特发性肠系膜静脉硬化性肠炎临床特点分析

目的:分析总结特发性肠系膜静脉硬化性肠炎的临床表现、影像学及结肠镜检查特征、治疗及转归等,旨在加强临床医生对该疾病的认识。方法:报道1例北京医院消化科收治的特发性肠系膜静脉硬化性肠炎患者,该患者因腹痛腹胀、停止排便排气3个月,再发伴呕吐2 d入院,结合患者病史、症状、体征、影像学及肠镜结果等,考虑患者不完全性肠梗阻病因...     

Idiopathic mesenteric phlebosclerosis associated with long-term use of Chinese herbs: a case report

A 59-year-old woman had been admitted to our hospital every two months for over a past year because of severe right abdominal pain. Colonoscopy revealed dark blue mucosa extending from the cecum to the transverse colon, and abdominal computed tomography showed wall thickening and linear calcification along the wall from the cecum to the transverse colon. Based on these findings, the patient was given a diagnosis of idiopathic mesenteric phlebosclerosis. Subsequently, we found that she had been a long-term user of a Chinese herbal product containing Gardeniae fructus for allergic rhinitis. After discontinuing the product, the patient has been free of abdominal pain for a year.     

Intraosseous fat necrosis associated with alcoholic pancreatitis

A 50-year-old man with a 30-year history of alcohol abuse was admitted because of abdominal pain. Based on an elevated serum amylase level and abdominal computed tomography findings, a diagnosis of alcoholic pancreatitis was made. The pancreatitis improved after 1 month of conservative therapy, but the patient complained of a tender right ankle that showed no abnormal findings on X-ray examination. Two months later, the patient was readmitted for recurrent pancreatitis and a swollen, warm, tender right ankle. Imaging studies, including plain radiographs, magnetic resonance imaging, and a bone scintigram showed the typical findings of intraosseous fat necrosis of the right tibia. We report a rare case of intraosseous fat necrosis associated with alcoholic pancreatitis.     

Autoimmune pancreatitis with normal IgG4-Levels: 4 case reports and review of the literature

We report four cases of autoimmune pancreatitis in an 18-, a 22- and a 26-year-old male patient and a 20-year-old female patient. The 20-year-old female patient was admitted to the hospital with upper abdominal pain and jaundice, the 18-year-old patient with recurrent acute pancreatitis and cholestasis, the 26-year-old patient with right upper abdominal pain for four weeks and laboratory findings suggesting an acute pancreatitis. The 22-year-old patient presented with painless jaundice. EUS-guided fine needle aspiration was performed in all patients. The cytological findings and the EUS were decisive for the diagnosis of autoimmune pancreatitis in all four cases. In contrast, no patient showed elevated IgG4, or antibodies for carboanhydrase-II, for lactoferrin, or rheumatoid factor, serum markers reported to be positive in autoimmune pancreatitis. All patients were treated successfully with steroids, one patient relapsed after discontinuing the steroid medication and required renewed therapy. These case reports demonstrate that autoimmune pancreatitis should be considered in the differential diagnosis in cases of pancreatitis and/or jaundice also in western countries. As demonstrated, the diagnosis should not be based solely on the elevation of IgG4 or autoantibodies.     

Midgut malrotation in adulthood

A 29-year-old man was admitted to our hospital with a history of recurrent right upper quadrant abdominal pain and vomiting. These symptoms appeared intermittently for 7 years. Various examinations revealed a diagnosis of midgut malrotation. Laparotomy was performed and revealed reverse rotation of the duodenum with paraduodenal hernia and a normal rotating colon. This case suggests that recurrent abdominal complaints in an adult should arouse suspicion of midgut malrotation.     

Portal thrombosis due to intrahepatic cholangiocarcinoma following successful treatment for hepatocellular carcinoma

A 57-year-old man, who had undergone hepatic arterial infusion chemotherapy with right portal occlusion for hepatocellular carcinoma was admitted to our hospital because of severe abdominal pain. Contrast-enhanced computed tomograms revealed that most areas of the liver were not enhanced, a finding suspicious for perfusion disturbance in the liver. Angiography revealed an interrupted right hepatic artery. Arterial portograms revealed complete obstruction of the right portal vein and a small left branch of the portal vein. Despite anticoagulant therapy with urokinase for portal vein thrombosis, the patient died from hepatorenal failure. Autopsy revealed that cholangiocarcinoma occupied almost the entire parenchyma of the right lobe, although the treated hepatocellular carcinoma lesion was completely necrotic. The right hepatic artery was obstructed due to direct invasion of tumor. There were diffuse thrombi in the left portal branches surrounded by tumor infiltrating along Glisson's sheath to the peripheral portion of the left lobe.     

Recurrent spontaneous esophageal rupture

Spontaneous rupture of the esophagus is a relatively uncommon event, and recurrent rupture is extremely rare. We present a patient who experienced and survived 2 spontaneous perforations of the esophagus, occurring 6 years apart. A 43-year-old man was admitted to our hospital with upper abdominal pain after vomiting. Esophagoscopy, esophagogram, and computed tomography were suggestive of esophageal rupture. Emergency left thoracolaparotomy revealed a 20-mm perforation of the left lower esophageal wall that had been previously repaired. After the perforation was repaired with a single-layer closure, the mediastinum and pleural cavity were drained. The patient recovered well and was discharged from the hospital on postoperative day 29. To the best of our knowledge, only 7 previous cases of recurrent spontaneous esophageal perforation have been reported in the literature.     

Contrast-enhanced ultrasound versus CT and operative findings in evaluation of renal vein aneurysm with AV fistula

We report the case of a 61-year-old patient admitted to our hospital owing to recent nonspecific abdominal pain. Five years earlier he had been treated with a graft owing to thoracic and abdominal aortic aneurysm with dissection. He now showed a left renal vein aneurysm with a diameter of 11x7.5 cm. This case demonstrates that contrast enhanced ultrasound (CEUS), employed in addition to computed tomography angiography, offers a promising new option for diagnosis and preoperative treatment planning in patients with abdominal vascular diseases. The results were compared with operative findings.     

A case of stump appendicitis after appendectomy]

Stump appendicitis is an acute inflammation of the residual appendix and a rare complication after an appendectomy. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history. Only a small number of stump appendicitis cases have been reported, but there has been no report of stump appendicitis in Korea. Herein, we report a case of stump appendicitis. A 28-year-old female was admitted to our hospital due to right lower quadrant abdominal pain. Fifteen months ago, the patient had a laparoscopic appendectomy under the diagnosis of an acute appendicitis, but she subsequently suffered from intermittent abdominal pain and fever. Abdominal ultrasonography and CT scan showed an inflamed appendiceal stump. Laparoscopic stump appendectomy was done and the biopsy revealed stump appendicitis.     

Endoscopic treatment of duodenal obstruction due to a gallstone ("Bouveret's syndrome")

We describe the case of a 73-year-old woman was admitted to our hospital because of constant abdominal pain in her right upper quadrant and postprandial bloating and fullness for several months. On abdominal x-ray the extrahepatic bile ducts were positive for gas and on ultrasound a gallstone in the duodenum was suspected whereas the gallbladder was not detectable. An upper gastrointestinal endoscopy confirmed a large gallstone that was impacted in the duodenal bulb ("Bouveret's syndrome"). The gallstone was fragmented employing mechanical lithotripsy and removed. Duodenoscopy revealed a cholecystoduodenal fistula and a second gallstone in the gallbladder. The patient underwent open cholecystectomy with closure of the cholecystoduodenal fistula and made a full recovery. We conclude that in patients with upper abdominal pain and pneumobilia on x-ray the unusual complication of cholelithiasis with an impacted gallstone in the duodenal bulb should be suspected. In those rare cases of Bouveret's syndrome endoscopic removal of the gallstone should be attempted to minimize the necessary surgical procedure whenever possible.     

Ovarian vein thrombosis in Beh?et disease

We describe a 35-year-old Chinese woman with Beh?et disease complicated by recurrent gastrointestinal flares. During admission for acute lower abdominal pain, a computed tomographic scan of the abdomen showed thrombosis of the left ovarian vein. She was treated with increased immunosuppressant and oral anticoagulant. Although she was not compliant to oral anticoagulant with her international normalized ratio frequently subtherapeutic, her symptoms abated and the thrombosis resolved. There has been only 1 reported case of a patient with Beh?et disease presenting with postpartum ovarian vein thrombosis and pulmonary embolism and no reported case of Beh?et disease with ovarian vein thrombosis occurring outside pregnancy and the puerperium. Ovarian vein thrombosis is a rare cause of abdominal pain that should be considered in patients with Beh?et disease.     

Thrombolytic therapy in patients with portal vein thrombosis: case report and review of the literature

A 29-year-old male patient with Crohn's disease of the terminal ileum and previous abdominal surgery was admitted because of severe abdominal pain and signs of bacterial sepsis. The diagnosis of portal vein thrombosis and multiple liver abscesses due to Streptococcus intermedius septicaemia was made and antibiotic therapy was instituted immediately. As high-dose heparin therapy was ineffective, urokinase was administered intravenously over a total of 7 days. Within 2 days, the patient's symptoms completely subsided. Colour duplex ultrasonography revealed complete recanalization of the main stem of the portal vein; the right branch of the portal vein, however, remained occluded. Other case reports on thrombolytic therapy in patients with portal vein thrombosis are reviewed.     

Mycotic aneurysm of the tibioperoneal trunk: a first manifestation of an infected endocarditis

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location.     

Congenital heart disease manifested as acute abdominal pain

We present a case of a 53-year-old man with complaints of severe abdominal pain and nausea. Emergency department abdominal workup was non-diagnostic. Physical examination revealed signs of right- and left-heart failure. A past medical history of dysrhythmias and chronic abdominal complaints prompted hospital admission. Subsequent right heart catheterization revealed a significant left-to-right shunt. CT scan of the chest and angiography confirmed the diagnosis of an abnormal ascending vein between the innominate vein and the left superior pulmonary vein. After the anomalous vein was ligated, the patient's abdominal pain resolved.     

Direct invasion to the colon by hepatocellular carcinoma： Report of two cases

Although hepatocellular carcinoma （HCC） is a common tumor, direct invasion of the gastrointestinal tract by HCC is uncommon. Recently, we encountered two cases of HCC with direct invasion to the colon. The first patient was a 79-year-old man who underwent transarterial chemo-embolization （TACE） for HCC 1.5 years prior to admission to our hospital. Computed tomography （CT） showed a 7.5-cm liver tumor directly invading the transverse colon. Partial resection of the liver and transverse colon was performed. The patient survived 6 mo after surgery, but died of recurrent HCC. The second patient was a 69-year-old man who underwent TACE and ablation for HCC 2 years and 7 months prior to being admitted to our hospital for melena and abdominal distension. CT revealed a 6-cm liver tumor with direct invasion to the colon. The patient underwent partial resection of the liver and right hemicolectomy. The patient recovered from the surgery. But, unfortunately, he died of liver failure due to liver cirrhosis one month later. Although the prognosis of HCC that has invaded the colon is generally poor due to the advanced stage of the disease, surgical resection may be a favorable treatment option in patients with a good general condition.     

Successfully resected hepatoblastoma in a young adult with chronic hepatitis B: report of a case

Hepatoblastoma usually occurs in children, but a few cases have also been reported in adults. We report the unusual case of hepatoblastoma in an 18-year-old adult with chronic hepatitis B. He visited a local hospital with right upper abdominal pain. Abdominal ultrasound showed a large mass in the right lobe of his liver. He was referred to our hospital and admitted for further examination. At admission, liver function tests gave slightly elevated results (aspartate aminotransferase (AST) 103 IU/l, alanine aminotransferase (ALT) 63 IU/l). A test for hepatitis virus revealed that he was a hepatitis B surface antigen (HBsAg) carrier and had experienced seroconversion. His alpha-fetoprotein (AFP) was elevated to 1 548 000 IU/ml. Abdominal ultrasound showed a 109 x 96 x 80-mm mass with mosaic pattern in the right lobe of the liver and right portal vein thrombus. Abdominal computed tomography (CT) demonstrated a large low-density mass occupying the right lobe, with some high-density parts that showed calcification. From these results, we diagnosed hepatoblastoma in a young adult. A right lobectomy was performed. Pathological examination showed a highly differentiated hepatoblastoma. Adjuvant chemotherapy was performed with cisplatin and pirarubicin. The patient has been well and free of recurrence for 12 months, and his AFP level remains almost normal.     

Splenic arteriovenous fistula--late complications of splenectomy

This is a case report of a 30-year-old female patient with a splenic arteriovenous fistula of rare, atypical clinical course. The patient was admitted to the hospital due to strong abdominal pains and fever. 13 years earlier, the patient underwent splenectomy due to post-traumatic rupture of the spleen. On imaging examinations prior to surgery (ultrasonography, CT), a splenic arteriovenous fistula was diagnosed. The patient was operated on due to increasing abdominal pain. The fistula was closed by splenic artery and splenic vein banding during the course of laparotomy. This case report will be discussed based on literature review.     

Urgent surgery for intraperitoneal bleeding from GIST during imatinib therapy

The rupture or bleeding of a gastrointestinal stromal tumor (GIST) is a life-threatening adverse event that can happen during imatinib therapy, but few such cases have been reported in the medical literature. Here, we report a case of intraperitoneal bleeding from GIST during imatinib therapy. A 75-year-old man was diagnosed with a large GIST with liver metastasis and admitted to our hospital for abdominal pain on the 13th day of imatinib therapy. The pain disappeared after 7 days of hospitalization; however, the patient complained of diffuse abdominal pain 5 days after discharge. He presented with muscular guarding, and abdominal-pelvic CT demonstrated dense ascites. The tentative diagnosis was peritoneal hemorrhage from GIST, and urgent laparotomy was performed. During the laparotomy, we noted hemoperitoneum of approximately 500 ml; we resected a bulky metastatic tumor on the greater omentum and a primary tumor on the jejunum. The patient took imatinib (400 mg daily) from the ninth postoperative day and underwent monthly checkups for 9 months after the surgery. When GIST patients complain of sudden and severe abdominal pain during imatinib therapy, bleeding from GIST should be considered as a possible adverse effect of imatinib.     

Portal vein gas embolism from hydrogen peroxide ingestion.

A 40-year-old woman who ingested a 35% hydrogen peroxide solution presented to the emergency department with abdominal pain. Acute abdominal series showed gas in the portal vein system. The patient was admitted and treated conservatively. She was released after five days in the hospital with no major sequelae.     

A case of portal vein thrombosis associated with acute cholecystitis/pancreatitis or coincidence

BACKGROUND: Portal vein thrombosis (PVT) is complex and risk factors include local precipitating factors and acquired and inherited factors. It occurs secondary to abdominal malignancy, infection or surgical intervention. PVT is commonly forgotten as a possible cause of abdominal pain. The clinical picture may vary but abdominal pain and low grade fever are the most characteristic picture. METHODS: A 58-year-old male patient was admitted to our hospital complaining of abdominal pain for three days. CT scan revealed an edematous area around the portal vein. Doppler ultrasonography showed evidence of a portal vein thrombosis. RESULTS: PVT can be diagnosed with CT and Doppler ultrasonography. Fresh thrombus can be undetected by sonography because of the low echogenity but can be recognised by color Doppler ultrasonography. Treatment ranges from observation and bowel rest to surgical resection of bowel. CONCLUSIONS: When we suspect a case of PVT, it should be treated at an early stage to prevent being lost in a diagnostic dilemma. The immediate use of anticoagulant could be important in preventing serious consequences of PVT.