Consequences of dysthyroidism on the digestive tract and viscera.

Thyroid hormones define basal metabolism throughout the body, particularly in the intestine and viscera. Gastrointestinal manifestations of dysthyroidism are numerous and involve all portions of the tract. Thyroid hormone action on motility has been widely studied, but more complex pathophysiologic mechanisms have been indicated by some studies although these are not fully understood. Both thyroid hormone excess and deficiency can have similar digestive manifestations, such as diarrhea, although the mechanism is different in each situation. The liver is the most affected organ in both hypo- and hyperthyroidism. Specific digestive diseases may be associated with autoimmune thyroid processes, such as Hashimoto's thyroiditis and Grave's disease. Among them, celiac sprue and primary biliary cirrhosis are the most frequent although a clear common mechanism has never been proven. Overall, thyroid-related digestive manifestations were described decades ago but studies are still needed in order to confirm old concepts or elucidate undiscovered mechanisms. All practitioners must be aware of digestive symptoms due to dysthyroidism in order to avoid misdiagnosis of rare but potentially lethal situations.

[A rare cause of acute abdomen: jejunal diverticulitis]. / Une cause rare d'abdomen aigu: la diverticulite jéjunale.

INTRODUCTION: Jejunal diverticulitis is a rare cause of acute abdomen and is diagnosed preoperatively only infrequently. CASE: A 34-year-old man presented with a history of increasing nonradiating epigastric and left upper abdominal pain and with fever, constipation, nausea and vomiting. His white blood cell count was 18,300/mm(3). Liver function tests and pancreatic enzymes were in the normal range. An abdominal CT scan showed jejunal diverticulitis and bubble gases in the extraluminal space. Perineal irritation led to an emergency midline laparotomy, which discovered diverticulitis of the jejunum at 50 cm from the Treitz ligament, resected the jejunum and performed end-to-end anastomosis. The pathology examination confirmed the diagnosis. DISCUSSION: Because the clinical presentation of complicated jejunal diverticulitis is generally nonspecific, diagnosis is very difficult. CT scan is a reliable diagnostic tool. Surgery, including resection of the diseased bowel portion with direct anastomosis, is the treatment generally reported for small intestinal diverticulitis complicated by hemorrhage, obstruction, or perforation. Some authors report using medical treatment only for diverticulitis.

[Surgical treatment of mesenteric venous thrombosis]. / Traitement chirurgical d'une thrombose de la veine mésentérique.

INTRODUCTION: Mesenteric venous thrombosis is a rare form of mesenteric ischemia that can be lethal when appropriate treatment is delayed. CASE: A 61-year-old woman consulted with nonirradiating epigastric and left upper abdominal pain, nausea and vomiting, all of which had been increasing for 4 days. Two years earlier, she had had phlebitis and a pulmonary embolism. Her white blood cell count was 15,300/mm3. Abdominal computed tomography (CT) showed thrombosis of the superior mesenteric vein with no evidence of intestinal parietal ischemia. The patient received a full dose of heparin promptly and underwent selective intra-arterial thrombolysis. As her clinical condition deteriorated, an emergency laparotomy was performed to resect 1.5 meters of gangrenous jejunum. Full anticoagulation with heparin was resumed postoperatively, and she was discharged 15 days after surgery. She continued taking oral anticoagulants. All results of a thorough laboratory work-up were negative. DISCUSSION: The clinic presentation of acute mesenteric venous thrombosis is generally insidious. CT scanning is a reliable diagnostic method. The goal of initial treatment is to define the underlying cause of the patient's hypercoagulable state and to treat it appropriately. After achieving appropriate anticoagulation, patients should start long-term warfarin. Indications for surgery include signs of peritonitis, possible bowel infarction, and hemodynamic instability. Once treated, patients with this condition have a fairly good prognosis.

Intrathoracic transverse colon and small bowel infarction in a patient with traumatic diaphragmatic hernia. Case report and review of the literature.

OBJECTIVE: Herniation of abdominal contents through the diaphragm has been described for a variety of diaphragmatic defects and may be secondary to diaphragmatic injury, either traumatic or iatrogenic. The sequelae of diaphragmatic hernia include intestinal obstruction, strangulation, gangrene and, eventually, perforation. The aim of this study was to report a case of intrathoracic infarction of transverse colon and two meters of small bowel in a patient with traumatic diaphragmatic hernia. PATIENT: Young man with past history of blunt abdominal trauma presented abdominal pain with dyspnea. An exploratory laparotomy was performed. The esophageal hiatus was normal but a 4.5 cm rent was discovered in the posterior leaf of the left hemidiaphragm. Passing through the defect was the transverse colon and a proximal small bowel. The herniated transverse colon and jejunum were massively dilated with evidence of infarction. Transverse colectomy and resection of two meters of jejunum with direct anastomosis were performed. Following bowel removal, diaphragm was directly repaired without graft. Finally, a chest tube was placed in the left hemithorax. RESULTS: Postoperative course was uneventful and he recovered without complications. He was discharged from hospital 10 days after surgery. CONCLUSION: Surgeons, internists and emergency medicine personnel should be aware of the possibility of diaphragmatic hernia in patients with a known history of abdominal trauma. Though uncommon, strangulation of colon and small bowel through a rent in diaphragm should be considered when there is radiologic evidence of herniation.