Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.     

Treatment of neglected femoral neck fracture

Intra-capsular femoral neck fractures are seen commonly in elderly people following a low energy trauma. Femoral neck fracture has a devastating effect on the blood supply of the femoral head, which is directly proportional to the severity of trauma and displacement of the fracture. Various authors have described a wide array of options for treatment of neglected/nonunion (NU) femoral neck fracture. There is lack of consensus in general, regarding the best option. This Instructional course article is an analysis of available treatment options used for neglected femoral neck fracture in the literature and attempt to suggest treatment guides for neglected femoral neck fracture. We conducted the “Pubmed” search with the keywords “NU femoral neck fracture and/or neglected femoral neck fracture, muscle-pedicle bone graft in femoral neck fracture, fibular graft in femoral neck fracture and valgus osteotomy in femoral neck fracture.” A total of 203 print articles were obtained as the search result. Thirty three articles were included in the analysis and were categorized into four subgroups based on treatment options. (a) treated by muscle-pedicle bone grafting (MPBG), (b) closed/open reduction internal fixation and fibular grafting (c) open reduction and internal fixation with valgus osteotomy, (d) miscellaneous procedures. The data was pooled from all groups for mean neglect, the type of study (prospective or retrospective), classification used, procedure performed, mean followup available, outcome, complications, and reoperation if any. The outcome of neglected femoral neck fracture depends on the duration of neglect, as the changes occurring in the fracture area and fracture fragments decides the need and type of biological stimulus required for fracture union. In stage I and stage II (Sandhu''s staging) neglected femoral neck fracture osteosynthesis with open reduction and bone grafting with MPBG or Valgus Osteotomy achieves fracture union in almost 90% cases. However, in stage III with or without AVN, the results of osteosynthesis are poor and the choice of treatment is replacement arthroplasty (hemi or total).     

Nodal Langerhans cell histiocytosis with prominent eosinophilic emperipolesis

Multinucleated giant cells of osteoclastic type are known to occur in nodal and extranodal lesions of Langerhans cell histiocytosis (LCH). These giant cells are thought to be derived from phagocytic histiocytes, which correlate with the degree of necrosis in LCH lesions. Emperipolesis commonly seen in Rosai–Dorfman disease is a distinct phenomenon characterized by intact phagocytosed cells in an intracytoplasmic vacuole protected from proteolytic digestion. We present a case of emperipolesis of inflammatory cells especially of eosinophils by multinucleated giant cells of Langhans type in a lymph node involved by LCH—a finding that has not been described previously in the literature. Diagn. Cytopathol. 2015;43:1000–1002. © 2015 Wiley Periodicals, Inc.