Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment.

BACKGROUND: Although lateral sphincterotomy heals chronic fissure in ano in over 90 per cent of cases it is a surgical technique with inherent complications. To avoid such complications, chronic fissure in ano was treated by fissurectomy in this study. To enhance postoperative tissue perfusion allowing stable wound healing, fissurectomy was combined with temporary chemical sphincterotomy by a nitric oxide donor cream. METHODS: Seventeen consecutive patients (ten women) with chronic fissure in ano not responding to conservative management underwent diathermy fissurectomy. After operation patients used a 1 per cent isosorbide dinitrate cream. Postoperative follow-up continued until wounds had healed, at which time anal endosonography was performed. A telephone inquiry into fissure recurrence and continence status was made. RESULTS: Seventeen patients underwent fissurectomy, without postoperative complications. All wounds had healed within 10 weeks. No fissure recurrence was seen after a median follow-up of 29 months. Histopathology showed non-specific scar tissue without signs of internal anal sphincter fibrosis. Postoperative endosonography showed no evidence of new internal sphincter defects. CONCLUSION: In the treatment of chronic anal fissure not responding to chemical sphincterotomy with nitric oxide donors, fissurectomy in combination with isosorbide dinitrate cream may be a sphincter-sparing surgical technique.

Colonisation density and topographic localisation of Helicobacter pylori do not depend on the cagA status.

AIMS: To explore the correlation between the cagA status of Helicobacter pylori and the density and topographic localisation of H pylori. METHODS: Gastric antral biopsy specimens were taken from 716 consecutive patients, including 293 H pylori positive patients (124 men, 169 women; mean age, 52.6 years; range, 12-87). A serum sample was taken for determination of IgG anti-CagA antibodies (sensitivity of 94.4% and specificity of 92.5%). The density of H pylori was assessed semiquantitatively (grades I-IV) in biopsy specimens stained with the modified Giemsa stain. Topographic localisation was classified as follows: score A, H pylori closely attached to the mucosa; score B, H pylori attached to the mucosa and in the mucus; and score C, H pylori solely in the mucus. RESULTS: CagA antibodies were present in 154 (52.5%) of the patients. There was no significant difference in colonisation density and cagA status: grade I, 23 (14%); grade II, 78 (50.6%); grade III, 42 (27.5%); and grade IV, 11 (7.2%) in the cagA(+) strains and 29 (21.2%), 57 (40.8%), 38 (27%), and 15 (11%), respectively, in the cagA(-) strains. There was no difference in topographic localisation between cagA(+) and cagA(-)H pylori. Mean anti-CagA titres were 0.84, 0.84, 0.89, and 0.73 in patients with grades I-IV bacterial density, respectively. CONCLUSION: Antibody titres do not correlate with H pylori density and there is no difference in density between cagA(+) and cagA(-)H pylori strains. In addition there is no difference in topographic localisation between cagA(+) and cagA(-) H pylori strains.

Functional dyspepsia has a good prognosis irrespective of H. pylori status. Long-term follow-up of symptoms after anti H. pylori treatment.

AIM: A prospective study with anti H. pylori therapy was done in patients with functional dyspepsia. METHODS: Inclusion criterion was the absence of any macroscopic abnormality in oesophagus, stomach, and duodenum, irrespective whether H. pylori was present or not. A questionnaire and a symptom score on a five-point Likert scale were used. Antral biopsy specimens were taken for detection of H. pylori. Treatment consisted of omeprazole 20 mg bid and amoxicilline 500 mg tid during 14 days. Patients were followed during 12 months. At follow-up the questionnaire and the symptom score were used. The main endpoint of the study was clinical remission after 1 year of follow-up. RESULTS: In 1 year 163 patients were included (85 men, 78 women, mean age 47 years, range 21-83 years). H. pylori was present in 91 patients. In the H. pylori positive group 38 patients showed a decrease in IgG antibody titre of more than 50% during follow-up of 3-12 months, 26 showed no change or increase following initial decrease. Overall there was no difference in presence or absence of specific complaints at inclusion and final follow-up. The symptom score decreased significantly in all groups (P < 0.001). CONCLUSION: The symptoms of functional dyspepsia improved to a similar extent in both H. pylori positive dyspeptics and the control group. This symptom improvement was irrespective of the change of IgG H. pylori antibodies after therapy.

[Histiocytic necrotizing lymphadenitis; Kikuchi's disease]. / Histiocytaire necrotiserende lymfadenitis; de ziekte van Kikuchi.

The case is reported of a woman aged 26 with painful swelling of the left cervical lymph nodes. These symptoms were preceded by paresthesias and pain at the left side of her body, especially the left leg and the left arm. A lymph node biopsy revealed the diagnosis of histiocytic necrotizing lymphadenitis (Kikuchi's disease). Physical examination and laboratory data showed no other abnormalities. The patient recovered soon without any therapy. The morphological findings are described and a review of the literature is given.

Development and regression of pulmonary arterial lesions after experimental air embolism. A light and electronmicroscopic study.

Repeated systemic venous air embolism produces pulmonary vascular lesions, the nature of which is still a subject of controversy. We investigated the pulmonary arterial lesions produced by repeated air embolism in rabbits, both at light and electron microscopic level. We found that they form a remarkable histopathological entity, consisting of initial pronounced vasoconstriction, combined with severe intimal inflammatory changes. Within 4 days after the last injection of air, peculiar sheet-like structures consisting of oedematous tissue and lined by endothelium, projected into the lumen. These structures probably resulted from the shearing stress of the blood, streaming over the severely oedematous intima. They subsequently became thinner and disappeared after two weeks. Various types of blood-borne and mesenchymal cells were present in the thickened intima and within the sheets. The origin of the latter cells remained undecided. They may originate from medial smooth muscle cells penetrating the internal elastic lamina as well as by transition from blood-borne cells into mesenchymal cells, or both.

A case of pre-eclampsia arising in the fourth pregnancy.

A case of severe pre-eclampsia, with histologically proven eclamptogenic glomerulopathy, appearing in the 32nd wk of the 4th pregnancy is presented. During 'conservative' management with bed-rest and sodium restriction, further deterioration of circulation took place. The results are described of treatment with a combination of a peripheral-acting antihypertensive drug and volume expansion, whereby the fetus could remain in utero until sufficient maturation of the respiratory system could be proven.

Hydramnios with hydrops fetalis and disseminated fetal neuroblastoma.

A white primigravida with acute toxemia and hydramnios delivered a hydropic male infant who died. A neuroblastoma of the right adrenal gland was found with metastic spread to the liver and other organs. The placental capillaries contained tumor cells. Pathogenesis of hydrops, hydramnios, and maternal toxemia and the consequence of tumor cells in the placenta are discussed.

The ultrastructure of the various forms of pulmonary arterial intimal fibrosis.

Intimal fibrosis of muscular pulmonary arteries may present in various forms and in varying degrees of severity according to the underlying condition. In patients with pulmonary hypertension, the type of initimal fibrosis is often significant with regard to prognosis and reversibility. For these reasons we have studied the ultrastructure of the thickened intimal layer in aged individuals, where intimal fibrosis occurs as a normal age change, and in patients with pulmonary hypertension associated with fibrosis of the lungs, mitral stenosis, chronic pulmonary thromboembolism and plexogenic pulmonary arteriopathy (either primary or secondary to congenital cardiac defects). In all these forms of intimal fibrosis, the cellular component of the subendothelial intimal layer was apparently almost exclusively the smooth muscle cell. The cells usually had a haphazard arrangement. In primary and secondary plexogenic pulmonary arteriopathy, however, there was a more regular circumferential arrangement. The ultrastructural evidence suggested that the intimal cells were derived from medial smooth muscle cells.

Pneumothorax in the Ehlers-Danlos syndrome: consequence of coincidence?

A 25 year-old man, known to suffer from Ehlers-Danlos syndrome, developed a left-sided pneumothorax. At thoracotomy, pulmonary blebs and bullae were found at the apex of the lung. Bullectomy with removal of adjacent lung tissue was performed. The histological and ultrastructural findings in the lung tissue must be regarded as non-specific. These findings do not reflect a direct cause-and-effect relationship, even in the presence of the inheritable connective tissue disorder.

Renovascular hypertension as a cause of cerebrovascular accident in childhood: a case report.

Report on a 10 year-old boy with acute hemiplegia after an ischemic cerebrovascular accident, provoked by an unilateral renovascular disease with malignant hypertension, for which nephrectomy was carried out. The few publications pertinent to cerebrovascular complications in children with hypertension and the value of comprehensive diagnostic operations, are the basic motives for this report.

Cardiac manifestations of Fabry's disease. Report of a case with mitral insufficiency and electrocardiographic evidence of myocardial infarction.

The light and electron microscopic findings in the heart of a patient with Fabry's disease are described. The study revealed that all cardiac tissues, including the conducting tissues and the valves, were involved. The latter finding was of particular interest since the patient was known to have mitral insufficiency. The findings of diffuse ballooning of the mitral valve with localized "overshoot" and massive glycolipid storage in the valve substance suggest that the abnormal storage process was itself responsible for the valvular insufficiency. The widespread involvement of the myocardium and conducting tissues is consistent with the elelctrocardiographic changes indicating infarction, although myocardial necrosis was not observed. The findings in this case suggest that the cardiac manifestations in Fabry's disease can be either primary, that is, directly related to the enzyme deficiency, or secondary, that is, evolving with time as a consequence of the disease.