Ovarian vein and IVC thrombosis due to normal vaginal delivery; a case report and literature review

Introduction and importanceOvarian vein thrombosis (OVT) is exceedingly rare, which commonly occurs in postpartum patients and can result in serious complication such as pulmonary emboli. With a presentation often mimicking that of acute abdomen, it can be often misdiagnosed and mistreated.Case presentationA 30-year-old woman referred with right lower quadrant abdominal pain, nausea and anorexia, one week after normal vaginal delivery. Physical examination demonstrated tenderness and rebound tenderness at the right side of the abdomen, with a stable vital sign except 38 °C fever. She had no history of coagulation problems or thrombotic disorders. Patient was admitted on a suspicion of appendicitis and was prescribed antibiotics followed by pelvic and abdominal ultrasonography that indicated an 8 to 10-centimeter hypoechoic tubular structure on the right side, next to the IVC. CT scan with contrast showed clear dilatation and thrombosis of the right ovarian vein with spread to the IVC. Anticoagulant treatment was started with 1000 intravenous units of heparin per hour, along with aPTT control, with a disappearance of the symptoms after 72 h.ConclusionSuspicion of OVT should be high in cases where patients refer with abdominal pain after childbirth, this diagnosis should be taken into account. In the absence of proper and timely diagnosis, it may lead to serious complications or mortality of the mother. CT scan with contrast and at least 3- months anticoagulant therapy (in case of thrombosis spreading to the IVC, this period should be extended) is recommended in diagnosing and treatment of OVT.     

Case report on the non-operative management of a retrievable inferior vena cava filter perforating the duodenum

IntroductionDeep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Placement of a retrievable inferior vena cava (IVC) filter is used when patients have contraindications to anticoagulation or recurrent pulmonary embolism despite therapeutic anticoagulation. Although retrievable IVC filters are often used, they carry a unique set of risks.Presentation of caseA 67-year-old man presents to the Emergency Room (ER) following large volume melena and complaining of syncope. One year prior, the patient had been diagnosed with Glioblastoma multiforme, for which he underwent a craniotomy with near-total resection of the mass. He subsequently developed a deep vein thrombosis and underwent placement of a retrievable inferior vena cava (IVC) filter. Computerized tomography (CT) and esophagogastroduodenoscopy showed duodenal perforation by the retrievable IVC filter. The filter was successfully retrieved through an endovascular approach.DiscussionRetrievable IVC filter placement is the preferred method of pulmonary embolism prevention in patients with significant risk for bleeding. Duodenal perforation by a retrievable IVC filter is a rare and serious complication. It is usually managed surgically, but can also be managed non-operatively.ConclusionFor patients with significant comorbidities or patients who are poor surgical candidates, non-operative management with close monitoring can serve as an initial approach to the patient with a caval enteric perforation secondary to a retrievable IVC filter.     

CT指导介入治疗下腔静脉Budd-Chiari综合征

目的评估CT对下腔静脉型Budd-Chiari综合征(BCS)介入治疗的临床指导价值。方法收集于我院接受介入治疗的329例下腔静脉型BCS患者,所有患者术前均接受CT检查,并根据CT诊断结果制定介入治疗方案。以DSA治疗结果为金标准,评估CT诊断的准确率、敏感度、特异度、阳性预测值和阴性预测值。结果 DSA示下腔静脉不完全闭塞型BCS 108例,下腔静脉完全闭塞型221例;CT诊断下腔静脉不完全闭塞型99例,下腔静脉完全闭塞型230例。与DSA结果相比,CT诊断15例假阴性,6例假阳性。CT术前制定是否破膜的准确率、敏感度、特异度、阳性预测值及阴性预测值分别为94.19%、97.29%、86.11%、93.49%及93.94%,CT术前制定介入治疗方法的准确率、敏感度、特异度、阳性预测值及阴性预测值分别为97.55%、100%、92.52%、96.49%和100%。结论 CT诊断下腔静脉型BCS准确率较高,且有助于制定介入治疗方案。     

Clostridium septicum: A usual suspect? Aortic rupture following right hemicolectomy: A case report

IntroductionThere is a known association between Clostridium Septicum, mycotic aneurysm and colon neoplasm.Case presentationWe report the case of a 90 year old female admitted with abdominal pain to the general surgery unit. Admission CT scan demonstrated a thick walled caecum and pericaecal inflammation suspicious for a perforated carcinoma. This was subsequently confirmed at colonoscopy with biopsy demonstrating a poorly differentiated adenocarcinoma. A laparoscopic right hemicolectomy was completed the following week after perioperative workup and intravenous antibiotic therapy. On the 9th postoperative day, fever and rising inflammatory markers prompted repeat abdominal CT scan which demonstrated a mycotic aneurysm of the upper abdominal aorta. After discussion with the vascular surgery and infectious diseases team, along the patient and family, the decision was made to palliate. The patient died at home from presumed spontaneous rupture two weeks after discharge.DiscussionMycotic aneurysm in colonic malignancy is a rare and often lethal complication. C. Septicum is causative in over 70% of cases with concomitant colonic malignancy.ConclusionMycotic aneurysm should be considered in any deteriorating patient with concomitant colonic malignancy.     

Post traumatic inferior vena cava thrombosis: A case report and review of literature

IntroductionPost traumatic inferior vena cava (IVC) thrombosis is a rare and not well described entity with nonspecific clinical presentation. It remains a therapeutic challenge in traumatic context because of haemorrhagic risk due to anticoagulation.Presentation of caseWe report a case of IVC thrombosis in an 18 year-old man who presented with liver injury following a traffic crash. The thrombosis was incidentally diagnosed on admission by computed tomography. The patient was managed conservatively without anticoagulation initially considering the increasing haemorrhagic risk. IVC filter placing was not possible because of the unusual localization of the thrombus. Unfractionated heparin was started on the third day after CT scan control showing stability of hepatic lesions with occurrence of a pulmonary embolism. The final outcome was good.DiscussionThe management of post traumatic IVC thrombosis is not well described. Medical approach consists in conservative management with anticoagulation which requires the absence of active bleeding lesions. Surgical treatment is commonly based on thrombectomy under extracorporeal circulation. Interventional vascular techniques have become an important alternative approach for the treatment of many vessel lesions. Their main advantages are the relative ease and speed with which they can be performed.ConclusionPost traumatic IVC thrombosis is a rare condition. Its management is not well defined. Early anticoagulation should be discussed on a case-by-case basis. Other alternatives such IVC filter or surgical thrombectomy may be used when the bleeding risk is increased. The most serious risk is pulmonary embolism. Outcome can be favorable even with non surgical approaches.     

Intestinal volvulus secondary to pneumatosis intestinalis: A case report

Introduction and importancePneumatosis intestinalis (PI) is a rare but important medical condition that is defined as a collection of individual gas cysts in the submucosa and subserosa of the intestine. PI can be primary or secondary; however, this condition is secondary to underlying diseases most of the time.Case presentationThis article presents a 30-year-old man as a case report complaining of generalized abdominal pain and several episodes of non-bilious bloodless vomiting. The patient was admitted to the surgical service department for further investigation, and his abdominal CT scan revealed PI.Clinical discussionThe patient underwent emergency laparotomy surgery due to progressive abdominal pain and peritonitis. The involved segment of the small intestine was resected, and ileo-ileal anastomosis was performed. The patient was discharged from the hospital after a week, stable, and in good medical condition.ConclusionThis article intends to emphasize that although most of the patients with PI are asymptomatic or show unspecific symptoms, surgeons must take into account rare but lethal complications of PI such as intestinal volvulus. Early recognition of such complications is so crucial and can be life-saving.     

The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report

Introduction and importancePenetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up.Case presentationA 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day.Clinical discussionEmergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury.ConclusionThis case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection.     

Anaphylactic shock due to traumatic rupture of pulmonary hydatid cyst: Case report

IntroductionHydatid cyst is an infectious disease caused by « ECHINOCOCCUS GRANULOSIS », it can be asymptomatic or manifests depending on size, location, and relation with other organs, or by complication like rupture. This latter might occur spontaneously or post-traumatic, and it might manifest with an anaphylactic shock, a life-threatening situation.ImportanceAnaphylactic shock is a rare cause of traumatic shock state.Case presentationA 30 years old man with no medical history was admitted to the emergency room after a car accident, on his admission, his Glasgow coma scale was 10/15 with a blood pressure of 80/30 mmHg, he was intubated and stabilized hemodynamically. The full-body CT scan showed no abnormalities except on the thoracic level where it showed a well-limited rounded formation with regular contours containing hydro-aeric level related to ruptured hydatid cyst.After ruling out the diagnosis of hemorrhagic, hypovolemic shock, the diagnosis of anaphylactic shock due to a post-traumatic rupture of the hydatid cyst was maintained.ConclusionPost-traumatic rupture of the hydatid cyst is a rare emergency that requires early diagnosis and management. Surgery remains the principal treatment of ruptured hydatid cyst.Anaphylactic shock is a life-threatening situation with various symptoms; epinephrine is the cornerstone for management of this type of shock.     

Pulmonary metastatic angiosarcoma from scalp with fatal complication: A case report

IntroductionAngiosarcoma is a rare malignant neoplasm with poor prognosis. Angiosarcoma of the scalp is frequently recurs locally, and metastasizes early despite various treatments. The common sites of metastatic are lung, liver, and lymph nodes. Pulmonary metastasis with hemoptysis and pneumothorax is rare but threatening.Presentation of caseA 77-year-old male had recurrent angiosarcoma of the scalp even with post operation radiotherapy. At the same time, recurrent pneumothorax was noted, thus he underwent wedge resection of the right upper lobe of the lung plus pleural biopsy. The final pathologic report of cystic lesions showed metastatic Angiosarcoma. He received intravenous paclitaxel and the lung lesions dramatically diminished subsequently.DiscussionPulmonary metastasis from soft tissue sarcoma had fatal complications and poor prognosis. Metastases of AS to the lung have a well-described morphology on CT scan, but appear to be hypometabolic on PET scan and are easily misinterpreted as benign cysts.ConclusionAngiosarcoma is a rare but highly vascular invasive endothelial tumor that generally metastasizes to the lung. It could cause repeated hemoptysis pneumothorax and pleural effusion. Preoperative chest CT may be recommended routinely. Aggressive treatment resulted in not only symptoms control but also good prognosis.     

Management of blunt adrenal gland injury in a community-based hospital

IntroductionInjury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital.MethodsCT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome.Results4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6–50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%).ConclusionsThe incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.     

Concomitant reconstruction of infrarenal aorta and inferior vena cava after en bloc resection of retroperitoneal rhabdomyosarcoma

Adult paratesticular rhabdomyosarcoma (PRMS) with invasion of the retroperitoneum and involvement of the infrarenal aorta and inferior vena cava (IVC) is rare. We describe a 23-year-old male diagnosed with PRMS in 2008, previously treated with right orchiectomy, chemotherapy, and radiation, who presented with new onset of lower back pain. Computed tomography (CT) scan revealed a 4.8 × 4.2 cm mass involving both the infrarenal aorta and the IVC. We resected the tumor en bloc with in situ reconstruction of the aorta utilizing a Dacron graft and the IVC with a bovine pericardium roll graft. His postoperative period was uneventful, and he was discharged on postoperative day 6 in stable condition. At 2-month follow-up, the patient recovered well from the surgery, patent grafts on CT scan with no clinical signs of lower extremity ischemia or edema, and he continues to receive cycles of chemotherapy.     

Duodenal rupture due to giant inguinal hernia: A case report

IntroductionGiant inguinal hernia is unusual, and duodenal rupture accompanying it is particularly very rare and significantly hard to manage surgically.Presentation of caseAn 81-year-old man was admitted to our institution with upper abdominal pain. He had tenderness of the upper mid abdomen and a bilateral large inguinal hernia but he did not have pain in the inguinal–scrotal area. Computed tomography (CT) showed slight dilatation of the small bowel and stomach. There were no remarkable signs of incarceration of the inguinal hernia. Therefore, he was admitted to the internal ward. On the second day in hospital, he suddenly went into shock. CT revealed that there was free air and ascites in the inguinal hernia and therefore an emergency operation was performed.The tranverse colon, ascending colon, and ileum were incarcerated, and perfolation of the cecum was found. We also detected duodenal rupture at the inferior duodenal angle. We resected the terminal ileal (almost 90 cm) and ileocecal area, followed by side-to-side anastomosis of duodenum and jejunum. We only repaired the peritoneum at the internal hernia ring. After the operation, despite intensive-care therapy, this patient passed away on the 18th postoperative day.DiscussionThe mesocolon and third portion of the duodenum were strongly pulled down into giant inguinal hernia, probably causing the rupture of the inferior duodenal angle.ConclusionGiant inguinal hernia possibly provokes duodenal rupture and therefore should definitively be repaired if feasible.     

Sacciform aneurysm of the right common iliac artery in Behcet's disease treated with EVAR: Case report

IntroductionBehcet's disease is a systemic vasculitis with vascular tropism usually manifested by phlebitis. Arterial manifestations are rare, most often result in aneurysms than occlusions. The objective of this article, is to relate our experience and pretherapeutic reasoning for the indication of an endovascular treatment of an atypical sacciform iliac aneurysm, in an elderly patient followed for Behcet's disease.Case reportThis is a 73-year-old patient, followed for Behcet's disease under immunosuppressive treatment and corticosteroids treatment, admitted to our structure, for the surgical management of an aneurysm of the right common iliac artery diagnosed by computed tomographic angiography performed for chronic paroxysmal abdominal pain, treated by EVAR after a multidisciplinary discussion, complicated by a thrombosis of the left leg of the bifurcated aortic stent graft the, managed by performing an extra anatomical bypass, complicated late by the appearance of a Scarpa hematoma, who was evacuated.DiscussionBehcet's disease is a systemic vasculitis with vascular tropism, usually affecting young. Our case is an elderly subject, whose diagnosis and follow-up of Behcet's disease is recent and whose discovery of this aneurysm was fortuitous, after performing a CT angiogram required for another reason.The objective of this article, is to relate our experience and pre-therapeutic reasoning for theindication of an endovascular treatment, and our management of the complications.ConclusionEndovascular treatment of iliac sacciform aneurysm by placing a covered stent is a good alternative to conventional surgery with fewer complications; especially in front of a field of Behcet's disease.     

Extreme dilatation of the interposed jejunal pouch after proximal gastrectomy associated with portal venous gas: A case report

IntroductionThe jejunal pouch interposition (JPI) after proximal gastrectomy (PG) was proposed as a reconstructive procedure to provide a gastric reservoir substitute and prevent postgastrectomy syndrome. However, food residue remaining in some of the pouches resulted in the adverse effect of abdominal bloating, thereby body weight loss. Here, we report a rare case with an extreme dilation of the interposed jejunal pouch (JP) 8 years after PG, requiring pouch resection.Presentation of caseA 65-year-old-man who had undergone PG with an inverted U-shaped JPI for early gastric cancer 8 years previously, suffered from shock after right hip joint implantation. Abdominal enhanced CT scan revealed an extremely dilated JP accompanied by portal venous gas. After 5 months of conservative therapy, he underwent resection of the JP and gastric remnant with Roux-en-Y esophagojejunostomy reconstruction. After the operation, the patient has remained in good health for over 3 years.Discussion and conclusionLong-term operative outcome following pouch operation for gastric cancer still remains controversial. Surgical intervention should be considered when we encounter patients who have refractory pouch dilatation after surgery for gastric cancer.     

大鼠下腔静脉型巴德-吉亚利综合征动物模型的制备

目的通过部分结扎大鼠肝后段下腔静脉(IVC)建立IVC阻塞型巴德-吉亚利综合征(BCS)模型。方法采用随机数字法将36只健康成年SD大鼠分为模型组和对照组。对模型组大鼠以3F微导管部分结扎肝后段IVC,对照组仅暴露肝后段IVC,其余处理相同。术后第28天取外周静脉血行肝功能检查,术后第84天和第85天分别行腹部超声和DSA,评价IVC阻塞程度及侧支静脉形成后处死大鼠,对肝脏、脾脏行病理学检查。结果建模成功率83.33%(15/18)。术后第28天,模型组大鼠静脉血谷丙转氨酶、谷草转氨酶、碱性磷酸酶、谷氨酰转移酶和总胆红素均较对照组升高(P均0.05);术后第84天和85天腹部超声及DSA检查均证实模型组大鼠存在IVC阻塞,肝内及肝外侧支静脉形成。光镜下模型组大鼠肝组织严重脂肪样变性,肝小叶中央静脉及其周围肝血窦扩张、淤血,汇管区纤维增生和轻度纤维化;电镜下可见肝细胞内细胞器减少,存在局限性水肿,胞质内大量脂滴堆积,粗面及细面内质网扩张,周围线粒体减少,肝细胞核膜裂隙增宽等改变。结论部分结扎大鼠肝后段IVC可成功制备IVC阻塞型BCS,为BCS研究提供平台。     

A case of bacterial aneurysm following Hardy's operation

Intracranial mycotic aneurysm of extravascular origin is reported. A 64 year-old male developed headache and visual disturbance. Computed Tomography (CT) revealed high density mass lesion with contrast enhancement in the intra- and suprasellar lesion. He was then admitted to our hospital under the diagnosis of pituitary adenoma. But he suddenly complained of headache and loss of vision during hospitalization. An emergency operation using the transsphenoidal approach was performed. The pathological diagnosis was craniopharyngioma. Postoperative radiation therapy was carried out using a tumor dose of 50Gy. Two months after the operation, he suffered from rhinorrhea and high fever. He was admitted again and treated with high doses of antibiotics. Two weeks after admission, he suddenly lost consciousness. A CT scan revealed an aneurysm of the anterior temporal artery. Immediately, removal of the hematoma and resection of the aneurysm were performed. Microscopic examination showed that inflammatory cells had infiltrated the aneurysmal wall, and lymphocytes and plasma cells had gathered around the microabscess. This rare case is discussed with other related cases in the literature.     

Optimal Management of Traumatic Aortic Injury

BackgroundThe best time to intervene in traumatic aortic injuries has long been a matter of debate. While emergency surgery is characterized by high morbidity and mortality, initial medical management of uncomplicated aortic injury and subsequent delayed surgery resulted in better outcome.Methods and resultsFrom analysis of medical literature of the last 10 years, major paradigm shift in management of traumatic injuries includes the use of different imaging methods for diagnosis, with a almost complete elimination of aortography and transesophageal echocardiography in favour of CT scan, and a significant change in method of definitive repair, shifting from exclusively open techniques in 1997 to predominantly endovascular repairs in 2007. At present several reports in literature provide data on comparative results of endovascular therapy with respect open surgery, supporting the use of stent-graft in traumatic injuries, both in acute and chronic cases. The authors' personal experience comprises 58 patients treated with endovascular stent-graft repair, with no mortality or treatment failure even during 11 years follow-up.ConclusionsFor many years traumatic aortic injury has been considered a highly lethal lesion and a potential cause of death in blunt chest trauma. Because of the lower invasivity endovascular repair can be applied in traumatic aortic injury with very low risk and limited impact on trauma destabilization. Long term follow-up seems indicate a substantial durability of the procedure.     

Lumbar spinal stenosis in a young individual as a result of ligamantum flavum ossification: A case report

INTRODUCTIONSymtomatic lumbar ligamantum flavum calcification is quite rare in the young age group.PRESENTATION OF CASEThe authors report a case of young adult with diagnosis of lumbar spinal stenosis, presenting with leg pain and neurological deficits. Computerized tomography (CT) scan and magnetic resonance (MR) imaging studies revealed ossification of the ligamantum flavum as the causative factor of the disease and the patient recovered completely after the decompressive operation.DISCUSSIONIt is emphasized that attention should be given to this rare etiological factor of lumbar spinal stenosis.CONCLUSIONComplete relief can be achieved with early and adequate surgery.     

3D影像融合技术用于腔内介入治疗主动脉病变

目的 分析3D影像融合技术用于腔内介入治疗主动脉病变的价值。方法 回顾性分析18例接受3D影像融合引导腔内介入治疗主动脉病变患者。于Siemens Artis Pheno工作站以Syngo-X-workshop软件将术前主动脉CT血管造影（CTA）与术中锥形束CT （CBCT）图像进行融合,分别于T10~L3椎体水平进行冠状位、矢状位及轴位3个维度的配对融合,将最终形成的3D融合影像投射至实时数字减影血管造影（DSA）影像中,用于导引主动脉腔内介入操作。记录治疗用时、碘对比剂用量及射线剂量等。结果 18例中,腹主动脉瘤7例、主动脉穿透性溃疡5例、胸主动脉夹层4例、胸主动脉瘤2例;对11例行腹主动脉瘤腔内修复术（EVAR）、7例行胸主动脉腔内修复术（TEVAR）,均获得成功,技术成功率100%;治疗用时（124.28±55.95） min,碘对比剂用量（178.89±37.87） ml,辐照时间（20.21±13.20） min,CBCT辐射剂量（225.17±60.10） mGy,总辐射剂量（815.68±439.10） mGy。7例术前合并肾功能不全,术后24 h、出院前及术后1、3个月血肌酐值与术前比较差异均无统计学意义（P均>0.05）。结论 3D影像融合技术用于腔内介入治疗主动脉病变安全、可行。