Distinct sonographic features of acute appendicitis in sickle cell disease.

BACKGROUND AND OBJECTIVES: The purpose of this study was to report sonographic findings of appendicitis in patients with positive screening tests for sickle cell compared to normal control patients. DESIGN AND SETTING: A retrospective study of the medical records of 396 patients who underwent appendectomy during a 3-year period from March 2005-2008. PATIENTS AND METHODS: The study included 216 males and 180 females, whose ages ranged from 7 to 55 years. Four patients (0.9%) had sickle cell disease (SCD), 101 had sickle cell trait (SCT) (25%) and 291 (74%) patients were without sickle cell anemia (control group). RESULTS: Positive sonographic findings of appendicitis were identified in 95 (90%) SCT patients and in 253 (87%) control patients. The mean maximal mural thickness was higher in sickle cell patients (4.5 [1.4] mm) in comparison with the control group (3.0 [2.2] mm) (P < .0001). Appendicolith was significantly detected in 53% of the control group and in 8.5% of the sickle cell group (P < .0001). Color Doppler showed hypervascularity in 72% of patients with appendicitis in the control group with a significant difference compared to only 12 cases (11%) of SC patients (P < .05). Ultrasonography findings suggesting perforation were found in 35 sickle cell patients and in 75% (3 of the 4 patients) with SCD. Findings suggesting perforation were found only in 49 patients (17%) of the control group. Perforated appendix was significantly higher in sickle cell patients in preoperative US and intraoperatively (P < .05) CONCLUSION: Positive sonographic findings of appendicitis in sickle cell patients are different from the general population. These findings include mural thickening with a low incidence of appendicolith and wall hypervascularity. Also sonographic features of perforation in sickle cell patients are more common suggesting a need for more urgent operative intervention.

Submucosal lipoma acting as a leading point for colo-colic intussusception in an adult.

Intussusception in adults is a rare condition, in contrast to paediatric intussusception where the majority of cases are idiopathic, ∼90% of adult cases have identifiable aetiology. The clinical presentation is often non-specific abdominal pain. We report the case of a 49-year-old gentleman who presented to our emergency department with a 10-day history of colicky abdominal pain. Computed tomography imaging revealed a lipomatous mass lesion in the transverse colon leading to intussusception. An extended right hemicolectomy was performed with a good result. Histology confirmed that the leading point of the intussusception was a large submucosal lipoma. Gastrointestinal lipomas are rare and largely asymptomatic. However, they may cause abdominal pain, bleeding per rectum, obstruction or intussusception. Since adult colonic intussusception is frequently associated with malignant organic lesions, the differential diagnosis is important, and timely surgical intervention paramount.

Unusual cause of a painful right testicle in a 16-year-old man: a case report.

INTRODUCTION: Urgent surgical exploration of the scrotum of a child or teenager who presents with a painful and swollen testicle is paramount if testicular torsion is not to be missed. It is extremely rare for a non-scrotal pathology to present with acute scrotal signs. Here we present such a rare case and emphasize the importance of being aware of this potential clinical pitfall. CASE PRESENTATION: A 16-year-old Caucasian man presented as a surgical emergency with a five to six hour history of a painful, red, and swollen right hemiscrotum. He also complained of vague lower abdominal pain, vomiting, and watery diarrhea. He had a temperature of 38.5°C and a tender, red, and swollen right hemiscrotum. The right testicle appeared elevated. He was mildly tender in his central and upper abdomen and less so in the lower abdomen. No convincing localizing abdominal signs were noted. He had an increased white cell count (15 × 109/L) and C-reactive protein (CRP; 300 mg/L). Urgent right hemiscrotal exploration revealed about 5 ml of pus in the tunica vaginalis and a normal testicle. A right iliac fossa incision identified the cause: a perforated retrocecal appendix. Appendectomy was performed, and both the abdomen and scrotum washed copiously with saline before closure. The patient made an uneventful recovery. CONCLUSION: Acute appendicitis presenting with scrotal signs due to a patent processus vaginalis is an extremely rare clinical entity. To date, fewer than five such cases have been reported in the medical literature. It is, therefore, extremely important to be aware of this unusual clinical scenario, as only a high index of suspicion will enable prompt, successful management of both the appendicitis and the scrotal abscess.

Use of hand held Doppler to identify venous tributaries in in situ vein arterial bypass.

BACKGROUND: It very important to reduce the morbidity associated with arterial bypass surgery by minimizing the length of incision used in infrainguinal bypass surgery using in situ vein as a conduit. This paper describes a quick and less invasive method of identifying the location of vein tributaries using Hand Held Doppler in arterial bypass surgery with local cut down instead of extensive exposure. METHODS: The technique was used in 19 consecutive procedures. Fourteen grafts were subsequently evaluated for completeness of tributary ligation using duplex scanning. RESULTS: A mean of 2.5 tributaries were identified per limb. Thus, there were 35 patent tributaries in our cohort of 14 patients. None was of clinical significance. Four occluded spontaneously during the period of study. Wound length was reduced by 30-60% depending on the total length of the incision. CONCLUSION: This technique is an effective, cheap and simple means of performing bypass surgery in high-risk patients (with significant comorbidity and a high ASA score) and also reducing inherent complications associated with the length of the incision.

Bleeding prolapsed hemorrhoids as a presentation of ruptured internal iliac artery aneurysm: report of a case.

Internal iliac artery aneurysms (IIAAs) are rare and their concealed location in the pelvis presents a diagnostic challenge. We report a case of a 79-year-old man who presented 12 years after an abdominal aortic aneurysm repair, with signs of prolapse, bleeding, hemorrhoids, and a deep vein thrombosis. His condition rapidly deteriorated, with the development of acute renal failure and obvious perianal and perineal ecchymoses, within a few days. Abdominal ultrasound and computed tomography showed a ruptured IIAA. His renal function returned to normal after surgical decompression of the aneurysm.

Role of angiotensin II in ischemia/reperfusion-induced leukocyte-endothelium interactions in the colon.

The aims of the present study were to determine the effects and mechanisms of angiotensin II (Ang II) on leukocyte-endothelium interactions and the role of Ang II in a novel model of ischemia/reperfusion (I/R) in the mouse colon. Ang II dose-dependently increased leukocyte rolling and adhesion in colonic venules. Importantly, Ang II-induced leukocyte rolling was completely inhibited by immunoneutralization of P-selectin, and leukocyte adhesion was abolished in lymphocyte function antigen-1 (LFA-1)-deficient mice. The P-selectin-dependent rolling was found to be a precondition for the subsequent LFA-1-dependent leukocyte adhesion. Moreover, Ang II-induced leukocyte responses involved generation of reactive oxygen species and up-regulation of CXC chemokines. Notably, CXC chemokines, but not Ang II, stimulated leukocyte chemotaxis in vitro. I/R increased gene expression of angiotensin converting enzyme (ACE) in the colon and plasma concentrations of Ang II. Inhibition of ACE and the type 1 angiotensin (AT1) receptor significantly decreased the I/R-induced leukocyte adhesion. Taken together, these novel findings demonstrate that Ang II exerts potent pro-inflammatory effects in the colonic microcirculation and that inhibition of Ang II expression or function protects against I/R-induced leukocyte responses in the colon. Thus, it is suggested that Ang II is a major target to control pathological inflammation in the colon.