SYMPTOMATIC COLITIS AS THE INITIAL PRESENTATION OF WEGENER'S GRANULOMATOSIS

SUMMARY Wegener's granulomatosis is a multisystem disorder which rarely presents with gastrointestinal involvement. We report a case in which colitis was the reason for hospital admission. Diagnosis may be difficult unless clinical, serological and histopathological features are all considered.     

Interplay between IFN-gamma and IL-6 signaling governs neutrophil trafficking and apoptosis during acute inflammation

Regulated recruitment and clearance of neutrophils (PMN) is the hallmark of competent host defense and resolution of inflammation. We now report that IFN-gamma controls PMN infiltration and modulates IL-6 signaling through its soluble receptor (sIL-6R) to promote their apoptosis and clearance. Induction of peritoneal inflammation in IFN-gamma-deficient (IFN-gamma-/-) mice emphasized that the initial rate of PMN recruitment was impaired. This defect in PMN recruitment was also associated with the suppressed intraperitoneal expression of IL-1beta and IL-6. Reconstitution of IFN-gamma signaling restored the rate of PMN infiltration and IL-6 levels and was accompanied by normalization of PMN-activating CXC chemokine expression. To test whether local IL-6 signaling modulated PMN recruitment, inflammation was induced in IFN-gamma-/- and IL-6-/- mice and cytokine signaling adapted by intraperitoneal sIL-6R-IL-6 fusion protein (HYPER-IL-6) or IFN-gamma. Although HYPER-IL-6 attenuated PMN influx in IFN-gamma-/- mice, IFN-gamma had no effect on PMN infiltration in IL-6-/- mice. Examination of the leukocyte infiltrate from IFN-gamma-/-, IL-6-/-, and wild-type mice showed that apoptosis was aberrant in the absence of IFN-gamma and IL-6 as a result of impaired sIL-6R signaling. These data emphasize a pivotal role for IFN-gamma in regulating innate immunity through control of both the recruitment and clearance phases of PMN trafficking.     

Angiomyolipomas of the liver in tuberous sclerosis

Although the association of tuberous sclerosis and renal angiomyolipomas is well established, the occurrence of hepatic hamartomatous lesions in this disease is less well documented. We describe two cases of tuberous sclerosis with associated multiple intrahepatic angiomyolipomas, and we review the literature on this subject. Radiologically, angiomyolipomas can range from entirely lipomatous to completely solid, features which are present in our cases. A characteristic finding of the hepatic involvement in this disease appears to be the multiplicity of the lesions. We suggest that in the setting of tuberous sclerosis it is reasonable to assume that intrahepatic lesions represent angiomyolipomas. However, in nontuberous sclerosis patients with similar findings malignancy cannot be excluded.An invited commentary on this article follows on pp. 552–553.     

Fluoroscopically guided percutaneous gastrostomy: Tube function and malfunction

We describe our experience with fluoroscopically guided percutaneous gastrostomy, assessing in particular the functional performance of inserted tubes. We also examine the ability of radiological investigations to detect intraperitoneal gastrostomy leakage after the procedure. A functioning gastrostomy tube was established and maintained for as long as was required in 34 (89.5%) of 38 patients referred during a 21-month period. This necessitated further gastrostomy tube placements in 13 patients. On average, inserted gastrostomy tubes functioned for 10.75 weeks and during the review period a total of 34 malfunctioning tubes required replacement or removal. This was most commonly due to tube dislodgement, blockage, or intraperitoneal leakage. We found increasing pneumoperitoneum on sequential postprocedure erect chest films a reliable sign in the diagnosis of the latter complication. In conclusion, while we have been disappointed with aspects of individual tube function, our satisfactory overall functional success rate indicates that percutaneous gastrostomy is an effective method for establishing and maintaining enteral feeding. We also propose a protocol for the management of suspected intraperitoneal leakage based on the findings on postprocedure erect chest films.     

Combined Procedures with Laparoscopic Cholecystectomy

With advancement in laparoscopic surgery a number of surgical procedures can be performed combined with laparoscopic cholecystectomy in a single surgery. We evaluate the safety & efficacy of such surgeries. A retrospective review of all patients who had undergone combined procedures with laparoscopic cholecystectomy during January 2005 to June 2009 was performed. 3144 laparoscopic cholecystectomies were performed in the period from January 2005 to June 2009. Of these, 401 cases were combined with another procedure. The mean operative time was 80 min (range 50–270 min). The mean hospital stay was 3.2 days (range 1–5 days). The mean no. of days injectable analgesics was required was 2 days (range 1 day–4 days). Combined procedures provide patients with all the benefits of minimal invasive surgery and also give the benefit of single time anaesthesia without adding to post operative morbidity & hospital stay.