Cirsoid aneurysms of the jejunum. An unrecognized cause of massive gastrointestinal bleeding

Cirsoid aneurysms (exulceratio simplex Dieulafoy) as a cause of massive gastrointestinal hemorrhage have been known to occur in the stomach. Endoscopy plays an important role in the diagnosis of and therapy for these lesions. We report two cases of a cirsoid aneurysm in the proximal jejunum; two cases have been previously reported in the literature. These lesions have the same pathologic features as gastric cirsoid lesions and cause massive gastrointestinal hemorrhage. Because these lesions are beyond the reach of current endoscopy, surgery was necessary to diagnose and treat the lesions in three of four patients. The fourth patient died after unsuccessful surgical exploration, and the lesion was found post mortem. Jejunal cirsoid aneurysms may be an unrecognized rather than a rare cause of gastrointestinal bleeding. They should be considered in the patient with massive proximal gastrointestinal bleeding in whom the source is not known, especially if angiography suggests a small-bowel site. With the advent of newer forms of endoscopy that can examine the small bowel, the management of these lesions may change; at present, surgery is lifesaving.     

Intrahepatic stones: The Taiwan experience

From 1970 to 1979, 95 patients with intrahepatic stones were seen. Since 1974, however, the annual rate of cases has been only half that of the previous decades. Patients with this disease are young; onset of symptoms in over a third of the patients occurred before 20 years of age and in 14 patients before 15 years. Average length of time between onset of symptoms and definitive diagnosis was 8.3 years. Southeast Asian stones are multiple, soft, muddy, pigmented, and located in the primary and secondary biliary radicles (particularly in the left hepatic lobe). Transhepatic cholangiography is the best diagnostic maneuver. Many procedures have been tried but no one procedure is entirely satisfactory. Previously unoperated patients (44) had cholecystectomy and exploration of the common bile duct. Patients whose stones recurred after exploration needed reoperation after an average of 2.5 years; patients whose stones recurred after cholecystectomy were seen an average of 5.7 years later, and 11 of 18 were treated medically. The mortality rate was surprisingly low.     

Failure of histamine H2-receptor antagonist therapy in Zollinger-Ellison syndrome

Review of a 5 year clinical experience with the histamine H2-receptor antagonists metiamide, cimetidine, and ranitidine in 20 patients with Zollinger-Ellison syndrome disclosed a treatment failure rate of 50 percent. The criterion for failure was hemorrhage in four patients, obstruction followed by hemorrhage in one patient, perforation in one, and intractable pain in four. Nine of the 10 patients in whom treatment failed required total gastrectomy for control of complications; the 10th patient refused operation. Retrospective analysis identified hepatic metastases, the multiple endocrine adenomatosis-type I syndrome, refractory diarrhea, and breaks in the medication schedule as being more common in the treatment failure group, but these trends were not statistically significant in our small series of patients. Nonhealing or recurrent ulcers were found in 90 percent of the patients in whom drug therapy failed and in only 10 percent of those patients in whom therapy was successful (p less than 0.01). There were no differences related to age, sex, duration of symptoms, previous gastric operation, ulcer location, presence of diarrhea, or amount of drug prescribed. Basal and peak acid outputs, basal serum gastrin levels, and response to secretin challenge were also nondiscriminatory. The degree of acid inhibition in response to cimetidine was highly variable from one patient to another and on repeat testing in individual patients, and there was no correlation between acid secretory inhibition and clinical course. When severe complications occurred, reinstituting H2-receptor antagonist therapy or increasing the dose did not avert the need for total gastrectomy. Patients refractory to drug treatment who have persistent or recurrent ulcers should be managed with prompt total gastrectomy to prevent life-threatening complications.     

Psychosocial rehabilitation: perceptions of the mental health staff

This study is inserted in assumptions of research's analysis qualitative which objective was to interpretate the Mental Health professional's perspectives about psychosocial rehabilitation of mental disorder's porter to know as them proceed it in their professional practice. Data collection came up by the application of semi-structured interviews to 8 Mental Health professionals that work in the Center of Psychosocial Attention. After the readings, notes of pieces of talk, subcategories and categories were composed after the interpretation based on the literature. The results pointed that psychosocial rehabilitation is a process which implementation and still needs effective overcome of traditional paradigma of health mental disease, that form conception and therapeutic practices and requires trust of professionals about the users' capacity of live as citizen in the most variable segments of social life.     

Pathophysiological and clinical trials of the abdominal compartment syndrome

The abdominal compartment syndrome (ACS) is defined a situation of high degrade abdominal hypertension (IAH) with clinicals signs of multiorganic dysfunction. It's observed like in the intensive care, in particular surgycals and postraumatics, there is ever a bigger frequence of complications presented by criticals patients. The various trials remark a changeable incidence, but the common factor is characterized by a particular severity of scores. All the possibles mechanicals, haemorragicals, infiammatories, and postraumatics causes act, but don't enable the stability among abdominal content, abdominal compliance and parietal tension. The initial triad of effects is constitued by the elevation of diaphragm and the visceral and vascular compression; after this triad provoke a pathophysiologic system that, through various levels, bring to a respiratory, renal and cardiocirculatory dysfunction and to a parietal, hepatic and intestinal ischemia with consequent bacterical translation: sepsis and MOF. The Burch's classification (1996) report four levels of gravity by the slight (< 15 mmHg) to the heavyest (> 35 mmHg): the firsts two levels are of intensivistic competence and for the detention are used conservatives metodics and pharmacological approach; instead in the lasts two levels it's necessary to foresee a surgycal treatment of laparotomy, washing and drainage with following temporary paret's closure. The mortality is now very elevated (29-62%) especially when it's already established a multiorganical dysfunction; therefore it's necessary forward its appearance through the monitorization of abdominal pression (IAP) with the measurement of vescical pression in alls criticals patients at the aim to treat immediately the firsts signs of IAH.     

Catamenial Bernard-Horner's syndrome related to thoracic endometriosis

We describe the case of a young woman with a recurrent right Bernard-Horner's syndrome associated with the onset of intermittent supraclavicular mass. Surgical excision of the mass revealed the endometrial pattern of the tumor and the close relationship between Bernard-Horner's syndrome and thoracic endometriosis. No other case of this syndrome has been reported in the literature.