Retroperitoneal haematoma seen on CT scan in 2 patients with abdominal symptoms, aneurysm of the abdominal aorta and normal haemodynamics

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.     

腔内隔绝术治疗肾下型腹主动脉瘤24例疗效分析

目的 探讨腔内隔绝术治疗肾下型腹主动脉瘤的疗效、适应证及其并发症的防治.方法 回顾性分析2006年4月至2008年9月经CT血管造影或磁共振血管造影确诊为肾下型腹主动脉瘤24例患者的临床资料.切开双侧股动脉,经股动脉将覆膜支架置于肾动脉下方,支架自膨张开,使血流经人造血管流向髂总动脉.结果 支架植入全部成功,术后即刻造影20例无内漏,4例存在轻度Ⅰ型内漏.无支架移位,无脏器及双下肢缺血表现.术后6个月复查CT增强扫描示全部病例支架形态完好,动脉瘤消失,支架外血栓形成.结论 腔内隔绝术治疗腹主动脉瘤具有简捷、微创、并发症少、术后恢复快等优点,为老年患者治疗肾下型腹主动脉瘤的首选方法.

Abstract：

Objective To investigate the efficacy and the indication and the management of perioperative complications in treatment of infra- kidney abdominal aortic aneurysm (AAA) by using endovascular graft exclusion (EVGE). Methods From April 2006 to September 2008, 24 patients with infra- kidney abdominal aortic aneurysms were diagnosed by contrast-enhanced CT or MRI scan. Vascular access was obtained through the bilateral femoral artery after arteriotomy and stent-graft was deployed into AAA of below the renal artery to occlude the left over cavity of AAA. The stent- graft was extended and anchored to the both side wall of AAA, the blood flow enter into the arteria iliaca communis through the sten't.Results Stent-graft deployment was successfully performed in all the patients. Immediate aortography after the procedure showed no leakage in 20 patients and the type Ⅰ minor leakage in 4 patients. No stent movement or organ and both lower extremities ischemia was found at the early post operative stage in all the patients. Six months after the operation, in all the 24 patients, contrast-enhanced CT scan showed the disappearance of the aneurysm and thrombosis at the level of the stent. Conclusions EVGE is simple,minimally invasive,less complication and quick recovery after operation. Thus it becomes first choice for the treatment of AAA for the elder patients.     

A woman with acute upper abdominal pain

A 42-year-old woman came to the emergency department with acute abdominal pain. CT-scan showed an isolated dissection of the A. mesenterica superior and signs of ischaemic colitis. The patient was treated with endovascular stent placement in the artery and partial small bowel resection.     

Spontaneous renal bleeding in haemodialysis patients

In three women on chronic haemodialysis because of end-stage renal disease who were 40, 59, and 73 years of age respectively, spontaneous renal bleeding was diagnosed. The first two patients presented with acute flank pain and signs of sudden blood loss, the third one had chronic abdominal pain and anaemia. A CT scan demonstrated perirenal bleeding in all three patients and expansion into the retroperitoneal space in the first and third patient. In the latter two patients, acquired renal cysts had been visible during earlier abdominal ultrasound. None of the patients had severe hypertension, but all of them had received medication enhancing bleeding tendency, such as nadroparin, which was administered during haemodialysis. The first and the last patient were treated conservatively and survived. The second patient was haemodynamically unstable and underwent embolisation to stop the bleeding. She died in hospital after fifteen days due to the complications of a cardiac arrest. Abdominal CT or ultrasound is the technique of choice to evaluate patients with end-stage renal disease with loin pain or bleeding. Most of the time, conservative treatment suffices.     

Percutaneous, endovascular treatment of innominate artery lesions is a safe and effective procedure

Percutaneous endovascular treatment (transluminar balloon angioplasty with or without stent implantation) of innominate artery lesions has become the treatment of choice prior to surgery in the past decades. Authors present the diagnostics, treatment and follow-up of two patients as examples from their largest series in the literature. A 74-year-old male patient with a history of hyperlipidemia, hypertension, nicotine abuse and lower limb claudication was admitted because of acute upper limb claudication and dizziness. Physical examination revealed blood pressure difference of 30 mmHg between his arms, and poststenotic flow pattern in the common carotid artery with retrograde flow in the vertebral artery on carotid duplex scan. Diagnostic angiography showed 80% stenosis of the innominate artery, which was treated with percutaneous transluminar balloon angioplasty with stent implantation. Follow-up examination at 5 months showed no significant restenosis or neurological complication. The second patient was a 59-year-old smoker female patient with hypertension and type 2 diabetes mellitus, who was evaluated for her upper limb claudication. Initial finding was the absence of radial pulse in the right side. Color duplex scan revealed proximal subocclusion, which was confirmed by angiography. In one stage, balloon angioplasty was made, with immediate pain relief. After 15 months the patient was symptom-free. These two cases demonstrate an excellent outcome of endovascular treatment of innominate artery lesions, as authors already reported in two retrospective studies. Balloon angioplasty with, or without stent deployment appears to be a safe procedure with excellent primary success rate. Review of international studies also indicates that endovascular therapy of the innominate artery is safe and effective.     

Emergency endovascular repair of acute descending thoracic aortic dissection

Background

Acute descending thoracic aortic dissection is a life-threatening emergency. It is not often considered as the initial diagnosis in patients presenting with epigastric pain and could easily be missed in a busy casualty department.

Aim

This case report is aimed to highlight the feasibility of the technique and the need for long-term surveillance following endovascular repair of acute thoracic aortic dissection.

Results

The patient presented with epigastric pain radiating to the interscapular region with a stable hemodynamic status. A computerized tomography (CT) scan demonstrated type B thoracic aortic dissection of the proximal descending thoracic aorta. A successful endovascular repair was carried out with uneventful recovery and follow-up CT scan six years after stent-grafting shows satisfactory position of the stent-graft, patent false lumen in the abdominal aorta perfusing the right kidney, and progressively enlarging diameter of the abdominal aorta.

Conclusion

Thoracic aortic dissection should be considered as a differential diagnosis in patients presenting with epigastric and interscapular chest pain. Emergency endovascular repair of acute thoracic aortic dissection is feasible and relatively safe. Regular follow-up with CT scan is required to evaluate the long-term efficacy and identify the need for re-intervention.     

Abdominal pain following placement of an endoprosthesis in the biliary duct

A 76-year-old man presented with diffuse progressive abdominal pain. He had undergone endoscopic retrograde pancreaticocholangiography (ERCP) 5 weeks earlier for jaundice and increased levels of liver enzymes. A dilated biliary duct with multiple concrements had been seen, and a plastic endoprosthesis was placed. During a follow-up ERCP the stent was not found, and the obstruction was still present. Another stent was placed. Abdominal x-ray revealed migration of the first endoprosthesis to the distal jejunum and signs of ileus and free gas. CT showed that the stent was stuck in a perforated diverticulum of the sigmoid, surrounded by an abscess mass. The stent was removed by laparotomy, the perforation was closed, and a double-loop stoma was made. Two weeks after initial recovery, abdominal pain recurred. CT revealed a second dislocated stent with a perforation of the jejunum. Laparotomy was performed again with removal of the stent and repair of the perforation. Migration is a known complication of biliary endoprosthesis placement, and should be considered in cases of abdominal pain after ERCP. Perforations rarely occur and mostly affect areas of the bowel that are fixed or that present obstacles to normal elimination. Two perforations within a short period of time is an extremely rare complication of migration.     

Acute abdominal and back pain in a patient with an aortic aneurysm and a duodenum perforation on CT-scan

An 82-year old man with a known aneurysm of the abdominal aorta (AAA) presented with a history of acute onset abdominal and back pain of a few hours. He was haemodynamically stable and had pain on pressure over the aneurysm. Ultrasound confirmed the AAA, but could not demonstrate or exclude rupture. Subsequent CT-scan confirmed a non-ruptured AAA and demonstrated a small, curvilinear, hyperdense structure thought to be a fish bone or chicken bone which had perforated the duodenum. On gastroduodenoscopy, a fish bone was found and removed. The patient's symptoms resolved completely within two days. In patients with a possible ruptured AAA, echographic or CT-scan investigations can confirm or exclude the condition thus avoiding unnecessary surgery. These investigations also gather preoperative data for potential endovascular reconstruction. Before the introduction of new visualization techniques a duodenum perforation resulting from the unnoticed swallowing of a sharp object could only be diagnosed by explorative laparotomy. Delay in diagnosis leads to high mortality.     

Urogenital Sinus Cyst in a 21-Year-Old Man

We report a case of a rare congenital malformation, a urogenital sinus cyst in a young patient with non-specific symptoms for several months. A 21-year-old male presented with vague and intermittent abdominal pain. Ultrasound scan showed a retrovesical hypoechoic collection (approximately 6 cm) and left renal agenesis, compatible with a possible congenital malformation. These findings were confirmed by MRI. A laparoscopic excision of the cyst was performed with no complications. Pathology report confirmed a urogenital sinus cyst. The postoperative recovery was uneventful and the patient was discharged within 48 h. Urogenital sinus cysts are rare entities with few cases described in the literature. Imaging techniques such as ultrasound, CT or MRI may help with diagnosis. Therapeutic modalities range from observation to needle aspiration or surgical removal. In our case, we chose a laparoscopic approach to minimize morbidity and achieve an early recovery.     

Pancreas pseudocyst or metastasis?

The authors review a case of a 24-year-old male patient hospitalised for repeated acute abdominal symptoms. His medical history included no diseases worth of mentioning. By imaging techniques (abdominal US and CT scan) a cystic lesion, measuring 40 x 35 x 30 mm in diameter was found, and was diagnosed as pseudocyst in the region of the tail of the pancreas. Jejunal feeding was introduced. The lesion did not improve and the second CT scan suggested a suspicion of pancreatic cystadenoma. Three months after first presentation the surgical resection was performed. The tumour, however, was found independent of the pancreas (90 x 80 x 50 mm). Both histologically and immunohistochemically the lesion proved to be the metastasis of a germ cell (yolk-sac) tumour. Following the morphological diagnosis, detailed urological and medical check up was performed. A previously nonpalpable small tumour was found in the left testis which was radically resected. The testicular tumour measuring 9 x 9 x 5 mm in diameter was diagnosed as embryonal carcinoma. Later on the patient underwent chemotherapy. He has been undergoing close oncological followup. Clinically, he is disease free. Authors emphasize the importance of imaging techniques and fine needle aspiration cytology in the case of retroperitoneal masses in young males. The possibility of a metastasis, especially of germ cell origin, should be excluded (not only by physical examination, but by ultrasound of testis also) in case of retroperitoneal cystic tumours even with unusual morphology.     

Two patients with emphysematous pyelonephritis

A 55-year-old man with diabetes mellitus was sick with shivering, abdominal pain and Escherichia coli in blood and urine cultures; a 40-year-old woman with asthmatic bronchitis had abdominal pain and anaemia. Both had renal dysfunction and the CT scan showed hydronephrosis with a perirenal inflammatory infiltrate and gas in the right and left renal pelvis, respectively. The man had a difficult recovery after treatment with antibiotics and percutaneous drainage. In the woman, a calculus obstructed the pyelo-ureteral passage; the resected kidney contained a squamous cell carcinoma. She was operated, received chemotherapy and recovered. Emphysematous pyelonephritis is a rare, severe disease. Percutaneous drainage and, if necessary, nephrectomy are paramount in the treatment. The condition is observed mostly in patients with diabetes mellitus or obstruction of the urinary tract.     

A case of retroperitoneal neurinoma

A case of retroperitoneal neurinoma is reported. The patient was a 34-year-old female without symptoms. CT scan showed a large low density mass, a part of which was enhanced. US showed a lobulated cystic mass. Angiography showed avascular mass and portal vein was shown with displacement and stenosis. Pathological diagnosis was benign retroperitoneal neurinoma (Antoni A and Antoni B).     

Abdominal pain with a microvascular cause

A 50-year-old Caucasian man was admitted with unexplained abdominal pain. Based on CT scan results, a perforation resulting from colitis of the transverse colon was suspected. Additional colonoscopy showed ulcerative stenosis of the transverse colon. Initially, the patient recovered on conservative treatment; however, because of persistent stenosis, an elective resection of the transverse colon was performed. A CT scan revealed free gas around the anastomosis on the fourth postoperative day. Relaparotomy revealed leakage and diffuse ischaemic changes around the anastomosis as well as perforations at different sites on the small bowel. Postoperative CT angiography showed stenosis of the proximal celiac trunk, which was successfully stented. Digital subtraction angiography (DSA) revealed luminal irregularities of the superior mesenteric, the middle colic as well as the main hepatic and splenic arteries. Eventually, the clinical presentation and surgical, radiologic and histopathological findings together led to the diagnosis of polyarteritis nodosa (PAN). Aggressive treatment with glucocorticoids and cyclophosphamide resulted in the resolution of symptoms and the disappearance of radiologic abnormalities.     

Fitz-Hugh-Curtis syndrome: 2 patients with perihepatitis and sepsis

Two women aged 53 and 22 years presented with abdominal pain and signs of sepsis with metabolic acidosis. The first patient had ecchymoses all over her body, the second patient had an enlarged left kidney with wedge-shaped hypo-intense areas on the CT scan. The clinical condition of both women deteriorated. On laparoscopy perihepatitis with fibrin wires ('violin strings') was seen, pathognomonic for Fitz-Hugh-Curtis syndrome. Upon appropriate antibiotic treatment, both patients fully recovered. Although it is common belief that Fitz-Hugh-Curtis syndrome is caused by local spread from the fallopian tubes into the peritoneal cavity, these presentations suggest a haematogenous spread of Neisseria gonorrhoeae as well as Chlamydia trachomatis in the first case, and C. trachomatis in the second case.     

Diagnostic policy in patients with a suspected ruptured abdominal aortic aneurysm

The clinical diagnosis of a ruptured aortic aneurysm is unreliable, and in haemodynamically stable patients both ultrasound and CT are used to improve diagnostic accuracy. In any patient with a suspected ruptured aneurysm, ultrasound is done upon arrival of the patient in the hospital to confirm or exclude the presence of an aortic aneurysm. If facilities for endovascular reconstruction are available at the hospital, an immediate CT scan with intravenous contrast follows, to find out if and how endovascular treatment should be performed. If endovascular reconstruction is not available, a CT scan without using contrast is carried out. If the CT scan shows a ruptured aneurysm, the patient is transported to the Operating Department without further delay. If the CT scan does not show any signs of rupture, there is time for further investigation. If no alternative condition to explain the patient's symptoms is found, further diagnostic tests such as repeat ultrasound, CT with contrast material and laboratory tests can be performed. If no other serious condition emerges, the aortic aneurysm should be considered symptomatic. In this case, the patient should undergo a rapid, but thorough pre-operative work-up, and go for operation as soon as possible by a rested and experienced operating team as part of the regular day programme.     

Pneumatosis intestinalis; no disease, but a symptom

In three patients, men aged 77, 83 and 69 years, pneumatosis intestinalis was detected during CT for abdominal pain occurring in the first patient after an aortic stent had been placed, and during laparotomy because of ileus in the latter two patients. The first patient underwent removal of an ischaemic intestinal segment but died later due to infection around the prosthesis. The other two patients recovered after conservative therapy. Pneumatosis intestinalis is defined as the presence of gas in the wall of the gastrointestinal tract. Often it is detected by accident during abdominal radiographic examination or laparotomy. Pneumatosis intestinalis is a symptom and has been found in a wide variety of diseases. The clinical condition of the patient and the underlying disease determine the clinical significance of pneumatosis intestinalis and the therapy. The main issue is whether surgical intervention is necessary because of intestinal ischaemia or perforation.     

Hepatocellular adenoma, a tumour particularly seen in mostly young women

A 37-year-old woman was examined because of temporary diarrhoea. On CT scan, there was an abnormality of the liver. MRI showed a tumour that was suspicious for adenoma. Biopsy confirmed the diagnosis of hepatocellular adenoma. The patient then discontinued the use of oral contraceptives. The tumour regressed and was resected after two years. A 22-year-old woman presented with abdominal pain. A tumour was found in the upper right quadrant of the abdomen. In the laboratory, liver function tests were abnormal. Ultrasound and a CT scan of the liver showed an adenoma. After withdrawal of oral contraceptives, abdominal complaints lessened, but no regression of the tumour was detected. Surgical resection was uncomplicated. Hepatocellular adenoma is a rare, benign tumour of the liver, most often seen in young healthy women. Its incidence is rising due to the prolonged use of oral contraceptives. Not rarely, benign liver tumours are incidental findings on echography. If symptomatic, the presentation usually consists of vague abdominal complaints. Spontaneous rupture and malignant degeneration have been reported for adenoma. A reliable diagnosis is mandatory for the decision whether to apply surgery or continue observation. Radiological investigations play a key role in the detection and diagnosis of hepatocellular adenoma. Due to the risk of bleeding and malignant degeneration, elective surgical resection is indicated in symptomatic adenomas, asymptomatic adenomas larger than 5 cm in diameter, and smaller adenomas without regression after discontinuation of oral contraceptives.     

Vertebral erosion resulting from a 'non-ruptured' abdominal aortic aneurysm: case report and literature review

The natural history of abdominal aortic aneurysms (AAAs) renders them clinically silent for much of their evolution. These aneurysms will inevitably expand with time and, although surveillance programmes exist, an acutely ruptured AAA is still a relatively common clinical scenario. The classical presentation is with rapid haemodynamic deterioration with accompanying severe abdominal or back pain. Less commonly, patients may present with a stable haemodynamic profile and vague symptomatology; they are usually found to have a chronic contained rupture with a defect in the vascular wall with co-existent pseudoaneurysm and retroperitoneal haematoma formation. We report a rare case of AAA with posterior wall defect and erosion into the vertebral body with no accompanying pseudoaneurysm or haematoma and discuss the clinical implications of such a presentation.     

StanfordB型主动脉夹层支架介入术的观察与护理

目的探讨StanfordB型主动脉夹层多型支架介入术的病情观察与护理要点。方法收集2004年5月至2012年3月我科收治的28例StanfordB型主动脉夹层患者的临床资料。总结28例StanfordB型主动脉夹层,个体化地使用多种支架介入治疗患者的病情观察重点及护理措施,包括术前病情监测,有效控制血压和心率,做好基础护理和心理护理,术后严密监测病情,防治并发症及做好健康指导等。结果1例患者腔内修复术后发生1型内漏,再次放置支架后进展为StanfordA型主动脉夹层瘤而行升主动脉人工血管置换术．1例放弃治疗,其余26例均手术顺利出院,CTA随访近中期疗效较好。结论严密的病情观察和行之有效的护理．可增加StanfordB型主动脉夹层患者的手术成功率,提高其生存率。     

Pulmonary sequestrum--not infiltrate--in a 45-year-old woman

A 45-year-old woman presented at the emergency room with acute dyspnoea and slight fever, without coughing. The chest radiography showed a consolidation in the lower left lobe. The CT scan revealed a consolidation in the posterior-basal segment of the lower left lobe without an air bronchogram but with various densities. Based on these findings, the possibility of pulmonary sequestration was considered. A CT scan showed an arterial branch arising from the aorta that supplied the consolidation, confirming pulmonary sequestration. The patient underwent resection of the intralobar sequestrum, after which she recovered and was asymptomatic. Pulmonary sequestration should be considered in any patient with pneumonia or recurrent pneumonia in the lower lobes of the lung, especially in the absence of an air bronchogram or signs of endobronchial obstruction. The treatment ofchoice is surgical resection.