Meckel's Diverticulitis. A rare cause of small bowel obstruction

Meckel’s Diverticulum is a sac-like protrusion of the intestinal wall. It is located at 40–60 cm from the caecum. In the majority of cases, Meckel’s Diverticulum is clinically silent, while complications are found in 4% of the population. Complicated diverticulitis is associated with the formation of abscess, fistula, bowel obstruction or frank perforation. We present a case of a 63-year-old woman with a distended abdomen, pain in the lower right abdominal quadrant, fever 37°C and where emergency exploratory laparotomy revealed that obstruction was caused by a bowel loop trapped by a mesenterium-diverticular band.

Mass of the neck: an extremely rare location of hydatid disease

Hydatid disease (HD) is a parasitic zoonosis which was first described by Hippocrates in the ancient years. Liver and lungs are the most commonly affected organs, while neck involvement is extremely rare. We report a case of a 75-year old male, who presented with an isolated right-side cervical mass. After clinical examination and screening tests, HD was diagnosed. Pre-operative and post-operative treatment with albendazole was administered and en-block surgical excision of the mass was performed. Histopathological examination of the specimen confirmed the diagnosis of HD. At one-year follow-up, the patient remained asymptomatic without any signs of recurrence. Although HD of the neck is an extremely rare entity, physicians should always include it in the differential diagnosis of neck masses.

Transrectal ultrasonography of perianal fistulas: a single center experience from a surgeon's point of view

AIM

Two-dimensional transrectal ultrasonography can nowadays be safely used for preoperatively evaluation of perianal fistulas. The aim of this study is to demonstrate its efficacy by comparing the results of this imaging technique with the surgical findings, as well as recurrence rates.

PATIENTS AND METHODS

A 4-year retrospective study with a mean follow-up of 4.7 years was performed, including patients treated surgically for a perianal fistula at the surgical department of a tertiary secondary hospital. All these patients underwent preoperatively a transrectal ultrasound with H2O2 for surgery planning, while 12 of them had also a MRI-scan.

RESULTS

The sample was consisted of 53 patients with a mean age of 32.4 years and a 0.3 female/male ratio. During the mean 4.7 years follow up 2 patients (3,8%) had a recurrence, while in none of these cases an anal-sphincter muscle trauma was noted. The operative findings were in all cases consisted with the transrectal ultrasonography Results. The MRI-scan failed to demonstrate the presence of a fistula in 3 out of the 12 patients (25%).

CONCLUSIONS

Our data support that the use of ultrasound with H2O2 preoperatively, for a safe surgery planning, leads to an accurate surgical procedure and fewer recurrence rates.

Malakoplakia of the large intestine: an incidental extremely rare finding

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

A rare cause for Hartmann's procedure due to biliary stent migration: A case report

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Migration of a biliary stent can cause life-threatening complications.

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When a stent migration occurs, in case of complications, surgical removal is the only treatment option.

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Among the complications associated with stent migration, intestinal bleeding, obstruction and perforation are of outmost importance.

Introduction

Biliary stent migration (proximal or distal) occurs in 6% of all cases. The majority of these migrating stents are passing through the intestine, without causing any complications. Usually when a stent migration occurs, endoscopic retrieval is the proper treatment option, except in case of complications when surgical removal is the only treatment option. This report presents a case of a biliary stent which migrated and caused a sigmoid colon perforation.

Presentation of case

A 75 years old female patient presented to the emergency department with diffuse abdominal pain, nausea and vomiting. Clinical examination showed distended abdomen and signs of peritoneal irritation.

CT scan of the abdomen revealed free gas and fluid in the left iliac fossa, as well as a foreign body penetrating the sigmoid colon. Emergency laparotomy was performed. A plastic stent was found perforating the sigmoid colon through a diverticulum. The rest of the sigmoid colon was intact presenting only uncomplicated diverticula. Hartmann’s operation was performed, involving the diseased segment, together with part of the descending colon due to profound diverticulosis. Patient’s post-surgical course was uneventful and was discharged on postoperative day 10.

Discussion

Migration of a biliary stent can cause life-threatening complications such as perforation of the intestine and peritonitis. The migration of the stent from the biliary tree may be mostly asymptomatic except in cases of intestinal perforation that immediate surgery is the proper treatment option. On the other hand, even in cases of benign lesions of the bile duct, the stent should be removed immediately after dislocation in order to reduce the risk of secondary complications such as obstruction, infection or perforation.

Conclusion

In cases of non-complicated stent migration endoscopic retrieval is the indicated treatment. In patients who suffer serious complications due to stent dislocation, emergency surgery may be the proper treatment option.

Incarcerated Amyand hernia with simultaneous rupture of an adenocarcinoma in an inguinal hernia sac: a case report

INTRODUCTION

An Amyand's hernia is a rare occurrence of an inguinal hernia, with an estimated prevalence of 1%. The major complications of an Amyand's hernia include necrotizing fasciitis of the anterior abdominal wall and secondary intestinal perforation. Though the incidence of this type of hernia is low, the appendix may easily become initially incarcerated, possibly leading to strangulation and perforation.

CASE PRESENTATION

A 92-year-old female patient presented to our emergency department with clinical signs of an incarcerated right inguinal hernia, accompanied by fever. A clinical examination revealed localized abdominal pain, reflecting to the right side of her groin. Laboratory tests showed leukocytosis (13,200/μL), while an abdominal X-ray showed colon distension with evidence of intestinal obstruction. Ultrasonography was performed and confirmed the presence of an inflamed tubular structure inside her right inguinal canal. Our patient underwent emergency surgery. We started with a right inguinal incision, which revealed an incarcerated right inguinal hernia, containing her ruptured appendix and showing macroscopic evidence of malignancy. A specimen biopsy was immediately performed and the results showed a ruptured cecal adenocarcinoma. The incision was slightly extended upwards, and a right hemicolectomy performed.

CONCLUSIONS

Diagnosis of an Amyand's hernia occurs primarily as an incidental finding during surgery and the optimal therapeutic approach must be considered individually for each case. Owing to the rarity of Amyand's hernia and the wide variance of its clinical characteristics, every case provides useful information toward the treatment of this type of hernia.

A case of pneumoperitoneum and retropneumoperitoneum without bowel perforation due to extensive intestinal necrosis as a complication to chemotherapy: CT evaluation

Acute intestinal ischemia continues to be a challenging diagnostic problem with high mortality. We describe a rare case of acute intestinal necrosis, due to vasculitis, related with chemotherapy.

A patient was examined in our emergency department, presenting with abdominal pain. Three months before he had undergone an operation for lung carcinoma (lobectomy) and received chemotherapy.

CT of the abdomen demonstrated free air in 10 different locations: hepatic part of the portal vein, branches of mesenteric veins, femoral and iliac veins, the bowel wall, peritoneal cavity and retroperitoneal space, abdominal muscles, inguinal canals, meso-sigmoid space, and in the para-rectal space. Moreover, pathological findings revealed that the free air in the peritoneum and retropneumoperitoneum occurred without intestinal perforation, but with transudation through the necrotic bowel wall. This is a rare complication of chemotherapy. This case refers to the unusual CT findings which appeared in this patient. The key to a better outcome is early diagnosis of this condition and the CT examination of the abdomen plays an important role.

Challenging behaviours on people with autism: A case study on the effect of a residential training programme based on structured teaching and TEACCH method

The purpose of the study is the investigation of how effective could be one of the first residential training programmes based on structured teaching and the principles of TEACCH method, in declining the frequency of challenging behaviours in adolescents and adults with autism, who had never received any kind of intervention or training. Functional assessment records (ABC) were analysed for each participant and frequencies of challenging behaviours were summarised for three deferent periods of time (beginning of the programme, after 12 and 18 months). The results showed significant decline of challenging behaviours frequency after the start of the training programme. The implications of the results in particular will be valuable for further research and service developments in Greece by the Greek Society for the Protection of Autistic People.

Evidence of less severe aortic valve destruction after treatment of experimental staphylococcal endocarditis with vancomycin and dexamethasone

The beneficial effects of therapy combining an antibiotic and dexamethasone have been reported in human studies on meningitis and in experimental studies on septic arthritis, nephritis, and endophthalmitis. Since most patients with staphylococcal endocarditis need a combination of medical and surgical treatment, the purpose of this study was to determine whether the addition of dexamethasone to vancomycin has any beneficial effect regarding the degree of valve tissue damage or the course of experimental aortic valve endocarditis caused by a methicillin-resistant strain of Staphylococcus aureus. Rabbits with catheter-induced aortic valve vegetations were randomly assigned to a control group and to groups receiving dexamethasone (0.5 mg/kg of body weight, intravenously [i.v.], twice a day [b.i.d]), vancomycin (30 mg/kg, i.v., b.i.d), or dexamethasone plus vancomycin, for a total of 10 doses (two doses per day for 5 days). The severity of valve tissue damage was significantly less in groups receiving vancomycin plus dexamethasone compared with that of the group receiving vancomycin alone (P < 0.001). The severity of tissue damage was inversely correlated with the mean polymorphonuclear leukocyte number in valve tissue. No statistically significant differences were observed between the vancomycin-treated group and the vancomycin-plus-dexamethasone-treated group in survival, blood culture sterilization rate, or reduction of the microbial burden (in CFU per gram) in valvular tissue. In conclusion, treatment with a combination of vancomycin and dexamethasone for 5 days reduces the severity of valve tissue damage in experimental staphylococcal aortic valve endocarditis. These findings could have significant implications in the treatment of staphylococcal endocarditis and deserve further confirmation in clinical trials.

Successful trovafloxacin prophylaxis against experimental streptococcal aortic valve endocarditis

Single-dose trovafloxacin (15 mg/kg given intravenously [i.v.]) and ampicillin (40 mg/kg given i.v.) protected 38 and 33% of animals challenged with an ampicillin-tolerant strain of Streptococcus oralis, respectively. As a double-dose regimen, trovafloxacin afforded total protection (100%; P < 0.001 versus controls). Trovafloxacin is the first fluoroquinolone effective in preventing experimental streptococcal endocarditis.