Urinary bladder bilharziasis as a cause of impaired bladder muscle contractility

In an attempt to evaluate the effect of bilharziasis on bladder contractility as a factor in the genesis of voiding disorders, 44 cases of bilharzial bladder neck obstruction diagnosed using traditional methods (symptomatological, radiographic, and endoscopic) were subjected to complete urodynamic evaluation (flowmetry, cystometry, pressure/flow study, and stop-flow test). Their parameters were compared with those of 28 patients with urodynamically obstructed benign prostatic hyperplasia and 8 nonsymptomatic controls. Contractility parameters (isometric detrusor pressure, maximum estimated flow rate, detrusor power at maximum flow) were calculated for the studied cases and their distribution according to the Schafer pressure/flow diagram was evaluated. Bladder biopsy including the detrusor was evaluated in all 72 patients. Poor bladder contractility associated with an extensive bilharzial effect on the detrusor muscle was found to be the major abnormality in 20 of 44 patients with presumed bilharzial bladder neck obstruction with no evidence of urodynamic outflow obstruction. We believe such a workup is essential in cases of suspected obstruction associated with bilharziasis to throw light on the pathophysiology of the voiding disorders, avoid unnecessary surgery, and provide a better prognosis.     

Endometriosis in the round ligament of the uterus as a cause of inguinal pain

Within one year three patients, women aged 31, 28 and 26 years, presented with a cyclic painful small mass in the inguinal region. Histopathological examination of the resected specimen showed a pattern consistent with an extra-abdominal localization of endometriosis in the round ligament. The patients' complaints disappeared after surgical resection. It is concluded that in case of a painful mass in the inguinal region in a fertile woman endometriosis of the round ligament should be considered.     

Mucinous cystadenoma of the pancreas as a cause of acute pancreatitis

Acute pancreatitis is only rarely the first presentation of a cystic neoplasm of the pancreas. Mucinous cystadenomas have not been reported to be a cause of acute pancreatitis; however, we present two cases of mucinous cystadenoma of the pancreas which have caused acute pancreatitis. Both patients (female) presented acute abdominal pain, with serum amylase elevation and ultrasound scan (US) and computed tomography (CT) evidence of moderate pancreatitis, which resolved with medical treatment; fluid collection in the distal pancreas had been misinterpreted as a pseudocyst. There was no history of alcohol abuse or gallstone disease. After distal pancreatectomy the diagnosis of mucinous cystadenoma was confirmed; in one case a large pseudocyst was associated with this diagnosis. Pre-operative differential diagnosis between inflammatory and neoplastic cysts is difficult, especially when the patient's first presentation is due to an episode of acute pancreatitis. A neoplastic cyst should be considered when acute pancreatitis attacks occur in non-alcoholic women, who do not have gallstone disease.     

Rupture of follicular and corpus luteum ovarian cysts--the cause of acute gynecological abdomen

The symptomatology of the ruptured follicular and corpus luteum cysts varies from clinical occult status to haemorrhagic shock according to clinical studies for a ten years period. The syndrome frequency is higher in women over 30 years of age at rate 1:2 of the follicular to luteum cysts affecting mainly the right ovary. Twenty percent of the patients have been treated conservatively. Preoperative and intraoperative diagnosis coincides in 92% of the cases.     

Postsplenectomy Capnocytophaga canimorsus sepsis presenting as an acute abdomen

Patients with intra-abdominal processes that require prompt surgical intervention, including appendicitis, perforated viscus, ischemic bowel, volvulus, and bowel obstruction, often present with signs and symptoms of an acute abdomen. Several medical problems can mimic an acute abdomen. Overwhelming postsplenectomy infection is a life-threatening condition that can present with acute abdominal symptoms. The incidence of overwhelming postsplenectomy infection ranges from 1% to 25%, and is caused by Streptococcus pneumoniae in 50% of cases. Capnocytophaga canimorsus, a bacteria commonly found in dog saliva, accounts for less than 1% of cases. Overwhelming postsplenectomy infection has a rapidly deteriorating course that progresses to respiratory and renal failure, cardiovascular collapse, and death. The mortality associated with overwhelming postsplenectomy infection is 60% to 80%. Early diagnosis and institution of appropriate antibiotic therapy and supportive care is essential to improve patient outcome. A previously healthy woman who had undergone splenectomy secondary to trauma 11 years earlier presented with symptoms of an acute abdomen. A diagnosis of overwhelming postsplenectomy infection due to C canimorsus was made based on her peripheral blood smear and blood culture findings. Early aggressive care and antibiotic treatment resulted in a successful outcome for this patient with no long-term morbidity. This patient's clinical course demonstrates the importance of early diagnosis and treatment of overwhelming postsplenectomy infection.     

Computer assisted diagnosis of the acute abdomen

Computer assisted diagnosis (CAD) has been claimed to improve the accuracy of assessment of the acute abdomen. Alternative techniques that may improve decision making are briefly reviewed and CAD is examined critically. The structured collection of complete clinical data with performance feedback, results in improvements comparable to CAD. Computer systems are costly and when installed are used selectively and variably by clinicians. Their place in surgical practice remains to be established.     

Sensitivity to a metabolite of diclofenac as a cause of acute immune hemolytic anemia

A 75-year-old woman taking the nonsteroidal anti-inflammatory drug diclofenac (DCF) presented with acute Coombs-positive hemolytic anemia and subsequently developed renal failure. A drug-dependent antibody specific for red blood cells (RBCs) could not be demonstrated by in vitro testing with DCF. However, her serum was found to contain an IgM antibody that reacted strongly with RBCs in the presence of urine from any of four subjects who had ingested DCF. The active substance in urine was isolated, subjected to high-performance liquid chromatographic (HPLC) analysis, and found to be a glucuronide conjugate of a known DCF metabolite, 4'-hydroxydiclofenac (4'-OH DCF). Negative results were obtained with four other DCF metabolites. Two 4'-OH DCF glucuronides were synthesized in vitro using a liver microsomal system. One promoted agglutination of normal RBCs by the patient's serum and was identified as the glucuronide ester of 4'-OH DCF by proton nuclear magnetic resonance (NMR) analysis. Studies with a panel of RBCs showed that the patient's antibody reacted preferentially with the e antigen of the Rh system. Acute immune hemolytic anemia in this patient appears to have been caused by sensitization to DCF modified by 4' hydroxylation and glucuronidation. This is the first reported example of immune cytopenia caused by sensitivity to a glucuronide conjugate of a drug metabolite. Since glucuronidation is a common pathway of drug metabolism, studies of the frequency with which glucuronide derivatives of primary medications cause immune cytopenia seem warranted.     

Interventional radiology in the acute pediatric abdomen

This article addresses the most common types of interventional procedures performed in the pediatric abdomen. Nonvascular interventions are stressed because they are more common than vascular interventions.     

Late complication of laparoscopic salpingoophorectomy: retained foreign body presenting as an acute abdomen

The technique of immunocytochemistry was used to identify myoglobin in kidney, confirming a diagnosis of neuroleptic malignant syndrome following an otherwise obscure autopsy in a decomposed body. The features of neuroleptic malignant syndrome are reviewed with a differential diagnosis of myoglobin renal casts. The report emphasizes a thorough and detailed assessment of deaths which occur during treatment with neuroleptic drugs.     

Primary volvulus of the small intestine: vascular-like acute abdomen

The Authors discuss etiology, clinical picture, diagnostic and therapeutic possibilities of intestinal volvulus, an uncommon disease in Europe, thinking of a case of primitive small intestine volvulus, recently observed, and considering the literature. The Authors have come to the conclusion that in all the cases of intestinal occlusion, in emergency hospitalization, it is important to suspect the intestinal volvulus and to operate on the patient urgently to avoid the raise of postoperative mortality in all the cases complicated with intestinal gangrene.     

Laparoscopic management of a noncommunicating uterine horn in a patient with an acute abdomen

INTRODUCTION: The presence of the apolipoprotein E4 allele (apoE4) has been recognized as a risk factor for the development of presenile and senile forms of Alzheimer's dementia (AD). MATERIAL AND METHODS: The apoE alleles frequency of 71 normal controls (NC), 60 demented controls (DC) and 50 senile type AD subjects was determined by polymerase chain reaction in order to get data about the apoE polymorphism of the Hungarian AD population. RESULTS: The apoE3/3 genotype was the most common in all groups. The apoE4 frequency was significantly higher (28%) in the AD group than that was (7% and 9%) in the NC and DC populations, respectively. No apoE4 homozygotes were found in the DC group and the number of heterozygotes was lower in the DC than in the AD group. CONCLUSION: The results are in good agreement with others in the literature and support the occurrence of an increased apoE4 allele frequency in Hungarian senile AD population.     

Middle-ear lipoma as a cause of otomastoiditis

We present a case report which describes a rare cause of a common clinical problem; eustachian tube dysfunction. A seven-year-old child presented with a history of chronic draining ears, despite rigorous medical therapy and multiple ventilation tubes. At myringotomy a mass was noted in the middle ear, and she was taken to the operating room for exploration. The patient was found to have a pedunculated lipoma arising from the anterior medial aspect of the middle-ear cleft producing intermittent obstruction of the eustachian tube orifice. This case represents the fourth case of a middle-ear lipoma in the world literature. We present a review of the literature and an exploration of possible aetiologies of this unusual entity in the differential diagnosis of eustachian tube dysfunction.     

Sacral haemangioma as a cause of coccydynia

We report a 55-year-old woman with coccydynia due to a sacral mass. The histological diagnosis was haemangioma. The MRI findings and the unusual location of this lesion are discussed.     

Systemic mastocytosis as a cause of osteoporosis

Out of 21 male patients with osteoporosis who visited an outpatient clinic for endocrine diseases in two years (1994-1995), three had systemic mastocytosis as diagnosed histopathologically. Two of these had characteristic features of urticaria pigmentosa, consisting of multiple brown nodules on the skin of trunk and extremities, and a positive Darier sign. In all of them the excretion of the histamine metabolites methylhistamine and methylimidazoleacetic acid in a 24-hour urine specimen was increased. When osteoporosis is diagnosed in men or premenopausal women, underlying pathology could be considered. Cautious investigation of signs and symptoms of systemic mastocytosis in such patients might prove this disease be less rare than is often assumed.     

Intestinal pseudoobstruction as a feature of myotonic muscular dystrophy

We report two cases of intestinal pseudoobstruction caused by visceral smooth muscle involvement due to myotonic muscular dystrophy. Two patients with myotonic muscular dystrophy presented with abdominal pain, distention, constipation, and vomiting. The exclusion of mechanical obstruction by plain abdominal radiography, contrast studies, and colonoscopy led to the diagnosis of intestinal pseudoobstruction. Diagnosis was confirmed by manometric and cineradiographic findings of abnormal intestinal motility. Conservative management including laxatives and cisapride led to the resolution of the pseudoobstruction syndrome and long-term remission without relapses during a two year follow-up. In patients with known myotonic dystrophy the occurrence of intestinal pseudoobstruction should be considered in order to avoid unnecessary laparotomies.