A Toothpick a day, keeps the doctor away?

A Toothpick is a dreaded offender when ingested, as it is risky to cause impaction, obstruction or perforation of the gut. When ingestion of a toothpick leads to one of these complications, it clinically mimics an acute abdomen. Often the patient doesn't recall the ingestion, leading to misdiagnosis as inflammatory bowel disease, appendicitis/diverticulitis, etc. We describe the case of a 50-year old woman presenting to the emergency department with right lower abdominal pain. CT-scan showed an obstruction without clear underlying cause. The hypothesis of obstruction due to intestinal adhesions without strangulation was assumed and non-operative management lead to recovery and dismissal of the patient. However, she presented 3 weeks later with identical complaints, this time showing a terminal ileitis on CT-scan. Surprisingly, a toothpick perforating the terminal ileum was found during endoscopy and could by removed. A clinician should think of foreign body ingestion when patients present with an acute abdomen with no clear underlying pathology.

Acute non-cirrhotic portal vein thrombosis : review.

A 35-year-old man with a medical history of myocardial infarction, presenting with fever, general malaise and vague abdominal discomfort, was diagnosed with a portomesenteric venous thrombosis and acute cytomegalovirus (CMV) infection. Thrombophilia screening resulted in detection of heterozygosity for factor II G20210A gene mutation. Low molecular weight heparin in therapeutic dose was started, followed by disappearance of thrombus on imaging CT two months after diagnosis. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this case and review of the literature. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation. Acute non-cirrhotic PVT is a rare but probably underestimated condition as symptoms may be discrete or non-specific. The origin of portal thrombosis is frequently multifactorial. Recent literature has emphasized the increasing prevalence of CMV-induced PVT in immunocompetent patients. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this review of the literature and included case. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation.

Autoimmune pancreatitis and extrapancreatic manifestations of IgG4-related sclerosing disease.

In a review of the literature concerning autoimmune pancreatitis we had special interest for the concept of IgG4-related pathology as a systemic disease with several clinical manifestations. In general, IgG4-positivity can not only be found in the pancreas, but also at the level of the kidneys, extrahepatic biliary ducts, gallbladder, lungs, salivary glands, lacrimal glands, retroperitoneal tissue, ureters, prostate, meninges and lymph nodes. IgG4 seems to be a central key player in the pathophysiology of this disease.

Large hiatal hernia and iron deficiency anaemia: clinico-endoscopical findings.

BACKGROUND: Iron deficiency anaemia (IDA) in men and postmenopausal women is mostly due to chronic gastrointestinal blood loss. One of the most common missed lesions while performing upper endoscopy in the work-up of IDA, are Cameron lesions, located at the neck of a large hiatal hernia. AIMS: Description of the bio-clinical and endoscopic findings of a large hiatal hernia, diagnosed in patients presenting with iron deficiency anaemia. Furthermore, a review of the literature concerning the diagnostic and therapeutic management of these patients will be outlined. STUDY: We retrospectively evaluated 36 patients, presenting with IDA (hemoglobin < 10 g/dl) associated with a large hiatal hernia. RESULTS: Cardiopulmonary complications of anaemia were the presenting symptoms, rather than gastrointestinal related complaints or bleeding. Cameron lesions were visualized only in 18 (50%) of our patients at their first presentation. There was no obvious correlation between the presence of Cameron lesions and visible gastrointestinal blood loss. Initially, almost all of our patients were treated medically. Seven underwent surgical repair of the hiatal hernia and all remained asymptomatic afterwards. CONCLUSION: We conclude that a hiatal hernia, with or without visible Cameron lesions, is a real and maybe underestimated cause of IDA. Finding a large hiatal hernia on upper endoscopy, together with a negative colonoscopy, completes the diagnostic work-up of IDA in most of these elderly patients. Currently, no guidelines concerning the optimal therapeutic management of this problem are available. Therapy may depend upon the need of transfusion, the efficiency of medical treatment, the risks of surgery and the preference and general condition of the patient.

Ileal carcinoid tumors and intestinal ischemia.

Three patients with carcinoid tumors of the ileum are presented; two had severe intestinal ischemia, one with infarction of the small intestine. In all three cases, histopathological examination revealed elastic vascular sclerosis (EVS) in the mesenteric blood vessels. Intestinal ischemia in the presence of a carcinoid tumor is probably due to a combination of tumoral secretion products, vascular changes, mesenterial retraction and nodal involvement. Selective superior mesenteric artery arteriography is diagnostic. All the reported carcinoid tumors with ischemic manifestations are ileal and invaded the mesentery or had positive nodes or metastases; two-thirds had EVS, and one-third mesenterial vascular luminal narrowing. Intestinal ischemia may be the underlying cause of vague symptoms in patients with a carcinoid tumor. This tumor may be small and must be looked for during laparotomy, mild intestinal ischemia or mesenterial thickening are important signs. Early resection can prevent intestinal complications. An aggressive attitude, including debulking of metastases, is justifiable.

Cholestatic hepatitis due to an amoxycillin/clavulanic acid preparation.

Two cases of reversible cholestatic hepatitis after treatment with an amoxycillin/clavulanic acid preparation (Augmentin) are described.

D-penicillamine-induced oesophageal ulcers.

A patient on treatment with D-penicillamine developed aphthoid ulcers of the oesophagus, which healed rapidly after withdrawal of this drug. The mechanism of these probably drug-induced oesophageal ulcerations is discussed.

Anisakiasis caused by herring in vinegar: a little known medical problem.

Six cases of intestinal anisakiasis, or herring worm disease, diagnosed over a two year period in a Belgian gastroenterology unit are described. They presented mainly as intestinal obstructions and larvae of this marine nematode were found in the intestinal wall of two of the four patients who were operated on. In two other patients awareness of the diagnosis permitted conservative treatment and spontaneous healing. In five patients symptoms developed after they had eaten herring marinated in vinegar, a hitherto little known source of the herring worm disease.

Mechanism of phase V in the single breath washout curve.

The underlying mechanism of the occurrence of a downward phase V at the end of a bolus washout curve was investigated in three healthy subjects. Phase V appeared not to originate from apical zones with low concentration of tracer gas but from dependent lung zones, which were not pathological. Indeed: 1) a reversed, upward, terminal slope was obtained when the bolus had been directed to the lung base by imposing a transition of the body through 180 degrees between inspiration and expiration or by inhaling a bolus close to TLC; 2) phase V was also present on N2 washout curves and, thus, originated from zones with smaller RV/TLC than the apical ones. Phase V increased with flow rate.

Gravity dependence of phases III, IV, and V in single-breath washout curves.

The gravity dependence of phases III (IIIa and IIIb), IV, and V of simultaneously performed He-bolus and N2-resident gas single-breath washout curves was studied in different body positions by the technique of 180 degrees body inversion between inspiration and expiration. Phase IIIa was mainly determined by nongravitational factors. Phase IIIb was influenced by gravitational, as well as nongravitational, factors. The former were more important with the bolus method in both lateral decubitus positions and the latter with the N2 method in the prone and supine positions. Phases IV and V were mainly gravity dependent. The difference in gravity dependence between the He and N2 methods appeared to be correlated with the vertical interregional concentration gradients of both gases; indeed the vertical gradient was larger for the 133Xe bolus inhaled at residual volume (which is comparable to the He-bolus distribution) than for the 133Xe residual volume-to-total lung capacity ratio (which is comparable to the N2-resident gas distribution). The greater gravity dependence in the lateral decubitus positions than in the supine or prone postures was related to the larger vertical interregional concentration difference as well as to the more pronounced sequential ventilation in the former positions. Finally the negligible effect of gravity on phase IIIa, its moderate effect on phase IIIb, and its predominant effect on phases IV and V were in agreement with the increased sequential filling and emptying due to gravity near residual volume.

Regional gas distributions and single-breath washout curves in head-down position.

Regional distributions of inspired 133Xe and single-breath washout curves were compared in six young healthy subjects for the upright and the head-down positions. The regional distributions of volumes (at 0, 25, 50, and 75% vital capacity, VC) and of 133Xe boluses inhaled at residual volume (RV) were inverted in the head-down position, thus behaving as if they were determined by gravity acting via the weight of the lung rather than by thoracicoabdominal shape adaptations. Nevertheless no mirror image was obtained. The vertical differences in regional distribution of the 133Xe RV bolus and of the volumes at 25% VC were increased in the head-down position, whereas the vertical difference in volumes at RV was decreased, indicating enhanced air trapping and sequential ventilation at low volumes. This was attributed to the effect of the increased pulmonary blood volume in the head-down posture. Accordingly the size of phase IV on the washout curves with the SF6-bolus as well as with the N2-resident gas method was increased in the head-down position.