1/16. Fatal haemorrhage from Dieulafoy's disease of the bronchus.A 70 year old woman with a previous history of healed tuberculosis and suspected chronic obstructive pulmonary disease presented with recurrent haemoptysis and respiratory failure from a lobar pneumonia. Massive bleeding occurred when biopsy specimens were taken during bronchoscopy which was managed conservatively, but later there was a fatal rebleed from the same site. Two different Dieulafoy's vascular malformations were found in the bronchial tree at necropsy, one of which was the biopsied lesion in the left upper lobe. This report confirms the possibility that vascular lesions occur in the bronchial tree. It is suggested that, if such lesions are suspected at bronchoscopy, bronchial and pulmonary arteriography with possible embolotherapy should be performed.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
2/16. Diffuse alveolar hemorrhage syndrome due to 'silent' mitral valve regurgitation.A variety of clinical diseases are associated with diffuse alveolar hemorrhage. Although mitral valve disease can cause hemoptysis, it rarely is associated with diffuse alveolar hemorrhage at presentation. A 49-year-old woman was admitted to the hospital with the abrupt onset of fever, anemia, dyspnea, azotemia, and diffuse alveolar infiltrates. Two-dimensional echocardiography done several months earlier to evaluate atypical chest pain had been unremarkable. Fiberoptic bronchoscopy 2 days after admission to the hospital revealed fresh blood throughout the tracheobronchial tree. The infiltrates resolved rapidly and completely during systemic steroid therapy only to reappear as the steroids were tapered, suggesting a beneficial therapeutic response. Results of serologic evaluation were negative. Transbronchial biopsies showed inflammation and hemosiderin-laden macrophages; no specific diagnosis was established. The patient was scheduled for open lung biopsy. The surgeon was concerned about the history of chest pain and requested placement of a pulmonary artery catheter, which revealed severe pulmonary hypertension. Transesophageal echocardiography and subsequent cardiac catheterization showed severe mitral regurgitation. mitral valve replacement resulted in complete elimination of symptoms.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
3/16. survival with an arterial pH of 6.57 following major trauma with exsanguinating haemorrhage associated with traumatic amputation.We report the survival of a multiply injured patient with exanguinating haemorrhage and an arterial pH of 6.5, following a road vehicle crash. The previously healthy 38 years old male driver veered off the motorway and collided with a tree. The ambulance arrived at the scene 9 min after being called by an eyewitness and, following rapid extrication from the wreckage; the patient arrived in hospital 27 min later (with a GCS of 6), and was immediately intubated. The patient had suffered near-complete amputation of the left leg at upper femoral shaft level, along with multiple distal fractures and open wounds. He also sustained a head injury and closed displaced fractures of left radius and ulna. The patient received 2 l of crystalloids in the pre-hospital phase. Once in hospital the haemorrhage was controlled with a pressure dressing and intra-venous fluids were kept to a minimum until he was taken promptly to theatre. His initial arterial blood sample revealed a pH of 6.57, pCo(2) of 9.18 kPa, a pO(2) of 70.11 kPa and a base excess of -27.5 mmol l(-1). The co-oximeter Hb was 5.8 g dl(-1). Haemorrhage was controlled in theatre where he was transfused a total of 30 U of blood, 1 pack of platelets, 12 U of fresh frozen plasma, 3.5 l of crystalloids and 1.5 l of colloid. sodium bicarbonate was administered three times. He subsequently remained ventilated in intensive care unit (ICU). Over the following week he survived sepsis, disseminated intravascular coagulation and myoglobinuria (with transient renal failure) attributable to rhabdomyolysis secondary to muscle necrosis. He later underwent diversion colostomy and disarticulating amputation of the left femur after several debridements. After 6 weeks on ICU he made an excellent recovery will full return of his mental abilities. In this case, the serial arterial blood samples obtained were reliable. The lactic acidosis observed was the result of profound tissue hypo-perfusion and its rate of clearance seems to have greater prognostic value than its peak or initial value. Several factors may have contributed to the patient's survival: rapid retrieval from the scene; early intubation with excellent subsequent oxygenation (thus avoiding the dangerous combination of hypoxia and acidosis with synergistic influence on cardiac depression) and limited initial fluid resuscitation in the emergency department with prompt surgical intervention and vigorous restoration of organ perfusion after surgical haemostasis. Immediate operative haemostasis, coupled with restricted fluid administration beforehand and vigorous restoration of organ perfusion afterwards is now replacing the old resuscitation paradigm. Perhaps this shift in practice has helped this patient to survive.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
4/16. Autologous blood clot embolization into a bleeding renal artery pseudoaneurysm.A young girl suffering from anuria due to periarteritis nodosa developed severe bleeding after left kidney needle biopsy. Angiography revealed, in addition to changes in the renal vascular tree, two saccular pseudoaneurysms in the course of a lobar artery in the left kidney. These caused life-threatening bleeding from the urinary tract. An autologous blood clot was injected into the bleeding artery by selective catherization, which resulted in cessation of bleeding for a period of 15 h, and thus permitted the performance of surgical intervention - nephrectomy - under more suitable conditions.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
5/16. Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent.AIM: To highlight the fatal complication caused by expanding biliary stents and the importance of avoiding use of expanding stent in potentially curable diseases. methods: Arteriobiliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudoaneurysm causing arteriobiliary fistula and presenting as severe malena and cholangitis, in a patient with a mesh metal biliary stent. The patient had lymphoma causing bile duct obstruction. RESULTS: Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolisation of the pseudo aneurysm successfully controlled the bleeding. CONCLUSION: Bleeding from the pseudo aneurysm of the hepatic artery can be fatal. Mesh metal stents in biliary tree can cause this complication as demonstrated in this case. So mesh metal stent insertion should be avoided in potentially benign or in curable conditions. Difficulty in diagnosis and management is discussed along with the review of the literature.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
6/16. Acute respiratory failure from tracheopathia osteoplastica.Tracheopathia osteoplastica is a benign cartilaginous and osseous metaplasia of the laryngo-tracheobronchial tree diagnosed more commonly in adults over 50 years of age. We report here the case of a 54-year-old man who underwent thyroidectomy for multinodular goiter. Immediately after an uneventful surgery, he developed an acute respiratory failure with radiologic picture of adult Respiratory Distress syndrome. Mechanical ventilation was set up again, bronchoscopy with biopsy disclosed a massive tracheobronchial haemorrhage from a tracheopathia osteoplastica. Supportive treatment was successfully provided and the patient resumed to a normal life 14 days after the operation.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
7/16. An autopsy case of heart rupture from a scooter accident with 3 riders.A 15-year-old male died of cardiac rupture due to blunt chest trauma from a traffic accident involving a low-speed scooter carrying 3 people and a head-on collision with a tree. The victim was sitting on the footrest of the scooter. It was concluded that the victim was compressed between the handlebar of the scooter and the other 2 passengers, causing cardiac ruptures via bidirectional compression and intravascular hydrostatic pressure. The victim may have served as a cushion for the other 2 passengers, who were not thrown from the scooter and sustained only minor injuries.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
8/16. Iatrogenic haemobilia: ultrasound appearance of intragallbladder haemorrhage. A report of two cases.Ultrasound appearance of intragallbladder haemorrhage in two patients with haemobilia is presented. gallbladder lumina were occupied by non-shadowing, firm masses of mixed echogenicity representing blood clots. In both cases iatrogenic trauma following percutaneous transcholecystic cholangiography and blind hepatic biopsy caused bleeding in the biliary tree.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
9/16. Management of major tracheal hemorrhage after repair of complex congenital heart defects.Two patients with complex congenital heart defects (a 4-year-old with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction and a 3 1/2-year-old with double-outlet right ventricle, subpulmonary stenosis, and complete atrio-ventricular septal defect) suffered multiple major hemorrhages from the tracheobronchial tree (28 and 7 bleeding events, respectively). Successful management included tracheostomy, sedation and paralysis, systemic hypotension, and systemic hypothermia for a period of seven days. Both patients survived.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
10/16. Intraoperative streptokinase. An adjunct to mechanical thrombectomy in the management of acute ischemia.streptokinase was injected directly into the arterial tree following balloon-catheter embolectomy on 13 occasions to remove residual thrombus that could not be mechanically retrieved in 12 patients with imminent limb (ten patients) or kidney (two patients) necrosis. Effective lysis, confirmed by arteriography, pulse return, and increased ankle pressures, was achieved in 11 trials (85%). Bleeding complications, minor in three patients and severe in two patients, were ascribed to systemic lysis although other factors were contributory. One of five deaths was related to therapy. Six limbs were salvaged. The average total dose of streptokinase used, 110,000 units, was given in intermittent boluses of 25,000 to 50,000 units injected below a clamp placed to temporarily occlude distal circulation. Safe application of this technique requires intraoperative monitoring of coagulation parameters, aggressive replacement therapy, and prudent patient selection. This preliminary experience suggests that intraoperative lytic therapy (1) is an effective method for clearing thrombus not amenable to mechanical extraction and (2) may improve patency and tissue salvage.- - - - - - - - - - ranking = 0.5keywords = tree (Clic here for more details about this article) |
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