Small intestinal sarcoidosis with massive hemorrhage: report of a case

Sarcoidosis of the small intestine is a rarely described complication of systemic sarcoidosis. Although bleeding from sarcoidosis of the esophagus, stomach, and colon has been reported, massive bleeding from this condition in the small intestine has not been previously described. We present here the first case of hemorrhage from a jejunal sarcoid lesion that was unsuspected and undiagnosed until laparotomy with resection was performed. As with most pathologic conditions of the small intestine, preoperative diagnosis is difficult. Furthermore, the refractory nature of bleeding from this lesion made resection necessary in this patient, suggesting the need for similar therapy in other affected patients.     

Aorto-esophageal fistula secondary to benign Barrett's ulcer: a rare cause of massive gastrointestinal hemorrhage

Aorto-intestinal fistula is a rare cause of massive upper gastrointestinal bleeding. The authors report on an 82-year-old man who had an aorto-esophageal fistula due to a benign Barrett's ulcer. The patient presented with a sentinel hemorrhage followed by fatal exsanguination despite vigorous attempts at resuscitation. Management of the entity requires awareness, appropriate radiologic and endoscopic investigation and early surgery. Even with appropriate management, the mortality remains high.     

Pyoderma gangrenosum associated with active chronic hepatitis: report of two cases

In two patients, active chronic hepatitis was complicated by the development of pyoderma gangrenosum. The favorable response of the pyodermatous lesions to azathioprine therapy suggests that this drug may be of value in treating this disorder in patients for whom corticosteroid therapy produces no benefit or is contraindicated because of side effects. Azathioprine, too, is a potentially toxic drug and may need to be discontinued. Possible causal relationships between pyoderma gangrenosum and active chronic hepatitis are discussed.     

Complete atlanto-axial dislocation associated with type II odontoid fracture: a report of two cases

Two cases of complete atlanto-axial dislocation with associated Type II odontoid fracture are reported. In one case, the instability associated with this injury was treated with primary odontoid fixation. In the second case, the patient had full cardiac arrest associated with this injury. Due to the extreme instability present with this fracture sub-type and the potential for neurological compromise, early recognition of this fracture pattern by the treating physician is imperative to prevent fatal spinal cord injury.     

Gastric rupture--an uncommon complication after successful cardiopulmonary resuscitation: report of two cases

In 1996, a sudden increase in pertussis incidence was reported in the Netherlands (2.1 per 100,000 in 1995, 18 per 100,000 in 1996). Although not all potential surveillance artifacts could be excluded, it is highly probable that the data reflect a true outbreak. However, the cause of this increase has not yet been determined. Further research is directed to the severity of disease and a possible mismatch between the vaccine and the circulating Bordetella strains.     

Carcinoid tumor associated with vascular malformation as a cause of massive gastric bleeding

Massive gastric bleeding in a 28-yr-old woman requiring emergency surgical treatment was found to originate from a polypoid carcinoid tumor 1.3 cm in diameter. Histologically, the tumor was found to be associated with a complex vascular malformation apparently originating from the underlying submucosa, crossing the tumor and ending in large mucosal sinusoids that opened on the mucosal surface. A similar clinical presentation was reported in three previous cases of small gastric carcinoids, one of which revealed an anomalous intratumoral bleeding artery. We recommend that in the absence of more common causative lesions of gastric bleeding, gastric carcinoid be considered in cases of focal massive hemorrhage requiring emergency treatment.     

Obstructive jaundice associated with extrahepatic portal vein obstruction: report of two cases

We herein report two cases of obstructive jaundice with markedly dilated collateral veins either in or around the bile duct in the setting of extrahepatic portal vein obstruction (EHPO). In the first case, a proximal splenorenal shunt provided relief of biliary stenosis as well as eradication of esophageal varices due to a decompression of portal hypertension. This evidence proved that the markedly extended collateral veins in the hepatoduodenal ligament caused biliary stenosis by compressing the bile duct. In the second case, obstructive jaundice was probably caused by cholangitis and was relieved with biliary drainage. Portal decompressive surgery was not indicated because of the slight degree of esophageal varices. The relationship between cholangitis and EHPO in these patients calls for further investigation. In cases with EHPO manifesting obstructive jaundice associated with risky esophageal varices, portal decompressive surgery is recommended as the procedure of choice.     

Ulcerative colitis associated with Weber-Christian panniculitis and musculitis: a case report

A case of 22-year-old man suffering from ulcerative colitis, in whom Weber-Christian panniculitis and musculitis occurred simultaneously, is reported. He had suffered from ulcerative colitis for 7 years and he again had bloody stools 1 month before being admitted. Two weeks before admission, large (2-4 cm) subcutaneous tumors appeared. Weber-Christian panniculitis, musculitis, and active stage ulcerative colitis were diagnosed. All the symptoms went into remission after steroid therapy. The possibility of the existence of a common antigen in enterobacterial wall, colonic epithelium, and adipose tissue was suggested.     

Case report: successful obliteration of a bleeding duodenal varix using endoscopic ligation

BACKGROUND: To determine the concentration of cytokines having an immunomodulating effect in the first trimester in women who subsequently developed preeclampsia. METHODS: The serum concentrations of IL-10, TNFalpha, IL-6 and IL-2R were determined in ten women who later developed severe preeclampsia and in ten healthy controls. The groups were compared with the Mann-Whitney U test. RESULTS: The IL-2R concentration was significantly higher in the women who later developed preeclampsia than in normal patients (p = 0.028). No significant differences were detected between the groups with respect to the other evaluated cytokines. CONCLUSION: Elevated IL-2R concentrations in maternal serum as early as in the first trimester may be a sign of immunological maladaptation and might be associated with a disturbance of trophoblastic invasion.     

Ischemic colitis arising in watershed areas of the colonic blood supply: a report of two cases

There are several weak points in the colonic blood supply, known as watershed areas, which result from incomplete anastomoses of the marginal arteries. These watershed areas are more vulnerable to ischemic injury than other parts of the colon. We report herein the cases of two patients who developed ischemic colitis well localized in the cecum, and in the rectosigmoid region at Sudeck's point, respectively. This report and our review of the literature suggest that watershed areas, including the splenic flexure, or Griffith's point, Sudeck's point, and the ileocecal region, are high-risk regions for the development of ischemic colitis.     

Performing a cost-effectiveness analysis: surveillance of patients with ulcerative colitis

OBJECTIVE: To illustrate the principles of cost-effectiveness analysis, this third article in the "Primer on Economic Analysis for the Gastroenterologist" applies published criteria for appraising an economic analysis to a study of the cost-effectiveness of surveillance of patients with ulcerative colitis. METHODS: We review and apply the 10 standard criteria for critical appraisal and evaluation of cost-effectiveness analyses. SUMMARY: We outlined the development and critique of a decision analytic model that examines the cost-effectiveness of surveillance of patients with ulcerative colitis, and we compared the cost-effectiveness of surveillance of patients with ulcerative colitis to other well-accepted medical practices.     

Tuberculosis associated haemophagocytic syndrome: two cases with a favourable outcome

Haemophagocytic syndrome is a heterogenous disease characterized by disordered macrophage activation associated with viral, bacterial or parasitic infection. The few reports of haemophagocytosis occurring in the presence of mycobacterial infection show a high mortality rate and we present two further cases notable for their favourable issue. Rapidity of diagnosis and immediate treatment could explain the avoidance of a fatal outcome.     

Unexpected death due to gestational choriocarcinoma: a report of two cases

The clinical and pathological manifestations of severe intestinal involvement in Wegener's granulomatosis were studied by a review of the literature and reports of two patients. Altogether, six cases, two females and four males, were studied. One patient developed two episodes of bowel manifestations necessitating immediate surgical interventions. The average age at onset of intestinal symptoms was 43.3 yr (26-55 yr) and, in all cases, the first signs of such manifestations developed within the first 2 yr of disease. Prior to the onset of intestinal symptoms, immunosuppressive therapy was administered in six of seven instances. Acute abdominal pain with signs of peritonitis or distention only constituted the main clinical picture in six of the seven events. The last episode was manifested clinically with profuse diarrhoea with blood and mucus. Of the seven instances of severe intestinal manifestations, the small bowel was involved in two, the large bowel in three, and both the small and large bowel were affected in two episodes. Histological evidence of vasculitis in the bowel was demonstrated in three of the seven biopsy specimens, while in four, ischaemia, inflammation and ulceration were the pathological findings. Intestinal perforation was seen four times and surgery was performed in six of seven episodes. Severe intestinal involvement is rare in Wegener's granulomatosis. The initial bowel manifestations occur within the first 2 yr of disease, and affect both the large and small bowel. Histologically, vasculitis, ischaemia, inflammation and ulceration are the prevailing findings. Death due to intestinal catastrophy occurred in one of the six patients reported. Most likely, the manifestations are associated with the disease process rather than related to the use of immunosuppressive agents.     

Spondylolysis associated with Arnold-Chiari malformation and syringomyelia. A report of two cases

STUDY DESIGN: This is a report of two cases. OBJECTIVE: To document the occurrence and association of spondylolysis and Arnold-Chiari malformation Type I. SUMMARY OF BACKGROUND DATA: The association of spinal dysraphism has been reported with Arnold-Chiari Type II, but not with Arnold-Chiari Type I. METHODS: The senior author was involved in the care of these patients. All medical records, laboratory and radiologic investigations, and related literature were reviewed. RESULTS: The presence of cephalic and caudal neuropore maldevelopment may be present in various combinations. The presence of spondylolysis, with or without spina bifida occulta, associated with Arnold-Chiari malformation type I and syringohydromyelia, is demonstrated. CONCLUSIONS: In some patients, the presence of spondylolysis may represent a congenital anomaly and may be associated with cephalic neuropore maldevelopment, such as cerebromedullary malformation syndrome (i.e., Arnold-Chiari malformation Type I).     

Cardiac asystole post-exercise: a report of two cases

Two patients are described with reproducible cardiac asystole post-exercise. No structural heart disease was demonstrable. At autonomic function testing no abnormal responses were noted. Also, head-up tilt tests were normal. However, electrophysiologic testing and heart rate variability during 24-h Holter monitoring were indicative of a high vagal tone in both patients. The findings suggest that post-exertional asystole may not be due solely to a vasovagal mechanism; excessive rebound vagotonia per se may also play a role.     

Epignathus: report of a case with successful outcome

Epignathus is an extremely rare form of teratoma that arises from the palate or pharynx in the region of the basisphenoid (Rathke's pouch). This condition is associated with a high mortality rate caused by severe airway obstruction in the neonatal period, thus requiring prenatal planning and prompt surgical treatment after birth. The authors describe a case of a giant epignathus that was successfully resected followed by an uneventful recovery.     

Intracranial hemorrhage associated with idiopathic thrombocytopenic purpura: report of seven patients and a meta-analysis

We present the results of a meta-analysis using clinical data obtained from seven of our patients and 24 previously reported patients with idiopathic thrombocytopenic purpura complicated by intracranial hemorrhage. Twenty-four had an intracerebral hemorrhage (ICH) and seven had a subdural hematoma (SDH). Mean age of the patients with ICH was significantly younger than those with SDH. The mortality rate of ICH associated with ITP was similar to that of spontaneous ICH. All seven patients with SDH improved without sequelae.