Crohn's Disease Presenting as Granulomatous Appendicitis.

Granulomatous appendicitis is uncommon. It can be caused by infectious or systemic disorders, such as Crohn's disease (CD) and sarcoidosis. It is therefore essential to investigate systematic causes of granulomatous appendicitis after surgery by appropriate examinations. It is also rare for acute appendiceal inflammation to develop due to active CD. We herein report a case of CD presenting as granulomatous appendicitis. The patient was a 28-year-old man who arrived at the emergency room with right lower abdominal pain. Computed tomography showed a low-density lesion with a clear boundary and a small high-density spot in its center behind the cecum. Acute appendicitis with abscess formation was suspected and conservative treatment was started. After 3 consecutive days of conservative treatment there was no improvement in his condition. We therefore performed open appendectomy. Histopathological examination showed numerous noncaseous epithelioid granulomas in the wall of the appendix. Specific staining revealed no evidence of acid-fast bacilli or fungi. During follow-up after discharge, colonoscopy demonstrated erosion from the cecum to the transverse colon. A colon biopsy showed severe inflammation with cryptitis, Paneth cells, and a granulomatous lesion. The patient was therefore diagnosed with CD and treatment with mesalazine was started. Careful examination is necessary to diagnose and properly treat patients with granulomatous inflammation of the appendix.

Angiosarcoma of the gallbladder with hemobilia: a case report.

A 61-year-old woman presented to our hospital with epigastric pain. She underwent abdominal contrast-enhanced computed tomography, which showed signal enhancement in the gallbladder fundus. As biliary obstruction was suspected, endoscopic nasobiliary drainage was performed, which revealed hemobilia. Based on this finding, gallbladder tumor was suspected, and open cholecystectomy was performed. Immunohistological staining of the resected tissue was positive for factor VIII that led to the diagnosis of gallbladder angiosarcoma. Hepatectomy and biliary reconstruction were performed for disease control; however, the patient died due to multiple liver metastases 4 months after the surgery.

[A case of primary hepatic actinomycosis].

Primary hepatic actinomycosis is relatively rare, but it should be remembered in the differential diagnosis of liver masses. A 66-year-old woman with right hypochondralgia was admitted and for detailed examination and treatment of a liver tumor. Abdominal ultrasonography revealed a hypoechoic lesion 55 mm in diameter in the anterior segment. Enhanced CT showed a deep-stained tumor in the early phase and a low density area in the late phase. The feeding arteries were the right hepatic artery and right inferior phrenic artery on abdominal angiography. The patient was given a diagnosis of hepatocellular carcinoma with invasion of the inferior lobe of the right lung. We performed a central bisegmentectomy of the liver and partial resection of the inferior lobe of the right lung. Microscopic findings of the resected specimen revealed sulfur granules and the tumor was diagnosed as primary hepatic actinomycosis.

Effectiveness of Roux-en-Y reconstruction after distal gastrectomy based on an assessment of biliary kinetics.

PURPOSE: To evaluate the efficiency of Roux-en-Y reconstruction (RY) after distal gastrectomy we compared postoperative physiological functions and disorders among patients who underwent RY, conventional Billroth I reconstruction (BI), or Billroth II reconstruction (BII). METHODS: The subjects were 91 patients who had undergone distal gastrectomy for gastric cancer more than 1 month earlier. To examine the severity of gastroesophageal reflux, acid reflux and alkali reflux were assessed, and to examine the severity of duodenal reflux into the remnant stomach, biliary scintigraphy was performed. The degree of inflammation in the esophagus and remnant stomach was examined by endoscopy. Questionnaires on postoperative complaints were sent out to the patients to determine how serious their reflux symptoms were. RESULTS: Both acid and alkali reflux were mild in the RY group. Biliary reflux into the remnant stomach, as assessed by biliary scintigraphy, was significantly less severe in the RY group than in the BI and BII groups. Endoscopy showed that inflammation of the lower esophagus and remnant stomach was much less severe in the RY group than in the BI and BII groups. According to the questionnaire survey, none of the patients in the RY group reported any reflux symptoms. CONCLUSIONS: In this series, RY was found to be a superior reconstruction method after distal gastrectomy since it was rarely accompanied by the reflux of duodenal juice into the remnant stomach or gastric reflux into the lower esophagus.