Pancreatic trauma: The role of computed tomography for guiding therapeutic approach.

AIM: To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach. METHODS: CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as "pancreatic injury", "pancreatic contusion", "pancreatic laceration", "peri-pancreatic fluid", "pancreatic active bleeding". All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid). RESULTS: One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases. CONCLUSION: CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.

Idiopathic adult colo-colonic intussusception: Case report and review of the literature.

INTRODUCTION: Acute colonic intussusception occurring in the absence of organic cause is uncommon in adults. PRESENTATION OF CASE: We report acute colonic intussusception in a 46-year-old female; clinical evidence of a palpable mass, abdominal pain and bloody mucoid stools appeared a few hours after hospital admission. Multislice CT-scan confirmed the clinical diagnosis and surgical exploration revealed right colonic obstruction caused by intussusception of the cecum into the ascending colon. Right hemicolectomy was performed and histopathological examination did not reveal any causative pathology. DISCUSSION: Intussusception remains a rare condition in adults, representing 1-5% of bowel obstruction and accounting for 0.003-0.02% of all hospital admissions. Intussusception occurs more frequently in the small (50-80%) than in the large bowel (12-50%). It is estimated that approximately 90% of intussusceptions in adults are secondary to an anatomical or pathological condition, of which more than half are malignant. Idiopathic cases are the exception in adults. The clinical presentation of adult intussusception differs considerably from the classic pediatric presentation of abdominal pain, palpable mass, and blood per rectum, which is rarely seen in adults. A pre-operative CT-scan showed a 10cm intussuscepted segment of right colon. Surgical resection was considered mandatory because of severe bowel obstruction, and the theoretical possibility of occult malignancy. This approach was vindicated by the presence of widespread ischemic lesions in the wall of the resected bowel, without any obvious lead point. CONCLUSION: There are few reports in the medical literature of acute colonic intussusception occurring in the absence of organic cause in adults.

Splenic localization of the peritoneal mesothelioma: case report and literature revue.

Peritoneal mesothelioma is a rare form of malignant mesothelioma, making up <30% of diagnosed mesothelioma cases. Because of a lack of specific symptoms (abdominal pain, abdominal swelling), normally it is diagnosed in advanced stages, sometimes in a surgical emergency (intestinal obstruction, severe ascites) and occasionally during image procedures or laparoscopy which can show a mass developing from peritoneal mesothelium surfaces, or an accumulation of small irregularities that may be tumors or plaques. The reported case refers to a particular localization of a peritoneal mesothelioma, the spleen, discovered only after a splenectomy, due to the clinical and radiological suspect of a rupture.

Case report of a primary multiloculate muscular cystic hydatidosis.

Hydatidosis is a zoonosis caused by the ingestion of Echinococcus granulosus eggs, released though the feces, from infected dogs to humans. Primary localization is mostly hepatic and/or pulmonary, whereas muscular involvement is very rare, even more so in muscular striated tissue. This is the report of a case of a primary intramuscular hydatid cyst in a 79-year-old woman who presented with a 3-year history of a painful lump in her proximal medial left thigh. The authors document the exceptional giant dimensions of the cyst, which have not previously been reported in a case of striated muscular hydatid disease.

Massive gastrointestinal bleeding due to splenotic nodule of the gastric wall. A case report.

Splenosis results from autotransplantation of splenic tissue after traumatic splenic rupture or surgery. Usually asymptomatic, splenosis is an incidental finding at surgery, unrelated to the splenosis, for intestinal obstruction or suspected appendicitis or gynaecological pathology. This article describes a unique case of massive gastrointestinal bleeding caused by deep invasion of a splenotic nodule into the gastric wall.

[Acute appendicitis: is this common pathology still of interest?]. / Appendicite acuta: c'è acora interesse per una patologia così comune?

Despite the indisputable progress of technology (laboratory analyses, scintigraphy, ultrasonography, computed tomography), the diagnosis of acute appendicitis often remains uncertain, with a rate of useless appendectomies amounting to almost 20% of cases. The ideal diagnostic test has yet to be discovered and, in any case, clinical observation remains the cornerstone of any decision-making algorithm. Thus, acute appendicitis continues to offer food for thought in relation to the aetiology of the condition, which is still unknown, the primacy of the clinical diagnosis, and the learning of the surgical skills required. In the present study, the authors compare their personal experience with the relevant data in the international literature, emphasising a number of issues such as the problem of diagnosis, acute appendicitis in pregnancy, laparoscopic therapy, and the so-called "useless appendectomies" and presenting their own point of view.

Small bowel obstruction due to intramural hematoma during anticoagulant therapy. With regard to two cases treated conservatively.

Hemorrhage following prolonged oral anticoagulant administrations is a well recognized hazard of therapy, and hemorrhagic complications are said to occur in 10-30% of patients. Following the presentation of the cases, the authors examine the current literature concerning the problems with anticoagulants, and recommend models of diagnosis and treatment of complications by bowel obstruction. Authors report on two cases of small bowel obstruction due to intramural hematoma during anticoagulant therapy. It is extremely important to recognize this syndrome in order to avoid unnecessary operative intervention. Therefore, laparotomy is not indicated.

Pathobiology of cholesterol gallstone disease: from equilibrium ternary phase diagram to agents preventing cholesterol crystallization and stone formation.

The primum movens in cholesterol gallstone formation is hypersecretion of hepatic cholesterol, chronic surpersaturation of bile with cholesterol and rapid precipitation of cholesterol crystals in the gallbladder from cholesterol-enriched vesicles. Associated events include biochemical defects (increased biliary mucin, and increased proportions of hydrophobic bile salts in the intestine and gallbladder), motility defects (gallbladder smooth muscle hypocontractility in vitro and gallbladder stasis in vivo, sluggish intestinal transit), and an abnormal genetic background. The study of physical-chemical factors and pathways leading to cholesterol crystallization in bile has clinical relevance and the task can be carried out in different ways. The lithogenicity of bile is investigated in artificial model biles made by three biliary lipids - cholesterol, bile salts and phospholipids - variably combined in systems plotting within the equilibrium ternary phase diagram; also, crystallization propensity of ex vivo incubated human bile is studied by biochemical analysis of precipitated crystals, polarizing quantitative light microscopy and turbidimetric methods. The present review will focus on the recent advances in the field of pathobiology of cholesterol gallstones, by underscoring the role of early events like water transport, lipid transport, crystallization phenomena - including a genetic background - in gallstone pathogenesis. Agents delaying or preventing precipitation of cholesterol crystals and gallstone formation in bile will also be discussed.