Das akute Abdomen

Schlu?folgerungen Makroskopisch und histologisch handelte es sich um eine ausgepr?gte nekrotisierende Vaskulitis vom Panarteriitis-nodosa-Typ mit akuter Glomerulonephritis. Von klinisch rheumatologischer und serologischer Seite konnten klassische Krankheitsbilder einer Panarteriitis nodosa, Morbus Wegener oder Churg-Strauss-Syndrom ausgeschlossen werden. Immunologisch handelt es sich um eine Hypersensitivit?tsangiitis als hypererge Reaktion des Immunsystems im Rahmen einer akuten Gastroenteritis nach Hühnerfleischgenu?. Differentialdiagnostisch ist sie mit einer Vaskulitis einer Purpura Sch?nlein-Henoch vergleichbar. Nur durch kompetente interdisziplin?re Zusammenarbeit verschiedener Disziplinen war es m?glich, den Patienten optimal zu betreuen. Schwierige akute Gastroenteroitiden sollten gelegentlich an hypererge Reaktionen des Immunsystems denken lassen.     

Sphincter preservation — A fascinating challenge in rectal carcinoma surgery

Background: In the last decades there has been an increasing trend toward sphincter preservation for rectal cancer. This paper analyses a uniformly operated patient collective with regard to complication, tumor recurrence and survival rates. Methods: Between January 1984 and July 1993, 440 patients were operated for rectal cancer. In the upper rectal third sphincter preservation was possible in 100%, in the middle third in 97% and in the lower third in 46%. Results: Tumor resection was possible in 98.9%, curative resection in 85.7% of the 440 surgically treated patients. Anastomotic leakage was observed in 10.5%, postoperative hospital mortality for curatively operated patients was 1.9%. The 5-year actuarial survival rates for tumor stages I to IV were 99%, 77%, 44% and 20% respectively. The local recurrence rate was 12.7%. Conclusions: A high rate of sphincter preservation can be achieved without sacrificing low morbidity, mortality or recurrence rates. The surgical trend towards sphincter preservation in the middle and lower rectal thirds is due to the increased application of stapler devices and to the histopathological examination of the distal and lateral resections margins. The mesorectum is recognized as an important source of local tumor recurrence.     

Is percutaneous liver biopsy using the Trucut (Travenol) needle superior to Menghini puncture?

The aim of this study was to compare the quality of biopsy cylinders obtained by the Menghini or Trucut liver biopsy-method as well as the frequency of complications observed with both these methods. For this purpose, 74 Menghini and 62 Trucut biopsies were analyzed. Both groups were comparable with respect to histologic diagnosis, but no final diagnosis could be made in eight cases of Menghini biopsy because of insufficiency of the material obtained. Fragmentation of the sample occurred significantly more often in the Menghini group (p less than 0.05; chi 2 test). Trucut biopsies were significantly longer (12 mm versus 8 mm mean value; p less than 0.001; Wilcoxon rank sum test) and contained significantly more portal tracts (16 versus 6 mean value; p less than 0.001). None of the total 136 biopsies led to serious complications. We conclude that Trucut liver biopsy is superior to the Menghini method since tissue yield is better and both methods are equally safe.     

Altered expression of the hormone- and xenobiotic-metabolizing sulfotransferase enzymes 1A2 and 1C1 in malignant breast tissue

Cytosolic sulfotransferases (SULTs) catalyze the biotransformation of steroid hormones as well as drugs and environmental toxins. Mostly, sulfonation leads to an inactivation of parent compounds, although formation of more toxic and cancerogenic metabolites also occurs. To assess possible alterations in the SULT enzyme expression pattern between malignant and non-malignant tissue, we studied the presence of 9 SULT enzymes of family 1 and 2 by semi-quantitative RT-PCR. Forty-two specimens from ductal and lobular breast carcinomas, lymph node metastasis, mastopathy and normal breast tissue were derived from 29 patients. Substantial expression of SULT 1A1, 1A2, 1A3, 1B1, 1C1, 1E1, 2A1, 2B1a and 2B1b mRNAs was observed in malignant and non-malignant tissue, although the pattern of the individual SULTs varied between the patients, and SULT1C1 mRNA was present in a greater number of malignant than non-malignant tissues (p<0.05). A major finding was that unspliced SULT1A2 mRNA, containing the complete intron between exons 7 and 8, was found in 4 of 16 non-malignant specimens, but was undetectable in the 26 malignant samples investigated. Taken together, the presence of various SULT enzymes in normal, premalignant and malignant breast tissue suggests an important role of SULT-mediated biotransformation in the breast. While the increased expression of SULT1C1 in malignant tissue seems to reflect tumor dedifferentiation, our finding of unspliced SULT1A2 mRNA in non-malignant tissue offers additional aspects regarding the search for breast cancer risk factors.     

Inherent growth advantage of (pre)malignant hepatocytes associated with nuclear translocation of pro-transforming growth factor alpha

The pro-peptide of transforming growth factor alpha (proTGFalpha) was recently found in hepatocyte nuclei preparing for DNA replication, which suggests a role of nuclear proTGFalpha for mitogenic signalling. This study investigates whether the nuclear occurrence of the pro-peptide is involved in the altered growth regulation of (pre)malignant hepatocytes. In human hepatocarcinogenesis, the incidence of proTGFalpha-positive and replicating nuclei gradually increased from normal liver, to dysplastic nodules, to hepatocellular carcinoma. ProTGFalpha-positive nuclei almost always were in DNA synthesis. Also, in rat hepatocarcinogenesis, proTGFalpha-positive nuclei occurred in (pre)malignant hepatocytes at significantly higher incidences than in unaltered hepatocytes. For functional studies unaltered (GSTp(-)) and premalignant (GSTp(+)) rat hepatocytes were isolated by collagenase perfusion and cultivated. Again, DNA synthesis occurred almost exclusively in proTGFalpha-positive nuclei. GSTp(+) hepatocytes showed an approximately 3-fold higher frequency of proTGFalpha-positive nuclei and DNA replication than GSTp(-) cells. Treatment of cultures with the mitogen cyproterone acetate (CPA) elevated the incidence of proTGFalpha-positive nuclei and DNA synthesis in parallel. Conversely, transforming growth factor beta1 (TGFbeta1) lowered both. These effects of CPA and TGFbeta1 were significantly more pronounced in GSTp(+) than in GSTp(-) hepatocytes. In conclusion, nuclear translocation of proTGFalpha increases in the course of hepatocarcinogenesis and appears to be involved in the inherent growth advantage of (pre)malignant hepatocytes.     

Hypersensitivity vasculitis causing an acute abdomen

The members of a family of four persons suffered acute gastroenteritis after eating a meal consisting of chicken. While three of them recovered rapidly, the 18-year old son developed an acute abdomen which had to be treated surgically and led to a complicated stay at the intensive care unit. Intraoperatively, a mild insignificantly inflamed appendix and an obscure segmental inflammatory process of the small bowel with local peritonitis were seen; this required an appendectomy and a peritoneal lavage. The development of bacterial peritonitis with multiple organ dysfunction required several surgical revisions with an open abdominal toilet treatment. Histological examination of the resected appendix specimen showed a severe primary fibrinoid necrotizing vasculitis with epitheloid-granulomatous reaction. Diseases such as Panenteritis nodosa, Wegener's disease and Churg-Strauss's syndrome were excluded by negative serology. By a process of exclusion, a hypersensitivity vasculitis was diagnosed and treated successfully with a high-dose cortisone regime.     

Pathologic findings in colorectal cancers and discussion of their significance for tumor therapy according to stage

The histological degree of differentiation is a valuable determinant of the malignancy of colorectal carcinomas. It correlates well with the tumour stage and has a prognostic relevance similar to the Dukes stages. Well and moderately well differentiated colorectal carcinomas showed significantly lower lymph node metastasis (35% and 45% of the cases, respectively) than the poorly differentiated tumours (70%). Among 20 carcinomas limited to mucosa and submucosa, only one poorly differentiated carcinoma produced lymph node metastases. The histological degree of differentiation of a given tumours assessed consecutively in biopsy and surgical material was identical in 81%. The degree of differentiation had to be corrected from moderate to well in only 9% of cases and in 8% from well to moderate. These corrections were without prognostic relevance. The prognostically important correction from moderate to poor histological degree of differentiation had to be made in only 2% of the cases. Therefore, the histological degree of differentiation can be accepted as an important preoperative criterium for the selection of adequate tumour therapy. An increased risk of tumour infiltration of resection margins was found only in cases with resection distances less than 1 cm from the tumour, whereas tumour infiltration of resection margins was minimal (below 1%) for distances of more than 1 cm. Consideration of the histological degree differentiation, clinical stage of tumour and sufficient distances of resection margins from tumours should lead to increased numbers of resections with preservation of sphincter function despite radical surgery.