Transjugular intrahepatic portosystemic shunt by direct transcaval approach in patients with acute and hyperacute Budd-Chiari syndrome

When Budd-Chiari syndrome (BCS) is due to occlusion of all three hepatic veins, the standard transjugular intrahepatic portosystemic shunt (TIPS) technique can be extremely laborious. A feasible alternative is to use the direct transcaval approach, by which a shunt can be created directly between the intrahepatic inferior vena cava and the portal vein. We describe two patients (one with acute BCS and one with hyperacute BCS) who were successfully managed with this modified technique. Both patients recovered; one of them underwent elective liver transplantation 15 months after the procedure, whereas the other still had good hepatic function and a patent stent 24 months after the procedure. We conclude that, in selected patients with acute and hyperacute BCS, placement of a TIPS by the direct transcaval approach is a rapid and effective emergency procedure, which can either be curative or function as a bridge for elective liver transplantation.     

Imaging spectrum of EBV-infection in a young patient

A wide variety of atypical presentations with complications affecting multiple organ systems during acute infectious mononucleosis (IM) is described in the literature, with an increase in the number of teenagers who are susceptible to a severe case of the disease. We report a case of a 14-year-old girl with severe IM and acute abdominal pain. Ultrasonographic (US) evaluation showed a marked thickening of the gallbladder wall (GBW) with enlargement of some mesenteric lymph nodes. CT scan showed multiple enlarged lung nodules of various sizes and a small pleural and pericardial effusion; a hypodense solid mass of unknown etiology was detected in the anterior mediastinum, mimicking a malignant tumor. Hematological analysis of peripheral blood smear was performed to exclude neoplastic pathology. IM was identified as the only underlying disease. The patient was carefully monitored: clinical evaluation, laboratory analysis and US examination were repeated at weekly intervals, until recovery.     

Successful use of caplacizumab in a case of refractory acquired thrombotic thrombocytopenic purpura following subacute thyroiditis

Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare condition mainly characterized by microangiopathic hemolytic anemia, thrombocytopenia, reported in approximately three cases per one million adults per year. Some reports describing co-occurrence of aTTP and other autoimmune disorders, as Graves’ thyroiditis, are reported. To the best of our knowledge this is the first report describing co-occurrence of subacute thyroiditis and aTTP. The patient was refractory to conventional therapy with plasma exchange, steroids and rituximab but was successfully treated with the addition of caplacizumab, an anti‐VWF bivalent variable‐domain‐only immunoglobulin fragment that inhibits interaction between VWF multimers and platelets.     

Bowel preparation for gynecological surgery

Bowel preparation is an established practice before abdominal surgery. Most surgeons would use both antibiotic prophylaxis and mechanical bowel preparation (MBP) before bowel surgery. In the literature, however, there is no evidence to support the use of MBP before elective colorectal surgery. Some randomized studies and a meta-analysis report a significantly higher incidence of wound infection in patients receiving MBP versus no bowel preparation. As to gynecological surgery, data are scanty, and there is a single randomized study reporting no advantage of MBP over no bowel preparation. Based on these evidences, the routine use of MBP should be reconsidered both in general and gynecological surgery.     

Proximal and Distal Gastric Distension in Normal Subjects and H. pylori-Positive and -Negative Dyspeptic Patients and Correlation with Symptoms

Aim of the study was to analyze gastricdistension with water in H. pylori-positive and-negative dyspeptic patients and normal subjects and thecorrelation with symptoms. Twenty dyspeptic patients and 19 normal subjects were studied. H. pylori wasdetermined in each dyspeptic patient with the rapid ureatest at endoscopy. Gastric distension was evaluated byreal-time ultrasonography with the ingestion of stepwise-increasing amounts of water up toa total of 600 ml. During distension, the symptom scorewas evaluated as well. The proximal stomach wassignificantly smaller in dyspeptic patients than in healthy controls, at 100-600 ml water (P <0.01). A larger distal stomach was observed at 500 and600 ml of water (P < 0.01). The score of bloating andfullness was greater in dyspeptics than in controls at 300 and 600 ml of water distension.The symptoms score was linearly correlated with proximaland distal gastric measurements in dyspeptic patientsand in controls. No significant difference was found in dyspeptic patients regarding theH. pylori status. In conclusion, dyspeptic patients showa defective adaptation of the whole stomach to waterdistension and an increased symptom perception score as compared to controls. H. pyloriinfection does not seem to be a determining factor inthese observed findings.