Pneumatosis Cystoides Intestinalis With Portal Venous Gas: Two Case Reports

Pneumatosis cystoides intestinalis is a rare condition which is characterized by multiple gas-filled cysts of varying sizes in the wall of the gastrointestinal tract. In 85% of the cases, it is associated with gastrointestinal, pulmonary, and connective tissue diseases or with other conditions. In about 15% of the cases, the etiology remains obscure. In most cases, the prognosis is poor, so early diagnosis and treatment are required. We report two cases of primary pneumatosis cystoides intestinalis with portal venous gas which were associated with alcoholism and diabetes mellites and which were complicated by pneumoperitoneum and panperitonitis.

Warfarin Toxicity Patients in the Emergency Department

PURPOSE: The number of patients who take warfarin is growing, and so is the number of complications. However, the treatments of these complications vary widely due to the lack of guidelines. Therefore, we felt the need to establish guidelines for warfarin toxicity treatment. METHODS: We reviewed the medical records of the patients taking warfarin, at the time of Severance Hospital Emergency Center visit with bleeding complications or an initial prothrombin time (PT) in international normalized ratio (INR) of more than 3, from March 1, 1999, to February 28, 2001. These patients were divided into major, minor, and no bleeding groups according to their bleeding status, and the groups were compared analyzed. RESULTS: There were 57 patients who met the criteria. Atrial flutter/fibrillation and heart valve replacement patients made up 71.9%. No significant difference in initial PT (INR) existed between the three bleeding groups. However, the difference existed in the amount of vitamin K given to the three bleeding groups. CONCLUSION: Initial PT (INR) is not an appropriate guide for treatment of bleeding complications of warfarin toxicity. Clinical manifestations were more reliable and significant to treat for bleeding complications of warfarin toxicity.

Contrast Nephrotoxicity Associated with Emergency CT scans

PURPOSE: In the last 30 years, there has been a markedly increased use of iodinated contrast agents in diagnostic and interventional radiological procedures. Due to the possible side effect of nephrotoxicity of these radiocontrast agents, we investigated the incidence of nephrotoxicity and attempted to identify the patient groups at higher risk for contrast nephrotoxicity among the patients who underwent emergency computerized tomography. METHODS: We reviewed the medical records of 1,572 patients who had undergone contrast computerized tomography at the Emergency Center, Yonsei Medical Center, from January to May 2002. We defined contrast nephrotoxicity as any increase in the creatinine value of more than 0.5 mg/dL (44 micromol/L) or 25% compared to the baseline value. RESULTS: We found 21 patients (1.3%) who met the criterion for contrast nephrotoxicity: 13 patients with normal renal function, and 8 patients with a higher than normal creatinine value before contrast-enhanced computerized tomography. The incidence of contrast nephrotoxicity in the patient group with normal renal function was 0.8% (13/1551), compared to 38.1% (8/21) in the pre-existing renal insufficiency group. There were no statistical differences on the amounts of dye used and the frequencies of risk factors for contrast nephro-toxicity between the patients in pre-existing renal insufficiency group who developed nephrotoxicity and who did not. The renal function of all patients returned to the baseline value without dialysis or renal replacement therapy. CONCLUSION: Pre-existing renal insufficiency is the most important risk factor for contrast nephrotoxicity. We need to take precautions and to have a proper protocol for the prevention of contrast nephrotoxicity in emergency care.

Immune Alteration in Rebleeding

PURPOSE: This study evaluates whether the adaptation mechanism could modulate immunosuppression following a hemorrhage. METHODS: Minor hemorrhage (10% of total blood volume) was induced in the rat model, 1, 2, 4, and 7 days before the main hemorrhage. The immune responses were observed by measuring Con A (Concanavalin A) stimulated proliferative capacity of the peripheral lymphocyte subpopulations, and the Interleukin-2 (IL-2) release from splenocytes. RESULTS: The proliferative capacity of the splenocytes (SPC) decreased in two days interval model with hemorrhages more than 20% of the total blood volume. The SPC increased in the group with 10% hemorrhage pretreatment 7 days prior to 20% main hemorrhage than it was for 20% or 30% main hemorrhage only with cardiac puncture groups. The SPC increased on the first day than it was on the fourth day after the 20% main hemorrhage, in the pretreatment group with 7 days interval. The amount of IL-2 release by the splenocytes was higher in the 10~20% group (10% pretreatment hemorrhage and 20% main hemorrhage) than it was in the 0~30% group, when the hemorrhage interval was 7 days, and it was higher on the first day than on the fourth day after the second hemorrhage in the 10~20% group. CONCLUSION: The immune response varied depending on the hemorrhage interval following pretreatment, and it increased after the main hemorrhage that, by itself, would cause immunosuppression. But this effect, however, was only observed during a short period (about 1 day) following the second hemorrhage.

Sonography of the Pediatric Acute Abdomen in the Emergency Center

PURPOSE: Diagnosis of acute abdomen in infants and children is difficult. The aim of this study is to evaluate the usefulness of sonography in the children suffering from acute abdominal pain. METHODS: From January 2001 through July 2002, abdominal sonography was carried out in 265 children who had abdominal pain, vomiting, or irritability. The suspected diagnosis were acute appendicitis, intussusception, congenital pyloric obstruction, inguinal hernia, and illeocolitis. Medical records were reviewed retrospectively for age, sex, sonographic diagnosis, and the impact of the sonography in the treatment was evaluated by comparing the sonographic diagnosis with the final diagnosis (guidance for treatment). RESULTS: Among 265 patiens, the sex ratio (male:female) was 1.7:1. According to the findings of sonographic studies, mesenteric lymphadenitis (40.8%) was the most common diagnosis and was followed by acute appendicitis (21.9%), normal abdomen (19.2%), intussusception (14.3%), ileus (3.4%), and epididymitis (0.4%). In 259 of the 265 patients, sonography helped guideline for treatment (97.7%). CONCLUSION: Sonography is very useful in the diagnosis and establishing the treatment guideline of pediatric patients with acute abdomen.

Colon Perforation by an Ingested Toothpick

Foreign bodies in the gastrointestinal (GI) tract can be seen in all age groups and is not uncommon to see in the emergency department. Most are pediatric, edentulous, incarcerated and/or psychiatric patients. Since ingested objects are expected to pass spontaneously in 80% to 90% of patients with normal anatomy, direct foreign body removal using surgical intervention is rarely required. However, an ingested toothpick is of surgical interest as a cause of significant morbidity and even mortality. This is due to the difficulty in preoperative diagnosis resulting from a lack of history of ingestion of the toothpick and to the toothpick's radiolucent qualities. We report the case of a patient with peritonitis due to perforation of the sigmoid colon, a complication of accidental ingestion of a toothpick, that was diagnosed at the surgical field. Related literature is reviewed together.

Time-Dependent Diagnostic Value of TROPT(R)TnT Rapid Assay in Patients with Ischemic Chest Pain

A prospective study was carried out to evaluate the validity of TROPT troponin T rapid assay in early diagnosis of acute myocardial infarction(AMI) in patients with ischemic chest pain, in comparison with conventional diagnostic tools such as serum troponin T(c-TnT) level, creatine Kinase(CK), CK-MB level and initial EKG finding. The study was performed at the emergency department(ED) of Yong Dong Severance hospital from March 1st 1996 to February 28th 1997. One hundred eighty one patients visiting ED with chief complaint of atraumatic chest pain within 24 hours of visit were eligible for the study. Those who lacked enough data collection and those who had chest paint of noncardiac origin and EKG of PSVT were excluded from the study. The overall study population was a total of 131 patients. Initial EKG, TROPT rapid assay, CK, CK-MB and c-TnT level were obtained simultaneously. Diagnosis of AMI was made according to the international diagnostic criteria for AMI. Of the 131 patients 61 patients(46.6%) were diagnosed as AMI. Within 4 hours of their symptom onset, initial EKG showed the highest sensitivity(63.2%) whereas the sensitivities of TROPT rapid assay, c-TnT, CK and CK-MB were poor(0-0.7%). From 4-8 hours, the sensitivities of c-TnT, CK and CK-MB were higher than that of TROPT rapid assay(80% vs. 30%). The sensitivites of TROPT rapid assay, c-TnT, CK and CK-MB rose over time and reached 100% after 8 hours symptom onset. The specificities of the TROPT rapid assay, c-TnT, CK & CK-MB and EKG were all 100% within 8 hours after symptom onset. Discrepancy between TROPT rapid assay and c-TnT was noted in nine patients(6.9%). In this study TROPT rapid assay was valuable in the diagnosis of AMI after 8 hours of symptom onset.