Mycotic splenic artery aneurysm secondary to Coxiella burnetii endocarditis.

Mycotic artery aneurysms are rare but potentially lethal vascular lesions due to their high risk of rupture. Bacterial endocarditis as well as trauma and inadequate immunity are predisposing factors. Surgery remains the treatment of choice, although alternative methods have been used. We report the first known case of a 6 cm mycotic splenic artery aneurysm proximal to the splenic hilum, secondary to bacterial endocarditis from Coxiella burnetii. Resection of the aneurysm, splenectomy, and distal pancreatectomy were performed. In all patients with culture-negative endocarditis and mycotic aneurysm, C. burnetii infection should be ruled out.

Effect of non-operative management (NOM) of splenic rupture versus splenectomy on the distribution of peripheral blood lymphocyte populations and cytokine production by T cells.

Post-traumatic splenectomy is associated with increased postoperative morbidity and mortality and long-term impairment of humoral and cellular immunity. Alternatives to surgery have been developed to minimize or avoid the immediate and/or long-term complications of splenectomy. Herein we investigated the long-term effect of non-operative management (NOM) of the traumatic rupture of the spleen on the distribution of peripheral blood (PB) lymphocyte populations and cytokine production by T cells. PB samples were drawn from six NOM patients, 13 age-matched adults who had undergone splenectomy after trauma (SP patients) and 31 age-matched controls. Cellular phenotypes and the intracellular production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4 and IL-10 cytokines in T cells were determined in whole blood +/- mitogens by flow cytometry. NOM patients did not show any changes in the absolute numbers of lymphocytes or the distribution of their subsets, compared to the controls. In contrast, SP patients showed a sustained increase in the percentage and/or absolute numbers of lymphocytes, CD8 T cells, activated CD8 T cells, natural killer (NK) T cells, NK cells and gammadelta T cells, and a reduction in naive CD4 T cells. The constitutive or induced cytokine production by T cells of the NOM group was similar to the control group, whereas SP patients had increased percentages of constitutive IL-2- and IFN-gamma-producing CD8 T cells and IFN-gamma-producing CD4 T cells. Our findings indicate collectively that the healing process in NOM does not affect the architecture of the spleen to such an extent that it would lead to long-term alterations of the proportions of PB lymphocytes or the T cell cytokine profiles.

Evidence for intestinal oxidative stress in patients with obstructive jaundice.

BACKGROUND: Obstructive jaundice results in failure of the intestinal barrier with consequent systemic endotoxemia associated with septic complications. We have recently shown that gut barrier failure in experimental obstructive jaundice is associated with high intestinal oxidative stress. This study was undertaken to investigate whether oxidative alterations occur in the intestinal mucosa of patients with obstructive jaundice. PATIENTS AND METHODS: Fifteen patients with malignant biliary obstruction and no signs of cholangitis and 15 control patients were subjected to duodenal biopsy to assess intestinal oxidative stress, estimated by lipid peroxidation (malondialdehyde - MDA) and glutathione redox state [reduced glutathione (GSH), glutathione disulphide (GSSG) and GSH/GSSG ratio]. In addition, mucosal biopsies were examined histologically and intestinal mucosal protein content was determined biochemically as an index of intestinal trophic state. RESULTS: Patients with obstructive jaundice presented high levels of intestinal oxidative stress, with significantly increased lipid peroxidation (P < 0.001). Glutathione redox state was also suggestive of high intestinal oxidative stress in jaundiced patients, indicated by significantly decreased GSH (P = 0.001) and GSH/GSSG ratio (P = 0.006) and increased GSSG (P = 0.026). Histological examination showed a mild infiltration of the lamina propria by chronic inflammatory cells in obstructive jaundice, whereas duodenal architecture remained intact and epithelial continuity was retained. Duodenal mucosa was atrophic in jaundiced patients as indicated by a significant reduction of mucosal protein content compared with controls (P = 0.001). Among oxidative stress parameters, intestinal GSH exhibited a significant positive correlation with mucosal protein content (r = 0.588, P = 0.021). CONCLUSIONS: Obstructive jaundice in humans induces intestinal oxidative stress, which may be a key factor contributing to intestinal barrier failure and the development of septic complications in this patient population.

Gastric ulcers and risk for cancer. Is follow-up necessary for all gastric ulcers?

The aim of this study was to determine the accuracy of initial endoscopy combined with histology and to define whether there is a point in following-up all gastric ulcers until complete healing. We have studied all patients with gastric ulcers documented at endoscopy during a 6-year period. Ulcers were macroscopically characterised as benign or suspicious for malignancy, and biopsies were taken. A follow-up endoscopy and histology was performed 4-6 weeks and 3 months after an anti-ulcer treatment. Resistant ulcers were treated surgically. All patients were followed-up clinically and endoscopically for a year after complete ulcer healing. 802 patients with gastric ulcers were enrolled. At initial endoscopy, 732 ulcers (91.3%) were macroscopically characterised as benign and 70 ulcers (8.7%) as suspicious for malignancy. In the group of endoscopically benign ulcers, only one (0.1%) had malignancy detected by biopsy in the first examination. None of these ulcers turned out to be malignant on subsequent examinations. From the suspicious for malignancy ulcers, 20 (28.6%) were proven to be malignant. Endoscopy may recognise with great accuracy benign ulcers, but it overestimates the malignant ones. The cost-benefit of serial follow-up endoscopies should be re-evaluated in ulcers that appear benign, and biopsies are negative at the initial examination.

Predictors of hemostatic failure after adrenaline injection in patients with peptic ulcers with non-bleeding visible vessel.

BACKGROUND: Non-bleeding visible vessel (NBVV) in patients with bleeding peptic ulcer is associated with a high risk of rebleeding. The aim of this study was to define factors associated with failure of endoscopic hemostasis and rebleeding in patients with NBVV. METHODS: Clinical and endoscopic parameters related to failure of endoscopic hemostasis with adrenaline in 191 bleeding peptic ulcer patients with NBVV were evaluated. RESULTS: Endoscopic hemostasis was permanently successful in 154 patients (80.6%). Emergency surgical hemostasis for rebleeding was required in 37 patients (19.4%). Univariate analysis showed that therapeutic failure was significantly related to the presence of shock on admission (P=0.003), posterior duodenal ulcers (P=0.001), peptic ulcer history (P=0.001), previous peptic ulcer bleeding (P=0.002), or lack of history of non-steroidal anti-inflammatory drugs consumption, when compared to use of such drugs (P=0.04). Patients where therapy failed had lower hemoglobin levels at admission (7.8+/-1.9 g/dL versus 10+/-2.4 g/dL, P=0.005). In a multivariate analysis low hemoglobin (P<0.001) as well as history of previous peptic ulcer bleeding (P=0.002) and posterior duodenal ulcers (P=0.001) were negative predictors. Using the mean value of hemoglobin as the cut-off point, it is noteworthy that only 2 out of 81 patients (2.5%) who had none of these predictive factors required emergency surgical hemostasis, whereas 34 out of 110 patients (30.9%) with at least one predictive factor required emergency surgery. CONCLUSION: It is possible, by employing specific characteristics, to define a subgroup of high-risk patients for rebleeding in patients with NBVV despite therapeutic endoscopy and thus candidates for a complementary endoscopic method of hemostasis or emergency surgical intervention.

In vitro study of the long-term effects of post-traumatic splenectomy on cellular immunity.

The purpose of this study was to investigate the effect of splenectomy on cellular immunity. We studied the cellular phenotype and type 1 [interferon-gamma, interleukin-2 (IL-2)] and type 2 (IL-4 and IL-10) cytokine-producing peripheral blood CD4+ and CD8+ T lymphocytes in 22 healthy adults who had undergone post-traumatic splenectomy about 1 to 35 years ago. Splenectomy resulted in a long-term reduction of the percentage of CD4+CD45RA+ cells and a late increase of the percentage and absolute numbers of T-cell receptor gamma/delta cells. Stimulation with Staphylococcal enterotoxin B resulted in normal IL-2 production by CD4+ T cells, indicating that the naïve cells were not anergic. Splenectomy also resulted in long-term priming of both CD4+ and CD8+ T cells. During the first 8 years, both type 1 and type 2 CD4+ T cells were primed to varying degrees. About 8 years later, the percentage of primed type 2 CD4+ T cells subsided, but that of type 1 CD4+ T cells, although decreased, remained detectable over a longer period. Priming of CD8+ T cells persisted throughout the study period. The long-term priming of type 1 CD4+ and CD8+ T cells, which may result in partial impairment of T-cell functions, may explain reported defects of immune responses to recall antigens in splenectomized individuals. In addition, changes in the profile of primed CD4+ T cells with time may be clinically relevant to relapses in autoimmune thrombocytopenia after splenectomy.

Evidence for intestinal oxidative stress in obstructive jaundice-induced gut barrier dysfunction in rats.

AIM: An important factor that promotes bacterial and endotoxin translocation in obstructive jaundice is intestinal injury that causes increased permeability. However, little is known of the submicroscopic biochemical events leading to defects of the intestinal barrier. This study was undertaken to investigate the effect of experimental obstructive jaundice on intestinal lipid peroxidation, protein oxidation and thiol redox state. METHODS: Rats were randomly divided into controls, sham operated and bile duct ligated (BDL). After 10 days, intestinal barrier function was assessed by measuring endotoxin in portal and aortic blood. Tissue samples from the terminal ileum were examined histologically and morphometrically, while other samples were homogenized for the determination of lipid peroxidation, protein oxidation and thiol redox state [reduced glutathione (GSH), oxidized glutathione (GSSG), total non-protein mixed disulphides (NPSSR), protein thiols (PSH) and protein disulphides (PSSP)]. RESULTS: Obstructive jaundice compromised intestinal barrier function leading to significant portal and systemic endotoxaemia. The intestinal mucosa in jaundiced rats was atrophic with significantly decreased villous density and total mucosal thickness. Determination of biochemical parameters of oxidative stress in the intestine showed increased lipid peroxidation and protein oxidation in BDL-rats. Thiol redox state revealed the presence of intestinal oxidative stress in jaundiced rats, indicated by a decrease in GSH and increased GSSG, NPSSR and PSSP. CONCLUSIONS: This study shows that experimental obstructive jaundice induces intestinal oxidative stress, which may be a key factor contributing to intestinal injury and leading to endotoxin translocation.

Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma.

BACKGROUND: Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non-operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice. DISCUSSION: In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient-related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour-related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital-related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra-operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down-staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear-cut evidence of irresectability.

A novel mobile telemedicine system for ambulance transport. Design and evaluation.

It is generally accepted that early and specialized pre-hospital patient treatment improves outcome in terms of mortality and morbidity, in emergency cases. The focus of this paper is to present the implementation and the evaluation of an ambulance located telemedicine system for pre-hospital patient treatment The primary emphasis is on the vital sign transmission from the accident site or the moving ambulance to the consultation site, using the GSM mobile telephony network. There, the experts evaluate the patient data, decides about the treatment protocol and provide directions to the ambulance's medical staff concerning on the patient handling until the arrival to the hospital.

Deformations and intrusions of the passenger compartment as indicators of injury severity and triage in head-on collisions of non-airbag-carrying vehicles.

In motor vehicle collisions the mechanism of injury is important in determining severity as well as for triage decisions in the pre-hospital phase of patient management. This study correlates deformation of the basic structures of the passenger compartment [windscreen, control panel (dashboard) and steering wheel] with occupants' injuries in passenger vehicle head-on collisions involving non-airbag-carrying vehicles, with or without compartment intrusion. The study took place in the broad urban area of Patras, over an 18-month period (January 2000-June 2001) and evaluated 48 vehicle crashes. Car and compartment deformation are significant factors affecting occupants' injuries and consequently the appropriate type of further treatment, either in the hospital setting or primary health-care centres. It would be particularly useful to transmit the post-crash condition of a vehicle to the trauma dispatch centre, utilising satellite technology, thus allowing the centre to organise the rescue teams, plan triage in advance and provide the emergency medical personnel with all necessary information before their arrival at the scene of the accident.

Treatment of postoperative bronchobiliary fistula by nasobiliary drainage.

Bronchobiliary fistula (BBF) is a rare condition. It may present as a complication of echinococcal or amebic liver disease. Management of such a fistula can be very difficult and is often associated with a high rate of morbidity and mortality. We report the case of a 70-year-old woman who presented with a BBF after a one-stage operation for hydatid cysts of the liver and lung that were approached via thoracotomy and transdiaphragmatic incision. The cause of the BBF was an inflammatory collection in the residual liver cavity due to inadequate drainage. This collection eroded the sutured diaphragm, and because of the existing adhesions, it perforated directly into the bronchial system at the area of the previous cystectomy. Initially, endoscopic sphincterotomy was performed to achieve biliary decompression by equalizing intrabiliary and duodenal pressure, but no significant improvement was seen. Subsequently, nasobiliary drainage was instituted by means of an endoscopically inserted, nasobiliary catheter, which further reduced biliary pressure and facilitated biliary flow to the duodenum, as opposed to the fistulous tract. The fistula was successfully closed in a short time. This conservative method reduces the risks of reoperation. Therefore, it should be considered the treatment of choice in the management of bronchobiliary fistula.

Pylorus-preserving total pancreatectomy. Early and late results.

BACKGROUND/AIMS: Preservation of the pylorus is an accepted alternative procedure to the classical Whipple operation for pancreatic head resection but data describing its value for total pancreatectomy are sparse. METHODS: A prospective analysis of 22 total pancreatectomies performed in a consecutive series of 436 pancreatic resections from 1.11.93 to 1.5.99. RESULTS: 11 patients underwent total pancreatectomy with preservation of the pylorus. Histopathological examination revealed pancreatic adenocarcinoma in 16 cases and duodenal adenocarcinoma in 1 patient, 5 patients had other types of pancreatic neoplasm. In-hospital mortality was 4.5% (n = 1), cumulative morbidity was 59% and reoperations were performed in 9.1% of cases (n = 2). Median follow-up was 37 months (range 5-66). 62% of patients (n = 13) developed tumor recurrence and 13 patients died during the follow-up period with 10 deaths being cancer related. There was no difference concerning postoperative and follow-up morbidity of survival between patients undergoing pylorus-preserving total pancreatectomy or pancreatectomy with gastrectomy. However, postoperative body weight was increased 3, 6, 9 and 12 months following preservation of the pylorus. CONCLUSION: Total pancreatectomy with preservation of the pylorus is a feasible type of resection for all types of pancreatic or ampullary tumors, which shows a similar morbidity and long-term survival but improved nutritional recovery compared with standard total pancreatectomy.

Factors associated with failure of endoscopic injection haemostasis in bleeding peptic ulcers.

BACKGROUND: The effectiveness of a submucosal injection of adrenaline solution in endoscopic haemostasis is well documented in patients suffering from peptic ulcer bleeding. After treatment, however, a significant number of patients continue to bleed or rebleed, and require emergency surgical intervention. The aim of this study was to define factors associated with the failure of endoscopic injection haemostatic therapy in peptic ulcer bleeding. METHODS: In the period 1992 to 1998, we prospectively studied all patients suffering from peptic ulcer bleeding and identified endoscopically as being either bleeding actively or carrying a visible vessel. A total of 427 patients (343 men and 84 women; mean age 58.6 +/- 16.6 years) were all subjected to endoscopic injection with adrenaline solution on an emergency basis. Patients who eventually required surgical intervention for permanent haemostasis were considered as endoscopic haemostasis failures, whereas those who did not were considered as endoscopic treatment successes. We evaluated all clinical and endoscopic parameters that might have been related to failure of endoscopic injection therapy. RESULTS: Endoscopic injection haemostasis was successful in 341 patients (79.9%) and a failure in 86 (20.1%) who finally underwent emergency surgical haemostasis. On analysing the examined parameters, failure was significantly related to shock on admission (OR 2.31, 95% CI 1.33, 6.97), spurt bleeding at endoscopy (OR 2.45, 95% CI 1.51, 3.98), posteriorly located duodenal ulcer (OR 2.48, 95% CI 1.37, 7.01) and anastomotic ulcer (OR 3.39, 95% CI 1.37, 7.29). Endoscopic injection haemostasis therapy was less effective in patients with chronic ulcers compared to those who had acute NSAID-related ulcers. A history of peptic ulcer (OR 1.57, 95% CI 1.14, 3.05), previous peptic ulcer bleeding (OR 2.45, 95% CI 1.51, 3.98) or non-use of NSAIDs (OR 2.81, 95% CI 1.33, 4.62) were negative predictors for the outcome of endoscopic haemostasis. CONCLUSION: With the use of specific clinical and endoscopic characteristics it is possible to define a subgroup of high-risk patients for continued bleeding or rebleeding despite endoscopic injection therapy. These patients may be candidates for intensive monitoring, early surgical intervention or possibly complementary endoscopic haemostatic methods.

bcl-2/bax ratio as a predictive marker for therapeutic response to radiotherapy in patients with rectal cancer.

Combined radiation therapy and chemotherapy are adjuvant treatments given after surgery to patients with rectal carcinoma. Because apoptosis seems to play a role in tumor response to radiotherapy, the current study investigates whether there is a correlation between the ratio of bcl-2 oncoprotein and bax expression in rectal adenocarcinoma and the clinical response to radiotherapy. Elective colectomy for primary rectal adenocarcinoma followed by adjuvant radiotherapy and chemotherapy was performed on 35 patients. Tumors were staged as B2 (n = 30) and C (n = 5), and were classified as radiation resistant (n = 19, group A) and radiation nonresistant (n = 16, group B). Immunohistochemical study, using the streptavidin-biotin complex technique and monoclonal antibody to bcl-2 and polyclonal antibody to bax protein was used on paraffin sections. Cases were considered positive if at least 5% of tumor cells displayed cytoplasmic staining for bcl-2 or bax. In each tumor, the bcl-2/bax ratio was calculated dividing the percentage of bcl-2-positive cells by the percentage of bax-positive cells. For statistical analysis, the Mann-Whitney rank sum test and Kruskal-Wallis analysis of variance test were used. Rectal tumors of group A displayed significantly greater bcl-2 immunoreactivity (40.2 +/- 4.2) compared with group B (20.2 +/- 3.8). In contrast, expression of bax protein was less in group A (30.3 +/- 3.3) compared with group B (41.3 +/- 2.3). The bcl-2/bax ratio was greater in group A (1.3 +/- 0.1) compared with group B (0.49 +/- 0.1), and was correlated with poor responsiveness to radiotherapy. The current study indicates that in patients with rectal carcinoma an elevated bcl-2/bax ratio in tissue specimens suggests increased tumor resistance to adjuvant radiotherapy. Thus, in such patients, the bcl-2/bax ratio may serve as a potential molecular marker for prediction of tumor prognosis.

Beneficial effects of growth hormone and insulin-like growth factor I on intestinal bacterial translocation, endotoxemia, and apoptosis in experimentally jaundiced rats.

BACKGROUND: This study was undertaken to investigate the effect of growth hormone (GH) and insulin-like growth factor I (IGF-I), two well-known growth factors, on bacterial translocation, endotoxemia, enterocyte apoptosis, and intestinal and liver histology in a model of experimental obstructive jaundice in rats. STUDY DESIGN: One hundred six male Wistar rats were divided into five groups: I (n = 21), controls; II (n = 22), sham operated; III (n = 22), bile duct ligation (BDL); IV (n = 21), BDL and GH treatment; and V (n = 20), BDL and IGF-I administration. By the end of the experiment, on day 10, blood bilirubin was determined, and mesenteric lymph nodes, liver specimens, and bile from the bile duct stump were cultured. Endotoxin was measured in portal and aortic blood. Tissue samples from the terminal ileum and liver were examined histologically and apoptotic body count (ABC) in intestinal mucosa was evaluated. Mucosal DNA and protein content were also determined. RESULTS: Bilirubin increased significantly after BDL (p < 0.001). Bile from the bile duct was sterile. In group III, MLN and liver specimens were contaminated by gut origin bacteria (significant versus group I and II, p < 0.001, respectively). GH reduced significantly positive cultures (p < 0.01), and IGF-I had no effect. BDL resulted in significant increase in portal and aortic endotoxemia (p < 0.001); treatment with GH and IGF-I reduced it (p < 0.001). Mucosal DNA and protein content were reduced in animals with BDL and after treatment with GH or IGF-I; an increase to almost normal levels was noted in DNA, but not in protein. Overall the ileal architecture remained intact in all animal groups. The ABC increased after BDL. After GH and IGF-I administration, the ABC decreased significantly, and there was no difference between GH and IGF-I treated animals. After BDL, liver biopsies displayed typical changes of biliary obstruction, which were significantly improved after administration of GH and IGF-I. CONCLUSIONS: Treatment with GH and IGF-I in rats with experimental obstructive jaundice reduces endotoxemia, and it improves liver histology. Apoptosis, in the intestinal epithelium, may serve as a morphologic marker of the ileal mucosal integrity, demonstrating the proliferative potential of GH and IGF-I in cases of obstructive jaundice, and this might be of potential value in patients with such conditions.

Growth hormone and insulin-like growth factor I protect intestinal cells from radiation induced apoptosis.

We studied whether programmed cell death (or apoptosis) is the predominant mechanism in radiation-induced cell damage to rat intestinal mucosa and investigated the mechanism of the protective effect of GH and IGF-I in the same model. Male albino Wistar rats were divided into four groups: controls, radiation, radiation plus GH and radiation plus IGF-I. Radiation was administered on the first day and on day 4. All animals were sacrificed and segments of the terminal ileum were stained with hematoxylin-eosin. Apoptosis of the epithelial cells was identified at the cellular level by the TUNEL stain and was distinguished from necrosis by the characteristic morphology of the cells (cytoplasmic shrinkage, marginal chromatin condensation and generation of nuclear apoptotic bodies). Apoptotic cells in the control animals were few and detected only at the tips of the villi while in the irradiated animals almost all the epithelial cells were apoptotic, distributed from the crypts to the tips of the villi and the mucosa showed severe epithelial atrophy and ulceration. The histologic picture of the mucosa in the GH and IGF-I treated animals was similar to normal controls and apoptotic cells were restricted only at the tips of the villi. DNA and RNA from the mucosa cells were isolated and analyzed by electrophoresis. DNA fragmentation and RNA 28s band ribonuclease cleavage was observed only in the irradiated animals. We have shown that abdominal radiation causes intestinal epithelial cell damage mainly through the induction of apoptosis and the treatment with GH and IGF-I inhibits apoptosis of the cells and preserves the mucosal integrity.

Unusual presentation of pancreatic mucinous cystadenocarcinoma by spontaneous splenic rupture.

BACKGROUND: Mucinous cystic neoplasms of the pancreas are uncommon tumors with varying potential for malignancy. Although traumatic splenic rupture is common, spontaneous rupture is a rare event. CADE REPORT: We present an unusual case of spontaneous splenic rupture, due to an otherwise asymptomatic mucinous cystadenocarcinoma of the tail of the pancreas. CONCLUSION: A tumor of the tail of the pancreas may uncommonly present as spontaneous splenic rupture, probably due to venous congestion and infiltration of the spleen, requiring emergency surgical treatment.

Pre-emptive analgesia: how important is it in clinical reality?

Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. In experimental studies, preinjury (e.g. pre-emptive) neural blockade using local anaesthetics or opioids has been shown to prevent or to reduce postinjury sensitization of the central nervous system, while similar techniques applied after the injury had less or no effect. Several clinical studies have evaluated possible pre-emptive analgesic effects by administering prior to surgery a variety of analgesic drugs both systemically or epidurally. These treatment modalities were compared to the same treatment following surgery or to control groups not given such treatment. In general, the results from these studies have been disappointing, although some clinical studies have confirmed the impressive results from animal studies. The present paper discusses deficiencies in study design of clinical trials, since the question regarding the effectiveness of pre-emptive analgesic regimens lies not so much in the timing of analgesic administration (e.g. preinjury vs. postinjury treatment), but in the effective prevention of altered central sensitization. Recent evidence suggests that administration of analgesics in order to effectively pre-empt postoperative pain should start before surgery and furthermore, this treatment should be extended into the early postoperative period.

Causes and clinical outcome of acute upper gastrointestinal bleeding: a prospective analysis of 1534 cases.

Despite considerable improvement in the diagnostic and therapeutic approach to patients with acute upper gastrointestinal (GI) bleeding, several studies suggest there has been no overall change in mortality. The aim of this study was to evaluate prospectively the effect of early emergency diagnostic and therapeutic endoscopy and medico-surgical collaboration in the clinical outcome of 1534 patients with acute upper GI bleeding treated in our hospital over the past five years. Emergency endoscopy and injection haemostasis were performed within 24 hours of admission, or immediately after resuscitation, in patients with massive bleeding; patients were then treated with close co-operation between surgeons and gastroenterologists. We observed an increase in the incidence of peptic ulcer (67%) with a simultaneous decrease in the incidence of gastroduodenitis (13.5%) as a cause of bleeding compared with the previous decade. In peptic ulcer bleeding, emergency surgical haemostasis was required in 92 patients (8.9%), while none of the patients with erosive gastroduodenitis required surgical intervention. Overall mortality was 2.9%, and in peptic ulcer bleeding patients 2.1% with a postsurgical mortality of 8.7%. Peptic ulcer remains the main cause of upper GI bleeding. Improved clinical outcome and low mortality can be achieved with early diagnostic and therapeutic endoscopy and medico-surgical collaboration.

The effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding.

BACKGROUND: Our aim was to investigate the effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding. METHODS: In this study 1203 patients admitted with peptic ulcer bleeding over a 5-year period (January 1987 to April 1991) before endoscopic therapy and 1028 patients admitted with peptic ulcer bleeding after introduction of endoscopic therapy (May 1991 to March 1996) were assessed. Endoscopic therapy was performed in all patients with active bleeding or non-bleeding visible vessels during emergency endoscopy with injection of adrenaline, 1:10,000 in 0.9% saline. RESULTS: The introduction of injection therapy was associated with a reduction in transfusion requirements (from 5.1 +/- 2.6 to 3.4 +/- 1.8 units), hospitalization days (from 10.8 +/- 6.5 to 7.8 +/- 5.1 days), surgical interventions (from 50.6% to 23.6%), and mortality (from 12.9% to 4.6%) in patients with active bleeding or non-bleeding visible vessels (P < 0.05) but remained unchanged in the rest. Patients with gastric ulcer had a more pronounced reduction in emergency surgical haemostasis and mortality than patients with duodenal ulcer. There were no deaths or procedure-related complications. CONCLUSION: Endoscopic injection therapy with adrenaline/saline is a simple, low-cost, and safe method that improves the clinical outcome and reduces the mortality in patients with peptic ulcer bleeding.