Breast carcinoma metastatic to the gallbladder and urinary bladder.

We present a patient with a history of infiltrating lobular breast carcinoma that metastasized to both the biliary and urinary tract after a ten year disease-free period following mastectomy and chemoradiotherapy. The patient presented with acute cholecystitis; imaging and histopathology revealed infiltrating lobular carcinoma of the gallbladder and urinary bladder. This report emphasizes the importance of long-term follow up in patients with a history of breast cancer and maintaining a high degree of suspicion for diagnosis of metastatic disease.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center.

BACKGROUND: Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy. METHODS: A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy. RESULTS: The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention. CONCLUSION: The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Verrucous carcinoma arising in hidradenitis suppurativa.

There are many reported cases of squamous carcinoma complicating hidradenitis suppurativa, but only one previous mention of verrucous carcinoma in this setting. We describe a case of verrucous carcinoma arising in hidradenitis suppurativa of the anal margin in a non-immunosuppressed man. This is the second report of verrucous carcinoma arising in a lesion of hidradenitis suppurativa. Although hidradenitis suppurativa can involve multiple intertriginous sites, malignant degeneration occurs mostly in the anogenital region. This suggests a role for a regional factor which, when combined with chronic inflammation, predisposes to malignant degeneration. A likely candidate for this factor is human papillomavirus; our case showed histologic evidence for this, but the specimen did not show viral DNA by polymerase chain reaction in situ hybridization. The ability of anogenital hidradenitis suppurativa to form squamous and verrucous cancers reinforces the argument for early and complete resection.

Radiographic changes after colonoscopic decompression for acute pseudo-obstruction.

PURPOSE: Colonoscopy has been the principal tool for decompression in acute colonic pseudo-obstruction, known as Ogilvie's syndrome. The objectives of this study were to determine the immediate effect of colonoscopy on the cecal diameter (measured on supine radiographs) and to delineate possible correlations in the diameters of dilated segments of the colon. METHODS: The charts and radiographs of 24 patients who had colonoscopic decompression for acute colonic pseudo-obstruction between 1992 and 1997 at the San Diego Veterans Affairs Medical Center and the University of California, San Diego Hospitals were reviewed. We measured cecal, transverse, descending, and sigmoid colon diameters on serial radiographs up to the point of clinical resolution. RESULTS: Mean +/- standard deviation cecal diameter change (between initial and post-decompression films) was -2+/-3.4 cm at four hours and -2.2+/-3.3 cm one day after decompression. On the daily radiographs between colonoscopic decompression and clinical resolution, there was a close correlation between the diameter of the cecum and that of the transverse colon (P<0.05). There was no correlation between the cecal diameter and that of the descending or sigmoid colon. CONCLUSIONS: Colonoscopic decompression only causes a small decrease in cecal size in the patient with acute colonic pseudo-obstruction. Dilation patterns of the cecum and transverse colon are significantly correlated in acute colonic pseudo-obstruction. This correlation provides additional support to the contention that the same pathophysiology affects these two segments of the colon.

All's Well That Ends Well: Shakespeare's treatment of anal fistula.

Textual and contextual evidence suggests that the French king's fistula, a central plot device in Shakespeare's play All's Well That Ends Well, is a fistula-in-ano. Anal fistula was known to the lay public in Shakespeare's time. In addition, Shakespeare may have known of the anal fistula treatise of John Arderne, an ancestor on Shakespeare's mother's side. Shakespeare's use of anal fistula differs from all previous versions of the story, which first appeared in Boccaccio's Decameron and from its possible historical antecedent, the fistula of Charles V of France. This difference makes sense given the conventions of Elizabethan comedy, which included anal humor. It is also understandable when one looks at what wounds in different locations mean in European legend. In this light, it is not surprising that subsequent expurgations treat Boccaccio's and Shakespeare's fistulas differently, censoring only Shakespeare's. This reading has implications for the staging of All's Well That Ends Well, and for our view of the place of anal fistulas in cultural history.

Use of tissue expander for tamponade of presacral hemorrhage. Report of a case.

A silastic tissue expander has been used to tamponade severe presacral hemorrhage in a patient undergoing abdominoperineal resection for rectal carcinoma. This technique may be applicable in similar cases when tamponade is required for uncontrolled venous hemorrhage. The presence of an expandable pelvic prosthesis may be of use postoperatively in avoiding radiation-associated small bowel injury.

Hemorrhoidal bleeding in chronic spinal cord injury: results of multiple banding.

Most patients with chronic spinal cord injury (SCI) have hemorrhoidal bleeding. 87 banding procedures were performed for bleeding on 62 men with chronic SCI. Multiple bands per session were routinely necessary. Bleeding sites at or distal to the dentate line were also banded. There were no major complications. An outcome questionnaire was completed by 60 subjects (97%). Mean follow-up was one year, minimum one-half year. 73% of patients reported significant reduction in bleeding post-banding, and 20% reported some reduction. A majority of patients felt the procedure was useful or worthwhile overall. Absent sensation allows banding of external hemorrhoids, although symptoms of autonomic hyper-reflexia may occur in patients with lesions at T6 or above. Multiple banding is a safe and effective treatment for hemorrhoidal bleeding in SCI.

Hinged anoscope.

A hinged anoscope for insertion of rectal catheters is presented. Catheters attached to or integrally part of an external monitoring device or collecting system can be inserted through this endoscope. The endoscope can be removed without disconnecting the catheter from the external device.

Single-operator hemorrhoid ligator.

A new device for elastic band ligation of hemorrhoids is presented. The three instruments used for this procedure, the anoscope, clamp, and ligator, are combined to allow performance of the procedure by a single operator.

Bilateral accessory tragus.

Bilateral accessory tragus is a rare congenital malformation of the external ear. An isolated, nonfamilial occurrence of bilateral accessory tragus in a forty-three-year-old man is presented, and the literature is reviewed. Congenital firm, preauricular papules should be recognized as accessory tragi.

Pyloric stenosis in a premature infant.

Workup of a case of hypertrophic pyloric stenosis in a premature infant showed absence of ultrasonic criteria for diagnosis. Transpyloric intubation for enteral feeding may delay the diagnosis of this disorder and has been thought to play a role in its development.

Gastrointestinal complications of chronic spinal cord injury.

Gastrointestinal problems are important in the chronic stage of spinal cord injury. We review the literature on problems of specific segments of the alimentary tract in this setting and add observations based on clinical experience. Emphasis is placed on the colon and rectum, where most clinically apparent problems occur. While bowel management programs are often successful in the near-term, long-term dysfunctions are common and difficult to treat. Studies to determine colonic transit time and rectal physiologic responses are useful to provide scientific basis of management of such patients. More information is needed on the relative roles of extrinsic and intrinsic nervous system in GI function.

Hypothyroidism caused by topical povidone-iodine in a newborn with omphalocele.

A case of physiologic hypothyroidism caused by the topical application of povidone-iodine (PVPI) in a newborn with an omphalocele is presented. The literature on systemic absorption and effects of PVPI is reviewed. A management strategy is offered.

Infectious disease in Antarctica and its relation to aerospace medicine: a review.

In many aspects, an Antarctic Station provides parallels to the environments encountered in space exploration, particularly with reference to infectious disease. In both instances, small groups of people live in isolation for long periods of time in a functionally sterile atmosphere. Therefore, studies of infectious disease in Antarctica should provide important insights into the experiences to be expected in spaceflight. This paper presents a summary of the information on the infectious and immunologic aspects of isolation derived over the years from research in Antarctica.