Intrahepatic sequestered segment of liver presenting as focal fatty change.

Focal fatty change of the liver is a lesion that is often discovered on imaging studies and must be distinguished from space-occupying lesions. The pathogenesis is unknown. We report a lesion of focal fatty change in which the portal supply and biliary drainage were anomalous so that the lesion represents sequestered liver tissue. Because insulin favors the development of steatosis, the pathogenesis of focal fatty change could be explained if the aberrant portal supply contained more insulin than the main portal vein, as would occur if the portal supply arose from pancreatic veins via the parabiliary venous plexus of Couinaud. Furthermore, focal fatty sparing could be explained if the spared segment was supplied by veins draining from the stomach that carry blood with lower insulin levels than the main portal vein.

Pancreatoduodenal necrosis after endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: a case report.

N-butyl 2-cyanoacrylate monomer was injected at endoscopy in an attempt to control arterial bleeding from a duodenal ulcer crater. Segmental infarction of the duodenum and pancreatic head followed and necessitated pancreatoduodenectomy. Butyl 2-cyanoacrylate monomers have been used with angiography as embolization agents and with endoscopy to control variceal bleeding. To our knowledge, there are no reports of its use by endoscopic injection to stop arterial bleeding. Its potential for embolism in nonselective endoscopic injections may minimize the clinical application of butyl 2-cyanoacrylate monomers in the treatment of arterial gastrointestinal bleeding.

Oophorovesicular-colonic fistula: a rare complication of Crohn's disease.

Salpingitis and vesicular fistulas are rare complications of Crohn's disease. In this report the authors describe a case of oophorovesicular-colonic fistula secondary to Crohn's disease. The patient presented with bleeding from the bladder during menstruation, fecaluria and pneumaturia. A single-stage left salpingo-oophorectomy, sigmoid resection and repair of the fistula were carried out, with complete resolution of symptoms and preservation of fertility potential.

Duodenal perforation by a Linton-Nachlas balloon tube.

In a patient with bleeding esophageal varices, inadvertent inflation of a Linton-Nachlas balloon in the third portion of the duodenum led to bowel perforation and death. This complication emphasizes a potential problem in passing a balloon catheter as far as possible down the nares, a technique that has been suggested to prevent balloon catheter inflation in the esophagus. To the best of our knowledge, this is the first reported case of duodenal rupture from attempted balloon tamponade for variceal hemorrhage.

Percutaneous drainage of a tuberculous liver abscess.

The authors describe the management by percutaneous drainage of a rare solitary tuberculous liver abscess in a 37-year-old woman. Open surgical drainage of such abscesses can be avoided using percutaneous drainage combined with transcatheter infusions of antituberculous agents. For the safe and successful use of this method three criteria must be met: the abscess should be unilocular, there must be a safe access route and a previously sterile compartment must not be contaminated. In addition a small (22 or 23 gauge) needle should be used for the initial puncture.

The role of intraoperative heparin in reducing the incidence of postoperative deep venous thrombosis.

A prospective study to determine the incidence of postoperative DVT in patients undergoing vascular surgical operations was carried out. Twenty-eight patients who underwent vascular surgical procedures were studied. Five thousand units of intravenously given heparin was administered intraoperatively to each patient, with no other prophylaxis against DVT being used. DVT was detected by means of radioactive fibrinogen uptake studies. Two patients had DVT develop, an incidence of 7.1 per cent which is lower than the 30 to 40 per cent that might be expected in patients of the same age undergoing general surgical procedures. Both DVT developed in the late postoperative period. It is suggested that the single dosage of heparin given to these patients protects them against the development of DVT and is responsible for the low incidence of DVT observed in these patients.

Prophylactic metronidazole in appendectomy: a double-blind controlled trial.

Ninety-eight patients with suspected nonperforated acute appendicitis have to date been entered into a continuing, prospective, blinded randomized trial to determine the role of prophylactic metronidazole in postoperative wound infection. Twenty-six patients were excluded for the following reasons: diagnosis other than acute appendicitis (16), perforation of the appendix (8), administration of other antibiotics (1), and refusal to enter study (1). Seventy-two patients, 47 men and 25 women, with a mean age of 27.5 years (range 15 to 60 years), underwent appendectomy and were studied. Thirty patients received 1 gm intravenous metronidazole preoperatively and five intravenous doses of 500 mg metronidazole postoperatively. Forty-two patients received placebo only. Cultures of the appendiceal stump grew aerobic cultures in 45 (62%) and anaerobic organisms in 29 (40%): Escherichia coli and Bacteroides fragilis, respectively. Six of the 72 patients (8.2%) developed postoperative wound infections: four of 42 (9.5%) who received placebo and two of 30 (6.6%) who received metronidazole (P = 0.54 by Fisher exact test). No toxicity from metronidazole was observed. The postoperative wound infection rate is insufficient to demonstrate the efficacy of metronidazole for prophylaxis in nonperforated acute appendicitis, although there appears to be a tendency of to assume its efficacy in this regard.

Intracranial pressure in pigs with surgically induced acute liver failure.

Cerebral edema has now been noted to occur frequently in patients dying of fulminant hepatic failure. In the present study, intracranial pressure was monitored in an animal model of acute liver failure. Acute liver failure was induced surgically by hepatic devascularization. Serial monitoring of the electroencephalogram revealed progressive slowing of the frequency with decreasing amplitude. Elevation of the blood ammonia was also observed from baseline values of 64 +/- 12 SE to 744 +/- 97 mumol/liter. Monitoring of the intracranial pressure with a subdural pressure transducer demonstrated a progressive and reproducible rise from 12.8 +/- 2.5 mm Hg immediately after the operation to a mean value of 51.6 +/- 11.8 mm Hg just before death 6--12 hr later. At autopsy, the brains of the test animals were found to be swollen with flattened cortical gyri. In the control animals, intracranial pressure rose slightly but returned toward normal levels (8.0 +/- 2.5 mm Hg) 8 hr after laparotomy and remained normal until their death. There was a statistically significant difference between intracranial pressure levels of the test animals and those of the controls (P less than 0.01). Intravenous methylprednisolone (2.0 g initially followed by 0.5 g every 2 hr) administered immediately before and after hepatic devascularization prevented rises in intracranial pressure but had no effect when given 4 hr after operation. The early and progressive increase in intracranial pressure was an unexpected finding, and an assessment of such a sequence in patients with fulminant hepatic failure is currently in progress.

Obstructive jaundice and portal vein calcification.

Two patients with extrahepatic portal vein obstruction are described in whom calcification within the thrombus was identified during investigation for obstructive jaundice. Evidence from percutaneous cholangiography in one, and endoscopic cannulation of the common bile duct in the other, supported the view that the common bile duct was being partially compressed by the calcified cavernoma.

Effects of cerebral oedema and arterial hypotension on cerebral blood flow in an animal model of hepatic failure.

The effects of arterial hypotension and a raised intracranial pressure on cerebral blood flow (CBF) have been investigated in an animal model of hepatic failure. Arterial hypotension was associated with a fall in CBF in the animals with liver failure but not in the controls. Significant differences in mean CBF between the two groups of animals could be demonstrated when the systolic blood pressure was in the 30-60, 60-90, and 90-120 mmHg range, but not in the 120-150 mmHg range. A raised intracranial pressure also resulted in a fall in CBF in the animals with liver failure, and a significant difference could be demonstrated between the two groups when the intracranial pressure was in the 20-40 mmHg range but not in the 0-20 mmHg range. Furthermore, in the animals with liver failure the cerebral metabolic rate for oxygen (CMRO(2)) fell as the CBF fell, there being a highly significant correlation between these two parameters. In the controls no such relation existed. Treatment with neither charcoal haemoperfusion nor high dose corticosteroids affected the fall in cerebral blood flow that occurred during arterial hypotension in the animals with liver failure. Corticosteroids, however, did reduce the fall in cerebral blood flow associated with a high intracranial pressure. These results suggest a disruption of the cerebral circulatory responses in hepatic failure. They also raise the possibility that CMRO(2) and cerebral blood flow may be maintained at normal levels in hepatic encephalopathy if cerebral oedema and arterial hypotension can be prevented.

Recognition and management of embolism to the superior mesenteric artery.

Two cases of superior mesenteric arterial embolism are presented. The diagnosis should be suspected when severe abdominal pain develops suddenly in a patient with a cardiac arrhythmia or a recent history of myocardial infarction. Further support for the diagnosis is given by the finding of a poor peripheral circulation and a paucity of abdominal physical signs. The value of arteriography is questionable except to distinguish between thrombosis and embolism. The importance of early laparotomy as a diagnostic and life-saving measure is emphasized.