrecognized entity with a high mortality rate. J Am Acad Dermatol 2006; 55:786-93. [PMID: 17052483 DOI: 10.1016/j.jaad.2006.05.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 04/28/2006] [Accepted: 05/05/2006] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cholesterol embolism (CE) is an increasingly common but often underdiagnosed medical problem. The recognition of clinical manifestations of CE is the first step toward a correct diagnosis. OBJECTIVE Our aim was to characterize the features of CE and the risk factors for fatal outcome. METHODS Clinical records of patients with clinical and histopathologic diagnoses of CE seen from January 1993 through March 2003 were reviewed. RESULTS Twenty-six male patients were identified. Mean age was 64 years (range, 48-88 years). All patients had two or more risk factors for atherosclerosis. All but one patient had preexisting symptomatic atherosclerotic disease. At least one precipitating factor was identified in 23 patients (88%). Diagnosis of CE at admission was made in 9 patients only (35%). Cutaneous lesions (88%) and renal failure (73%) were the most common clinical findings. Complications (dialysis, acute pulmonary edema, amputation, or gastrointestinal surgery) were present in 21 patients (81%), and 15 patients died (58%). Previous chronic renal failure was the only variable associated with mortality (relative risk: 4.54, 95% confidence interval 1.26-16.6; P = .02). LIMITATIONS The results were obtained from patients admitted to a university hospital. This fact may have selected a higher proportion of severe cases. CONCLUSIONS CE was frequently misdiagnosed. Skin lesions were the most common clinical findings and skin biopsy provided histologic confirmation in most of the patients. Chronic renal failure was the only factor related to death.
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Affiliation(s)
- Anna Jucgla
- Department of Dermatology, Hospital Universitari de Bellvitge, University of Barcelona, Spain.
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32
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Affiliation(s)
- D R Gaya
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, Scotland
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Wisniewski B, Vadrot J, D'Hubert E, Drouhin F, Fischer D, Denis J, Labayle D. [Spontaneous splenic rupture secondary to cholesterol embolisms: a case study]. ACTA ACUST UNITED AC 2004; 28:922-4. [PMID: 15523235 DOI: 10.1016/s0399-8320(04)95162-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Affiliation(s)
- A Somogyi
- CHIC, 20, rue Armagis, 78100 Saint-Germain-en-Laye, France
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50036-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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