Abdominal pain as a symptom of a late complication following endovascular treatment of an aneurysm of the abdominal aorta

A 72-year-old man presented with progressive pain in the left lower abdomen thought to be due to diverticulitis of the colon. Antimicrobial therapy had not reduced the symptoms. Four years before, during an endovascular procedure, the patient had been given a stent because of an abdominal aortic aneurysm (AAA). A CT scan showed a large retroperitoneal haematoma on the left side and an increased diameter of the AAA of 8.5 cm. X-rays showed a gap between the endovascular stent and the left iliac leg of the endoprosthesis. Due to the space between the two grafts, there was retroperitoneal leakage ofblood. In endovascular surgery this life-threatening situation is called a type III endoleak. The patient was operated immediately using the endovascular technique. Through the left femoral artery a new coated stent was positioned over the gap, which led to rapid recovery of the patient. Patients with abdominal pain and a history of a vascular endoprosthesis should be given a CT scan and plain radiography to exclude an endoleak.     

Self-expanding stents for malignant dysphagia.

Self-expanding metallic stents have been employed successfully for vascular, urethral, and biliary strictures. In a prospective study we examined the efficacy of the 16 mm Wallstent for palliation of malignant dysphagia. Eight patients with severe dysphagia due to advanced primary (four) or secondary (four) oesophageal malignant disease were recruited and nine Wallstents were inserted (one patient required two). Dysphagia was reduced in all but one patient, who died after oesophageal perforation; a second patient had a self-limiting bout of haematemesis. Two patients required subsequent treatment for tumour ingrowth but five had no further palliative therapy from stent insertion to time of death. With careful patient selection and skillful application, a 16 mm self-expanding metal endoprosthesis affords effective palliation in malignant oesophageal obstruction.     

Abscess formation due to lost stones during laparoscopic cholecystectomy

Two women aged 79 and 69 years presented with abdominal pain at 15 and 38 months respectively after a laparoscopic cholecystectomy. In both cases perforation of the gallbladder had occurred with spillage of bile and gallstones. A CT-scan carried out at presentation showed signs of an abdominal abscess. The origin of the abscess was initially unknown. The first patient was operated on immediately. In the second patient a drain was placed in the abscess under ultrasound guidance. During operation gallstones were seen in the abscess cavity in both patients. Both patients recovered well. Although perforation of the gallbladder with spillage of gallstones during laparoscopic cholecystectomy often occurs, the incidence of major postoperative complications is low. However, in some cases reoperation is necessary. Removal of all spilled stones is therefore indicated to prevent complications. If abdominal symptoms persist after laparoscopic cholecystectomy, an abscess due to spilled gallstones should be considered. Ultra-sound or CT are the most sensitive means of for tracing spilled gallstones or abscesses.     

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.     

Evaluation of a biliary endoprosthesis using expandable metallic stents

A biliary endoprosthesis constructed of Gianturco self-expanding metallic stents was placed in twenty-nine patients with obstructive jaundice, 27 malignant and 2 benign. All endoprostheses were placed successfully. External drainage catheters were removed in twenty-seven patients. At the follow-up, ranging from two to 59 weeks, the 30 day mortality rate was 7.4%. Twenty-eight patients had obvious clinical improvement with relief of jaundice. Seven patients experienced recurrent jaundice. In two of these patients, the obstruction was relieved by additional metallic stents. The expandable metallic biliary endoprosthesis is suggested as an effective treatment for biliary obstruction.     

鼻胆管引流治疗腹腔镜胆囊切除术后胆漏

目的 探讨经内镜逆行胰胆管造影（ERCP）和经内镜鼻胆管引流（ENBD）在腹腔镜胆囊切除术（LC）后胆漏诊治中的应用价值.方法 回顾性分析9例LC后胆漏患者的临床资料.结果 9例均行ERCP.其中8例经ENBD治疗获得成功,1例因胆总管横断伤,经再次手术治愈.结论 ERCP是LC后胆漏患者理想的诊断方法,ENBD结合腹腔引流治疗LC后胆漏效果满意.     

食管狭窄患者介入成形术的围手术期护理

目的:探讨食管狭窄行介入成形术患者围手术期的护理方法。方法:对32例食管狭窄患者在X线监视下采用介入性球囊导管扩张技术和带膜内支架植入治疗,术前做好物品准备、病人准备,术中给予密切配合,术后加强并发症观察与护理、饮食指导。结果:32例患者单纯行球囊扩张18例,共扩张32次;14例患者行球囊扩张后立即放置食管支架成形,共放置带膜内支架19枚,均一次置入成功,位置准确,无腹痛、消化道大出血和穿孔等严重并发症。结论:介入成形术治疗食管狭窄简单易行、安全可靠,科学规范的围手术期护理是手术成功和疗效的重要保障。     

Obstructive cholangiopathy: are endoscopic retrograde cholangiopancreatography and papillotomy always really necessary?]

In two women aged 76 and 29 years, who presented with cholangitis and small ductus choledochus calculi and with painless icterus respectively, endoscopic retrograde cholangiopancreatography (ERCP) was carried out with papillotomy. Both developed a duodenal perforation which, however, could not be localized. The first patient eventually died, the second recovered after prolonged hospitalization. A third patient, a 53-year-old man, developed abdominal pain and fever four days after laparoscopic cholecystectomy. ERCP was planned, but in the meantime the patient showed signs of recovery. The ERCP was carried out nevertheless. It failed and the patient suffered a prolonged recovery with necrotizing pancreatitis and multiple operations necessitating a temporary colostoma. In all three patients the endoscopic procedure was performed routinely without strict individualized indication. ERCP and papillotomy may be relatively safe procedures, but it should always be considered whether they will really serve the patient.     

Diagnosis of perforated enterocystoplasty

In the operation of enterocystoplasty, now widely practised, segments of bowel are used to augment or replace the urinary bladder. An occasional complication is perforation, and this may present in non-specialist settings. We investigated the management of spontaneous perforations among 264 patients with enterocystoplasty followed by one surgeon for 2-18 years. Patients' charts were examined for data on presentation, diagnosis and treatment. 10 patients had thirteen perforations; data were available for nine perforations in 9 patients. Mean time from enterocystoplasty to perforation was 45 months. Presentation was shoulder pain in 1 and abdominal pain (with or without fever) in 8. Perforation was diagnosed without delay in 3, but the initial diagnosis was urinary tract infection in 4 and small-bowel obstruction in 2. Ultrasound was the most useful investigation being diagnostic in 6 of 7 cases; contrast cystography showed a leak in only 2 of the 6 patients in whom it was performed. Treatment was successful in 8 cases (surgery 6; percutaneous drainage 2); 1 patient, who remained undiagnosed, was treated medically and died. Patients with enterocystoplasty need to be educated about this potentially lethal complication, so that they can alert non-specialist clinicians to what may have happened. In any patient with enterocystoplasty who reports abdominal pain or shoulder pain, perforation has to be ruled out.     

内镜下自膨式无覆膜结肠金属支架置入治疗左侧结肠恶性梗阻

目的 探讨经内镜自膨式无覆膜金属支架置入治疗左侧结肠癌性梗阻的临床价值.方法 根据梗阻情况进行不同术前肠道准备后,经内镜放置金属支架治疗左侧结肠癌性梗阻患者21例,术后进行常规处理并随访.结果 21例结肠癌性梗阻中,放置金属支架成功率为100％,术后1～2d肠梗阻症状均得到缓解或消除;支架术后均有少量的便血6例,无大出血、穿孔及支架移位等并发症发生;21例患者术后均能恢复经口进食,生存期4 ～ 22月,平均生存期为7月.结论 经内镜放置自膨式无覆膜金属支架治疗左侧结肠癌性梗阻,操作简单、经济有效、术后并发症少,有效缓解患者的梗阻症状,提高其生活质量.     

Endovascular treatment of 2 patients with an aneurysm of the descending thoracic aorta]

Two men, aged 71 and 70, who had previously experienced an abdominal aneurysm were found to have thoracic aortal aneurysms of respectively 8 cm and 7.5 cm in length. For the first patient an endovascular operation was carried out due to a high operative risk: with the help of a radiograph, four endoprostheses were inserted into the thoracic descending aorta via the femoral artery, after which the aorta diameter became more normal. A month later, the patient died from persistent renal failure, which had developed as a result of the previously ruptured abdominal aneurysm. In the second patient with an aneurysm of the proximal descending aorta, a left decompensation arose following aortal clamping during open surgical repair. Ten weeks later an endoprosthesis was inserted via the femoral artery. A year later the aortal diameter had decreased to 6.5 cm; the patient functioned well. The insertion of an endoprosthesis in the thoracic aorta is a minimally invasive procedure in which the patient experiences little perioperative inconvenience.     

冠心病支架置入术患者血清IL-6及CRP水平变化研究

目的 观察冠心病患者冠状动脉内支架置入术前后外周血IL-6及C反应蛋白（CRP）水平变化.方法 分别于术前和术后24 h检测60例行冠状动脉内支架置入术的冠心病患者外周血IL-6及CRP水平,与60例冠状动脉造影正常者（对照组）进行对比,并观察患者术后IL-6、CRP水平变化与并发症及再狭窄发生的关系.结果 冠心病患者术前外周血IL-6及CRP水平与对照组相比无显著性差异（P＞0.05）;患者术后血清IL-6及CRP水平均显著高于术前（P＜0.01）;术后发生并发症及再狭窄者与未发生者相比,IL-6及CRP水平均明显升高（P＜0.01）.结论 IL-6及CRP水平变化是反映冠心病患者冠状动脉内支架置入术后早期炎症反应及评估病情的敏感指标,其可能在支架置入术后再狭窄发生过程中发挥作用.     

Severe gastric dilatation due to superior mesenteric artery syndrome in anorexia nervosa

Forty‐seven year old female, with a history of anorexia nervosa, was admitted to a medical stabilization unit (ACUTE) complaining of abdominal pain exacerbated by oral intake, associated with nausea, and relieved by emesis. Admission body mass index was 10.6. Labs were notable for hepatitis and hypoglycemia. On her progressive oral refeeding plan, she suddenly developed severe abdominal pain. Computed tomography (CT) revealed gastric dilatation and superior mesenteric artery (SMA) syndrome. SMA syndrome is a rare complication of severe malnutrition resulting from compression of the duodenum between the aorta and the SMA. It is diagnosed by an upper gastrointestinal series or an abdominal CT. Gastric dilatation, in turn, is a rare complication of SMA syndrome to be included in the differential diagnoses of abdominal pain in severely malnourished patients as it is potentially life‐threatening. The patient was switched to an oral liquid diet, began weight restoring, and had resolution of symptoms. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:532–534)     

Tumors in the gallbladder: a possible differentiation between malignant and benign tumours

In a 59-year-old woman with pain in the right upper abdomen, echography and CT-scan revealed adenomatosis of the gallbladder. Her symptoms did not disappear after cholecystectomy, even though echography showed no further abnormality. In a 46-year-old man with fever and weight loss, echography revealed two polyps in the gallbladder. Following cholecystectomy, histopathology revealed cholesterol polyps and an infection with Entamoeba coli. In a 63-year-old man with systemic symptoms, a biopsy of the echographically diagnosed tumour of the gallbladder revealed that he had actually had cholecystitis. The management was wait-and-see and the patient recovered completely. In a 68-year-old woman with jaundice and attacks of abdominal pain, a CT-scan revealed gallstones. The symptoms recurred following an ERCP. Following cholecystectomy, an adenocarcinoma of the gallbladder was found. One year later, a contact metastasis developed forwhich she received radiotherapy. After 4 years she was in good condition. Patients with a tumour in the gallbladder are often diagnosed with gallbladder cancer, which has a poor prognosis. Other diseases should also be considered, since the treatment and prognosis differ greatly. It is important to differentiate at an early stage. Ultrasound, CT and MRI have improved the possibility of differentiating and choosing the correct treatment.     

Severe oesophagus injury as a complication during treatment with risedronic acid

A 77-year-old man, treated with risedronic acid to prevent corticosteroid-induced osteoporosis, was admitted to hospital with acute abdominal pain. The patient appeared to have an oesophageal perforation, which was treated with an endoprosthesis. Additional research showed a motility disorder of the oesophagus. Although bisphosphonates are considered a safe medication, the perforation was probably secondary to treatment with an oral bisphosphonate in combination with the motility disorder. Pre-existent gastrointestinal diseases such as motility disorders of the oesophagus occur more frequently among elderly. Therefore it is important to take the increased risk of complications to the gastrointestinal tract into account when prescribing bisphosphonates to these patients.     

十二指肠镜治疗胆道术后并发症34例分析

目的探讨十二指肠镜在治疗胆道手术术后并发症中的应用价值。方法回顾性分析近10年(2000年1月～2010年1月)胆道手术术后并发症在我院行十二指肠镜治疗34例病例。胆总管残余结石行乳头括约肌切开及气囊扩张术取石23例;胆漏行鼻胆管引流(ENBD)治疗7例,其中LC术后胆漏5例,胆道探查引起胆瘘2例;胆管狭窄行胆管球囊扩张,放置胆管塑料内支架2例;肝门胆管癌术后再狭窄及胆道术后胆道不通行金属支架治疗2例。结果 23例胆总管残余结石患者经乳头括约肌切开及气囊扩张术取石,其中有5例经碎石操作取净结石。7例胆漏患者经鼻胆管引流2~3周后胆漏闭合,无严重并发症发生。2例胆管狭窄患者经胆管球囊扩张、放置胆管内支架治愈。2例恶性肿瘤患者安置金属支架一年内未发生胆管炎。结论十二指肠镜在治疗胆道术后并发症中具有重要应用价值,是胆总管残余结石、胆漏及胆管狭窄和恶性梗阻治疗的很好方法。     

Four patients with aneurysm of the hepatic artery

Two men aged 73 and 71 years and 2 women aged 76 and 80 years were referred for a false aneurysm (the 3rd patient) or true aneurysm (the other 3 patients) of an extrahepatic portion of the hepatic artery. The first patient was asymptomatic, the third patient had a rupture in the biliary duct and the remaining 2 patients had upper abdominal pain. In the first 2 patients, the aneurysm was removed surgically and replaced with a venous interposition graft. The 3rd patient received a coated stent. In the 4th patient, the artery was occluded, after which hepatic circulation recovered spontaneously. Treatment was successful in all 4 patients. Aneurysm of the hepatic artery is identified increasingly more often due to the current capabilities of diagnostic imaging. Elective treatment is indicated if the diameter is > 2 cm due to the increased risk of rupture, which has been associated with mortality rates of up to 40%. Primarily, endovascular treatment should be considered by means of a coated stent or aneurysm coiling. For patients with compromised intestinal circulation, surgical elimination with venous reconstruction is the treatment of choice.     

内窥镜逆行胰胆管造影联合胆道微结石检查在急性胆管炎中的临床价值

目的 探讨内窥镜逆行胰胆管造影(ERCP)联合胆道微结石检查在急性胆管炎中的临床价值.方法 对于54例急性胆管炎患者,行超声、CT、磁共振胰胆管造影(MRCP)常规检查及ERCP,经ERCP或内窥镜鼻胆管引流收集患者的胆汁,通过普通光和偏振光显微镜查找微结石.结果 54例患者行常规检查提示36例胆总管结石或扩张,阳性诊断率为66.67%.54例患者均行ERCP,3例ERCP插管失败.ERCP提示39例胆总管结石或扩张,阳性诊断率为76.47%.12例ERCP未见明显异常的患者中,9例在显微镜下检查有胆道微结石,ERCP联合胆道微结石检查的阳性诊断率为94.12%,与常规检查和ERCP比较,差异有统计学意义(P＜0.05).结论 ERCP联合胆道微结石检查可以提高急性胆管炎的阳性诊断率.临床上不明原因的急性胆管炎与胆道微结石密切相关.     

Atypical Presentation of Perforated Sigmoid Diverticulitis in a Kidney Transplant Recipient with Autosomal Dominant Polycystic Kidney Disease

Perforated sigmoid diverticulitis, a complication of colonic diverticulosis commonly associated with autosomal dominant polycystic kidney disease (ADPKD), can be life-threatening in allogeneic kidney transplant recipients in the postoperative period. Immunosuppressive medications not only place the patient at risk for intestinal perforation, but also mask classic clinical symptoms and signs of acute abdomen, and subsequently lead to delayed diagnosis and treatment. We report a case of an ADPKD patient post kidney transplantation presenting with nausea, vomiting, and abdominal pain without signs of peritonitis. Chest x-ray revealed free air under the diaphragm consistent with intestinal perforation. Post kidney transplant recipients with ADPKD presenting with abdominal pain should prompt a search for possible perforated colonic diverticulitis in order to diagnose and treat this life-threatening condition early.     

ERCP相关技术诊治胰胆道疾病517例临床观察

目的：探讨经内镜逆行胰胆管造影术（ERCP）及相关技术在胰胆道疾病诊治中的有效率及安全性,旨在提高ERCP成功率及减少并发症的发生。方法：回顾性分析本院2010年1月-2014年3月经ERCP相关技术诊治的517例胰胆道疾病患者的临床资料。结果：517例中插管成功496例,成功率95.94%,发生并发症25例,发生率4.84%。结论：ERCP及其相关技术对胰胆道疾病具有极高的诊断治疗价值,具有安全、有效、并发症较少的特点,是目前治疗胰胆道疾病的理想方法。