Relative value of clinical, laboratory and imaging tools in diagnosing pediatric acute appendicitis.

OBJECTIVE: Aim of the study was to evaluate the relative value of the tools used to diagnose suspected acute appendicitis (AA) in children. METHODS: A retrospective review of data from 1 848 children admitted to the Pediatric Surgery Department between 2004 and 2008 in our university-affiliated medical center was conducted. A total of 780 children underwent appendectomy at first presentation. Of these patients, 75 children required removal of their appendix during laparotomy for other reasons and 19 had appendectomy following peri-appendicular abscess and were excluded from the study. The study included 686 children (2-16 years of age) with presumed AA managed by appendectomy. Clinical, laboratory, and imaging data were collected and compared to pathology results. RESULTS: Of the 686 children who underwent surgery for suspected AA, 34 (5%) had a normal appendix (negative appendectomy rate). No statistical differences were found between normal and AA groups with regard to vomiting, diarrhea, pain duration, and peritoneal signs on admission. Children in the AA group were younger (10.9±3.2 vs. 12.1±2.3 years, p=0.004), had higher fever (36.9±0.7°C vs. 37.4±0.8°C, p=0.004), WBC (14.8±4.8 vs. 10.5±4.6×103/mL, p<0.0005), and neutrophil counts (77.2±11.1% vs. 64.0±15.9%, p<0.0005) on admission, and larger appendicular diameters on ultrasound (US) examination (0.9±0.2 cm vs. 0.7±0.08 cm, p<0.0005). The parameters with the highest positive predictive values for AA were WBC (>10×10 (3)/mL), neutrophil (>66%) count on admission (positive predictive value [PPV]=0.971 and 0.975, respectively), and appendicular diameter on US (>6 mm; PPV=0.968). These 3 parameters combined had a PPV of 0.991. CONCLUSIONS: The results of laboratory tests (WBC, neutrophils) and imaging (US) contributed far more than clinical signs and symptoms (pain duration, vomiting, diarrhea, fever, and peritoneal signs at first physical examination) to the correct diagnosis of AA in children. When these 3 parameters were positive, the probability of a false positive (normal appendix) was only 1%. The contribution of US was particularly high as it was used primarily in patients in whom the diagnosis was in doubt and its results matched the final diagnosis better than diagnoses based on clinical signs and symptoms alone. It provides the additional benefit of no radiation exposure.

Massive upper GI bleeding: a rare complication of Zenker's diverticulum.

Bleeding from a Zenker's diverticulum is rare. A 71-year-old man was urgently admitted with massive hematemesis. It was known that he had a Zenker's diverticulum, but on emergency endoscopy, the source of bleeding was not detected due to large blood clots in the esophagus, hypo-pharynx and also into the tracheal-bronchial tree. Computerized tomography angiography demonstrated a blush of intravenous contrast arising from the diverticulum. The patient was operated upon urgently; the diverticle had a deep ulceration which was the source of the bleeding. The cause of the ulceration is unknown but it is possible that it was caused by the direct effect of an aspirin pill within the diverticle. A similar case with the same conclusion has been published in the past and since the use of aspirin has become common, especially in the elder population, we present this case report to highlight this possible life-threatening complication of Zenker's diverticulum in patients receiving aspirin.

Thoracic sympathectomy and cardiopulmonary responses to exercise.

The purpose was to study the effect of endoscopic thoracic sympathectomy (ETS) for palmar and/or axillary hyperhidrosis on physiological responses at rest, and during sub-maximal and maximal exercise in ten healthy patients (7 females and 3 males 18-40 years old) with idiopathic palmar and/or axillary hyperhidrosis. T2-T3 thoracoscopic sympathectomy was performed using a simplified one stage bilateral procedure. Physiological variables were recorded at rest and during sub-maximal (steady-state) and maximal treadmill exercise immediately prior to and 70 days (+/-7.5, SD) after bilateral ETS. Exercise performance capacity and peak VO(2) were not found to be different following bilateral ETS than prior to the ETS. However, heart rate was significantly reduced at rest (14%), at sub-maximal exercise (12.3%), and at peak exercise (5.7%), together with a significant increase in oxygen pulse (11.8, 12.7, and 7.8%, respectively). The rate pressure product (RPP) was also significantly reduced following the surgical procedure at all three study stages, while all other physiological variables measured remained unchanged. It is suggested that thoracic-sympathetic denervation affects the heart, sweating, and circulation of the respective denervated region but does not affect exercise performance or mechanical/physiologic efficiency, despite a significant reduction in heart rate (both at rest and during exercise). The latter was, most likely, fully compensated by an increase in stroke volume and less likely by an improved muscle O(2) extraction due to more efficient blood distribution, keeping the work-rate and oxygen uptake unaffected.

Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients.

The aim of this study is to report the CT findings in patients proved to have congenital internal hernia (CIH) as a cause of small bowel obstruction (SBO). The CT scans of 11 patients (9 men and 2 women, with ages ranging from 20 years to 95 years (mean 60.7 years), presenting with clinical symptoms and signs of SBO without previous abdominal surgery or trauma, were retrospectively reviewed. In all patients features of SBO were seen. In addition, in nine of them a saclike mass, containing dilated small bowel loops with mesenteric vessels converging toward its orifice was demonstrated and a pre-operative diagnosis of an incarcerated internal hernia was suggested. In the other two, a closed loop obstruction was seen without an identifiable cause. Mural thickening of the entrapped loops within the hernial sac was seen in five patients, with hypoperfusion in four of them, blurring of the mesenteric vessels with localized mesenteric fluid was demonstrated in seven and free peritoneal fluid in 10. All patients were operated on following the CT and an incarcerated CIH was confirmed. Gangrenous bowel was present at exploration in seven cases. One patient died. In conclusion, in patients with intact abdomen and SBO, CT may be the first imaging modality to discover a clinically unsuspected CIH, which requires prompt surgical intervention. Radiologists should be aware of the CT features suggestive of a SBO caused by CIH, i.e. a saclike mass of dilated small bowel loops, as a correct diagnosis will influence patient management and prognosis.

Intraperitoneal heated chemotherapy affects healing of experimental colonic anastomosis: an animal study.

BACKGROUND: The peritoneal spread of cancer is a well-known entity carrying a dismal prognosis. A new therapeutic approach is the combination of cytoreduction with heated intraperitoneal chemotherapy (HIPC). The risk of an intra-abdominal anastomosis in the presence of such chemotherapy is recognized clinically but the experimental data on the subject are lacking. The aim of this study is to examine the influence of chemotherapy and hyperthermia on the healing of colonic anastomosis. MATERIALS AND METHODS: Colonic anastomosis were performed in four groups of male Wistar rats: (1) control (operation only), (2) HIPC with saline, (3) with mitomycin C (MMC), and (4) with cisplatinum. HIPC was performed using a closed circulation system at 40 degrees C over 20 min. Anastomotic strength was tested on day 4, 7, 10, and 21. RESULTS: The bursting pressure of anastomoses in rats treated by HIPC was significantly lower than in controls. On day 4, it was 54.8 mm Hg, 38 mm Hg, 18 mm Hg, and 14.8 mm Hg in groups 1-4, respectively, while on day 7 it was 170 mm Hg, 188 mm Hg, 83 mm Hg, and 19 mm Hg, respectively (P < 0.01). The difference decreased on day 10 and almost vanished on day 21. HIPC with cisplatinum had the worst effect on anastomotic healing during the early postoperative period. CONCLUSIONS: Cytoreduction and HIPC are gaining popularity. However, the use of heated chemotherapy has a detrimental effect on the strength of colonic anastomosis, especially during the early postoperative period (until day 10). This may cause anastomotic failure and postoperative morbidity. Therefore, careful selection and avoidance of unnecessary anastomoses are mandatory.

Small bowel obstruction secondary to Crohn disease: CT findings.

We investigated the computed tomographic (CT) findings in patients with small bowel obstruction (SBO) and Crohn disease (CD). Fourteen patients, seven men and seven women (mean age, 41.3 years), were retrospectively reviewed. All presented with clinical symptoms and signs of SBO. Eleven had a history of CD, whereas three experienced the bowel obstruction as the first manifestation of the disease. On CT, features of complete SBO were seen in nine patients, whereas incomplete obstruction was found in the other five. One patient had CT findings of an adhesive obstruction. The other 13 were diagnosed as having CD-related SBO; a markedly stenotic bowel segment caused the obstruction in one patient, and a thickened-wall small bowel segment with luminal narrowing was evident at the transition zone in the other 12. The mural thickening had a target appearance in seven and homogeneous thickening in the other five. Additional thickened bowel segments were found in five patients and mesenteric involvement was found in 10. Five patients were treated conservatively, and the other nine underwent surgery (one with adhesiolysis only). Resection of the stenotic bowel was performed in six patients and stricturoplasty was done in the other two, with associated intestinal biopsy in one of these two patients. Histopathology revealed findings of active on chronic disease in all. CT is frequently performed for suspected SBO, so radiologists should be aware of the diagnosis of CD, because SBO may be its first manifestation. Alternatively, radiologists can accurately diagnose a CD-related obstruction in a patient with known CD and differentiate it from an obstruction due to adhesions. Patient management in these cases, however, is based most often on the clinical condition.

Mesenteric and portal vein gas: computerized tomography findings and clinical significance.

BACKGROUND: Gas in the mesenteric or portal veins (PVG) is an uncommon entity. It was first described only in patients with mesenteric ischemia and bowel gangrene. Later, several reports described other causes for PVG in which conservative treatment was successful. In the past, the diagnosis was made by vague signs in abdominal plain films. Since the era of computerized tomography (CT) scan the diagnosis became more objective, but nevertheless it is still an elusive entity. Our objective was to relate clinical and CT findings with outcome of patients with PVG, and to determine the indications for surgical treatment. METHODS: Six-year records of patients from one general hospital with CT scan findings of gas in the mesenteric or portal veins were retrospectively studied, together with details of the clinical presentation, hospital course and outcome. RESULTS: Between 1995 and 2000, 12 patients with findings of mesenteric and portal vein gas were identified. In 7 of 12 patients (58%) PVG developed secondary to ischemia of the small or large bowel, with mortality of 86%. Metabolic acidosis was the prominent laboratory finding. Pneumatosis intestinalis was present in all of these patients. Two patients with PVG had inflammatory bowel disease and both recovered with conservative management. Another 2 patients who were treated conservatively died. One patient had severe pancreatitis and died 2 weeks after PVG was diagnosed, from septic complications, while the other patient admitted with septic shock, died of multiorgan failure. In the last patient, PVG was diagnosed in a CT scan performed to investigate fever of unknown origin. She survived with no specific treatment. CONCLUSION: We suggest that patients in whom PVG is found by CT scan should be treated according to their clinical status, and underlying disease. Patients suspected of having an ischemic mesenteric event should be immediately explored.

[Acute colonic pseudo-obstruction].

Colonic Pseudo-obstruction is a poorly understood syndrome. It was first described by Ogilvie in 1948 and is characterized by signs of large bowel obstruction with a non-mechanical etiology. The suggested cause of this pathophysiology is an imbalance in the autonomic nerve supply to the colon. The syndrome affects mainly old, bedridden patients, usually hospitalised for non-colonic causes. The actual incidence of this syndrome is unknown, mainly due to the fact that spontaneous recovery may occur. When massive abdominal distention is apparent, diagnosis and treatment are usually problematic and other causes of obstruction must be ruled out. It is usually managed by water soluble contrast administered orally or rectally, or by colonic decompression. In extreme cases surgical treatment is required with significant morbidity and mortality. Pharmacologic management with parasympathomimetic drugs has been suggested recently. We describe the successful treatment of a patient with neostigmine and review the current literature.

A pilot study of a long acting somatostatin analogue for the treatment of refractory rheumatoid arthritis.

OBJECTIVE: To evaluate the efficacy and safety of a long acting somatostatin analogue in a subset of patients with refractory rheumatoid arthritis (RA). METHODS: Ten patients with active, refractory RA, who had failed to respond to at least four disease modifying antirheumatic drugs (DMARDs), were treated with monthly intramuscular injections of 20 mg of a long acting preparation of octreotide (Sandostatin-LAR) for three months. They were evaluated every two weeks in an open label pilot study. The primary measure of clinical response was the American College of Rheumatology criteria for a 20% improvement in measures of disease activity (ACR 20). RESULTS: Eight patients completed the 14 week trial, while two patients received only one or two doses of the somatostatin analogue, but were eligible for evaluation. On an intention to treat basis 6/10 patients responded: four patients met the ACR 20 criteria at weeks 6-10, while two patients continued to improve with time, and met the ACR 50 and 70 criteria respectively, at week 14. On evaluation of the 10 patients as a group, a significant improvement (p<0.05) was noted in the mean visual analogue scales of pain, doctor's and patient's global assessment of disease activity, and in the mean number of swollen joints. Adverse effects were minor: transient bloating and loose stools, an urticarial rash (n=1), and a transient increase of liver enzymes (n=1). CONCLUSION: Treatment with a long acting somatostatin analogue led to significant clinical improvement in a subset of patients with active, refractory RA. The treatment was relatively safe and well tolerated. Further large, placebo controlled studies are required to evaluate this drug as a potential DMARD for patients with RA.

Experimental acute necrotising pancreatitis: evaluation and characterisation of a model of intraparenchymal injection of sodium taurocholate in rats.

OBJECTIVES: To evaluate a simple model that produces progressive dose dependent pancreatitis, by intraparenchymal injection of sodium taurocholate. DESIGN: Open laboratory study. SETTING: Teaching hospital, Israel. MATERIALS: Forty eight Wistar rats. INTERVENTIONS: Sodium taurocholate was injected, 0.3 ml/100 g body weight, in concentrations of 5% and 10% into the pancreatic parenchyma of 32 Wistar rats, resulting in two distinct groups of severity. In 16 sham controls, saline was injected into the pancreas in similar fashion. Blood samples were withdrawn before, and 6, 24, 48, and 72 hours after induction of pancreatitis. RESULTS: Six hours after taurocholate injection, there was a sharp increase in the plasma activities of amylase, lipase, and lactate dehydrogenase (LDH). After 24 hours plasma activities of amylase and lipase decreased to near normal values while LDH remained slightly increased for 48 hours and decreased only after 72 hours. At 6 hours after the injection, interleukin-6 (IL-6) concentrations had increased slightly in the 5% group and decreased to the baseline values at 24 hours. In the 10% group, the increase in IL-6 values was significantly greater than in the 5% group (p = 0.04), and correlated well with severity of pancreatitis as defined by histology (p = 0.01) and mortality (p = 0.037). Twenty four hours after injection of taurocholate, morphological changes comprising diffuse necrosis of the pancreas, fat necrosis, and intestinal dilatation secondary to paralytic ileus were severe. Histopathological examination of the pancreas showed good correlation with the clinical findings and with mortality. No morphological changes were detected when saline was injected into the pancreas (sham control), and only mild rises of IL-6, lipase, amylase, and LDH activities were seen at 6 hours after injection. The mortality, after 10 days, was 80% in the 10% taurocholate group, 30% in the 5% taurocholate group, and 0 in the sham control group (p < 0.05). CONCLUSION: The intraparenchymal injection of taurocholate is easy to perform and highly reproducible. The histopathological injury is dose-dependent, as is the mortality. We conclude that this model is valuable for the study of new treatments for pancreatitis.

Treatment of acute colonic pseudo-obstruction with neostigmine.

BACKGROUND: Colonic pseudo-obstruction is a poorly understood syndrome, described by Ogilvie, and characterized by signs of large-bowel obstruction, without a mechanical cause. An imbalance in the autonomic nerve supply to the colon has been suggested as the pathophysiology. Recently, promising results with pharmacologic manipulation with neostigmine have been described. STUDY DESIGN: A prospective study was undertaken with 11 consecutive patients with clinical and radiologic signs of colonic pseudo-obstruction, in one general hospital, over a 1-year period. Patients were treated primarily with 2.5 mg of neostigmine in 100 mL of saline for 1 hour, under cardiac monitoring. Results were assessed by the clinical and radiologic responses. RESULTS: Rapid and effective spontaneous decompression of the colon was achieved in 8 patients after a single dose of neostigmine, within a mean of 90 minutes from the beginning of treatment. In another two patients decompression occurred only after a second dose was administered 3 hours after the first dose. In one patient, no changes were observed and colonoscopic decompression was performed. No significant bradycardia was observed in any of the patients. CONCLUSIONS: Neostigmine is a simple, safe, and effective therapy for treatment of colonic pseudo-obstruction.

Octreotide treatment in patients with severe acute pancreatitis.

We investigated the effect of octreotide in the treatment of severe acute pancreatitis in a case-control study. Experimental and clinical studies on the effect of octreotide in the treatment of acute pancreatitis have shown controversial results. Since January 1992, we have been conducting a prospective randomized study on the effect of octreotide in severe acute pancreatitis, in three hospitals in Israel. The entering criteria included three or more of the Ranson prognostic signs and CT findings of severe pancreatitis. Patients were randomly assigned to conservative treatment either with or without octreotide (0.1 mg subcutaneously three times a day). The end points of the study included: complication rate (ARDS, sepsis, renal failure, pseudocyst, fistula, and abscess), length of hospital stay, and mortality. From January 1992 to December 1996, 60 patients entered the study. After evaluating the files, 10 patients were excluded due to failure to meet the entering criteria, incomplete data, or incorrect diagnosis. Of the remaining 50 patients, 25 were assigned to octreotide (treatment group) and 25 to conservative treatment only (control group). The two groups matched with regard to age, sex, etiology, and severity of the disease. The complication rate was lower in the treatment group with regard to sepsis (24% vs 76%, P = 0.0002) and ARDS (28% vs 56%, P = 0.04). The hospital stay was shorter in the treatment group (20.6 vs 33.1 days, P = 0.04). Two patients died in the treatment group and eight in the control group (P < 0.019). These results suggest that octreotide may have a beneficial effect in the treatment of severe acute pancreatitis.

[Laparoscopic cholecystectomy--1,000 procedures in a surgical department].

The first 1,000 laparoscopic cholecystectomies performed in our department were reviewed. There was no operative mortality; conversion to open cholecystectomy was necessary in 2%. In the last 600 cases the rate of conversion had decreased to 0.5%. There was common bile duct injury in 0.3%, with the injuries identified during primary surgery. This clinical experience is consistent with previous studies, which proved that laparoscopic cholecystectomy is safe and should replace open operation as the procedure of choice.

Enema-induced perforation of the rectum in chronically constipated patients.

INTRODUCTION: The use of retrograde irrigation enemas is common in the treatment of chronic constipation, especially in the elderly. Perforation of the rectum and sigmoid colon caused by cleansing enemas, used by chronically constipated patients, has not been previously described. METHODS: We reviewed all patients with colorectal perforations caused by irrigation enemas admitted to our service in the three-year period between January 1995 and December 1997. RESULTS: Thirteen patients were treated by our surgical service because of perforations of the rectum and sigmoid colon related to a previous retrograde irrigation enema. Ten of these patients came from nursing homes, and the other three lived at home. The relevant information relating the enema administration to the patient's condition was given in only two of the ten patients referred to the emergency room by the institution's nursing or medical staff. In the other eight the information was vague and sometimes misleading. The diagnosis of colorectal perforation was made by history, plain abdominal x-rays, and CT scan with or without meglumine diatrizoate enemas. Ten patients survived, regardless of age, previous diseases, or operative findings. In all of them, diagnosis was made within 36 hours from the perforation. The three deaths occurred in patients in whom the diagnosis was made late. CONCLUSIONS: Awareness of the possible injury from enemas administered to chronically constipated patients should be stressed. A high degree of suspicion by the attending physician is extremely important, because prompt diagnosis and early surgical treatment carries a relatively good prognosis.

Effect of the somatostatin analogue octreotide on experimental pancreatitis in rats.

Somatostatin and its analogue octreotide have a profound inhibitory effect on the endocrine and exocrine secretions of the pancreas, stomach, and small intestine. Previous studies have been inconclusive about the possible therapeutic effect of somatostatin and its analogues in the treatment of pancreatitis. This study assessed the effect of the long acting somatostatin analogue, octreotide, in two models of experimental pancreatitis in rats. Necrotizing pancreatitis was induced by pancreatic injection of 5 ml taurocholate, 5% in male Wistar rats. In a second model mild edematous pancreatitis was induced by intravenous injection of caerulein at a supramaximal dose, 6 micrograms/kg/hr, for 5 hr. Compared to untreated rats, treatment with octreotide either prior to or following the induction of necrotizing pancreatitis resulted in less hypocalcemia (P < 0.05) and acidosis (P < 0.05), and prevented the increase in pancreatic weight (P < 0.05). Amylase levels remained high. After 20 days, there was less pancreatic damage, lower mortality rates (P < 0.05), and increase in body weight (P < 0.05). In the model of milder pancreatitis, octreotide treatment attenuated the increase in pancreatic weight (P < 0.05) and pathological damage (P < 0.05). We concluded that the somatostatin analogue octreotide has a beneficial effect in the treatment of experimental acute pancreatitis.