Bicycle handlebar hernia with multiple enterotomies: a case report.

BACKGROUND: Bicycle handlebar hernias are uncommon form of traumatic abdominal wall hernias (TAWH) resulting from a direct blunt trauma to the anterior abdominal wall. CASE PRESENTATION: This report describes a 14 year-old boy with no history of previous abdominal hernia, presented in the emergency department with an isolated, tender lump in his right iliac fossa after falling off his bicycle. Contrast Enhanced Computer Tomography (CE-CT) showed intestinal loops protruding through the abdominal wall defect with free air in peritoneum suggesting hollow viscus perforation. He underwent emergency laparotomy through transverse skin incision, which showed mid jejunum mesentery tear and multiple enterotomies. A wedge small bowel resection of enterotomies with primary closure, repair of mesenteric tear followed by a primary repair of the abdominal wall hernia was performed. The patient made an uneventful post-operative recovery. CONCLUSION: Bicycle handlebar Hernia (BHH) is a type of traumatic abdominal wall hernia caused by a low impact energy direct blunt injury. We describe a case of BHH associated with small bowel injury which was treated with exploratory laparotomy through skin crease traverse incision. This surgical approach allowed an appropriate exploration of all the intrabdominal structures and primary repair of the hernial defect.

An isolated lump in right groin: an unusual initial presentation of Crohn's disease.

BACKGROUND: Retroperitoneal abscess, extending to the groin as an isolated tender lump, is rare as the first manifestation of Crohn's disease. CASE PRESENTATION: This report describes a young, fit and healthy 22 year-old woman with no previous history of gastrointestinal disorder, who presented with an isolated, tender lump in her right groin as the initial presentation of Crohn's disease. The patient, after a conventional incision and drainage of the abscess, was readmitted with enterocutaneous fistula at the right groin. After radiological investigations, she underwent a laparotomy, which showed jejunal perforation through ileocaecal mesentery producing retrocaecal abscess. There was also a suspicious fistulous connection between jejunum and ileo-caecal junction. A segmental small bowel resection and a limited right hemicolectomy with primary anastomoses were performed. The patient made an uneventful post-operative recovery and was discharged home on the fifth post operative day. CONCLUSION: Crohn's disease could manifest as an isolated, tender groin lump which has not been described in the published literature so far. Since retroperitoneal abscess remains a rare but serious complication of Crohn's disease, aggressive operative therapy should be ensued without delay in order to remove the source of the abscess. Groin abscess could conceal surprises and should always be investigated radiologically before proceeding to incision and drainage.

Health-related quality of life measurement.

PURPOSE: The purpose of this article is to discuss the value of health-related quality of life (HR-QOL) measurement and describe its development with a few examples. DESIGN/METHODOLOGY/APPROACH: The methodology is a literature review of various articles published in the last 25 years on health-related quality of life. FINDINGS: HR-QOL tools are health status instruments, which are utilized to assess the changes in the health status of patients. These surveys are of increasingly importance as healthcare providers are challenged to justify treatment approaches and rationale for any intervention. Objective criteria can be used to determine whether there is clinical evidence of disease. However, the impact of disease on the individual's life is not included in such a clinical assessment. The use of validated and reliable health instruments is directed at measuring this impact in a reproducible and valid fashion. In patient-centred research, "experimental" conditions are constantly changing because human beings with values, feelings, perspectives and social relationships are being treated. It is especially important to use valid measurement tools when assessing these impacts. ORIGINALITY/VALUE: This article is written from the authors' own experience and knowledge and adds those benefits to the literature already available.

Granular cell tumour of the bile duct mimicking distal cholangiocarcinoma: one case report and review of the literature.

Granular cell tumours (Gcts) are rare and most commonly located in the oral cavity, skin or subcutaneous tissue. The occurrence of this tumour in the biliary tract is rare. A 26 year old African man presented with abdominal pain and obstructive jaundice was found to have a localised distal bile stricture suggestive of cholangiocarcinoma which was resected by pylorus preserving partial pancreaticoduodenectomy. Histology revealed a gct of the intrapancreatic portion of the distal bile duct. GCT of the biliary tract are important as they are benign and can mimic bile duct cancers. A review of the 77 reported cases of Gcts of the biliary tract showed that the common bile duct is the most common site of occurrence (n=35). Only 2 cases in literature have been reported to be diagnosed preoperatively. Since there are no characteristic radiological features, the GCTs are difficult to differentiate from cholangiocarcinoma, sclerosing cholangitis or other benign tumors.

HER2/neu expression in bladder cancer: relationship to cell cycle kinetics.

BACKGROUND AND OBJECTIVES: The incidence of overexpression of HER2/neu in bladder cancer is one of the highest among all human malignancies tested; such overexpression is thought to play a role in the aberrant proliferation of cancer cells. This study was conducted to evaluate the quantitative assessment of HER2/neu expression by enzyme immunoassay (EIA) and its prognostic significance in differentiating between high and low proliferating tumors. PATIENTS AND METHODS: Tissue samples were collected from 35 patients with benign bladder lesions, 28 with bilharzial bladder cancer, and 25 with nonbilharzial bladder cancer. Twenty normal samples were obtained from normal safety margin areas in nonbilharzial bladder cancer patients. Out of the malignant samples, 22 were found to be squamous cell carcinoma and 31 were transitional cell carcinoma. All samples were examined for HER2/neu expression by EIA and Western blot (WB). Flow cytometric (FCM) analysis was also performed in all the samples provided. RESULTS: HER2/neu was found to be significantly overexpressed in the malignant group compared to the benign and normal groups (P < 0.001) and no significant difference was found between the bilharzial and nonbilharzial cancer groups or between the transitional and squamous cell carcinoma groups. HER2/neu was significantly correlated to ploidy (P = 0.001), synthetic phase fraction, SPF (P = 0.012), and DNA index (P = 0.002). No significant correlation was found between HER2/neu and stage or grade while it was significantly associated with lymph node status of the tumour (P = 0.02). CONCLUSION: HER2/neu can be measured reliably by the EIA method as confirmed by WB. The quantitative assessment of HER2/neu expression in malignant tumors aided by other proliferation markers such as SPF, DI, and ploidy could be useful in selecting patients for more aggressive treatment or for predicting outcome.

Pancreatic cystic tumors.

Cystic tumors of the pancreas are less frequent than other tumors in neoplastic pancreatic pathology, but in recent years the literature has reported an increasing number. After the first report by Becourt in 1830, cystic tumors were classified into 2 different types by Compagno and Oertel in 1978: benign tumors with glycogen-rich cells and mucinous cystic neoplasms with overt and latent malignancy. The WHO classification of exocrine tumors of the pancreas, published in 1996, is based on the histopathological features of the epithelial wall, which are the main factor in differential diagnosis with cystic lesions of the pancreas. Thanks to the knowledge acquired up to now, a surgical procedure is not always required because the therapeutic choice is conditioned by the correct classification of this heterogeneous group of tumors. Clinical signs are not really useful in the clinical work up, most patients have no symptoms and when clinical signs are present, they may help us to pinpoint the organ of origin but never to identify the type of pathology. In the last few years, the great improvement in imaging has enabled us not only to discriminate cystic from solid lesions, but also to identify the features of the lesions and label them preoperatively. More invasive diagnostic procedures such as fine needle aspiration and intracystic fluid tumor marker level are not really useful because they are not sensitive and the cystic wall can show different degrees of dysplasia and de-epithelialization. These are the reasons for sending the entire specimen to pathology. Good cooperation between surgeons, pathologists, radiologists and gastroenterologists is mandatory to increase the chances of making a proper diagnosis. Therefore, we must analyze all the information we have, such as age, sex, clinical history, location of the tumor and radiological features, in order to avoid the mistake of treating a cystic neoplasm as a benign lesion or as a pseudocyst, as described in the literature. Except for inoperable cases due to the critical condition of the patient or non-resectable lesions, surgical treatment differs with the diagnosis. Cystic tumors of the pancreas, therefore, are a heterogeneous group of tumors, with a real problem regarding differential diagnosis between neoplastic and inflammatory lesions. Even with a proper work up, some perplexity may remain about the nature of the lesion and in these cases the surgical procedure has a therapeutic value as well as playing a diagnostic role. The role of surgery is central in the treatment of these tumors because it could be curative when complete resection is possible. In this way, the lack of good therapeutic results with chemotherapy and radiotherapy force the surgeon to go ahead with the procedure. Intraductal papillary mucinous neoplasms represent a new and, from the epidemiological point of view, important chapter in the world of cystic tumors. The margin of resection is important and the surgeon has to be aware that in order to have a curative resection, total pancreatectomy is sometimes required. In the last few years the therapeutic approach has changed thanks to new knowledge of the biological behavior of these tumors. In fact, from a surgical approach in all cases, we are now discussing the possibility of a follow-up not only for asymptomatic serous cystadenomas but also for the little branch side intraductal papillary mucinous neoplasms (IPMNs) in critical patients. A follow-up could be planned even for solid pseudopapillary tumors but it seems risky to leave untreated big tumors in young patients without a certain diagnosis and with so few studies reported in the literature.

The secondary dyslipidemia and deranged serum phosphate concentration in thyroid disorders.

Hyperlipidemia is a secondary disorder associated with many metabolic disorders including hypothyroidism. The occurrence of dyslipidemia in subclinical hypothyroidism is controversial. Hyperphosphatemia may accompany the dyslipidemia in some metabolic disorders. Both hyperlipidemia and hyperphosphatemia are considered to be risk factors for the coronary heart diseases. In the present study, we investigated the occurrence of dyslipidemia and altered serum phosphate concentrations in patients with thyroid disorders. The results indicated a significantly elevated serum cholesterol and triglyceride concentrations in the hypothyroid patients. The dyslipidemia was accompanied with significantly elevated serum phosphate level. On the other hand, no significant difference was evident in the serum lipid or phosphate concentrations of subclinical hypothyroid patients compared to euthyroid subjects. A significantly reduced serum phosphate level was shown in hyperthyroid patients with unaltered serum lipid levels. Significant correlations were evident between TSH and T(4) levels as independent parameters and the serum concentrations of triglyceride, cholesterol and phosphate. The results indicate in hypothyroidism that a secondary hyperphosphatemia may aggravate myocardial and arterial abnormalities induced by the secondary hyperlipidemia, which may need correction.