Drugs recently associated with lupus syndromes

To assess the long-term outcome in patients with acute cholecystitis treated initially by percutaneous cholecystostomy, the authors reviewed the medical and radiology records of all such patients treated at their hospital from January 1990 to September 1993. Of the 50 patients, 29 had calculous and 21 had acalculous cholecystitis. In the group with calculous cholecystitis, 1 of the patients required no further treatment, 3 subsequently underwent percutaneous stone removal, 14 underwent elective cholecystectomy, 6 underwent emergency cholecystectomy and 5 died of the underlying condition shortly after cholecystostomy. In the group with acalculous cholecystitis, 12 of the patients needed no further treatment after a mean follow-up period of 12 months; 8 of these underwent follow-up ultrasound examination, which revealed gallbladder calculi in only 1 patient. Four patients underwent elective cholecystectomy, 1 underwent emergency cholecystectomy, and 4 died of the underlying condition shortly after cholecystostomy. Over the long term, 23 (79%) of the 29 patients with calculous cholecystitis underwent surgery or removal of calculi. In the other group surgery was required in only 5 (24%) of the 21 patients. The authors conclude that percutaneous cholecystostomy is a useful temporizing measure, which allows patients with calculous cholecystitis to undergo elective cholecystectomy. In most cases of acalculous cholecystitis the procedure is curative, obviating the need for cholecystectomy.     

Gallbladder and biliary tract disease in AIDS

Biliary disease occurs in a subset of AIDS patients with CD4 counts of less than 100 per mm3. These patients present with right upper quadrant and epigastric pain, cholestasis, and usually abnormal findings on imaging. In 75% of patients, an associated opportunistic infection can be identified. In patients with biliary disease, pain is often relieved following endoscopic sphincterotomy, whereas cholecystectomy provides pain relief in patients with acalculous cholecystitis.     

Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens

The objective of this study was to review the incidence, risk factors, methods of diagnosis, and outcome of acute acalculous cholecystitis (AAC) and to identify the sensitivity and limitations of current radiographic modalities used to establish the diagnosis. Our study was a retrospective chart review in a tertiary-care university hospital. Over a 53-month period, 27 cases of AAC (17 males, 10 females; mean age 50 years; mean Acute Physiology and Chronic Health Evaluation II score, 17) were encountered. Of these, 14 (52%) occurred in critically ill patients and 17 (63%) in patients recovering from non-biliary tract operations. AAC occurred in 0.19 per cent of surgical intensive care unit admissions and accounted for 14 per cent (27 of 188) of all cases of acute cholecystitis. Presenting symptoms and laboratory values were nonspecific. Twenty patients had radiographic studies before surgery. Among the various radiological studies used for AAC, morphine cholescintigraphy had the highest sensitivity (9 of 10; 90%), followed by computed tomography (8 of 12; 67%) and ultrasonography (2 of 7; 29%). Ten of the 20 patients had more than one study done preoperatively. All 27 patients had an open cholecystectomy. AAC was associated with a high incidence of gangrene (17 of 27 cases; 63%), perforation (4 of 27; 15%), and abscess (1 of 27; 4%). The mortality rate was 41 per cent (11 of 27). We conclude that AAC is a rare, but potentially lethal, disease occurring in critically ill patients and those recovering from non-biliary tract operations. The clinical presentation is nonspecific, and significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. To improve outcome, a high index of suspicion with early radiographic evaluation, often employing multiple studies, is necessary. An algorithm for the evaluation of patients for suspected AAC is proposed.     

Imaging evaluation of the diaphragm

The diaphragm performs most of the physiologic work of inspiration, and forms an anatomic barrier between the thoracic and abdominal cavities. Disorders of the diaphragm can be related to impairment of either of these functions, and most have radiologic manifestations. Both intrathoracic and intra-abdominal disease processes can alter the normal radiologic appearance of the diaphragm. Abnormalities are usually first detected on chest radiographs, often incidentally in asymptomatic patients, and many require further characterization by other imaging studies for definitive diagnosis. Fluoroscopy, CT, and MR imaging are frequently the most useful additional studies, whereas ultrasonography, barium contrast studies, and liver-spleen scintigraphy are occasionally helpful. Selection of the most appropriate radiologic technique in a given clinical situation can greatly facilitate the diagnosis of diaphragm abnormalities.     

Disposition and metabolism of the new hypocholesterolemic compound S-8921 in rats and dogs

Antimicrobial agents are appropriate treatment for acute, severe, persistent, or progressive infectious diseases. The efficacy of treatment depends on the accuracy of the diagnosis of infection and the appropriateness of the antimicrobial agent for the causative microorganism. In this symposium, the antimicrobial agents reviewed correspond with the bacterial, fungal, viral, mycobacterial, parasitic, chlamydial, and other microorganisms that cause disease in humans. Usually, the etiologic possibilities can be limited on the basis of the history and physical examination, laboratory tests, or results of treatment trials. Many of the same findings, however, can result from noninfectious, other inflammatory, or unknown mechanisms. Manifestations such as fever and organ dysfunction are nonspecific and often not caused by an infectious process. Even when infection is clinically apparent, the causative microorganism may not be identified, and empiric treatment with broad-spectrum agents is appropriate in many cases of serious disease.     

Gallbladder puncture and drainage as therapy of acute cholecystitis

PATIENTS AND METHODS: An ultrasound-guided, percutaneous puncture (n = 30) and cholecystostomy (n = 10) was performed on 40 high-risk patients aged between 38 and 99 (mean age 78 years old) suffering from acute lithogenic cholecystitis or acalculous stress cholecystitis on account of general inoperability. Two catheter dislocations and in 3 cases a slight bile leakage were observed as complications. RESULTS: The puncture and drainage led to a dramatic alleviation of pain for all patients, the involution of a paralytic subileus and improvement of the general condition. Eighteen patients underwent a laparoscopic or open interval cholecystectomy in a stabilised condition. There was no recurrence of inflammation in 22 patients over a follow-up period of up to 5 years, so that one can assume a cicatrised healing of the acute choleycstitis. CONCLUSIONS: Ultrasound-guided, percutaneous puncture and cholecystostomy are effective, low-risk, and only slightly invasive procedures which can be employed for risk patients with acute cholecystitis as a life-saving, and in some cases definitive treatment. On account of pathogenic considerations, they should be included in the diagnostic and therapeutic concept at an early stage, particularly for acute, acalculous stress cholecystitis.     

Problem-based learning: its rationale and efficacy

Intestinal pneumatosis is an infrequent disease of difficult clinical and radiologic diagnosis. It may be accompanied by pneumoperitoneum in up to 30% of the cases leading to differential diagnosis with pictures of visceral perforation. We herein present 4 cases of intestinal pneumatosis in whom pneumoperitoneum was associated in 3 patients. Diagnosis was intraoperative in 2 patients submitted to emergency surgery because of an associated acute gastrointestinal event (intestinal volvulus and acute cholecystitis). The other 2 cases were diagnosed by computerized tomography and colonoscopy, respectively, and given their satisfactory clinical evolution they received conservative treatment. The course of the disease was favorable in all the patients with the radiologic signs of pneumatosis disappearing.     

Managed cost

We report a case of acalculous cholecystitis in an AIDS patient, that appeared with insidious onset, abdominal right upper quadrant pain and fever. Cholecystectomy was performed and CMV inclusions were observed in tissue sections. CMV acalculous cholecystitis is an uncommon condition associated to the acquired immunodeficiency syndrome. It should be considered, especially when abdominal pain and fever are present in marked immunosuppressed AIDS patients. Unfortunately, a limited experience in treatment, either medical or surgical, was reported. In our case, the response to surgical procedure was successful, disappearing the abdominal pain and the fever. The patient refused both ganciclovir and foscarnet therapy.     

Postoperative and post-traumatic acute cholecystitis. Value of ultrasound diagnosis

An often unrecognized but potentially fatal complication, mostly seen in posttraumatic patients under intensive care, is reactive acute cholecystitis. On account of the high specificity of ultrasound diagnosis in the biliary system we decided to examine the ultrasound criteria for early detection of posttraumatic cholecystitis. Ultrasound of the abdomen was performed prospectively, seven times on different days, in each of 40 artificially respirated patients under intensive care conditions over a period of 12 months. The results show that artificial respiration, parenteral feeding and previous trauma can lead to tardive (28/40) wall-thickening or to a three-layered wall of the gallbladder (9/40). In 22.5% of patients (9/40) we found the sonographic signs of acute cholecystitis. In correlation with the clinical signs, cholecystectomy was indicated in only two patients. The preoperative ultrasonographic findings and clinical signs of 23 patients with the diagnosis of acute reactive cholecystitis were analysed retrospectively. We found good correlation between sonographic and clinical signs of acute cholecystitis in 21 of these 23 patients. Our study shows that the morphological correlate of a thickened three-layered gallbladder wall can occur in the context of systemic alterations, even if there is no underlying cholecystitis. The diagnosis of acute reactive cholecystitis and the indication for cholecystectomy should be based on the synopsis of pathologic and clinical findings.     

Technics for laparoscopic cholecystectomy--their use and results]

With a new technique for the assessment of lipid peroxidation products in chloroform bile extracts it was possible to register an increase in the ratio malonic dialdehyde/phospholipids in patients with both calculous and acalculous cholecystitis. Bile of all patients with acute cholecystitis was characterized by a decrease in concentration of all the components, but use of relative parameters (malonic dialdehyde/phospholipids, index of bilirubin fractions and cholesterol/lecithin index) allows to verify the stage of the inflammation. The changes were unidirectional in B-bile and C-bile portions in all the patients with acalculous cholecystitis.     

Welch''s comments on Shapiro''s walk in the woods and the origin of eye movement desensitization and reprocessing

Polypoid lesions of the gallbladder in children are rare. We report a case of a gallbladder polyp in a 14-year-old boy who presented with recurrent right upper quadrant abdominal pain. Ultrasound examination of the abdomen revealed a polypoid lesion of the gallbladder. His symptoms resolved after laparoscopic cholecystectomy. Histological examination of the gallbladder demonstrated a benign adenomatous polyp. Although the experience with polypoid lesions of the gallbladder in children is limited, we currently recommend cholecystectomy because these lesions are associated with acalculous cholecystitis, and because their long-term effects are unknown.     

Clinical study of gallbladder cancer associated with acute cholecystitis

The clinical features of gallbladder carcinoma associated with acute cholecystitis and problems in diagnosing this condition by ultrasonography were investigated. Nine cases of gallbladder cancer with acute cholecystitis and 51 cases of gallbladder cancer without acute cholecystitis were reviewed. There were no obvious differences between those two groups as far as depth of invasion, location of cancer, and the prevalence of gallstones were concerned. However, there was a tendency for detection of cancer associated with acute cholecystitis by ultrasound to be more difficult than detection of cancer without acute cholecystitis. Macroscopic examination of resected specimens showed that superficial or flat type cancers tended to occur more often in cases of acute cholecystitis. This is considered to be the main cause of the difficulty in diagnosing such cancer by ultrasound.     

The changing face of emphysematous cholecystitis

Emphysematous cholecystitis is a variant of acute cholecystitis characterized by the presence of gas in the gall bladder lumen, wall or pericholecystic tissues in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. In the past, the diagnosis has relied on the plain abdominal radiograph (AXR), since there are no clinical features to separate this condition from simple acute cholecystitis. The apparently high mortality and morbidity associated with emphysematous cholecystitis has previously emphasized the importance of emergency cholecystectomy. We have reviewed eight cases of emphysematous cholecystitis presenting to this hospital over the last 5 years. The diagnosis was made on AXR in only one of these cases. Ultrasound (US) scans were performed in all eight cases, of which five were positive and three negative, due to non-visualization of the gall bladder. In the three negative cases, the diagnosis was made on subsequent CT scans. On initial clinical examination, only one of the eight patients appeared systemically unwell and conservative management was employed in five of the patients. The remaining three patients underwent cholecystectomy within 3-5 days because of continuing signs or symptoms. It is concluded that the AXR is relatively insensitive in the diagnosis of emphysematous cholecystitis. As a result of the regular use of US in suspected hepatobiliary disease, emphysematous cholecystitis is being diagnosed with increased frequency, uncovering a broad spectrum of disease ranging from mild to severe. Previously, failure to separate milder cases from simple acute cholecystitis may have been responsible for reports of unremitting severity and progression requiring emergency cholecystectomy. Based on clinical assessment, conservative surgical management is possible in a significant proportion of patients.     

Getting the "go ahead". Helping patients understand informed consent

The results of investigations the hepato-pancreatico-duodenal organs are analysed. High diagnostic effectiveness of the ultrasound examination in acute cholecystitis (95.5%) is demonstrated. In chronic calculous cholecystitis and in choledocholithiasis the ultrasound examination appeared to be accurate in 97.0% and 84.2% of cases respectively. Retrograde cholangiopancreatography was the most informative method for detection of the concrements in choledochus (effective in 94.4% of the cases). The diagnostic effectiveness of the ultrasound examination and laparoscopy in detection of mechanical jaundice and acute pancreatitis are considered to be equal. Ultrasound examination, retrograde cholangiopancreatography, laparoscopy appeared to be the most accurate and informative methods in diagnosis of the diseases of the organs of hepato-pancreatico-duodenal zone. The role of the X-ray examination decreased. At the same time the significance and reliability of intraoperative cholangiography has been stressed.     

Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Skin manifestations of graft-versus-host reaction following bone marrow transplantation

We review the cutaneous manifestations of acute and chronic graft versus host disease (GvHD). Acute GvHD is characterized by initial itching, pain on pressure and erythema which begins on posterior auricular skin, palms and soles. The disease evolves into a typical but nonspecific maculopapular rash. Confluent rashes and follicular erythema may occur. Erosive oral lesions usually develop. The most severe variant of GvHD is toxic epidermal necrolysis, which often has a fatal outcome. The onset of chronic GvHD usually occurs more than 100 days after bone marrow transplantation and may be preceded by the acute form. The spectrum of skin changes includes lichenoid pruritic lesions with violaceous color and scleroderma-like skin involvement. Investigation of unknown rashes in these patients includes skin biopsy, which clearly differentiates leukocytoclastic vasculitis and erythema exsudativum multiforme with lymphocytic vasculitis from cutaneous manifestations of GvHD. Special stains may reveal bacteria and fungus in septicemic patients. The therapeutic options are discussed.     

The changing role of village health volunteers in northeast Thailand: an ethnographic field study

Aspergillus sinusitis is an uncommon complication of advanced human immunodeficiency virus (HIV) infection. We describe 2 patients with AIDS who developed histologically proven invasive Aspergillus sinusitis. We also review the findings of 14 histologically documented and 5 probable cases of invasive Aspergillus sinusitis. The literature on the prevalence, predisposing factors, diagnosis, treatment, and prognosis of the infection is reviewed. Major risk factors for the disease are advanced AIDS, chronic sinusitis or otitis, neutropenia, use of corticosteroids and prolonged use of broad spectrum antibiotics. The most common presenting symptoms are nonspecific and include fever, local pain, and swelling. Despite the newer diagnostic and therapeutic approaches discussed herein, the infection is usually fatal in HIV-infected patients. Early diagnosis and aggressive treatment remain the only available means to improve the currently dismal prognosis of Aspergillus sinusitis.     

Ultrasound diagnosis of acute cholecystitis

The results of ultrasonographic examination of the gall-bladder in its acute inflammation in 1070 patients are presented. Parallels between the anatomic changes and ultrasound visual picture of the inflamed wall of the gall-bladder were drawn. The analysis of the results of the examination revealed the most typical symptoms of acute cholecystitis and permitted to differentiate it from similar ultrasonographic symptoms in other diseases of the gall-bladder. From all patients who underwent surgical treatment or diagnostic laparoscopy, the diagnosis was confirmed in 97%. The possibilities of the method in a series of patients after the operation and patients with concomitant diseases are limited, in such cases the punction or drainage of the gall-bladder under the ultrasound scan control for diagnostics and treatment is advisable.     

Laparoscopic management of acute cholecystitis with subtotal cholecystectomy

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.     

Respiratory kinesitherapy. For whom? Why do it?

Intussusception of the appendix vermiformis in adults is an uncommon event. The combination of a mucinous cystadenoma with an intussuscepted appendix is extremely rare. Clinical symptoms are nonspecific; in most cases the correct diagnosis is not made before surgical exploration. With the radiologic and endoscopic presentation of a polypoid lesion of the caecum, a neoplasm is often considered. Endoscopic appendectomy or disinvagination by enema have been described. Thus the definitive therapy is surgery and depends on the histological diagnosis.