1/12. Jejunal perforation caused by abdominal angiostrongyliasis.The authors describe a case of abdominal angiostrongyliasis in an adult patient presenting acute abdominal pain caused by jejunal perforation. The case was unusual, as this affliction habitually involves the terminal ileum, appendix, cecum or ascending colon. The disease is caused by the nematode angiostrongylus costaricensis, whose definitive hosts are forest rodents while snails and slugs are its intermediate hosts. infection in humans is accidental and occurs via the ingestion of snail or slug mucoid secretions found on vegetables, or by direct contact with the mucus. Abdominal angiostrongyliasis is clinically characterized by prolonged fever, anorexia, abdominal pain in the right-lower quadrant, and peripheral blood eosinophilia. Although usually of a benign nature, its course may evolve to more complicated forms such as intestinal obstruction or perforation likely to require a surgical approach. Currently, no efficient medication for the treatment of abdominal angiostrongyliasis is known to be available. In this study, the authors provide a review on the subject, considering its etiopathogeny, clinical picture, diagnosis and treatment.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
2/12. Successful use of the "patch, drain, and wait" laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered "good angiogenesis" involved?The traditional and most frequently employed surgical approach to perforated necrotizing enterocolitis (NEC), laparotomy and bowel resection with enterostomy creation, has been associated with an unacceptably high mortality and major morbidity (sepsis, short-gut syndrome, strictures, long-term total parenteral nutrition (TPN), prolonged and costly hospitalizations with multiple operations, the inevitable open-and-close procedure for "hopeless" extensive gut ischemia in approximately 10% of laparotomy cases, etc.). The use of the laparotomy "patch, drain, and wait" (PD&W) approach to this serious of NEC complication has provided a simple, direct, and effective means of dealing with this problem. The basic principle is to resect no gut and do no enterostomies. The details are presented here as well as the multiple types of "patching" and the importance of use of extensive direct-vision draining with bilateral small Penrose drains from the undersurfaces of both diaphragms into the pelvis with exit sites in both lower quadrants. Proper and effective patching and draining cannot be done blindly,but requires direct vision (laparotomy or laparoscopy). The critical components and timing of the "waiting" are emphasized, including the vital importance of strict avoidance of early post-drainage laparotomy in the 7- to 14-day post-drainage period (whether the drainage is percutaneous, laparotomy PD&W, or laparoscopy PD&W) due to the early, life-threatening-ending hypervascularity that occurs at this time and if left unmolested will function beneficially as life- and gut-saving "good angiogenesis". The bilateral Penrose drains capture fecal fistulas and function quite well as de-facto enterostomies as the peritoneal cavity is rapidly obliterated by adhesions and massive, florid hypervascularity/gut hypoxia triggered "good angiogenesis" (no peritoneal cavity, no peritonitis). Broad-spectrum triple antibiotics and the routine use of TPN contribute to favorable results. The lessons/experiments of nature encountered in newborns with midgut atresia(s) and remarkable levels of gut survival, in the occasional case with only meconium peritonitis and no obstruction ("auto-anastomosis") are pertinent here as the TPN of PD&W is provided in atresia(s) by the maternal-placental circulation and the sterile peritoneal cavity of atresia(s) is simulated by the combination of antibiotics and peritoneal-cavity obliteration. life- and gut-saving "good angiogenesis" is common to both situations. A 15-year personal experience with the PD&W laparotomy approach to perforated NEC in 23 cases is reported here with no mortality in the initial 60 postoperative days, no major morbidity, and no second operation required in 70% (spontaneous "auto-anastomosis") of cases. All infants with extensive gut ischemia/necrosis (NEC totalis) who would otherwise be classified as "hopeless" and managed by open-and-close only were managed in this experience successfully by PD&W with preservation of both life and an adequate amount of gut, although a second operation was required in these cases to re-establish intestinal continuity. A particularly striking observation was the rapid transition of these infants from profound illness to near-normalcy in a matter of hours after the initiation of PD&W--much like the rapid clinical changes accompanying the lancing of a boil or an abscess. An involvement of hypoxia-induced "good angiogenesis" with marked hypervascularity and involving molecules, genes, and receptors of the vascular endothelial growth factor family of hypoxia-induced angiogenesis molecules is speculated upon, and clinical studies to document these speculations are suggested as well as studies evaluating the potential of laparoscopic PD&W. The usefulness of Argyle chest-tube "venting" and "stenting" by trans-anal passage above colonic "patched" areas as seen in 2 cases is worthy of further study and use.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
3/12. Toothpick injury mimicking renal colic: case report and systematic review.We describe a case of a patient with left flank pain that was caused by a perforation in the splenic flexure of the colon by a toothpick. We conducted a systematic review of the literature to examine the nature of injuries caused by ingested toothpicks. Articles were analyzed for the following outcome variables: presenting complaint, site of injury, recollection of toothpick ingestion, time to presentation, findings from imaging studies, and mortality. Most patients (70%) presented with abdominal pain. Few patients (12%) remember swallowing a toothpick. The onset of symptoms ranged from <1 day to 15 years. Toothpicks caused perforation most frequently at the duodenum and the sigmoid. In some cases, toothpicks migrated outside the gastrointestinal tract and were found in the pleura, pericardium, ureter, or bladder. Toothpicks were apparent on imaging studies in 14% of the cases. The definitive diagnosis was most commonly made at laparotomy (53%), followed by endoscopy (19%). overall mortality was 18%. Ingested toothpicks may cause significant gastrointestinal injuries, and must be treated with caution.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
4/12. Filiform polyposis: a case report describing clinical, morphological, and immunohistochemical findings.Filiform polyposis (FP) is a rare condition of uncertain pathogenesis, 28 cases of which have been published since it was first described in 1965. It is usually found in association with chronic inflammatory bowel disease, especially Crohn's disease and ulcerative colitis. The condition is characterized by the presence of numerous, densely packed, filiform polyps in the colon, which may resemble villous adenomas on endoscopy. We describe a case of FP occurring in a 33-year-old man with a 5-year history of Crohn's disease, in whom subtotal colectomy was performed because of perforation of the sigmoid colon. microscopy revealed inflammatory pseudopolyps covered by largely normal and non-dysplastic colonic epithelium. The neuroendocrine system of the intestine in FP was investigated for the first time in this case: marked hyperplasia of endocrine cells immunoreactive for serotonin, somatostatin and enteroglucagon and of neural structures immunoreactive for substance p and vasoactive intestinal peptide was noted in the polyps and the adjacent intestinal mucosa. The patient has experienced no further complications in the 12 months since the operation. Medication administered in FP depends mainly on the nature of the underlying disease, and the amount of information published about this condition is as yet insufficient to allow any one specific type of treatment to be recommended. FP alone is not an indication for bowel resection but complications, such as massive haemorrhage or intestinal obstruction, may necessitate surgical intervention.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
5/12. Bowel perforation due to metastatic lung cancer.lung cancer infrequently metastasizes to the bowel. When this occurs, the symptoms may vary from mild to emergent in nature. Three patients are presented illustrating the life threatening complications that may occur due to bowel metastases of lung carcinoma. A review of the literature reveals that only four of 24 reported patients have survived bowel perforation due to metastatic lung carcinoma. One of the three patients presented herein survived to be discharged home. patients with known lung carcinoma who develop abdominal complaints should be investigated aggressively to prevent life-threatening complications by early intervention.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
6/12. Colonoscopic impaction in left colon strictures resulting in right colon pneumatic perforation.Colonic perforation during flexible colonoscopy is a rare but recognized complication. We reviewed 4,593 colonoscopies performed from 1984 to 1989. The perforation rate for diagnostic colonoscopy was 0.17% (6/3,538) and for therapeutic colonoscopy it was 2% (21/1,055). Four perforations of the right colon occurred at a site proximal to the level of the impacted colonoscope. The lesions being evaluated were obstructive in nature: two diverticular strictures (sigmoid colon), one ischemic stricture (descending colon), and one annular carcinoma (descending colon). The four perforations occurred in the right colon and manifested as distension with pneumoperitoneum or retroperitoneal emphysema. Operative management included total abdominal colectomy in two patients (ileoproctostomy in one and ileostomy in one) and right colectomy in two. Outcome was favorable in all cases.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
7/12. Colon perforation after percutaneous nephrolithotomy revisited.Objective was to remind the reader of a rare but nevertheless serious complication of percutaneous nephrolithotomy (PCNL) which is further complicated by the lack of pre-operative and intra-operative warning signs. A patient underwent an apparently normal PCNL. Only just before removal of the nephrostomy tube, signs of colonic perforation became apparent. In spite of no clinical signs of sepsis or shock, the patient developed severe complications during and after the ensuing surgery. Every urologist, surgeon, or radiologist performing PCNL must be aware of the risk of an aberrant retrorenal colon loop, the perforation of which will most likely not be noticed during the procedure. Abdominal symptoms of a more general nature must lead to the active exclusion of this complication. If a CT scan has been performed pre-operatively for whatever reason, attention should be paid to the juxtarenal colon. Although a CT scan can exclude a retrorenal colon, such a procedure would exceed the needs and limitations of routine evaluation in all patients for PCNL.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
8/12. Intraabdominal desmoid tumour presenting with perforation.We present a rare case of a desmoid tumour presenting with perforation of the small bowel. Although desmoid is classified pathologically as a benign tumour, its infiltrative nature leads to a locally aggressive mass, which can invade surrounding structures and organs making surgical resection difficult. Some unresectable tumours show oestrogen receptor positive cells and can be managed with tamoxifen. The aetiology, investigation and management options are briefly described.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
9/12. Stercoral perforation of the colon proximal to an end colostomy.Stercoral perforation of the colon is rare, and has not previously been reported as a postoperative complication, proximal to an end colostomy. Two such cases are reported; in addition in one the stercoral perforation was recurrent, emphasizing the multifocal nature of the disease. Both cases demonstrate the failure of standard techniques to deal with scybala in the loaded proximal colon. It is, therefore, suggested that intra-operative orthograde colonic lavage is indicated to protect a terminal colostomy from the risk of stercoral perforation in such cases.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
10/12. association of small intestinal diverticulosis with chronic pancreatitis leading to severe malabsorption. Report of three cases.Three cases of chronic pancreatitis occurring in patients with small intestinal diverticulosis and bacterial overgrowth are reported. In two of the cases, pancreatic supplements were therapeutically beneficial (the third being unable to tolerate them). Two of the patients also developed diverticular perforation. The possible nature of the association between small intestinal diverticulosis and chronic pancreatitis is discussed.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
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