Eosinophilic colitis.

Eosinophilic colitis is a rare chronic inflammatory bowel condition of unknown etiology. We report a case of cecal volvulus causing obstruction in a patient with eosinophilic colitis. A 48-year-old lady presented with abdominal pain, constipation, and abdominal distension. Clinically and radiologically, she was diagnosed to have cecal volvulus. Preoperative colonoscopic reduction failed. At laparotomy, a right hemicolectomy with primary anastomosis was undertaken. Histology of the resected specimen showed diffuse eosinophilic infiltration suggesting eosinophilic colitis. To the best of our knowledge, this association has been never reported.

Diaphragm disease of the ileum.

Diaphragm disease is a condition wherein the bowel lumen is divided into a series of short compartments by circular membranes of mucosa and submucosa, leading to a pinhole lumen and subsequent obstruction. It is a very rare condition commonly attributed to non-steroidal anti-inflammatory drugs (NSAIDs) usage. We present two cases of obstruction secondary to diaphragm disease of the ileum diagnosed on histology of the resected specimen. One patient had no history of chronic NSAID intake.

Audit of methods of laparoscopic cholecystectomy.

BACKGROUND: The operation of laparoscopic cholecystectomy began the modern era of laparoscopic surgery. Refinements in technique continue to appear. The techniques currently favoured by British surgeons have been reviewed. METHODS: A questionnaire-based survey was carried out among surgeons with a special interest in minimal access surgery. The data collected were entered into a database and analysed. Current literature relating to surgical technique was reviewed. RESULTS: Many aspects were evaluated and the results have shown that there is no uniform approach. It is interesting that only 30.8 per cent of surgeons use the open (Hasson) technique for peritoneal access. In addition, the use of intraoperative cholangiography continues to vary, with 65.8 per cent using the technique in selected cases. Fascial repair is not undertaken by 12.2 per cent of surgeons. CONCLUSION: Some trends are clearly discernible. There is a greater willingness than previously to perform intraoperative cholangiography, but the consensus seems to be against performing it in all cases. Similarly, British surgeons seem to be largely unimpressed by the dangers of the Veress needle; the Hasson technique has not been widely adopted. The need to prevent port-site herniation seems to be generally accepted, with most surgeons performing fascial repair.

Dissemination of pancreatic carcinoma following endoscopic sphincterotomy.

Endoscopic sphincterotomy (ES) is sometimes advocated for the temporary decompression of an obstructed bile duct by a periampullary tumor. We report a 27-year-old woman with a small carcinoma of the pancreatic head who developed acute pancreatitis and a pseudocyst following ES. At operation, malignant spread was virtually confined to the walls of the resolving pseudocyst cavity. Despite radical resection, she died from recurrent carcinoma 7 months postoperatively.

Injury to the superior mesenteric artery during pancreatectomy for chronic pancreatitis.

Four cases are described of injury to the superior mesenteric artery (SMA) during pancreatectomy for chronic pancreatitis. Review of the literature indicates that this is a rare event. In three patients (arterial ligation, 2; haemorrhage, 1), the injury was immediately recognised and successfully repaired. In the fourth (with probable occlusion of the vessel), the problem was not appreciated at operation and the patient eventually died. Vessels adherent to a pseudocyst are at particular risk of injury, as in two of our patients. Two patients had ectopic origin of the right hepatic artery. Since awareness of such vascular anomalies is important, we now perform selective mesenteric angiography in all patients requiring pancreatic resections, whether proximal or distal.

Swallowed button batteries: is there a consensus on management?

The optimum management of ingested button batteries was ascertained by postal questionnaire sent to 608 members of the endoscopic and paediatric sections of the British Society of Gastroenterology. Some 312 returns were suitable for analysis: 36.2% of the respondents were not concerned about ingested button batteries and gave no treatment, 6.4% used medical treatment, 48.4% removed them under certain circumstances, and 9% did not know how to manage the problem. Emetics and H2 antagonists or antacids were often used for batteries in the oesophagus, stomach, and duodenum and laxatives were commonly prescribed for batteries in the small and large bowel. Of the 48.4% who felt batteries should be removed under certain circumstances, 78%, 72%, and 48% extracted them from the oesophagus, stomach, and duodenum respectively within 24 hours of ingestion. The main reason for operative removal from the small and large bowel was failure of the battery to progress. Current management is therefore variable. Heavy metal poisoning may be occurring more frequently than is suggested in the published reports.

Delayed cardiac tamponade following accidental injection of non-ionic contrast medium into the pericardium.

A case of cardiac tamponade developing over 10 hours after accidental injection of 80 ml iohexol (350 mg i/ml) during an intravenous digital subtraction arteriography (DSA) examination is described.

Anticoagulation in abdominal aortic aneurysm surgery: the approach of vascular surgeons in Great Britain and Ireland.

A questionnaire was sent to 283 vascular surgeons in Great Britain and Ireland regarding their use of heparin in elective abdominal aortic aneurysm surgery. The answers form the basis of this study and show that there is great variation. The majority of surgeons routinely anticoagulate their patients peroperatively. Heparin is usually given intravenously--most giving the drug 2 to 3 min prior to cross clamping the aorta. Approximately half of the respondents use the same dose in all patients, whilst the remainder vary the dose, usually on the basis of weight or "size". Most surgeons use 5000 units but the range of dose varies from 400 to 20,000 units. Just under a quarter of surgeons continue to anticoagulate their patients postoperatively, almost all of these using subcutaneous heparin for prophylaxis against deep vein thrombosis. Only approximately 10% of surgeons routinely reverse the heparin with protamine.

Cardiac tamponade: a review of diagnosis and anaesthetic and surgical management illustrated by three case reports.

Cardiac tamponade is an uncommon problem in a district general hospital. Three patients were admitted to the intensive therapy unit at Northampton General Hospital with tamponade in a 7-week period, each with a different underlying aetiology. Their case histories are presented and the management in the light of these described. The aetiology, physiology, clinical signs and investigations leading to the diagnosis are considered. In the discussion the opportunity is taken to review the recent literature on the subject.

Blood flow measurement in the canine pancreas.

Blood flow in the anesthetized animal has been measured indirectly by plethysmography and directly with the stromuhr, venous outflow, and electromagnetic flow techniques. Tissue perfusion in the gland has been assessed qualitatively with thermocouples and quantitatively by isotope fractionation, the distribution of microspheres, hydrogen desaturation, and clearance of either 133Xe or 85Kr. The results of these investigations have been conflicting as there is a large variation in both flow and perfusion measurements, not only overall but also in the values reported by each technique (Table 1). Taking all methods into account flow measurements have been recorded from 9 to 63 (mean 29.8) ml/min, and 10 to 200 (mean 66.1) ml/min/100 g. The mean percentage of the cardiac output distributed to the pancreas is 1.28. Some of these differences are due to various drawbacks associated with each of the techniques; some are almost certainly due to variations in the surgical preparations, and others are undoubtedly caused by the complexity of the pancreatic circulation. Measurements of perfusion in different regions of the pancreas of individual dogs show no difference if all vessels are intact, but accessory vessel ligation affects perfusion in certain areas. In ambulant dogs the studies suggest that pancreatic blood flow is higher than in the anesthetized animal. This is probably true despite inaccuracies associated with each of the techniques. In addition to this drawback there is also the problem of obtaining measurements with the dogs in a relaxed state. It is probably for this reason that the majority of investigators have preferred to examine blood flow and perfusion in the canine pancreas in the anesthetized animal. It is not possible to make a definitive statement regarding the best model and measurement technique available to measure blood flow or tissue perfusion in the canine pancreas. The choice should undoubtedly be governed by the aims of the proposed study. In studies of tissue perfusion in the intact gland, it is obviously preferable that all vessels should be intact, as division of any vessels supplying the gland has been shown to affect perfusion in certain areas. Measurements in such a preparation could be taken using the 85Kr clearance technique, with a flow probe placed around the gastroduodenal artery to ensure stable flow during measurements. It is difficult to assess total arterial blood flow to the whole gland due to the number of vessels supplying the organ.(ABSTRACT TRUNCATED AT 400 WORDS)

Blood flow and perfusion in acute haemorrhagic pancreatitis in the dog.

Experimental evidence suggests that in acute haemorrhagic pancreatitis in the dog the percentage of the cardiac output distributed to the pancreas falls. Histological evidence indicates arteriovenous shunt flow, but this has not been confirmed by flow measurements. It has recently been reported that in experimental preparations in which pancreatic blood flow is measured through the superior pancreaticoduodenal artery after ligation of other (accessory) vessels, perfusion is reduced in distal regions of the gland. There are no data regarding regional perfusion measurements in acute pancreatitis or the effect of ligating accessory vessels. This study therefore evaluates blood flow and regional perfusion in haemorrhagic pancreatitis in various preparations of the canine pancreas. Perfusion was assessed by measuring the clearance of Krypton-85 after injection into the arterial blood supply of the pancreas. Arterial blood flow was measured by the electromagnetic flow technique. The results show that perfusion in different regions of the gland is similar both before and during disease. If accessory vessels are ligated, however, only perfusion in the head of the gland is maintained. No arteriovenous shunt flow was shown. The percentage of the cardiac output being distributed to the gland did not change in any of the experiments; this contradiction to previous reports may arise from the effective control of acid base balance in this study.

Regional pancreatic perfusion. An experimental study in the dog.

Blood flow and perfusion in the canine pancreas have been measured in many experimental models but little attention has been directed to perfusion in different regions of the gland. In some preparations "accessory" vessels have been ligated to allow measurement of flow through one vessel and the effect on perfusion of ligating these vessels is unclear. This study has measured pancreatic blood flow by the electromagnetic flow technique and regional perfusion by the clearance of Krypton-85 (85Kr) in three preparations of the pancreas. Results demonstrate no difference in perfusion between different regions if all vessels are intact. However, following accessory vessel ligation, the tail and part of the body of the gland become macroscopically ischaemic and perfusion in the uncinate process is reduced. This problem was overcome when the head of the gland was isolated as the measurements of both arterial blood flow and perfusion were almost identical; it is therefore the preferred preparation of the gland for measuring blood flow and perfusion.

An evaluation of blood flow and perfusion in the canine pancreas.

This study evaluates pancreatic blood flow in the anaesthetised dog. Total flow was measured with an electromagnetic flowmeter and tissue perfusion using a Krypton-85 (85Kr) clearance technique. Cardiac output was also monitored with an electromagnetic flow probe placed on the ascending aorta. The flow and tissue perfusion in the pancreas were measured before and after devascularisation of the duodenum from the pancreas. The results show that the two techniques give similar values after pancreaticoduodenal devascularisation. If these vessels are left intact, however, electromagnetic measurements overestimate pancreatic flow by approximately 35%. Pancreatic blood flow in the dog is considered to have a normal value of 60-65 ml/min/100 g, or 25 ml/min, approximately 1.7% of the cardiac output being distributed to the gland.

Effects of indomethacin on blood flow in the normal pancreas in conscious dogs.

In anesthetised animals basal pancreatic blood flow, both in the normal gland and in acute pancreatitis, and basal renal blood flow have been shown to be dependent on prostaglandins (PGs). However, in conscious dogs it has been demonstrated that the reliance of basal renal blood flow on PGs is only apparent, and probably due to the effect of anesthesia and surgery stimulating PG synthesis through enhanced stimulation of the sympathetic nervous system. This study was undertaken to investigate the changes in mean blood pressure, cardiac output, and pancreatic arterial blood flow, relative to the cardiac output, in the normal pancreas, with and without PG synthesis inhibition (indomethacin) in conscious dogs. Blood flows were measured with electromagnetic flow probes. The effects of indomethacin were measured over a 2-hr period and compared to a control group. The results show that the relative pancreatic blood flow is not affected by doses of indomethacin which decrease cardiac output (P less than 0.5). It is suggested that PGs may have no effect on blood flow in the normal pancreas in conscious animals.

Cellulose granulomatous peritonitis.

The case history of a patient developing granulomatous peritonitis due to cellulose is described. At a second laparotomy following an operation for intestinal obstruction due to adhesions, the peritoneum was found to be studded with multiple, yellow nodules, closely resembling tuberculous lesions, but shown on microscopy to be tuberculoid granulomata containing cellulose fibres. The main features of the condition, which is self-limiting, and probably more common than is generally realized, are discussed.

Experimental acute pancreatitis in dogs and effects of steroids. A light and electron microscopic study with reference to pathogenesis.

Acute pancreatitis was induced in 39 dogs by injecting 10 ml of autologous bile into the pancreatic duct system. Of these dogs, 19 received hydrocortisone. As control, used were two normal dogs and six that were injected with 10 ml of normal saline solution into the pancreatic duct. Of all, 14 dogs were examined by electron microscope. All dogs that were injected with bile developed acute pancreatitis and histologically the lesion produced was acute necrotizing pancreatitis. Dogs treated with steroids showed an improved survival and a reduction in the severity of the acinar lesion. Ultrastructurally, pancreatic changes in these animals were mainly in the acinar cells and capillaries. Although ultrastructural lesions were similar in animals treated with steroids, steroid therapy appeared to be associated with an improved structural preservation of the acinar cells. These results suggest that the bile infusion method is reliable in producing acute necrotizing pancreatitis and that steroid administration is associated with an improved survival and reduction of the severity of the pancreatic lesion. The pathogenetic mechanism in this model and the mode of action of steroids were suggested by the ultrastructural study.