Common bile duct stones: an unusual case of diarrhoea through a mucous fistula

We present a very unusual case of diarrhoea in a 77-year-old man. He had a previously complicated surgical history, with a loop ileostomy and a colonic mucous fistula. He developed a sudden onset of diarrhoea from his mucous fistula. A contrast enema suggested a cholecystocolonic fistula and subsequent computed tomography demonstrated a common bile duct stone caused a degree of obstruction. The patient was treated successfully by endoscopic retrograde cholangiopancreatography and stone extraction. This case demonstrated the role that contrast enema may still play in unusual cases of diarrhoea.     

McKittrick-Wheelock syndrome: acute renal failure by a colorectal adenoma. A case study

A case of acute renal failure because of chronic watery diarrhoea is presented. The cause is a secretory villous adenoma. The triad chronic diarrhoea, electrolyte disturbance and prerenal renal failure due to a villous adenoma, known as the McKittrick-Wheelock syndrome is a rare entity. The patient can evolve to acute renal failure, shock and death. Initially, the patient is medically treated to restore the fluid and electrolyte balance, but the surgical removal of the polyp is necessary to obtain a definite recovery.     

McKittrick-Wheelock Syndrome: Acute Renal Failure by a Colorectal Adenoma. A Case Study.

A case of acute renal failure because of chronic watery diarrhoea is presented. The cause is a secretory villous adenoma. The triad chronic diarrhoea, electrolyte disturbance and prerenal renal failure due to a villous adenoma, known as the McKittrick-Wheelock syndrome is a rare entity. The patient can evolve to acute renal failure, shock and death. Initially, the patient is medically treated to restore the fluid and electrolyte balance, but the surgical removal of the polyp is necessary to obtain a definite recovery.     

Haemolytic uraemic syndrome: an overview

Haemolytic uraemic syndrome (HUS) is the most common cause of acute renal failure in children. The syndrome is defined by triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure (ARF). Incomplete HUS is ARF with either haemolytic anaemia or thrombocytopenia. HUS is classified into two subgroups. Typical HUS usually occurs after a prodrome of diarrhoea (D+HUS), and atypical (sporadic) HUS (aHUS), which is not associated with diarrhoea (D-HUS). The majority of D+HUS worldwide is caused by Shiga toxin-producing Esherichia coli (STEC), type O157:H7, transmitted to humans via different vehicles. Currently there are no specific therapies preventing or ameliorating the disease course. Although there are new therapeutic modalities in the horizon for D+HUS, present recommended therapy is merely symptomatic. Parenteral volume expansion may counteract the effect of thrombotic process before development of HUS and attenuate renal injury. Use of antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs should be avoided during the acute phase. Prevention is best done by preventing primary STEC infection. Underlying aetiology in many cases of aHUS is unknown. A significant number may result from underlying infectious diseases, namely Streptococcus pneumoniae and human immunedeficiency virus. Variety of genetic forms include HUS due to deficiencies of factor H, membrane cofactor protein, Von Willebrand factor-cleaving protease (ADAMTS 13) and intracellular defect in vitamin B12 metabolism. There are cases of aHUS with autosomal recessive and dominant modes of inheritance. Drug-induced aHUS in post-transplantation is due to calcineurin-inhibitors. Systemic lupus erythematosus and catastrophic antiphospholipid syndrome may also present with aHUS. Therapy is directed mainly towards underlying cause.     

Enteropathogens associated with acute infantile diarrhoea in Cape Town

The results of a year-long controlled study on the causation of acute infectious diarrhoea in infants are reported. Campylobacter fetus subspecies jejuni, rotavirus and certain enteropathogenic Escherichia coli (EPEC) types were identified as the most common enteropathogens. Shigella, Salmonella group B and Yersinia enterocolitica were significant but less common pathogens. Campylobacter, rotavirus, the significant EPEC types and Shigella infections were more frequent in the warm summer and autumn months. This only partially accounts for the marked summer peak of diarrhoea, since at this time the percentage of cases of undetermined causation is highest (61%). Over the year an identifiable cause of the diarrhoea was found in 49% of the patients studied. A specific EPEC type, 0126:K71(B16), appeared to vary in pathogenicity on a seasonal basis. Multiple enteropathogens occurred relatively frequently.     

Steatorrhoea complicating post-infectious diarrhoea in a renal transplant patient on mycophenolate mofetil therapy

Mycophenolate mofetil (MMF) is licensed as a prophylaxis in combination therapy to prevent renal transplant rejection. Gastrointestinal side effects are fairly common and include diarrhoea, abdominal discomfort, nausea, vomiting, gastritis and constipation. This drug has recently been described as causing villous atrophy, nutrient malabsorption and colonic mucosal changes. We present a case of reversible steatorrhoea occurring in a patient treated with MMF following an episode of infections diarrhoea.     

Duodenal obstruction: unusual complication of acute pancreatitis

The authors notice that, though the duodenal involvement in patients with acute pancreatitis is very common, the duodenal obstruction is quite exceptional and the reported cases are very few. The Authors describe; then, the case of a patient with duodenal obstruction caused by a peri-duodenal phlegmon due to an acute pancreatitis treated with a gastro-jejunostomy and a drainage of the abscess.     

Ischaemic colitis in an ironman triathlete: A case report and review of the literature

Participation in endurance sports is growing and gastrointestinal complaints including abdominal pain and rectal bleeding are common. The most severe lower gastrointestinal complication of endurance sport is ischaemic colitis. Only a few cases have been reported, all in amateur long distance runners. The majority of cases involve the right colon and, if diagnosed early and managed appropriately, few patients require operative intervention. A 51‐year‐old male presented 24 h after completing an ironman triathlon with severe right‐sided abdominal pain and bloody diarrhoea. Computed tomography confirmed right‐sided ischaemic colitis. Conservative management with intravenous rehydration and antibiotics led to the complete resolution of his symptoms over a 72 h period. Participation in endurance sport is increasing and awareness of its complications is important. In the case of ischaemic colitis related to extreme exertion, early recognition and appropriate management will decrease the risk of potentially life‐threatening complications.     

Pouchitis following restorative proctocolectomy for ulcerative colitis: incidence and therapeutic outcome.

BACKGROUND: Pouchitis is a significant sequel of restorative proctocolectomy. This study was undertaken to document the incidence of pouchitis at the Edinburgh Royal Infirmary and to assess outcome of treatment with metronidazole. METHODS: Patients who developed pouchitis following restorative proctocolectomy for ulcerative colitis form the basis of this study. Pouchitis was suspected if patients developed diarrhoea with or without blood, mucus or pus. Diagnosis was confirmed with pouch endoscopy and biopsy. RESULTS: From 1990 to 1999 (10 years) 139 patients underwent restorative proctocolectomy and ileo-anal pouch anastomosis (135 J pouches and 4 W pouches). Their median age was 35 years (range 13-74). There were 68 females and 71 males. The indication for operation was failed medical treatment in 104 patients and toxic megacolon in 35. Forty-seven patients (34%) developed pouchitis (21 females and 26 males). Symptoms were diarrhoea (35), diarrhoea, mucus and pus (5) and diarrhoea and blood (7). Symptoms of pouchitis started at an average of 33.51 + 29.2 months (range 2-102, median 18). All patients were treated with metronidazole for a minimum of one month. Thirty-six patients (77%) resolved on metronidazole alone. Nine patients (19%) went on to develop chronicity and were managed by long-term metronidazole (and/or ciprofloxacin). A further 2 patients (4%) had treatment resistant pouchitis and required pouch excision. CONCLUSION: Pouchitis is common following restorative proctocolectomy for ulcerative colitis. Treatment with metronidazole is associated with improvement in the majority of cases. In patients with chronic pouchitis maintenance of remission is possible with antibiotics. A high index of suspicion is advocated in patients who develop severe diarrhoea following this procedure.     

急性胆囊炎腹腔镜胆囊切除术79例临床分析

目的总结腹腔镜下处理急性胆囊炎的临床经验. 方法回顾性分析2002年9月～2003年8月79例腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗急性胆囊炎(acute cholecystitis,AC)的临床资料. 结果 75例术中胆道造影成功,显示胆总管结石6例,其中4例行LC联合术中内镜括约肌切开取石,2例中转开腹行胆总管切开取石T管引流.单纯胆囊结石73例,70例LC成功,3例因炎症粘连明显而中转开腹.全组无严重并发症发生. 结论绝大多数急性胆囊炎行腹腔镜胆囊切除术安全可行.     

The re‐emerging of SADS‐CoV infection in pig herds in Southern China

A new highly virulent swine acute diarrhoea syndrome coronavirus (SADS‐CoV) emerged in Guangdong province in 2017 followed by fatal diarrhoea that involved the death of 24,693 piglets. And yet from May 2017 to January 2019, there were no new SADS cases arising in pig herds in Guangdong. In this study, we reported the recent diarrhoea outbreak of SADS‐CoV in Southern China on February 2019. Intestinal samples collected from diarrhoeal piglets were detected for common swine virus and confirmed that SADS‐CoV was responsible for the diarrhoea case. Meanwhile, serological investigation of sows’ sera implied that SADS‐CoV has existed in the farm and PEDV antibody may not directly contribute to the amplification of SADS‐CoV. Homology and phylogenetic analysis of the whole genome showed that the re‐emerging SADS‐CoV strain shared high sequence identities with existing SADS‐CoV strains and all strains clustered together in Alpha coronavirus. All in all, the report herein emphasized the re‐emerging of SADS‐CoV and highlights continuous monitoring for this virus.     

Management of osteonecrosis of proximal tibia using trabecular osteonecrotic rods

Osteonecrosis of the knee is a well-described cause of acute knee pain. It can lead to significant functional impairment, rapid arthritic joint changes and subsequent collapse. Several hypotheses exist different treatment options are used ranging from conservative management to joint arthroplasty. The majority of cases involve the distal femoral condyle and to a much lesser extent the medial tibial plateau.We are presenting a rare case of osteonecrosis of the proximal tibia affecting the lateral tibial condyle in 44 years old Caucasian male which was treated successfully using osteonecrotic tantalum rods with 26 month follow-up.     

Monteggia and equivalent lesions in childhood

One hundred two children with acute Monteggia lesions treated over a 25 year period were reviewed. Using the Bado classification system, type 1 (53%) and type 3 (26%) fractures were the most common. The type 1 equivalent injury associated with a proximal radius fracture is more common in children than previously reported. The majority of injuries could be treated with closed reduction, except the type 1 equivalent lesions, which required operative treatment in 10 of 14 children. Varus angulation of the ulna was the most common deformity after closed treatment. Nerve injuries occurred in 11% of the injuries, and resolved in all cases without operative treatment.     

Should Ruptured Liver Haemangioma Be Treated by Surgery or by Conservative Means ? A Case Report

Spontaneous rupture of a liver haemangioma is a rare but life-threatening acute clinical situation following haemorrhage within the liver, the subcapsular space and the peritoneal cavity in cases of capsular rupture. Rupture of a liver haemangioma has been reported to occur spontaneously in the majority of cases. In the past, prompt surgical treatment was recommended but was associated with high morbidity and mortality. Currently, conservative management and, in cases of recurrent haemorrhage, delayed surgery may be proposed. We report a case of spontaneous rupture of hepatic haemangioma treated by arterial embolisation and conservative means. The literature is also reviewed.     

腔内修复术治疗孤立性髂动脉瘤14例

目的探讨腔内治疗孤立性髂动脉瘤的疗效。方法回顾性分析2004年10月至2006年5月腔内修复孤立性髂动脉瘤14例的临床资料。其中,右髂总动脉瘤8例,左髂总动脉瘤5例,左髂内动脉瘤破裂1例。髂动脉瘤腔内修复的标准是瘤体直径〉3．0cm。结果14例均取得技术成功。8例右髂总动脉瘤,钢圈栓塞右髂内动脉后选用分叉支架型人工血管行腔内修复术。其中1例右髂总动脉瘤累及腹主动脉下端,选用AUl支架型人工血管腔内修复加股．股动脉旁路术。5例左髂总动脉瘤栓塞同侧髂内动脉后选用直型支架型人工血管。1例左髂内动脉瘤破裂急诊行钢圈栓塞后选用直型支架覆盖左髂内动脉开口。术后即刻数字减影血管造影显示动脉瘤消失,远近端支架型人工血管与宿主动脉结合处均未见明显渗漏。1例术后出现急性左心功能不全和肺水肿,经抢救痊愈,其余13例无手术并发症。术后CTA随访10．2个月（3～19个月）,瘤体无增大,支架无移位,无内漏,旁路人工血管通畅。结论腔内修复术治疗孤立性髂动脉瘤具有可行、安全、微创等特点,近期疗效较好,远期效果需进一步随访。     

腹腔镜技术在外科急腹症中的应用

目的探讨腹腔镜技术在外科急腹症中的应用价值。方法2002年3月～2007年3月,行306例急诊腹腔镜手术探查与相应治疗。术前诊断急性阑尾炎105例,腹痛原因待查34例,急性胆囊炎、胆囊结石64例,消化道穿孔51例,胆总管结石、急性胆管炎5例,肠梗阻33例,有明确外伤史9例,重症急性胰腺炎5例。结果本组306例全部术中明确诊断,腹腔镜手术成功275例,其中阑尾切除术123例,胆囊切除术57例,消化道穿孔修补术48例,22例肠梗阻中行肠粘连松解13例、小肠复位联合斜疝修补4例、腹腔镜辅助下乙状结肠癌根治直肠前吻合4例、小切口小肠肠段切除端端吻合术1例,胆总管切开取石T管引流术3例,右叶肝破裂修补术2例,脾破裂止血3例,重症急性胰腺炎清创冲洗引流术5例,腹腔镜探查12例（肠系膜挫裂伤2例,腹壁刀刺伤伴大网膜挫伤1例,原发性腹膜炎8例,过敏性紫癜腹型1例）;余31例腹腔镜完成困难而中转开腹。306例随访1～18个月,无术中、术后并发症。结论急诊腹腔镜探查术不仅可以对病因不明的急腹症做出准确诊断,且可同时行腹腔镜手术治疗。即使腹腔镜下不能完成的手术,也可以指导及时开腹,以及采取较为合适的手术切口。     

The endemic bladder stones of Indonesia---epidemiology and clinical features.

Bladder stone is a relatively common disease of childhood in West Sumatra with an incidence of 8.3/100,000 population per year. We have studied 87 cases with a peak age of onset of 2-4 years and a male/female ratio of 12:1. The majority of these are from poor families with a diet low in protein and phosphate. Diarrhoea is common. The composition of the stones is primarily ammonium acid urate. Patients with sterile urine have shown significantly higher levels of urinary ammonia than controls, and only approximately 50% of patients' urine were infected. This is consistent with excretion of a high acid load, due both to an acidogenic rice diet and diarrhoea, combined with a low level of phosphate. This condition was once endemic in Europe but is now confined to a belt of countries from the Balkans through Asia.     

Upper-extremity deep venous thrombosis following humeral shaft fracture

Upper-extremity deep venous thrombosis (DVT), although not as common as its lower-extremity counterpart, is a clinical entity with potentially devastating complications. Approximately 1% to 4% of all DVT cases involve the upper extremity, with 9% to 14% of these cases complicated by pulmonary embolism. Prompt diagnosis with duplex ultrasonography and subsequent anticoagulation are the gold standards for identification and treatment. The majority of these cases are secondary to medical comorbidities such as malignancy, hypercoagulable states, and indwelling catheters. Although rare, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively. A 58-year-old man presented with right elbow pain after a fall from scaffolding. Radiographs demonstrated a distal humeral shaft fracture at the tip of a previously placed intramedullary nail. Initial treatment consisted of closed reduction in a coaptation splint. The patient re-presented 4 days later with increasing forearm pain and swelling. An ultrasound revealed an extensive thrombus of the right brachial vein. A coaptation splint was replaced and the patient was admitted to the hospital for therapeutic anticoagulation. After hematology consultation and a short hospitalization, the patient was discharged home on a 3-month course of Warfarin. The goal of treatment of upper-extremity venous thrombosis is to improve the patient's acute symptoms and prevent both pulmonary embolism and post-thrombotic syndrome. Post-thrombotic syndrome is a chronic, potentially debilitating condition that occurs in approximately 15% of upper-extremity DVT cases with symptoms consisting of pain, swelling, paresthesias, and functional limitation.     

Stabilizzazione artroscopica della lussazione acromion-claveare acuta con il sistema TightRope®

Acromioclavicular (AC) joint dislocation is common in athletes and in contact sports. The majority of these AC lesions can be successfully treated conservatively but high grade dislocation and some cases of type III dislocation need a surgical treatment. The purpose of this study is to evaluate the results of arthroscopic stabilization of acute AC joint dislocation with the TightRope^® system in nineteen patients.     

Case report: Colon ischemia and perforation as a result of Norovirus infection

IntroductionNorovirus (NoV) gastroenteritis has been documented as the worldwide leading cause of the majority of acute cases of viral gastroenteritis. Here, we present a Case of NoV that progressed into colon perforation.Presentation of caseA 47-year-old woman was admitted via the emergency unit with diarrhoea, lower abdominal pain, vomiting and fever. The virological testing of her stool revealed a NoV infection. The abdominal CT scan showed massive pneumatosis intestinalis. Following the scan findings, the patient was admitted for a diagnostic laparotomy the same day. A side-to-side ileosigmoidostomy was performed. We performed two clinical re-evaluations of the patient, the first one took place 2 weeks after we discharged the patient and another one-year later. The patient is in perfect health.DiscussionTo the best of our knowledge and following a thorough bibliographical search, this is the first case report in Germany and the first case report of colon perforation due to NoV infection in adults in the European Union.ConclusionA NoV infection could, along with the typical symptoms, indicate a life-threatening bowel ischemia and/or necrosis.