atypical presentation of acute appendicitis: a 77 years old man with left lower quadrant pain

With an occurrence of 7%, appendicitis is one of the most common abdominal emergencies requiring surgery. Since the variation in positions and length of the appendix may produce varying symptoms and signs which mimic other diseases, having knowledge of the variations in the position of the appendix is of significant importance

Here, we present a 77-year-old man with acute appendicitis presenting with lower abdominal pain, fever, chills, and dys-uria. Physical examination revealed tenderness and rebound tenderness in the left lower quadrant more pronounced in the right lower quadrant with Icukocyiosis on blood tests. Both ultrasonography and abdominopelvic computed tomography scan demonstrated a severe inflammation at paracecal mesenteric fat with extension to para sigmoid portion which was in favor of diverticulitis rather than appendicitis

A 2-week treatment with intravenous antibiotic regimen was initiated for the patient and from the second day of antibiotic therapy, the patient's fever and abdominal pain improved. A second CT-scan performed three weeks after completion of a 14-day course of antibiotics, revealed a dilated long appendix [diameter: 12mm, length: 10 cm] with extension of its tip to the medial wall of sigmoid. Physicians should consider appendicitis when evaluating an acute abdomen to prevent any delay in diagnosis of atypical presentations and decrease the mortality and morbidity related to the complications

diagnostic role of magnetic resonance enterography as a complementary test to colonoscopy in active Crohn's disease

Background: According to recent studies comparing magnetic resonance enterography [MRE] with ileocolonoscopy for assessing inflammation of small bowel and colonic segments in adults with active Crohn's disease [CD], we aimed to compare the accuracy of these two diagnostic methods in Iranian population

Method: During 2013-2014 a follow-up study was done on 30 patients with active CD ina gastroenterology clinic affiliated to Tehran University of Medical Sciences. MRE and ileocolonoscopy were performed for all the patients. All statistical analyses were performed using SPSS [version 18] and P value<0.05 was considered as statistically significant

Results: Of the 30 patients with active CD, 11[36.7%] were men and 19 [63.3%] were women with mean age of 37.30 +/- 13.66 years [range: 19-67 years]. MRE had sensitivity and specificity of 50% and 90% with positive predictive value [PPV] and negative predictive value [NPV] of 71.43 and 78.26, respectively for localizing sigmoid lesions and ileum had sensitivity and specificity of 84.21 and 45.45 with PPV and NPV of 72.73 and 62.50, respectively

Conclusion: While moderate sensitivity and high specificity of MRE in localizing colonic lesions makes it an appropriate confirmatory test after colonoscopy, the reported high sensitivity and moderate specificity of MRE versus colonoscopy in detecting ileal lesions makes it a suitable screening test for ileal lesions. Finally we can conclude that MRE can be an important complementary test to colonoscopy in detecting active disease

Accuracy of 99mTc [V]-dimercaptosuccinic acid scintigraphy and fecal calprotectin compared with colonoscopy in localizing active lesions in inflammatory bowel disease

Introduction: Due to limitation of colonoscopy in assessing the entire bowel and patients' intolerance in inflammatory bowel disease [IBD], in the current study, we aimed to prospectively compare the accuracy of [99m]Tc[V]-dimercaptosuccinic acid [DMSA] and fecal calprotectin with ileocolonoscopy as new methods for localizing inflammations

Methods: Current prospective study conducted between 2012 and 2014 on 30 patients with IBD attending Gastroenterology Clinic of Tehran University of Medical Sciences. Fecal calprotectin and disease activity were measured for all participants and all of them underwent [99m]Tc [V]-DMSA scintigraphy and colonoscopy. The accuracy of [99m]Tc [V]-DMSA scintigraphy and calprotectin in localizing bowel lesions were calculated

Results: A total of 22 patients with ulcerative colitis [UC] and 8 patients with Crohn's disease [CD] were evaluated in our study. Sensitivity, positive likelihood ratio [PLR], and positive predictive value [PPV] of scintigraphy and calprotectin over colonoscopy in localization of UC lesions were 86.36%, 0.86%, 100.00% and 90.91%, 0.91, and 100.00%, respectively. Meanwhile, it showed 66.67% sensitivity and 81.25% specificity with PLR=3.56, negative likelihood ratio [NLR]=0.41, PPV=84.21%, and negative predictive value [NPV]= 61.90% in localizing lesions in patients with CD. The calprotectin level had sensitivity, PLR, and PPV of 90.00%, 0.90, and 100.00% in detecting active disease over colonoscopy, respectively

Conclusion: The [99m]Tc [V]-DMSA scintigraphy would be an accurate method for detecting active inflammation in follow-up of patients with IBD and assessing response to treatment as a non-invasive and complementary method beside colonoscopy for more accurate diagnosis of CD or UC

rare presentation of primary heptic lymphoma: a case report

Primary hepatic lymphoma [PHL] was a rare malignancy usually presenting with abdominal pain, malaise, Hepatomegaly, B-symptoms, fatigue, nausea, vomiting and jaundice. It mostly involves liver without any palpable lymphadenopathy and leukemia in peripheral blood smear. On July 22, 2014, a 64 year old man presented with abdominal pain localizing in Right upper quadrant and fullness from 2 years ago without any weight loss or constitutional symptoms. His physical examination revealed no mass or lymphadenopathy and lab data showed rise in Alkaline phosphatase [ALP] and Gamma-glutamyl transferase [gamma-GT]. Abdominal computed tomography [CT] scan with contrast showed a calcified lesion in the left lobe of liver and ill-defined hypodense area in medial segment of the left lobe of liver adjacent to gallbladder associated with mild central intra hepatic bile ducts dilation showing more enhancement in delay phase suggested peripheral cholangiocarcinoma. Finally surgical core needle biopsy of the liver confirmed malignant lymphoma of B cell type and patient was referred to oncologist for chemotherapy. His chemotherapy regimen consisted of rituximab 600 milligram [mg], endoxan 1250 mg, adriamycin 80 mg, vincristine 2 mg, prednisolone 100 mg [durgin five days] for 6 courses. After 5 months chemotherapy, on December 22, 2014 a follow up CT scan with IV and oral contrast was done. There was no evidence of previous mass lesion in the liver. In the follow up on May 9, 2015, he had no specific symptoms and all of his lab data were in normal range

review of the etiology, diagnosis and management of halitosis

Halitosis generally refers to the unpleasant odor of breath irrespective of its origin. Oral malodour could result in diverse problems in daily life such as social embarrassment and can adversely affect individuals' social interactions. Though many oral and non-oral sources could give rise to halitosis, it was mainly associated with oral cavity conditions and volatile sulfur compounds -produced by microbial activity- were the main elements of oral malodor. Objective measurement was the first step in assessment to determine presence of malodour. Then, taken a complete history including diet and habit history and performing a comprehensive physical examination contribute to the primary two steps for evaluating a patient complaining. The oral malodor management was mainly achieved by determining and eliminating the etiology of the condition. A major step in this regard was improving the oral health by means of establishing appropriate oral hygiene measures and controlling tongue flora by brushing or scraping and also, use of antiseptics as adjuvant therapy. Current article was systematic reviews the literature on prevalence, classification, diagnosis and treatment of halitosis

Peripheral neuropathy in ulcerative colitis: a case report

Inflammatory bowel diseases [IBD] were systemic disorders involving many organ systems. Besides intestinal manifestations, extra intestinal manifestations [EIMs] including neurologic complications have been reported among 6%-40% of IBD patients. Ulcerative colitis [UC] was a subtype of IBD only affecting the colonic mucosa and sub mucosa. Although the EIMs of UC could affect any organ system, central and peripheral neurological manifestations were relatively rare. Here, we described a case of UC and concurrent primary sclerosing cholangitis [PSC] who complained about paresthesia and weakness of his upper and lower limbs for the past two months. Through physical examination revealed decreased muscle tone in his legs and arms. Electrophysiological studies were compatible with the diagnosis of chronic mixed polyneuropathy which improved after administration of intravenous immunoglobulin [IVIG] and the patient was discharged in good general condition. Although both immunologic and non-immunologic mechanisms we considered to play a role in development of neuropathies, further investigations were still required to accurately understand the underlying mechanism

bibliometric study of epidural anesthesia: a 24-year review

After introduction of epidural anesthesia [EA] in the early 20[th] century, it has become an essential technique in anesthesiology and many physicians consider it the gold standard analgesic technique for major surgeries. As EA has improved anesthesia methods dramatically and aimed to perform a scientometric analysis on this topic. Cross-sectional study Mashad University of Medical Sciences, Iran Articles were retrieved from the Web of Science [ISI] from 1990 to 2013. Intervention[s]: The total number of published items was 4612; subsequent analysis was performed on results considering published items per year, country, funding agency, institution, journal, publication language, and author and subject area. The results were analyzed considering published items per year, country, funding agency and institution, journal, publication language and author. Additionally, subject areas under which the articles were published were evaluated. The primary search yielded 4612 publications; out of these 3200 [69.38%] were original articles. More than half of articles [2466] were published under "anesthesiology" subject. The USA was the leading country in producing articles under this topic and engaged highest collaboration rate with 64 collaborations. It seems that there is an overall increase in total number of articles, citations and highly cited articles about EA during these two decades

case of rhabdomyolysis associated with peginterferon use in chronic hepatitis C

Rhabdomyolysis is a serious clinical condition resulting from release of toxic intracellular materials into the systemic circulation. Multiple factors have been demonstrated to be responsible for this syndrome. However, currently medications and alcohol are considered to be the primary causative agents. To the best of our knowledge there are few reported cases of rhabdomyolysis following prescription of peginterferon alfa-2b in patients with chronic hepatitis. Here, we have reported the case of a 46-year-old male with hepatitis C virus [HCV] infection who suffered an acute onset of generalized myalgia and weakness, with elevated serum creatine phosphokinase [CPK] and lactate dehydrogenase [LDH] levels six months after administration of peginterferon alfa-2b. Considering the clinical picture and laboratory findings, we diagnosed the patient with rhabdomyolysis. Peginterferon alfa-2b and ribavirin were discontinued and intensive intravenous hydration commenced. Within ten days the patient improved significantly after which he was discharged in an appropriate physical condition.

review of the clinical manifestations, pathophysiology and management of opioid bowel dysfunction and narcotic bowel syndrome

Opioids are widely used for the treatment of malignant and non-malignant pains. These medications are accompanied by adverse effects, in particular gastrointestinal symptoms known as opioid bowel dysfunction [OBD]. The most common symptom of OBD is refractory constipation that is usually stable regardless of the use of laxatives. Narcotic bowel syndrome [NBS] is a subset of OBD described as ambiguous chronic pain aggravated by continual or increased opioid use for pain relief. Pathophysiology of these disorders are not definitely disentangled. Some challenging hypothesis have been posed leading to specific management in order to mitigate the adverse effects. This article is a review of the literature on the prevalence, pathophysiology and management of OBD and NBS.

survay case of pylephlebitis associated with diverticulitis

Pylephlebitis was a rare condition with high rates of morbidity and mortality. It is defined as thrombosis of the hepatic and portal veins that complicates intra-abdominal infections, however prompt diagnosis plays a significant role in the treatment of pylephlebitis and the disorder can be diagnosed by means of ultrasound or contrast tomography, it was often missed due to nonspecific clinical presentation including fever, abdominal discomfort and fatigue. When it came to treatment, despite controversies about the use of anticoagulants, administration of antibiotics and anticoagulants was still the mainstay of treatment. In this report, we described a 67-year-old man with chief complaint of bouts of high fevers and mild abdominal tenderness located in right lower quadrant. The patient suffered from pylephlebitis secondary to cecal diverticulitis. Our patient's symptoms did not resolve with antibiotic therapy thus he had surgical resection of the infection focus and received anticoagulation. To put in a nutshell, as early diagnosis and treatment are essential steps for proper management of pylephlebitis and preventing its adverse complications, it is of high importance to keep this differential diagnosis in mind in patients with abdominal sepsis sings

Menetrier's disease presenting with ulcerative colitis: a case report and review of the literature

Menetrier's disease or hypertrophic gastritis is a premalignant rare disease that often presents with hypertrophy in the gastric folds, hypoalbuminemia and decreased acid secretion. There are a few papers worldwide that report concomitant Menetrier's disease and ulcerative colitis [U. C], however none are from Iran. This is the first case reported in Iranian literature. The pathogenesis of this coexistence is unknown. We report the case of a 28-year-old woman with intermittent bilateral edema of the lower extremities, weight loss and epigastric pain associated with chronic intermittent diarrhea and one episode of nocturnal dysentery. Paraclinical evaluations showed hypoalbuminemia, low serum protein level, severe 25 OH vitamin D deficiency, a positive Helicobacter pylori urea breath test and negative cytomegalovirus [CMV] IgM antibody. Histologic, radiologic and endoscopic findings were consistent with Menetrier's disease associated with U. C. The patient was prescribed mesalazine, asacol suppositories and pantoprazole. During a follow up visit the patient noted improvement in her symptoms. She was referred to a surgeon to discuss additional possible therapeutic treatments

Gender Role in Irritable Bowel Syndrome: A Comparison of Irritable Bowel Syndrome Module (ROME III) Between Male and Female Patients

BACKGROUND/AIMS: Irritable bowel syndrome (IBS) is a widespread chronic health condition which is significantly more prevalent in women. We conducted a gender difference analysis by comparing findings of men and women to determine whether any significant differences exist or not. METHODS: This single-center study was conducted in Tehran, Iran during 2009-2010. IBS was diagnosed on the basis of Rome III criteria. A simple "10 point" objective questionnaire was used. RESULTS: A total number of 144 IBS patients including 44 (30.6%) males and 100 (69.4%) females with the mean age of 37.50 +/- 11.50 years, were assessed. The only differently observed symptom was nausea which was significantly more prevalent in females (49% vs 18.2%, P < 0.001). The commonest subtype of IBS in male patients was diarrhea predominant IBS (38.6%); while, constipation predominant IBS was the most frequent type among females (38%). Moreover, the frequency of loose, mushy or watery stools within the last 3 months was significantly higher among males (2.11 +/- 1.67 vs 1.37 +/- 1.50, P = 0.009). CONCLUSIONS: We report that gender is important in IBS. Although qualitative comparison of different subtypes of IBS between male and female failed to meet the statistically significant level, the answers to the corresponding questions of ROME III IBS module suggest the higher prevalence of bowel movements and looser stool in males. Moreover, nausea was reported more often by females.

Hemodynamic response to tracheal intubation via direct laryngoscopy and intubating laryngeal mask airway [ILMA] in patients undergoing coronary artery bypass graft [CABG]

A marked stress response including hypertension, tachycardia, arrhythmias and an increase in intracranial pressure often follows direct laryngoscopy. This response can be harmful specially in patients with underlying cardiac disease. The intubating laryngeal mask airway [ILMA]-a new modified laryngeal mask airway-has been introduced that facilitates tracheal intubation without using laryngoscopy. Oropharyngeal stimulation-proposed as the probable cause of stress response-have been shown to be attenuated in ILMA. We conducted this study to evaluate the stress response following two techniques in patients undergoing coronary artery surgery which are most likely to benefit from decreased hemodynamic changes during intubation. In this trial, eighty patients, forty in ILMA group and forty in DL group were involved. To determine hemodynamic response during these manipulations, blood pressure [BP] and heart rate [HR] were recorded before and after anesthetic induction [one minute before and one, two and five minutes after successful intubation via either method]. A significant increase in heart rate and blood pressure was detected in both groups after intubation. Despite existence of noted changes in both groups; quantity of these changes was similar in both groups, however quality of changes was not completely similar. Finally we could hardly ascertain if intubation with ILMA is a prefered method in patients with high cardiac risk or not. But it seems that ILMA does not have much greater benefit over conventional DL in patients undergoing coronary artery by-pass grafting