Spontaneous intramural duodenal hematoma in type 2B von Willebrand disease

Intramural duodenal hematoma is a rare cause of a proximal gastrointestinal tract obstruction.Presentation of intramural duodenal hematoma most often occurs following blunt abdominal trauma in children,but spontaneous non-traumatic cases have been linked to anticoagulant therapy,pancreatitis,malignancy,vasculitis and endoscopy.We report an unusual case of spontaneous intramural duodenal hematoma presenting as an intestinal obstruction associated with acute pancreatitis in a patient with established von Willebrand disease,type 2B.The patient presented with abrupt onset of abdominal pain,nausea,and vomiting.Computed tomography imaging identified an intramural duodenal mass consistent with blood measuring 4.7 cm×8.7 cm in the second portion of the duodenum abutting on the head of the pancreas.Serum lipase was 3828 units/L.Patient was managed conservatively with bowel rest,continuous nasogastric decompression,total parenteral nutrition,recombinant factorⅧ(humateP)and transfusion.Symptoms resolved over the course of the hospitalization.This case highlights an important complication of an inherited coagulopathy.     

冠状动脉介入术后腹膜后血肿的危险因素研究

目的探讨冠状动脉介入术(PCI)后腹膜后血肿(RPH)的发生率、临床特征和危险因素。方法对北京安贞医院心内科2000-01—2005-09共3729例经股动脉穿刺进行PCI术的病例进行回顾性分析,其中并发RPH的21例设为观察组,选择另外30例未发生RPH的病例设为对照组。采用单因素和多因素分析RPH发生的危险因素。结果RPH的发生率为0·6%。RPH最常见的临床特征为贫血(100%),其余还包括低血压(95%)、出汗(57%)、腹股沟痛(48%)、下腹痛(38%)和背痛(38%)。RPH的独立预测因素有3个:女性(OR=5·23,P<0·0001)、体表面积(BSA)<1·53m2(OR=7·11,P=0·005)和高部位股动脉穿刺(OR=5·42,P=0·001)。结论女性、低BSA和高部位股动脉穿刺是RPH发生的独立预测因素。     

Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: A case report

Intramural duodenal hematoma (IDH) is a rare complication following endoscopic retrograde cholangiopancreatography (ERCP). Blunt damage caused by the endoscope or an accessory has been suggested as the main reason for IDH. Surgical treatment of isolated duodenal hematoma after blunt trauma is traditionally reserved for rare cases of perforation or persistent symptoms despite conservative management. Typical clinical symptoms of IDH include abdominal pain and vomiting. Diagnosis of IDH can be confirmed by imaging techniques, such as magnetic resonance imaging or computed tomography and upper gastrointestinal endoscopy. Duodenal hematoma is mainly treated by drainage, which includes open surgery drainage and percutaneous transhepatic cholangial drainage, both causing great trauma. Here we present a case of massive IDH following ERCP, which was successfully managed by minimally invasive management: intranasal hematoma aspiration combined with needle knife opening under a duodenoscope.     

儿童十二指肠肠壁血肿3例

对上海市儿童医院3例临床怀疑为十二指肠肠壁血肿的患儿,通过GI、B超、CT平扫+增强,以及CT扫描随访检查,结合患儿病史,对影像学特点进行分析比较,发现GI、B超对十二指肠肠壁血肿诊断没有特异性,CT平扫+增强,以及CT扫描随访检查,在十二指肠肠壁血肿的诊断上具有很明显的特异性,结合病史可作为可靠的诊断依据.CT检查对于十二指肠肠壁血肿的诊断具有重要的临床价值.     

Duodenal hematoma following endoscopic duodenal biopsy: a case report and review of the existing literature.

Duodenal hematoma is a rare complication of endoscopic duodenal biopsy that occurs mainly in children or adults with impaired coagulation. The clinical presentation consists of signs of intestinal obstruction, and pancreatitis and direct hyperbilirubinemia are possible complications caused by ampullary obstruction. A case of a six-year-old girl who presented with a duodenal hematoma and acute pancreatitis after having an endoscopic duodenal biopsy is reported. A review of the literature and data from all similar cases reported so far are briefly presented and discussed.     

Endovascular treatment of iliocaval occlusion due to idiopathic retroperitoneal fibrosis

Idiopathic retroperitoneal fibrosis is a rare cause of venous occlusion that is mainly treated conservatively or surgically. However, endovascular techniques can be proposed for its treatment. We report here a case of a 64-year-old man who was admitted for bilateral lower limb swelling due to iliocaval occlusion caused by idiopathic retroperitoneal fibrosis. Due to high anesthetic risk, related mainly to congestive heart failure, the patient was treated percutaneously by balloon angioplasty and stenting instead of receiving surgical treatment. Clinical and radiological results were excellent, both early and in midterm, confirming that endovascular techniques constitute an interesting alternative to surgery, especially in fragile patients.     

Percutaneous vertebroplasty in osteoporotic vertebral compression fracture with huge spinal epidural hematoma: A case report

Rationale:Osteoporotic vertebral compression fracture (OVCF) accompanying huge spinal epidural hematoma (SEH) is fairly rare. The aim of this report is to investigate the management strategies and treatment outcomes of OVCF accompanying SEH.Patient concerns:An 89-year-old female patient was admitted to hospital because of severe back pain and numbness of both lower limbs after a slight fall. The magnetic resonance imaging examination of the patient showed a fresh compression fracture at L2 accompanying a large dorsal SEH which extended from the T12 to L3 and deformed the spinal cord.Diagnosis:The patient was diagnosed with OVCF accompanying SEH.Interventions:Given mild neurologic deficits, the hematoma was not treated, and the patient underwent percutaneous vertebroplasty (PVP) only.Outcomes:After the procedure, immediate pain relief was achieved and the numbness of both lower limbs disappeared 3 days later. Three months after the procedure, the follow-up magnetic resonance imaging revealed a complete resolution of the hematoma.Lessons:OVCF accompanying SEH is fairly rare, and the exact pathophysiological mechanisms are still not clear. In selected patients without or with only slight neurologic symptoms, it is reasonable to perform PVP alone in OVCF accompanying SEH. Moreover, intravertebral stability after PVP might have played a role in spontaneous resolution of SEH.     

Laparoscopic drainage of an intramural duodenal hematoma

A 21-year-old man was admitted with vomiting and abdominal pain 3 days after sustaining blunt abdominal trauma by being tackled in a game of American football. A diagnosis of intramural hematoma of the duodenum was made using computed tomography and upper gastrointestinal tract contrast radiography. The hematoma caused obstructive jaundice by compressing the common bile duct. The contents of the hematoma were laparoscopically drained. A small perforation was then found in the duodenal wall. The patient underwent laparotomy and repair of the injury. Laparoscopic surgery can be used as definitive therapy in this type of abdominal trauma. (Received Nov. 12, 1997; accepted Aug. 21, 1998)     

Hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation

Here, we present the case of a 53-year-old man with a hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation. On admission, the patient complained of severe acute abdominal pain, with physical examination findings suspicious for a perforated peptic ulcer. Of note, the patient had no history of other medical conditions or recent trauma, and the initial chest radiography and laboratory findings were not specific. A subsequent abdominal computed tomography revealed intrathoracic displacement of the liver, gallbladder, transverse colon and omentum through a right diaphragmatic defect. The patient then underwent an explorative laparotomy that confirmed duodenal ulcer perforation. A primary repair of the duodenal perforation was performed, and the diaphragmatic defect was repaired using a polytetrafluoroethylene patch after the organs were reduced and the cavity irrigated. This particular case proves interesting as right-sided spontaneous diaphragmatic ruptures are very rare and difficult to diagnose. Additionally, the best treatment for such large diaphragmatic defects is still controversial, especially in cases of intrathoracic or intra-abdominal contamination.     

Massive gastric distention due to duodenal involvement by retroperitoneal tumors.

We present three patients with retroperitoneal tumor involving the duodenum in whom upper gastrointestinal (GI) studies revealed delayed gastric emptying and massive gastric dilatation out of proportion to the degree of duodenal dilatation. While the radiographic findings mimicked acute gastric outlet obstruction, delayed films demonstrated narrowing and encasement of the duodenum at the site of obstruction in all three patients. Thus, the duodenum should be carefully evaluated radiographically in patients with acute gastric dilatation, particularly if there is a known history of malignancy.     

Management of 28 consecutive iatrogenic femoral pseudoaneurysms with ultrasound-guided compression

We attempted to evaluate nonsurgical methods of treating postcatheterization iatrogenic femoral pseudoaneurysms at our hospital and compared the results with those in the literature. The hospital records of 25273 patients who underwent femoral catheterization at our institution from September 1997 to December 2002 were collected retrospectively. All complications were detected and femoral pseudoaneurysm cases were selected. Diagnostic criteria and treatment strategy were documented. All results were compared with those in the literature. Twenty-eight patients were diagnosed as having a pseudoaneurysm (0.11%). In 11 patients the pseudoaneurysms closed by themselves within 3–7 days. Ultrasound-guided compression therapy was applied to the remaining 17 and was effective in 10 of them. The last 7 patients were operated on with success. Ultrasound-guided compression is also an effective and noninvasive method of therapy for femoral pseudoaneurysms. Surgical therapy can be reserved for progressive and complicated lesions.     

Sickle beta-thalassemia presenting as orbital compression syndrome

Orbital compression syndrome is caused by disorders of varying etiologies involving the orbit and presents with ocular and extraocular dysfunction. Ocular involvement of sickle cell disease is uncommon. A 17-year-old male presented with low backache and proptosis of both eyes of 5 days duration without past history of pain crisis or transfusion. Examination revealed pallor, icterus, bilateral proptosis, conjuctival chemosis, and symmetrical restriction of ocular movements with preserved visual acuity. He was drowsy with no other focal deficits. The fundus showed macular edema, venous engorgement, and no hemorrhage. His peripheral smear showed presence of sickle cells. Computed tomography (CT) scan of the orbit revealed orbital subperiosteal hematomas. CT head images showed epidural hematoma in the frontal lobe. High-performance liquid chromatography (HPLC) and mutation studies revealed sickle beta-thalassemia in the patient. He was managed with supportive care, transfusions to keep hemoglobin above 10 g/dl, and hydroxyurea. The patient recovered fully and remained well during follow-up of 12 months. Our case was unique for presenting as orbital compression syndrome without any history of vaso-occlusive crisis.     

Recurrent hepatic hematoma due to familial lysozyme amyloidosis resolves with conservative management

Fatal familial insomnia - Inherited prion diseases, sleep and the thalamus Edited by C. Guilleminadt, E. Lugaresi, P. Montana and P. Gambetti Raven Press, New York 1994 234 Pages, $90.00 ISBN: 0-7817-0114-7

Liver transplantation: Practice and management Edited by James Neuberger and Michael R. Lucey BMJ Publishing Group, London 1994 400 Pages, Illustrated. £37.00 ISBN: 0-7279-0787-5

Pathology of the peripheral nerve Edward P. Richardson, Jr. and Umberto DeGirolaini 32 in the series Major Problerns in Pathology W.B. Saunders Co., Philadelphia 1995 159 Pages, $55.00 ISBN: 0-72 16-3298-X

Immunocytochemistry. A Practical Approach Edited by Julian E. Beesley Oxford University Press, New York 1993 248 Pages, ISBN: 0-19-963270-7 $59.00

NMR of macromolecules. A practical approach Edited by Gordon C. K. Roberts Oxford University Press, New York, 1993 399 pages ISBN: 0-19-963225-1 (h/bk) $68.00 0-19-963224-3 (pibk) $47.00     

动物实验性脑出血后血肿内红细胞管涌现象研究

目的探索脑出血后血肿内红细胞通过"管涌现象"的分布特征。方法 SD雄性大鼠60只,随机分为实验组30只和对照组30只,每组分为5个不同观察时间点:1h、6h、24h、3d、7d,每个时间点5只。采用异硫氰酸荧光素(FITC)标记血液中红细胞,建立大鼠自体动脉血脑出血模型,分别于不同时间点进行大鼠脑组织、颈深淋巴结组织病理切片,荧光显微镜下观察以及HE染色后显微镜下观察,对比分析红细胞的分布特征。结果实验组血肿形成1h后,病灶以及血肿周围可见到FITC-RBC和游离FITC分布,双侧大脑半球和脑干的维乔-罗宾间隙内也有游离FITC分布,双侧颈深淋巴结内均可见FITC-RBC和游离FITC分布。6h后血肿内开始出现含有黄色或黄绿色荧光颗粒的吞噬细胞,同时FITC-RBC和游离FITC逐渐减少。随时间延长,含有黄色荧光颗粒的吞噬细胞在各脑区内逐渐增多,淋巴结生发中心内可见成团分布的黄色荧光颗粒。对照组未见以上变化。结论血肿内红细胞通过"管涌现象"在脑出血后扩散范围比较局限,游离红细胞成分扩散范围比较广泛;"管涌现象"是血肿内有红细胞吸收途径之一。     

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus： Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing difficulty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.     

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrog...     

Compressive femoral neuropathy caused by anticoagulant therapy induced retroperitoneal hematoma: A case report

Rationale:Spontaneous retroperitoneal hematomas due to anticoagulant therapy rarely occur. Retroperitoneal hematomas can cause severe pain in the groin, quadriceps femoris muscle weakness, hemodynamic instability, and abdominal distension. They rarely cause compressive neuropathy of the femoral nerve transversing the iliacus muscle. Differential diagnosis is not easy because they have similar clinical features to retroperitoneal hematomas.Patient concerns:A 72-year-old female patient whose right arm was stuck in a bookshelf for 5 days developed right cephalic vein thrombosis. After 5 days of intravenous heparin therapy for venous thrombosis, she presented with sudden right groin pain, right leg paresis, hemodynamic instability, and abdominal distension.Diagnosis:Emergency abdominal and pelvic CT showed a large number of hematomas in the bilateral retroperitoneal space with active bleeding of the right lumbar artery. An electrodiagnostic study was performed 2 weeks later to check for neuromuscular damage in the right lower extremity, and right compressive femoral neuropathy was confirmed.Interventions:Heparin therapy was discontinued; emergency embolization of the lumbar artery was performed. After 2 weeks, the patient started receiving physical, occupational, and transcutaneous electrical stimulation therapies.Outcomes:She became hemodynamically stable after arterial embolization; a significant decrease in hematoma and patency of the femoral nerve was confirmed on follow-up pelvic MRI. After 2 months of comprehensive rehabilitation, the muscle strength of the right leg significantly improved, and the pain disappeared.Lessons:Although rare, spontaneous retroperitoneal hematomas may occur in patients receiving anticoagulant medications. They may even occur in patients receiving emergency anticoagulant therapy. Compressive femoral neuropathy due to retroperitoneal hematomas should be considered if muscle weakness and groin pain are observed. Early diagnosis and appropriate treatment plan of compressive femoral neuropathy due to retroperitoneal hematoma are helpful for a good prognosis.