Necrosis of the small intestine leading to a diagnosis of polyarteritis nodosa: a case report.

BACKGROUND: Polyarteritis nodosa is a disease that presents with necrotizing vasculitis in small and medium-sized arteries. It may occur in various organs, but approximately half of cases have gastrointestinal involvement. Prognosis is not favorable once organ dysfunction begins as evidenced by gastrointestinal symptoms; thus, treatment with steroids should be promptly initiated. We report the case of a patient who presented with necrosis of the small intestine, which was pathologically diagnosed as polyarteritis nodosa and treated successfully with steroids. CASE PRESENTATION: An 18-year-old Japanese woman reported a sudden onset of abdominal pain and vomiting that led her to visit our emergency department, where she was evaluated by a physician. On physical examination, tenderness to palpation in the upper umbilical region was noted, and diagnostic imaging with computed tomography showed emphysema of the wall of her small intestine. She was diagnosed as having necrosis of the small intestine requiring urgent surgery. No strangulations were noted intraoperatively but approximately 20 cm of her small intestine was necrotized. The surrounding arteries were examined and no palpable pulse was observed; therefore, segmentectomy of the necrotized regions was performed. Pathological findings revealed active vasculitis with fibrinoid necrosis, as well as destruction, fibrogenesis, and luminal stenosis of the elastic lamina found in the muscular arteries. A diagnosis of polyarteritis nodosa was confirmed as the cause of the necrosis of her small intestine. No recurrence of polyarteritis nodosa symptoms was observed when she was administered 40 mg of prednisolone daily. CONCLUSION: In cases of idiopathic intestinal necrosis or perforation, systemic diseases such as polyarteritis nodosa should be considered in the differential diagnosis.

Mesh penetrating the cecum and bladder following inguinal hernia surgery: a case report.

BACKGROUND: Tension-free repair using mesh is a common inguinal hernia surgical procedure. However, various complications such as mesh-related infection and recurrence may develop as a result. Moreover, although rare, there are also reports of intestinal obstruction caused by adhesion of the mesh to the intestinal wall and cases of mesh migration into various organs. Here, we report our experience with a patient in whom mesh extraction was performed due to migration of mesh into the intestinal tract following inguinal hernia surgery and formation of a fistula with the bladder. CASE PRESENTATION: Our patient was a 63-year-old Japanese man who had a history of operative treatment for right inguinal hernia during early childhood. Because a relapse subsequently occurred, he was diagnosed as having recurrent right inguinal hernia at the age of 56 years for which operative treatment (the Kugel method) was performed. He presented to our hospital 6 years later with the chief complaint of lower abdominal pain. Computed tomography findings revealed a mass shadow in contact with his bladder and cecal walls, and enteric bacteria were detected in his urine. Furthermore, because lower gastrointestinal endoscopic findings confirmed mesh in the cecum, we performed operative treatment. The mesh had migrated into the cecum and a fistula with his bladder had formed. We removed the mesh through ileocecal resection and partial cystectomy. CONCLUSIONS: It appeared that a peritoneal defect occurred when the mesh was placed, allowing the mesh to migrate into our patient's intestinal tract. Because contact between the mesh and the cecum resulted in inflammation, a fistula formed in his bladder. It is important to completely close the peritoneum when placing the mesh.