Massive pancreatic duct haemorrhage.

Direct fistula between the splenic, artery and the pancreatic duct is briefly reviewed. The literature indicates that such a fistula is almost always due to a pancreatic artery aneurysm. Because of diagnostic difficulties, a variety of operations have been performed on these patients prior to arriving at the correct diagnosis. A patient's history of direct fistula between the splenic artery and the pancreatic duct, causing recurrent haemorrhage and eventual death from massive blood loss, is described. Unlike other reported cases, this was not associated with an angiographically demonstrable aneurysm of the splenic artery. Treatment by distal pancreatectomy or radiologically guided pancreatic artery embolization is discussed.

Fast food arthritis--a clinico-pathologic study of post-Salmonella reactive arthritis.

OBJECTIVE: To study the clinical presentation, immunogenetics, and serum immune response to lipopolysaccharide (LPS) in a cohort of patients with post-Salmonella reactive arthritis (ReA). METHODS: A validate ReA screening questionnaire (Quest 2) was mailed to 919 individuals reporting symptoms of gastroenteritis to the health department after eating at a single restaurant. Three hundred twenty-one persons returned questionnaires; 170 reported symptoms outside the gastrointestinal tract; 23 of those 170 reporting persistent joint symptoms were seen 4 to 16 weeks after the outbreak and 5 of the 23 were seen in followup 12 to 20 weeks later. Clinical features, HLA Class I typing, serum soluble CD8 levels, and serum antibodies to gram negative LPS by ELISA were determined. RESULTS: Joint complaints were reported more frequently by individuals with a longer duration of diarrhea. Upper extremity joints were frequently involved, and 66% reported one or more extraarticular symptoms of Reiter's syndrome. Three of 5 typed individuals were HLA-B27 positive, including 3 of the 4 most severely involved. Serum soluble CD8 levels correlated poorly with disease activity measured either clinically or by C-reactive protein. Antibodies to Klebsiella and Shigella LPS rose over time, while antibodies to Salmonella LPS fell. CONCLUSION: The clinical picture of post-Salmonella ReA is less stereotyped than often assumed, although severity correlated with HLA-B27 status. The association of joint symptoms with duration of diarrhea and the kinetics of the anti-LPS antibody response support the hypothesis that abnormal gut permeability plays a role in the pathogenesis of post-Salmonella ReA.

Perforated appendix in an inguinal hernial sac: Amyand's hernia.

A patient with a perforated appendix in a right inguinal hernial sac is reported. Some of the history of this condition is reviewed and a case is made that an appendix appearing in an inguinal hernial sac should carry the eponymous term "Amyand's hernia".