Disseminated intravascular coagulation in nonocclusive mesenteric ischemia: the lack of specificity of fibrin thrombi in intestinal infarction

The significance and frequency of fibrin thrombi (FT), the pathological hallmark of disseminated intravascular coagulation (DIC), in ischemic intestine were analyzed in a retrospective study of the infarcted bowel of patients with occlusive mesenteric ischemia (OMI) and nonocclusive mesenteric ischemia (NOMI). Representative intestinal sections were studied from 10 patients with NOMI of the small and/or large bowel and 12 patients, with OMI of varied etiology. Three patients with inflammatory bowel disease and 1 patient with DIC and bowel necrosis were also studied. Routine hematoxylin and eosin stains for fibrin were prepared for each specimen. The number of FT was quantitated. FT were identified in each of the 10 cases of NOMI; however in only 2 were they prominent. FT were identified in 6 of the 12 cases of OMI and in 4 of these 6 they were a prominent feature. Rare FT were present in the cases of inflammatory bowel disease and did not correlate with the inflammatory process. No FT were present in the intestinal sections of the DIC case. FT are a nonspecific feature of necrosis and can be identified in both occlusive and nonocclusive ischemic bowel disease. Their presence in the intestine of NOMI therefore cannot be used to implicate DIC as the primary cause of this entity.     

Diabetes mellitus accompanied by nonocclusive colonic ischemia

A 70-year-old man with diabetic triopathy was hospitalized with left lower quadrant abdominal pain and tenderness, muscle guarding and absent bowel sounds. Three hours after admission, creatine phosphokinase (CPK) was elevated and an abdominal plain film X-ray showed intestinal gas retention, indicating paralytic ileus due to inferior mesenteric artery occlusion. Urokinase (60,000 units/day) and heparin (10,000 units/day) were administered. Angiography showed no occlusion in the mesenteric artery. On the 16th day, the abdominal signs had disappeared and CPK was normalized. We diagnosed this case as nonocclusive colonic ischemia because of the hemorheological abnormalities due to diabetic triopathy and the hypercoagulable state.     

Acute mesenteric ischemia

Acute mesenteric ischemia resulting from specific etiologies is a treatable vascular emergency. It requires a high index of suspicion and prompt, aggressive resuscitation and diagnostic maneuvers to determine the specific underlying cause. This will allow specific directed surgical revascularization, optimization of cardiac performance, or correction of a hypercoagulable state, all directed at maximizing the amount of functional bowel that is salvageable. These strategies are the cornerstones for a successful outcome in this life-threatening vascular catastrophe.     

Chronic mesenteric ischemia

Thirty-four patients (twelve men, 22 women, mean age 53[16-71] years) with chronic mesenteric ischaemia were operated upon between 1979 and 1992. The most frequent symptom was loss of weight (50%) and postprandial pain (44%). The mean interval between onset of symptoms and diagnosis was 35 months. Angiography revealed disease of the coeliac trunk (CT) or the superior mesenteric artery (SMA) in 16 patients, of only the SMA in ten, and of only the CT in eight. Revascularisation was obtained with an autologous vein graft in 21 patients (on the TC in 12, AMS in nine), while transaortic endarterectomy was performed in 15 (on the CT in seven, the AMS in nine). There was one perioperative death. 20 patients were symptom-free 1-126 months after the operation, while five still had residual symptoms even though improved in three. Seven patients had a recurrence of symptoms, three immediately after operation and four after an initial symptom-free period. These results show that freedom from symptoms can be achieved even in advanced stages of chronic mesenteric ischaemia by reconstructive surgery of the intestinal and visceral arteries. However, residual symptoms that are possibly not of a vascular nature may persist after successful vascular reconstruction. Patients with recurrent obstruction may become symptom-free by repeat surgery even many years later.     

Acute mesenteric ischemia. CT and plain radiographic analysis of 26 cases

GABA acts as a trophic signal for cultured embryonic rat monoamine neurons by activating GABA(A) receptors. These effects are blocked by the organochlorine insecticide dieldrin and the classic GABA(A) antagonist bicuculline. Both dieldrin and another organochlorine insecticide, lindane, block the effects of GABA on the GABA(A) receptor by binding directly to the Cl- channel. Therefore, prenatal exposure to these chemicals could lead to disturbances in the trophic actions of GABA on monoamine neurotransmitter systems in the embryonic brain and produce alterations in GABA(A) receptor expression and function. Effects of daily prenatal exposure to organochlorine insecticide (dieldrin or lindane) or bicuculline from embryonic day (E)12-17 were determined in brains of E17 fetal rats using t-[35S]butyl-bicyclophosphorothionate ([35S]TBPS) binding. This radioligand was chosen because, like organochlorine insecticides, it binds directly to GABA(A) receptor/Cl- channels. [35S]TBPS binding was analyzed in extensively washed membranes from E17 brainstem and whole brain with the brainstem removed ('rest of brain') at a TBPS concentration that approximated the KD determined in [35S]TBPS saturation binding experiments performed on normal E17 rat brainstem. In utero exposure to dieldrin, lindane, or bicuculline from E12-E17 caused a significant reduction in the amount of [35S]TBPS binding in E17 brainstem compared to vehicle-injected controls, but had no significant effect on 'rest of brain'. These data suggest that in utero exposure to organochlorine insecticides that act as GABA(A) antagonists negatively regulate expression of GABAA receptors in fetal brainstem. If these effects persist, they could lead to disturbances in postnatal functions of the ascending GABAergic system, possibly with behavioral consequences.     

Acute arterial mesenteric ischemia

The authors report the experience of their surgical department, in the treatment of acute arterial mesenteric ischemia. They insist on the diagnostic, and sometimes therapeutic, interest of mesenteric arteriography. Arterial revascularisation must be the surgical aim. In spite of this attitude, the prognosis of acute mesenteric ischemia remains very severe.     

Treatment of locally advanced carcinoma of the urinary bladder with preoperative radiotherapy and radical cystectomy versus radical cystectomy alone

Metastasis to the orbit from pancreatic adenocarcinoma is rare. A 38-year-old man with metastatic adenocarcinoma of the right orbit at initial examination is described. Two months later he was diagnosed with a pancreatic primary tumor. The incidence and pattern of orbital metastasis in carcinomas is briefly discussed.     

Comparison between results of ileal conduit and continent ileal bladder (VIP), after radical cystectomy

OBJECTIVES: The aim of the present study is to analyze the results achieved with the ileal bladder according to the VIP (vescica ileale Padovana) procedure. METHODS/RESULTS: We compared the results obtained in 31 patients with invasive bladder cancer who underwent radical surgery (22 underwent the ileal conduit procedure and 9 were treated by orthotopic bladder substitution) and analyzed the early complications, long-term results and physiological data of the group submitted to the VIP procedure. In the patient group submitted to the VIP procedure, there was only one case who required removal of the new bladder due to an enteroneovesical fistula. Another case developed medium serrate anular stricture of the bulbar urethra about 8 months postoperatively and was treated by endoscopic urethrotomy. The uroradiologic and urodynamic evaluations confirmed urinary tract stability integrity of renal function and good adaptation of the new reservoir. The andrological studies showed complete sexual potency in 2 of 9 patients. CONCLUSIONS: The VIP procedure appears to be a good technique, with complications no greater than those of traditional urinary diversion, and improves the quality of life of patients undergoing radical surgery for invasive bladder cancer.     

Pregnancy outcome after laparoscopic fimbrioplasty in nonocclusive distal tubal disease

OBJECTIVE: To determine pregnancy rates (PR) after fimbrioplasty and salpingostomy in nonocclusive distal tubal disease. To evaluate the relative impact of various factors using contemporary statistical analysis. DESIGN: Prospective cohort. SETTING: Tertiary institutional infertility clinic. PATIENTS(S): Infertility patients. INTERVENTION(S): Fimbrioplasty and salpingostomy. MAIN OUTCOME MEASURE(S): Cumulative PR, monthly fecundity rates, monthly probability of pregnancy, crude PR, and cure rates. RESULTS(S): Thirty-five percent of patients conceived with a cure rate of 72.2%, monthly probability of pregnancy of 3.9%, and monthly fecundity rate of 3.9%. Cumulative PRs were 22%, 35%, and 58% at 6, 12, and 24 months, respectively. Pairwise comparisons (unilateral, bilateral, or either) failed to detect any statistical difference between the salpingostomy and fimbrioplasty groups. Salpingostomy patients initially may have a higher tendency to become pregnant but appear to lose that advantage after the first few months. When patients with tubo-ovarian adhesions are excluded from the analysis, patients who underwent a bilateral salpingostomy as their sole procedure had better outcome compared with those who only underwent bilateral fimbrioplasty. There was no significant association between pregnancy outcome and the presence of endometriosis, other infertility factors, or tubo-ovarian adhesions. The staging of adnexal adhesions and endometriosis did not predict pregnancy outcome. CONCLUSION(S): Laparoscopic fimbrioplasty and salpingostomy are clinically efficacious for the treatment of nonocclusive distal tubal disease. After accounting for statistical interactions of various factors among them, no particular association with pregnancy outcome could be identified. This illustrates the need for a revision of the classification of patients with distal tubal disease.     

Two cases of depressive disorder after pacemaker implantation

We report 2 patients who showed psychological symptoms after pacemaker implantation. Pacemaker syndrome was excluded, and a diagnosis of depressive disorder not otherwise specified was made in both patients. Patient 1 complained of discomfort early after pacemaker implantation but became unaware of the pacemaker after 1 year. However, after 3 years, lack of activity, general fatigue, and unaccountable sensations developed. These symptoms improved with symbiosis with the pacemaker. Patient 2 developed many complications after pacemaker implantation. Therefore, he was markedly aware of the pacemaker as not-self and wanted to remove it. One month after implantation, unaccountable sensations and irritations began to occur. He did not return to work, and the symptoms improved with progression of "mourning for the loss of the perfection of the own body". In both patients, their symptoms improved after "acceptance that their own body depended on the pacemaker" and "symbiosis with the pacemaker as not-self", not complete integration of the pacemaker. Therefore, the psychological process after pacemaker implantation consisted of the establishment of "mourning for the loss of the perfection of the own body" and "symbiosis with not-self". In these patients, this process was impaired, causing depressive symptoms. This process resembled the integration process in patients undergoing dialysis or renal transplantation. As, compared with renal transplantation, it is more difficult to integrate the pacemaker to the own body, so, it seems better to aim for "symbiosis with the pacemaker" to promote the adjustment process. To promote the adjustment process and decrease depression, support after understanding of this psychological process is needed.     

Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.     

Hydroxyl radical generation after the third hour following ischemia contributes to brain damage

The effects of 10 antiallergic drugs (astemizole, azelastine, ebastine, emedastine, epinastine, ketotifen, oxatomide, terfenadine, pemirolast and tranilast) on neuronal dopamine uptake were examined. Some drugs examined showed a concentration-dependent inhibition of [3H]dopamine uptake into synaptosomal preparations of the rat striatum. The inhibition constant (Ki) values were 231-876 nM for ebastine, terfenadine, oxatomide and astemizole. The specific binding of [3H] (1-[2-(diphenylmethoxy)ethyl]-4-(3-phenylpropyl)piperazine) (GBR12935) to the rat striatal membranes was also inhibited by these antiallergic drugs. There was a good correlation between the degrees of inhibition of [3H]dopamine uptake and [3H]GBR12935 binding. Then, the behavioral excitement induced by L-DOPA (100 mg/kg, s.c.) plus pargyline hydrochloride (80 mg/kg, i.p.) in mice was significantly enhanced by i.p. treatment with ebastine (10 mg/kg) and astemizole (5 mg/kg). These results suggest that the neuronal dopamine uptake is inhibited by some antiallergic drugs, especially ebastine.     

The effect of intermittent pneumatic compression devices on intraoperative blood loss during radical prostatectomy and radical cystectomy

Intermittent pneumatic compression devices are a widely used, effective and presumed risk-free method of deep venous thrombosis prophylaxis, presumably by increasing peak venous blood velocity, and stimulating local and systemic fibrinolysis. We investigated whether intermittent pneumatic compression devices had any effect on intraoperative blood loss or transfusion during radical pelvic urological surgery. To our knowledge no previous study has addressed these issues. Records were reviewed for patients undergoing radical retropubic prostatectomy or radical cystectomy with diversion from 1985 to 1990. A total of 91 cases was reviewed: 38 radical retropubic prostatectomies and 53 radical cystectomies with diversion (34 male and 19 female patients). There were 59 patients with intermittent pneumatic compression devices (29 radical retropubic prostatectomies and 30 radical cystectomies with diversion) and 32 without intermittent pneumatic compression devices (9 radical retropubic prostatectomies and 23 radical cystectomies with diversion). Intraoperative blood loss and transfusions were calculated for each group with and without intermittent pneumatic compression devices. No clinically apparent lower extremity deep venous thrombosis or pulmonary embolus was diagnosed in any patient. For the group with intermittent pneumatic compression devices mean intraoperative blood loss was 2,541 ml. (range 700 to 8,850) versus 1,807 ml. (range 450 to 5,100) without a device, for a statistically significant difference of 734 ml. (p = 0.005). When 5 patients with excessive intraoperative blood loss (more than 5,000 ml.) were excluded the statistically significant difference was maintained. When comparing radical retropubic prostatectomy and radical cystectomy with diversion, with and without intermittent pneumatic compression devices, blood loss was greater for the group with a device for each procedure. Differences in intraoperative blood loss were independent of sex or tumor stage. Intraoperative transfusions were increased by approximately 0.6 units per patient with the device. Our study suggests that intermittent pneumatic compression devices may increase blood loss during a radical pelvic operation.     

Influence of neoadjuvant treatment on bladder infiltrating tumors treated with radical cystectomy

Retrospective study of 107 patients diagnosed with infiltrant tumour of the bladder in stage T3-T4 N0-N1, treated with radical surgery. Eighty-four (84) received neoadjuvant therapy with radio- and/or chemotherapy. The neoadjuvant treatment was seen to provide significantly better survival, but the specific type of neoadjuvant treatment appears to have no influence. The multivariate study evidenced that the two most influential variables for survival are the complementary treatment and the clinical stage.     

Non occlusive mesenteric ischemia: a late complication of cardiogenic shock

The case of a diabetic 62-year-old man with a past history of myocardial infarction, developing a cardial arrest followed by successful cardiopulmonary resuscitation, is reported. In the late clinical course, the patient displayed abdominal signs related to mesenteric ischaemia. The pathophysiology of non-occlusive mesenteric ischaemia is discussed. Risk factors such as diabetes, cardiovascular disease, hemodialysis, the use of digoxine or alpha-adrenergic drugs are listed. Non-occlusive mesenteric ischaemia is not an infrequent complication of cardiac failure in high risk patients.     

Histologic spectrum of arterial and arteriolar lesions in acute and chronic cocaine-induced mesenteric ischemia: report of three cases and literature review

Gastrointestinal complications of cocaine abuse occur less frequently than those of the cardiovascular and nervous systems. The clinical history and pathologic findings of three patients with cocaine-induced mesenteric ischemia are described, and the mechanism of acute and chronic cocaine-induced mesenteric ischemia is discussed. The role of preoperative angiography in detecting occlusive arterial lesions so that arterial revascularization can be carried out is emphasized. Briefly, recent intravenous cocaine use in a 45-year-old man resulted in sharply demarcated small intestinal ischemia with perforation characterized by pseudomembranous enteritis. Histologic sections of the small-bowel resection showed intraluminal fibrin and intimal hyperplasia in rare submucosal arterioles. Two women, 29 and 35 years of age, both with a 2-year history of intravenous cocaine use, presented with acute abdominal pain and had angiographic documentation of occlusion of the celiac axis and the superior mesenteric arteries. Vascular bypasses were performed in both cases. Microscopic examination of both arteries and their branches revealed total obstruction by luminal thrombus with recanalization.