Appendicitis in pregnancy: an ongoing diagnostic dilemma.

INTRODUCTION: Appendicitis in pregnancy (AIP) is the most common nonobstetric cause of an acute abdomen requiring surgical intervention. Diagnostic difficulties arising from gestational symptoms compound the risk of foetal loss after negative appendicectomy and exponentially increase the risk to mother and foetus with delay in genuine cases. In this article, we investigate the symptoms and signs of AIP and attempt to identify consistent clinical features and review the role of imaging in diagnosis. METHOD: MEDLINE and PubMed were searched for case-control studies recording preoperative symptoms/signs suggestive of AIP, as well as appendiceal pathology. Combined likelihood and odds ratios (OR) were created for clinical features across homogenous papers. Papers examining the use of laparoscopy, ultrasound (US), computerized tomography (CT) and magnetic resonance imaging (MRI) were assessed qualitatively. RESULTS: Seven papers met the inclusion criteria for the analysis of consistent clinical features (450 patients). The only symptoms or signs significantly associated with a diagnosis of appendicitis were nausea (OR: 2.21, 95%CI: 1.34-3.66), vomiting (OR: 0.82-15.6 range) and peritonism (OR: 1.80, 95%CI: 1.06-3.04). US, CT and MRI have all been used to successfully diagnose AIP. Laparoscopic appendicectomy has been safely undertaken in pregnancy. CONCLUSION: Appendicitis will continue to challenge the diagnostic acumen of surgeons. Whilst useful, consensus regarding the safety of laparoscopy, CT and MRI in pregnancy is yet to be achieved.

Herniography (peritoneography) for diagnosis of Spigelian hernia.

BACKGROUND: Spigelian hernia is a rare clinical condition. It is difficult to diagnose in absence of obvious clinical signs. Ultrasound scan, cross-sectional imaging and contrast studies like herniography have been widely used for detecting occult abdominal wall hernias in symptomatic patients. AIM AND METHODS: We present our experience of detecting a clinically occult Spigelian hernia in a 56-year-old symptomatic male patient, who had concomitant left sided inguinal and Spigelian hernias. In this patient, the Spigelian hernia was not detected on ultrasound scan. We also present a review of literature on the role of herniography in the diagnosis of this rare condition. RESULTS AND CONCLUSION: Herniography is a sensitive investigation for evaluation of occult hernias. However, it is an invasive contrast study and therefore must be used selectively. Non-invasive real-time imaging like ultrasonography remains the first line of investigation for detecting occult hernias.

Bile peritonitis due to intra-hepatic bile duct rupture.

Generalized biliary peritonitis is a serious intra-abdominal emergency. Most of them occur due to duodenal ulcer perforation and rapidly evolve into bacterial peritonitis due to contamination by gut organisms and food. In this situation, recognition of the pathology and its treatment is straightforward and is usually associated with a good outcome. There are a few unusual causes of biliary peritonitis, of which rupture of the biliary tree is one. We describe a rare case of biliary peritonitis due to rupture of an intra-hepatic biliary radical. Unusual causes of peritonitis do interrupt our daily routine emergency surgical experience. Rapid recognition of the presence of peritonitis, adequate resuscitation, recognition of operative findings, establishment of biliary anatomy, and performance of a meticulous surgical procedure resulted in a good outcome.

Thoracoscopic management of thoracic duct injury.

Thoracotomy has long been the conventional surgical approach in dealing with chylothorax due to thoracic duct injury which has been refractory to conservative treatment. The development of thoracoscopic access provides an alternative means of dealing with thoracic duct injuries thereby reducing the morbidity from thoracotomy and prolonged chylous leak. It will encourage earlier intervention in thoracic duct injury.

The prognostic significance of the accumulation of p53 tumour-suppressor gene protein in gastric adenocarcinoma.

We have studied the expression of p53 in 206 patients with gastric adenocarcinomas. A standard immunohistochemical technique employing the CM-1 anti-p53 polyclonal antibody was applied to the routinely fixed and paraffin-embedded material from these tumours; overexpression of p53 was defined as positive nuclear staining: 46% (94/206) of gastric carcinomas expressed high levels of p53. There was no significant correlation between p53 positivity and the tumour grade, growth pattern, the Lauren type or lymph node metastases. Correlation with disease stage was only marginally significant (P = 0.05). Life table analysis revealed a highly significant association between p53 expression and survival (P = 0.0062), the odds ratio of death being 1.89 (95% confidence interval 1.33-2.69). The overall 5-year survival of patients with p53-positive tumours was 3% compared with 16% for those with p53-negative tumours (median survival time being 5.6 and 11.4 months respectively). These data suggest that overexpression of the p53 oncoprotein is an independent marker of shortened survival in gastric cancer patients.

Immunoscintigraphy of primary colorectal cancers with indium-111 monoclonal antibody B72.3.

Immunoscintigraphy with CYT-103, an 111indium-labelled immunoconjugate of B72.3, was evaluated in 10 patients before surgery for suspected or biopsy-proven primary colorectal cancer. The imaging results were compared with computed tomography (CT) findings at surgery, histopathology and immunohistochemistry. There were no adverse reactions following the administration of 1.0 mg 111In-CYT-103. Surgical and pathological findings identified 15 sites of disease (10 primary and five metastatic) and all but one lesion (severe dysplasia) were malignant. CT detected nine of 14 sites of malignancy compared to 12 as identified by immunoscintigraphy. It failed to detect two primary lesions and one case of peritoneal metastasis, all of which were imaged by CYT-103. Both imaging modalities failed to detect two of three cases with lymph node metastases and the dysplastic lesion (true negatives). The results indicate that 111In-CYT-103 imaging exhibits high sensitivity and specificity in the detection of primary and secondary lesions in patients with colorectal cancer.

Enzyme-linked immunosorbent assay for p53 in gastrointestinal malignancy: comparison with immunohistochemistry.

Mutations in the p53 nuclear oncogene occur frequently in a wide spectrum of human malignancies and the mutant protein may prove to be a useful diagnostic or prognostic marker. It can be detected in fixed tissues by immunohistochemistry, but the type of fixative and conditions of fixation used can introduce variability. For routine clinical use, a method of analysis which is more easily standardized would, therefore, be of benefit. A two-site enzyme-linked immunosorbent assay (ELISA) was used to measure the level of p53 protein in soluble extracts from 20 gastrointestinal cancers (11 colonic, nine gastric). Immunohistochemistry was also performed on the paraffin-embedded sections of these tumours and the results of the two assays were compared. ELISA detected p53 at various levels in 10 cases, all of which were also positive by immunohistochemistry. Of the other 10, eight were immunohistochemically negative but two were positive. When the immunohistochemically positive specimens were ranked by scoring the degree of staining, there was a highly significant correlation with the quantitative ELISA results. Our study shows that the ELISA is sensitive and highly specific. It offers an alternative and simple method of assessing the p53 status in human tissues.

Expression of p53 protein in normal, dysplastic, and malignant gastric mucosa: an immunohistochemical study.

Mutations in the p53 nuclear oncogene are the most frequent genetic abnormalities encountered in human malignancies. Using the polyclonal antibody CM-1, we have examined the expression of the p53 oncoprotein immunohistochemically in archival material of normal, dysplastic, and malignant gastric mucosa. Abnormal expression of this protein was not observed in biopsies of normal gastric tissue (n = 30) but was detected in 22 of the 36 gastric cancers analysed (61 per cent). Nuclear staining was diffuse in 15 of the positive cancer cases, the remaining seven showing a more varied heterogeneous staining pattern. Abnormal p53 protein was not detected in mild (n = 14) or moderate (n = 16) gastric dysplasia but was present in 3 out of 15 severe dysplasia cases. The results suggest that expression of the p53 oncoprotein is a common finding in gastric cancer and occurs as a late event in the malignant transformation process.