Circadian periodicity and other clinical features of biliary pain.

We studied the time of onset and other clinical features of biliary pain in 54 patients living in Northern Italy. All patients had cholelithiasis documented by ultrasonography. The time of onset of pain followed a circadian periodicity with its peak occurring at 9:30 p.m. The typical biliary pain was steady, mostly localized in the right upper quadrant of the abdomen or the epigastrium, lasted over 1 h, and required analgesics for relief. The pain was not related to meals or body position. What precipitates biliary pain is still an enigma.     

Should routine spiral computed tomography be performed in adult patients with acute abdominal pain of the right lower quadrant?

BACKGROUND AND AIMS: To determine whether spiral computed tomography (SCT) is helpful in the management of adult patients with acute pain of the right lower quadrant. PATIENTS AND METHODS: The prospective study included 204 patients with acute pain of the right lower quadrant during two periods: 104 before and 100 after the introduction of SCT. A questionnaire was completed for each patient before and after standard clinical and laboratory assessment and SCT, indicating the suspected diagnosis and a provisional therapeutic option. RESULTS: In the pre-SCT period the negative laparotomy rate was 29% vs. only 13% in the SCT period. During the SCT period 10 of the 24 nonoperated patients were discharged on the same day, and 14 were hospitalized 1.6+/-1 days, and only one was readmitted for operation on day 7. The accuracy of SCT assisted by results of clinical and laboratory findings (true positives + true negatives/total of patients) was 86% (vs. 73% for standard clinical and laboratory assessment): 93% in men (vs. 76% for standard clinical and laboratory assessment) but only 63% in women (vs. 60% for standard clinical and laboratory assessment). SCT changed the therapeutic decision guided by standard clinical and laboratory assessment in 18 cases, accurately in 16 cases (90%). CONCLUSION: SCT is helpful in the management of adult patients with acute abdominal pain of the right lower quadrant. In our study it reduced negative laparotomy rate from 29% (guided by standard clinicobiological evaluation) to only 13%.     

Die akute Gallenkolik

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Clinical outcome of Fitz-Hugh-Curtis syndrome mimicking acute biliary disease

AIM： To analyze the clinical characteristics of patients diagnosed with Fitz-Hugh-Curtis syndrome. METHODS： The clinical courses of patients that visited St. Mary＇s Hospital with abdominal pain from January 2005 to December 2006 and were diagnosed with Fitz-Hugh-Curtis syndrome were examined. RESULTS： Fitz-Hugh-Curtis syndrome was identified in 22 female patients of childbearing age; their mean age was 31.0 ± 8.1 years. Fourteen of these cases presented with pain in the upper right abdomen alone or together with pain in the lower abdomen, and six patients presented with pain only in the lower abdomen. The first impression at the time of visit was acute cholecystitis or cholangitis in 10 patients and acute appendicitis or pelvic inflammatory disease in eight patients. Twenty-one patients were diagnosed by abdominal computer tomograghy （CT）, and the results of abdominal sonography were normal for 10 of these patients. Chlamydia trichomatis was isolated from 18 patients. Two patients underwent laparoscopic adhesiotomy and 20 patients were completely cured by antibiotic treatment.CONCLUSION： For women of childbearing age with acute pain in the upper right abdomen alone or together with pain in the lower abdomen, Fitz-Hugh- Curtis syndrome should be considered during differential diagnosis. Moreover, in cases suspected to be Fitz-Hugh- Curtis syndrome, abdominal CT, rather than abdominal sonography, assists in the diagnosis.     

Acute biliary colic. Etiology,diagnosis and therapy

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Diverticulitis of the right colon

The authors' experience with right-sided diverticulitis is reviewed. The symptoms among 18 patients were continuous right lower quadrant abdominal pain and periumbilical pain radiating to the right lower quadrant. Only three patients had nausea and vomiting. Twelve patients (67 per cent) had an abnormally high white blood cell count; three had granulocytosis. Barium enema examination was not a helpful diagnostic aid; and in only two patients was the preoperative diagnosis correct. The operative procedures undertaken were right colectomy with ileotransverse colostomy (15 patients), partial right colectomy with ileoascending colostomy (two patients), and diverticulectomy and appendectomy (one patient). There were no deaths; the average hospital stay was 14.2 days (range 5 to 30 days). The authors conclude that there is no characteristic clinical pattern pointing to this diagnosis; diagnostic maneuvers are usually unrewarding; right hemicolectomy is a safe and expeditious procedure; and open cecotomy is not favored, as recommended in the medical literature, to establish the diagnosis. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Stratified models of care

Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the ‘Holy Grail’ of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.     

Gonococcal Perihepatitis: Diagnostic and Therapeutic Value of Laparoscopy

Two patients with pelvic and right hypochondrial pain and with purulent vaginal exudate in which Neisseria gonorrhoeae was isolated, are presented. Laparoscopy was used in both cases. A diagnosis of perihepatitis was made by demonstrating the typical adhesions in "violin string" shape and by obtaining clinical improvement after breaking up those adhesions. Our conclusion is that laparoscopy is a useful diagnostic and therapeutic procedure in young women with pain in the right upper quadrant of the abdomen and with signs of lower genital infection.     

Decision making in right-sided diverticulitis

AIM: To evaluate systematically our nine-year experience in treating right-sided diverticulitis of the colon, and to explore its clinical and radiological relationship. METHODS: The clinical and radiological data of 40 patients with colonic diverticulitis treated in Mackay Memorial Hospital, Taipei, from 1993 through 2002 were reviewed retrospectively. RESULTS: The average age of the patients with right-sided diverticulitis was 53.1 years, which was 11.6 years younger than that of the patients with left-sided diverticulitis. The preoperative diagnosis of appendicitis was made in 8 of 13 right-sided diverticulitis patients. Nine (69 %) had right lower quadrant abdominal pain for more than 48 hours, and ten patients (77 %) presented with fever. CT findings suggesting acute right-sided diverticulitis including thickening of the intestinal wall and pericolonic inflammation were present in five patients. CONCLUSION: Right-sided diverticulitis is easily confused with acute appendicitis because it occurs at a somewhat younger age than that in left-sided diverticulitis. Barium enema and CT are helpful for the early diagnosis of right-sided diverticulitis. While clearly not required in the majority of patients with right lower quadrant abdominal pain, barium enema and CT may be helpful in making the decision with a clinical history or physical examinations atypical of acute appendicitis.     

原发性抗磷脂抗体综合征合并肺血栓栓塞症1例并文献复习

目的：了解原发性抗磷脂抗体综合征合并肺血栓栓塞症的临床特征。方法对近期北京医院收治的1例原发性抗磷脂抗体综合征合并肺血栓栓塞症患者进行分析,并复习32例国内外文献发表的原发性抗磷脂抗体综合征合并肺血栓栓塞症病例。结果33例患者中,男18例,女15例,主要症状包括呼吸困难、胸痛、咯血和下肢疼痛等,其中合并呼吸困难、胸痛、咯血三联征的比例为42.4%,双下肢静脉血栓占38.7%,双侧肺动脉栓塞占87.1%,右房和/或右室增大者占56.3%,合并肺动脉高压者占75.0%。部分患者合并血小板减少,活化部分凝血活酶时间明显延长。及时诊断和治疗能取得良好的疗效。结论原发性抗磷脂抗体综合征合并肺血栓栓塞症患者合并三联征(胸痛、咯血、呼吸困难)的比例高,血栓范围广泛,常合并右房和/或右室扩大、血小板和凝血机制异常,及时诊断和治疗可获得良好的疗效。     

Cecal necrosis: Infrequent variant of ischemic colitis

PURPOSE: Spontaneous nonocclusive ischemic colitis involving only the right colon is an infrequent occurrence. Because this problem is less recognized than its counterpart involving the left colon, the correct diagnosis may not be considered. The purpose of this article was to describe the presentation and management of this unusual clinical problem. METHODS: Five cases of nonocclusive ischemic cecal necrosis are described. Four of the patients presented with right-sided abdominal pain, tenderness, and leukocytosis. The preoperative diagnosis was incorrect in all patients, although cecal necrosis was considered in one. Two patients were thought to have. appendicitis, two were thought to have carcinoma, and one was thought to have a perforated viscus. Each patient underwent a right hemicolectomy and four survived. RESULTS: Each of the patients had ischemic cecal necrosis without evidence of emboli or vasculitis. Although cecal gangrene may occur after systemic hypotension, no such event preceded these patients' presentation. We believe that the patients we treated had a form of nonocclusive ischemic colitis, which occasionally affects only the right colon. CONCLUSION: Ischemic necrosis of the cecum is an infrequent variant of ischemic colitis that should be considered in the differential diagnosis of the elderly patient presenting with right lower quadrant pain.     

Chronic Right Upper Quadrant Pain without Gallstones: Does HIDDA Scan Predict Outcome after Cholecystectomy?

Patients with chronic right upper quadrant pain who do not have gallstones on ultrasound or cholecystography are often referred for surgery for presumed acalculous chronic cholecystitis. We followed 26 patients who had cholecystokinin (CCK) cholescintigraphy for evaluation of chronic right upper quadrant pain without demonstrable gallstones on ultrasound who underwent cholecystectomy so that it could be determined whether there was any relation between a low ejection fraction (EF), morphological features of chronic cholecystitis, and clinical outcome. Eighteen patients (69%) were considered therapeutic successes, whereas eight (31%) were failures after an average 2-yr follow-up. Both patient groups had significantly reduced EF: the successful group at 0.39 and the failures at 0.25. Thus, a low EF did not predict clinical outcome, since the failure group had an even lower EF than the success group. Seven gallbladders demonstrated chronic acalculous cholecystitis; the average EF of this group was 0.35. The remaining 19 gallbladders were normal, yet also had an EF of 0.35. Thus, decreased EF does not predict the histologic features of chronic cholecystitis without gallstones. The diagnostic value of cholescintigraphy in patients with acalculous right upper quadrant pain is low, probably because this entity represents a variety of processes, including inflammation, gallbladder dysmotility, and the irritable bowel syndrome.     

Intrahepatic biliary cystadenocarcinoma: clinical analysis of 4 cases

BACKGROUND:Intrahepatic biliary cystadenocarcinoma (IBC)is a low-incidence disease which is often mis- diagnosed because of insufficient recognition.This study aimed to investigate the clinical features,diagnosis and treatment of the disease. METHOD:The clinical data of 4 IBC patients treated in the Second Affiliated Hospital of Sun Yat-Sen University were retrospectively analyzed. RESULTS:The 4 patients complained of right upper abdominal pain and mass or masses.One patient presented with moderate fever an...     

Chest pain in cardiac syndrome X-caused by neuromuscular disorders?

We wanted to find out if chest pain in cardiac syndrome X can be a manifestation of neuromuscular disorders. Five patients with cardiac syndrome X (3 women, 2 men), aged 34 to 70 years, consented with a clinical neurological examination, muscle enzyme testing, electroneurography of the right median and peroneal nerves and electromyography of the right brachial biceps and anterior tibial muscles. A neuromuscular disorder was found in 1 of the 5 investigated patients. The 60-year-old man presented with a monoparesis of the left leg and sensory dysfunction of the left upper and lower limb. He was diagnosed as having either posttraumatic myelopathy or radiculopathy. Since chest pain in cardiac syndrome X can be caused by neuromuscular disorders, a comprehensive neurological examination is recommended in patients with this disorder.     

Corrected transposition of the great arteries simulating coronary heart disease in adults.

Two middle-aged adults with corrected transposition of the great arteries presented with chest pain and dyspnea, initially attributed to coronary arterial disease with left ventricular dysfunction and mitral regurgitation. The clinical diagnosis of coronary arterial disease was supported in these patients by electrocardiographic changes of probable old anteroseptal myocardial infarction and by an abnormal cardiac silhouette on the chest x-ray film suggestive of ventricular aneurysm. Coronary arteriographic studies in both patients showed that the morphologic left coronary artery supplied the venous ventricle, and the right coronary artery supplied the systemic ventricle. Neither patient had coronary arterial luminal narrowing. We propose that anginal chest pain in these patients resulted from inadequate coronary reserve of the morphologic right ventricle functioning as a systemic ventricle.     

心室激动异常合并急性心肌梗死的心电图特点分析

心电图是公认的诊断急性心肌梗死最简单易行、价格低廉的重要辅助检查之一,是急性ST段抬高心肌梗死快速选择再灌注治疗方案的最重要依据之一。但心室激动异常（完全性左束支传导阻滞、右室起搏心律、预激综合征等）可能掩盖急性心肌梗死图形,导致误诊漏诊,可能延误急性心肌梗死的再灌注时机,严重影响患者预后。尤其是合并左束支传导阻滞的急性心肌梗死患者病死率可能更高,预后更差,但从急诊冠状动脉血运重建术中获益也最大。1996年Sgarbossa首次提出、2005年Reuben和Mann等进行简化的鉴别诊断,心室激动异常合并急性心肌梗死的心电图在原发性ST-T改变的基础上出现＂QRS波群———ST-T不一致＂法则,包括（1）QRS波群主波向上的导联ST段抬高〉0.1 mV;（2）QRS波群主波向下的导联ST段抬高〉0.5 mV（V1～V3导联常见）;（3）V1、V2和V3等S波为主的导联ST段压低〉0.1 mV。除左束支传导阻滞外,右室起搏心律和预激综合征也可掩盖急性心肌梗死图形。上述法则可辅助急诊科、心内科医生较快速地诊断心室激动异常合并急性心肌梗死,从而尽早选择下一步再灌注策略,有重要的临床意义。     

Relation between the site of origin of ventricular premature complexes and the presence and severity of coronary artery disease

The clinical implications of ventricular premature complexes in patients with coronary heart disease have received increasing interest. It has been suggested that ventricular premature complexes of right ventricular origin have more benign implications than those that originate from the left ventricle. To define more precisely the relation between the site of origin of ventricular premature complexes and the presence and severity of coronary heart disease in patients with a chest pain syndrome, 39 patients with ventricular premature complexes of right or left ventricular contour who were undergoing cardiac catheterization and coronary arteriography for evaluation of chest discomfort were studied. Ninteen patients had left and 17 had right ventricular premature complexes and 3 had both. Of the 19 with left ventricular premature complexes, 15 had coronary artery disease (12 with two or three vessel obstruction and 3 with single vessel obstruction). Four had normal cardiac catheterization studies. Twelve patients had asynergy on ventriculography. The 17 patients with right ventricular premature complexes had similar angiographic findings. Eleven of the 17 had coronary artery disease (8 with triple vessel disease and 3 with isolated obstruction of the left anterior descending coronary artery). Six had normal arteries. Eight of the 11 with coronary artery disease and right ventricular premature complexes also had asynergy. All three patients with both left and right ventricular premature complexes had coronary obstructive disease. These findings indicate that in patients with a chest pain syndrome there is no relation between the site of origin of ventricular premature complexes and either the prevalence or severity of coronary artery disease.     

Reflex sympathetic dystrophy secondary to deep venous thrombosis mimicking post-thrombotic syndrome

The objective of this report is to represent a case of reflex sympathetic dystrophy (RSD) secondary to the upper extremity deep venous thrombosis (DVT). A 21-year-old man admitted with the complaints of pain and swelling in his right upper limb was presented. The patient had been diagnosed DVT in the right subclavian vein. The thrombosis had recovered completely with the standard treatment of DVT and doppler ultrasound had revealed normal findings at follow-up. After few months, he developed limb edema and pain considering post-thrombotic syndrome (PTS). The patient showed no response to the treatments for PTS. He was diagnosed with RSD according to the clinical findings. The bone scan confirmed the diagnosis. He responded well to the physical therapy and therapeutic exercises program. RSD and PTS are the two conditions having some common features and resembling clinical pictures. RSD also should be kept in mind in differential diagnosis of patients who developed limb pain and edema after DVT. There are some different points in the characteristics of the common symptoms obtained in both of the clinical conditions. Bone scan can help to confirm the diagnosis if RSD is suspected. Because the treatments of two conditions are different, making the differential diagnosis is crucial.     

Pain Patterns after Distension of the Gallbladder in Patients with Acute Cholecystitis

Background: Visceral pain is characterized by poor pain localization and a referred or radiating pain pattern. Its clinical importance in the abdomen is stressed by the finding that about one-third of patients still complain of abdominal pain after cholecystectomy. A better understanding of symptoms arising from the gallbladder and the underlying pathophysiology is therefore desirable. The aim of the present study was consequently primarily to characterize the symptom patterns after distension of the gallbladder. Secondary aims were to describe the pressure-volume relation in the gallbladder and the cystic duct opening pressure. Methods: Twelve patients (nine women, three men) treated with cholecystostomy for acute cholecystitis were investigated. Simultaneous cholescintigraphy and measurement of changes in intraluminal gallbladder pressure after injections of saline through a gallbladder catheter were performed. After each injection of saline the localization of pain and the presence of nausea and vomiting were registered. The injections continued until the patient felt abdominal pain necessitating cessation of the investigation or until the cystic duct opened (visualized on cholescintigraphy). Results: Distension of the gallbladder caused pain in 10 of the 12 patients. In 70% the pain was localized under the right costal margin or in the epigastrium. No mathematical formula could describe the pressure-volume relation in the gallbladder. The cystic duct opening pressure varied between 3 and 44 mmHg. Conclusions: Pain caused by increased gallbladder pressure is localized mostly, but not always, under the right curvature and in the epigastrium. A substantial variation in cystic duct opening pressure was found.     

Budd-Chiari syndrome

Budd-Chiari syndrome is a spectrum of disease states, including anatomic abnormalities and hypercoagulable disorders, resulting in hepatic venous outflow occlusion. Clinical manifestations observed in the majority of patients include hepatomegaly, right upper quadrant pain, and abdominal ascites. This article outlines the approach to clinical diagnosis and supportive medical therapy in patients who have BCS and reviews the clinical data supporting surgical shunting and liver transplantation as viable treatment options in this patient population.