Synchronous haematogenous colonic metastasis from a primary renal cell carcinoma: an unusual cause of colonic haemorrhage: [case report]

Background: renal cell carcinoma [RCC] represent 2-3% of all malignant tumors in adults. Clear cell carcinoma is the most frequent histological type, and 25-30% of renal carcinoma have metastasis at the time of diagnosis. RCC very rarely metastasize to the colon. The objective of the present study is to report synchronous haematogenous solitary colonic metastasis that presented as severe recurrent lower gastrointestinal haemorrhage which required right hemicoloectomy and right nephrectomy plus chemotherapy

Clinical Case: we report the case of a 46-year old male patient who presented with multiple episodes of severe haemotochezia and anemia. He had a right flank mass. CT scan of the abdomen showed a large right kidney mass together with a lesion in the ascending colon, not connected to the renal mass. It also showed hepatic metastasis, lung metastasis and ascites. Colonoscopy revealed an ascending colonic mass. The patient was managed by right nephrectomy and right hemicolectomy. The pathology report of the colonic mass showed clear cell carcinoma with involvement of the colon from serosa to mucosa. It indicated the presence of haematogenous spread of the RCC as the mechanism of metastasis. The colonic haemorrhage did not recur. the patient survived close to a year after surgery

Conclusion: RCC metastasis to the colon is very rare and can be synchronous with the primary renal tumor and can be metachronous after nephrectomy. Also, it can be the result of direct invasion, haematogenous spread or after local recurrence following nephrectomy. Metastatic RCC requires surgery, immunotherapy, tyrosine kinase inhibitors, and mammalian target rapamycin inhibitors. Surgery is the first step for disease control and control bleeding from colonic metastasis. Metastectomy is indicated in localized disease and when surgically accessible

Uncommon incidental pseudoaneurysm. Diagnostic and management challenges

To analyze patients with uncommon incidental pseudoaneurysms, secondary to non-catheterization causes, and to discuss the peculiar clinical spectrum, and focus on some aspects of difference from post-catheterization pseudoaneurysms. Eleven patients, 8 males and 3 females, were studied retrospectively in Jordan University Hospital, Amman, Jordan, between 2002-2008. Radiological studies performed included duplex sonography [DS], computed tomography [CT], conventional angiography, magnetic resonance imaging [MRI], and magnetic resonance angiography [MRA]. Pseudoaneurysms were most commonly encountered in young males [63.6%], especially in the lower limb vessels [36%]. Clinical findings were suggestive of pseudoaneurysms in 27% of our cases. Four out of the 8 DS scans showed the neck of pseudoaneurysms, and the "to and fro" waveform, the strongest indicators for pseudoaneurysms. Both CT with intravenous contrast and angiography failed to establish the diagnosis in one out of 5 cases. The MRI with MRA showed the pseudoaneurysms in 2 patients that underwent the scan. Incidental pseudoaneurysms are considered following iatrogenic procedures, penetrating, or blunt traumas with variable delay time. Young healthy males are at increased risks, as opposed to elderly females with calcified vessels in post-catheterization cases. Duplex sonography is less sensitive in incidental than post-catheterization pseudoaneurysms. The CT scan with intravenous contrast has high accuracy in establishing the diagnosis in small, or medium sized pseudoaneurysms. The MRI and MRA are accurate valuable studies and comparable to conventional angiography

Electron microscopic and autoradiographic studies of the myenteric ganglia of the ferret stomach after highly selective vagotomy

In this study, the preganglionic fibres of the vagus nerve were investigated in the myenteric ganglia of the ferret stomach three and four months after highly selective vagotomy. Autoradiographic technique at the electron microsscopic level was used to analyze the vagal nerve terminals after injection of tritiated leucine as an anterograde labeling tracer into the vagal dorsal motor nucleus. Electron microscopic examination of the body of the stomach of control animals showed normal ulrastructure of the myenteric ganglia and labeled nerve fibres were seen distributed in the myenteric ganglia of the body and pyloric areas of the stomach. In the acute experimental animals injection of tritiated leucine was carried out immediately after surgery. After 48 hours survival period, electron mictoscopic examination of the body of the stomach showed no morphological changes, and no labeled nerve fibres as a results of highly selective vagotomy while the pylorus showed many labeled nerve fibres. In the chronic experiments, the animals were left to survive for three months after highly selective vagotomy. After injection of tritiated leucine and analysis by autoradiography, two important findings were observed in the denervated areas of the body of the stomach [i] Morphological changes affecting the ganglionic cell bodies, axons and nerve terminals [ii] Re-appearance of labeled nerve fibres in the body of the stomach. Interstingly, electron microscopic examination of the same areas of the body of the stomach four months after highly selective vagotomy showed normal ultrastructure of the myenteric ganglia with labeled nerve fibres in the same areas. It is concluded that the deprivation of the preganglionic input to the myenteric ganglia produced trans-synaptic neurological changes. These morphological degenerative changes disappeared when the stomach was re-innervated. Re-appearance of the labeled nerve fibres in the denervated areas of the stomach is due either to regeneration of the cut branches of the vagal nerve or due to the sprouting of the intact vagal nerve terminals which spread from the pyloric areas to innervate the denervated areas of the body of the stomach. This phenomenon of sprouting of the intact vagal nerve terminals or regeneration of the cut nerves, which was demonstrated by autoradiography at the electron microscopic level may explain the recovery of gastric function after vagotomy and may account for the failure of vagotomy for the treatment of peptic ulcer patients. It also could reduce the need for surgical intervention in peptic ulceration

Sprouting of the vagus nerve after highly selective vagotomy: an autoradiographic study in the ferret stomach

In this study, the sprouting of the vagal nerve terminals were investigated in the ferret stomach after highly selective vagotomy by using the autoradiographic technique. The acute experimental animals which had highly selective vagotomy were injected immediately with tritiated leucine into the vagal dorsal motor nucleus. autoradiographic examination of the body of the stomach failed to show any labelled nerve fibres, while the pylorus showed many labelled nerve fibers. These observations indicate that the highly selective vagotomy has been performed successfully. Abdominal examination, of the chronic experimental animals, three months after highly selective vagotomy. bridges of scar tissue were observed by passing the vagotomy ligatures to supply the stomach. Histological examination of the regrown tissue showed that it was normal nerve fibres. After cutting this regrown tissue and injection of these chronic animals with tritiated leucine into the vagal dorsal motor nucleus, labelled nerve fibres were seen in the body of the stomach. This indicates that terminals reactive sprouting of the vagus nerve has spread from the pylorus to supply the body of the stomach. This phenomenon of the compensatory reactive sprouting of the vagal nerve terminals may explain the recovery of gastric function and may account for the failures of highly selective vagotomy in humans. However, modification of surgery may decrease the high rate of incidence of recurrent peptic ulcer after highly selective vagotomy