Acute Necrosis Research Articles

3235 Black Stomach: A Rare Clinical Entity in a Patient With Recurrent Primary Sclerosing Cholangitis With Cirrhosis

INTRODUCTION: Acute gastric necrosis is rarely encountered given the stomach's rich vascular distribution and collateral circulation. Reported causes of gastric necrosis include gastric outlet obstruction, intrathoracic herniation, ingestion of caustic substances, anorexia nervosa and bulimia, and systemic hypotension. We present a case of “black stomach” secondary to persistent shock in the setting of end-stage liver disease. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of primary sclerosing cholangitis status post orthotopic liver transplant in 2017 was initially hospitalized for pneumonia complicated by worsening graft function (MELD 38). Liver biopsy confirmed recurrent PSC with cirrhosis. Her course deteriorated after developing multiple episodes of coffee-ground emesis and melena requiring pressors. Initial EGD showed mild portal hypertensive gastropathy and two, 5 mm clean-based ulcers in the gastric antrum. No esophageal varices were visualized. Despite medical therapy, her melena and hypotension continued, leading to acute renal failure requiring CVVH. Repeat EGD two days later showed an adherent clot in the gastric fundus and severe portal hypertensive gastropathy with spontaneous oozing. Despite supportive measures, she continued to have melena. A third EGD showed a large blood clot in the fundus that was unable to be removed. Friable mucosa was noted throughout, as well as a non-healing, clean-based antral ulcer. Two days later, a fourth EGD revealed mucosa in the fundus and proximal body that appeared black and diffusely necrotic with sloughing of mucosa, with normal mucosa distally. The patient was not a candidate for IR embolization, TIPS procedure or surgery. One week later, she decompensated and died of septic shock from VRE bacteremia. DISCUSSION: Our case demonstrates that persistent gastric ischemia in the setting of shock and underlying end-stage liver disease results in gastric necrosis noted endoscopically over the course of a week. It is possible that the patient's underlying decompensated graft cirrhosis predisposed her to developing segmental gastric necrosis and “black stomach” in the area supplied and drained by the left gastric vessels, which can be affected by shock and portal congestion. Despite aggressive measures and supportive care, gastric necrosis carries a high morbidity and mortality. Therefore, a high index of clinical suspicion is required to make an early diagnosis in order to guide potential therapeutic interventions in such critically ill patients.

Free jejunal flap esophagoplasty for ischemic colon conduit replacement

Colon interposition is mainly used as a second-line treatment, when the stomach has to be resected, or when the stomach is deliberately kept intact for benign diseases in patients with long-life expectancy. Colon provides extended conduit length, reliable blood supply and low incidence of reflux. However, the early and late postoperative ischemic complication rate is 5–15%. The most serious but rare complication is the acute conduit necrosis. More severe cases of necrosis require conduit take down with proximal esophageal diversion and placement of an enteral feeding tube. Reconstruction can be planned for later if possible. An uncommon complication is the colonic stricture due to chronic ischemia, which can be treated with conservative methods such as dilation and stenting. Surgery may be indicated since the impaired deglutition can compromise the quality of life. Supercharged or free jejunal interposition is a suitable alternative conduit for esophageal replacement in patients with otherwise limited delayed reconstructive options. Good functional outcomes can be achieved despite the formidable technical challenges in this group of patients. In three such cases, we could successfully use a free jejunal flap for reconstruction; in two cases after colon conduit necrosis and in one case due to a late ischemic stricture. In each case the replacement type was different, using substernal, presternal and sternotomy routes. The arterial blood supply was provided by the internal mammary artery. Saphenous graft was used to interconnect to external jugular or innominate vein to reestablish the venous drainage. All three patients survived without further complications.

Advanced magnetic resonance imaging of cortical laminar necrosis in patients with stroke.

The aim of this study was to assess the novel advanced magnetic resonance imaging findings of acute stage cortical laminar necrosis developing after complicated cardiovascular or abdominal surgery. This institutional review board-approved study included patients with postoperative stroke due to cortical laminar necrosis imaged with magnetic resonance in the acute stage. Brain magnetic resonance imaging examinations were obtained on a 3T magnetic resonance scanner within 48 hours of the neurological symptoms, including diffusion-weighted images (b value, 1000 s/mm2) and arterial spin labelling using a pseudo-continuous arterial spin labelling method in four patients. Conventional and advanced magnetic resonance images were analysed to assess the imaging features in acute stage cortical laminar necrosis. The final population consisted of 14 patients (seven men and seven women, mean age 61 years, range 32-79 years) diagnosed with stroke and acute phase cortical laminar necrosis. All the patients presented with cortical lesions showing restricted diffusion on diffusion-weighted images and hypointensity on the apparent diffusion coefficient map. Cortical hyperintensity on T2-weighted or fluid-attenuated inversion recovery images was found in three (21%) and six (43%) patients, respectively. Reduced perfusion was noted in three out of four patients imaged with arterial spin labelling, while in one case no corresponding perfusion abnormality was noted on the arterial spin labelling maps. Arterial spin labelling abnormalities were much more extensive than diffusion restriction in two patients, and they were associated with a poor outcome. Cortical hyperintense abnormalities on diffusion-weighted imaging may be the only sign of developing cortical laminar necrosis injury. The acquisition of arterial spin labelling helps to identify perfusion alterations and the extension of the ischaemic injury.

Surgery with minimally invasive technologies for acute infected pancreatic necrosis in an elderly patient. Case report

One of the main problems in the treatment of pancreatic necrosis continues to be the choice of the most rational surgical tactics. The wide use of minimally invasive technologies in the complex treatment of acute pancreatitis reduced mortality significantly, even with its infected forms. The effect on the severity of the patient’s condition and the course of acute pancreatitis of premorbid background does not cause discussion. Here, a special group of people of advanced and senile age, the severity of concomitant diseases of which is not inferior to the severity of the underlying pathology. A case of surgical treatment of acute infected pancreatic necrosis in an elderly patient is described. Just minimally invasive technologies were applied in the treatment regimen. The patient was hospitalized in the surgical department with complaints of severe pain in the upper parts of abdomen with radiation to the back, nausea, vomiting, general weakness and malaise for two days. After an appropriate clinical and instrumental examination, the diagnosis of acute pancreatic necrosis was established. The concomitant pathology was established too: hypertension III stage 2nd degree, ischemic heart disease: stable angina pectoris II class, diffuse cardiosclerosis, aortic atherosclerosis, heart failure IIB stage, atherosclerotic encephalopathy II stage with cerebrospinal venous distension, chronic bilateral pyelonephritis, fatty hepatosis, chronic gastroduodenitis, deforming gonarthrosis of the II degree. Considering age and comorbidity, conservative therapy was carried out for 4 hours. A decision was made to perform surgical intervention due to the lack of positive dynamics and the progression of acute pancreatic necrosis with enzymatic peritonitis clinical picture. The chosen intervention was minimally invasive, which influenced the success of the treatment. the use of minimally invasive technologies in the treatment of pancreatic necrosis in this age group is a promising direction.

Comparison of Scoring Systems in Predicting Severity and Prognosis of Hypertriglyceridemia-Induced Acute Pancreatitis

In China, hyperlipidemia is the second major reason of acute pancreatitis. Comparison of Scoring Systems in identification patients at risk for severe acute pancreatitis (SAP), pancreatic necrosis (PNec), and infected pancreatic necrosis (IPN) early in the course of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). Predictive accuracy of scoring systems was measured by the area under the receiver operating characteristic curve (AUC) in a retrospective study. Pairwise AUC comparisons were performed to calculate the difference between scoring systems. A total of 238 patients diagnosed with HTG-AP were included. Sixty patients (25.2%) were classified as SAP. Twenty-nine patients (12.2%) had evidence of PNec. Nine patients (3.8%) were diagnosed with IPN. One patient (0.4%) died during hospitalization. In predicting SAP in HTG-AP, the AUCs of APACHE-II, SOFA, SIRS, Ranson's, BISAP, and MMS were 0.77, 0.83, 0.73, 0.88, 0.83, and 0.85, respectively; in predicting PNec, were 0.75, 0.77, 0.75, 0.86, 0.80, and 0.75, respectively; and in predicting IPN, were 0.92, 0.86, 0.76, 0.85, 0.84, and 0.87, respectively. Pairwise AUC comparisons revealed that Ranson's, MMS, BISAP, and SOFA had higher accuracy than SIRS, Ranson's and MMS had higher accuracy than APACHE-II in predicting SAP; Ranson's had the same accuracy with BISAP, but higher than other four criteria in predicting PNec; APACHE-II had higher accuracy than SIRS in predicting IPN. APACHE-II had high performance in predicting IPN, and all other score systems had medium performance in predicting SAP, PNec, and IPN in HTG-AP. Each score has its merit and weakness; BISAP may be the best criterion in predicting severity and prognosis of HTG-AP.

Torsional Necrosis of an Output Loop Internal Hernia After Roux-en-Y Choledochojejunostomy: A Case Report

Ultra-short bowel syndrome (USBS) refers to a clinical condition characterized mainly by severe diarrhea and nutritional disorders caused by the residual small intestine length of <30 cm (1). After Roux-en-Y choledochojejunostomy, the output loop herniated from the back of the anti-reverse peristalsis loop, resulting in intestinal torsion and necrosis, and leading to this rare case of internal hernia. Patients with torsion often show severe abdominal pain and persistent aggravation, but this symptom lacks specificity, making it easy to be misdiagnosed. Acute intestinal torsion and necrosis often lead to large-scale small bowel resection, resulting in USBS. We report a case of torsional necrosis of an output loop internal hernia after Roux-en-Y choledochojejunostomy, providing certain reference for the diagnosis and management of such cases.

Hypernatraemia following surgery for a congenital extrahepatic portosystemic shunt in a Shih Tzu presenting with marked polyuria and polydipsia

A 3-year-old male Shih Tzu was referred to the University Veterinary Hospital of the University College Dublin with a suspicion of congenital hepatopathy based on investigations performed by the referring...

Inhaled Furan Selectively Damages Club Cells in Lungs of A/J Mice.

Furan, a possible human carcinogen, is a product of incomplete combustion and is present in cigarette smoke, engine exhaust, and processed food. Oral administration induces liver toxicity and carcinogenesis in F344 rats and B6C3F1 mice. To assess possible adverse effects from inhalation, A/J mice were nose-only exposed for 3 hours to furan (0, 30, 75, 150, 300, or 600 ppmv) and euthanized after 24 hours, 48 hours, or 1 week. Histopathology evaluation revealed bronchiolar club cell necrosis (diffuse, marked) with airway denudation following exposure to 300 and 600 ppmv furan with evidence of club cell regeneration and partial repair after 1 week. Initial signs of hepatotoxicity were observed in the 150 ppmv furan-exposed group. Acute necrosis and mineralization were observed in livers at 24 and 48 hours with hepatocyte regeneration by 1-week postexposure in mice exposed to 300 and 600 ppmv furan; the 300 ppmv exposed group had multifocal mineralization that evoked a mild granulomatous response. Measurement of urinary furan metabolites confirmed that the mice metabolized furan to the toxic intermediate, cis-2-butene-1,4-dial. These observations indicate that inhaled furan is toxic to lungs with club cells as the target as well as liver.

Development of advanced skin dose evaluation technique using a tetrahedral-mesh phantom in external beam radiotherapy: a Monte Carlo simulation study

Incorrect prediction of skin dose in external beam radiotherapy (EBR) can have normal tissue complication such as acute skin desquamation and skin necrosis. The absorbed dose of skin should be evaluated within basal layer, placed between the epidermis and dermis layers. However, current treatment planning systems (TPS) cannot correctly define the skin layer because of the limitation of voxel resolution in computed tomography (CT). Recently, a new tetrahedral-mesh (TM) phantom was developed to evaluate radiation dose realistically. This study aims to develop a technique to evaluate realistic skin dose using the TM phantom in EBR. The TM phantom was modeled with thin skin layers, including the epidermis, basal layer, and dermis from CT images. Using the Geant4 toolkit, the simulation was performed to evaluate the skin dose according to the radiation treatment conditions. The skin dose was evaluated at a surface depth of 50 µm and 2000 µm. The difference in average skin dose between depths was up to 37%, depending on the thickness and region of the skin to be measured. The results indicate that the skin dose has been overestimated when the skin is evaluated using commercial TPS. Although it is not possible with traditional TPS, our skin dose evaluation technique can realistically express the absorbed dose at thin skin layers from a patient-specific phantom.

Levels of creatine kinase MB-mass in chronic kidney disease patients on maintenance hemodialysis without coronary complications

Introduction: A triad of clinical evaluation, electrocardiography and biomarkers of acute cardio necrosis are basis for diagnosing acute coronary syndrome (ACS). Evaluation of ACS by electrocardiography can be inconclusive in patients on maintenance hemodialysis; thereby making cardiac biomarkers better indicators. Hemodialysis is known to alter troponin I values with studies suggesting high false positives but not for the values of CKMB mass. Aim: The aim of the study was to estimate the levels of cardiac CKMB-mass in patients with stage IV/stage V renal failure on maintenance hemodialysis (MHD) with no evidence of cardiac disease, and to correlate these values with manufactures guidelines for healthy individuals (cut off of Materials and Methods: The study was conducted on 23 patients between age group 20 to 70 years, diagnosed with stage IV or V Chronic Kidney disease (CKD) (confirmed biochemically and ultrasonographically). These patients were undergoing regular biweekly regime of maintenance hemodialysis for more than 3 months at dialysis unit PESIMSR, Kuppam. CKMB mass levels were measured in these patients. Results and Conclusion: The kidney function tests and electrolyte values were deranged in patients with CKD, however as the patients were on calcium supplementation, mineral levels were within normal range. Liver function tests of these patients were found to be normal. The hemoglobin and RBC levels were lower due to CKD associated anemia. CKMB-mass levels of these patients were done in Biomerieux Vidas analyzer using Enzyme linked fluorescent assay (ELFA) method. The values were within manufacturer’s cutoff range of 5ng/ml with mean value of 3.0±1.69 ng/ml. The patients were followed up either until death or for 24 months for any cardiac related events and follow up rate was 99%. The overall survival rates of the patients were found to be 77% and none of the patients were found to have developed cardiac related events and specifically myocardia

Typhlohepatitis and Amyloidosis Associated with High Mortality in Chukar Partridges (Alectoris chukar)

Twelve chukar partridges (Alectoris chukar) from a farm experiencing poor uniformity and increased mortality of up to 65% were submitted for diagnosis. Several birds had mild to moderate multifocal white foci or multifocal petechial hemorrhages throughout the liver. Livers and spleens of older birds were moderate to severely diffusely enlarged. In addition, some birds had caseous cores mixed with blood within the ceca as well as segmentally thickened cecal walls. Histopathology showed acute, multifocal, severe, often coalescing foci of necrosis with accumulation of fibrin and/or fibrinosuppurative inflammation in livers and spleens. Scattered within exudate were protozoa that were spherical or round and measured 12-20 µm in diameter. In the ceca, acute necrosis of the mucosa was observed, often with ulceration and fibrinosuppurative inflammation. Immunohistochemistry using an antiserum against Tritrichomonas foetus revealed round protozoa in ceca, small intestines, liver, spleen, and lung. Quantitative PCR to detect DNA of Histomonas meleagridis was negative. Non-species-specific PCRs amplifying the partial rDNA, the internal transcribed spacer (ITS) region, and the partial beta-tubulin gene yielded products of the expected size. Sequences of the PCR products had the highest homology to sequences of Tetratrichomonas gallinarum and less homology to sequences of H. meleagridis. In addition there was accumulation of amyloid in the space of Disse in the liver, splenic sinuses, and walls of the blood vessels. The typhlohepatitis and other inflammatory processes that were diagnosed might be the underlying cause of the amyloidosis. Other findings were clusters of Clostridium perfringens associated with the lesions in the ceca; multifocal granulomas in the lungs, occasionally associated with fungal hyphae; hyperkeratosis associated with bacteria and Candida sp. cells in the crop; mild infection of the bursal mucosa with Cryptosporidium.

Alpha-1 Antitrypsin Attenuates Acute Lung Allograft Injury in a Rat Lung Transplant Model.

Background.Ischemia-reperfusion injury (IRI) after lung transplantation triggers a cascade of inflammatory changes that can contribute to acute allograft injury. This influences both the short- and long-term survival of the lung allograft. Alpha-1 antitrypsin (AAT) is a protease inhibitor with known anti-inflammatory and immune-regulatory properties that mitigate tissue damage. This study explores the protective effects of AAT in the setting of IRI utilizing a rat lung transplant model.Methods.Orthotopic left single lung transplantation was performed from Lewis to Sprague-Dawley rats; recipients did not receive systemic immunosuppression. Before transplantation, the donor lungs were primed with either albumin (control) or AAT. Starting the day of transplantation, recipient rats also received either albumin (control) or AAT with subsequent doses administered over the next 7 days. On the eighth postoperative day, lung allografts were recovered and analyzed.Results.Degree of inflammatory infiltrate, as quantified by the allograft weight (g)/body weight (kg) ratio, was significantly reduced in the AAT-treated group compared with controls (3.5 vs 7.7, respectively, P < 0.05). Treatment with AAT also significantly decreased allograft necrosis in treated animals, as measured by a semiquantitative score that ranged from 0 to 4 (1.25 vs 4, P < 0.05). In addition, lymphocytes isolated from recipients treatment group showed significant proliferative inhibition via a mixed lymphocyte response assay in response to donor antigens.Conclusions.AAT attenuates acute allograft injury and necrosis in a rat model of lung transplantation, suggesting that AAT may play a role in reducing IRI-induced inflammation.

SPECIFIC CHANGES IN THE PANCREATIC ARTERIES IN PATIENTS WITH ACUTE NECROTIC PANCREATITIS IN THE ELDERLY AND SENILE AGE

At 42 patients with acute necrosis pancreatitis of elderly and senile age is study patomorfology changes in the walls of intra- and extrapancreatic vessels, in particular, transversal pancreatitis artery and its branches, and a large pancreatitis artery of Heller and its branches. All patients are operated by the «opened» method on 10-26 days from hospitalization concerning festering-septic complications of pancreonecrosis. After the early performed laparotomy in other medical institutions or laparotomy "on demand", 15 (35.7 %) of 42 patients were performed. Indications for relaparotomy were acute profuse bleeding into the lumen of the gastrointestinal tract and abdominal cavity (5), an increase in the phenomena of multiple organ failure and progression of pancreatic necrosis (9). Postoperative complications arose in 13 (30.9 %) out of 38 patients. The 11 (26 %) patients are died. The exposed changes in the walls of intra- and exstrapancreatic vessels, cause the substantial decline of intensity splanhnic blood stream and are the cooperant factors of development necrosis changes in the parenchima of pancreas and parapancreatic cellulose.

IL-1\u03b1 promotes liver inflammation and necrosis during blood-stage Plasmodium chabaudi malaria

Malaria causes hepatic inflammation and damage, which contribute to disease severity. The pro-inflammatory cytokine interleukin (IL)-1α is released by non-hematopoietic or hematopoietic cells during liver injury. This study established the role of IL-1α in the liver pathology caused by blood-stage P. chabaudi malaria. During acute infection, hepatic inflammation and necrosis were accompanied by NLRP3 inflammasome-independent IL-1α production. Systemically, IL-1α deficiency attenuated weight loss and hypothermia but had minor effects on parasitemia control. In the liver, the absence of IL-1α reduced the number of TUNEL+ cells and necrotic lesions. This finding was associated with a lower inflammatory response, including TNF-α production. The main source of IL-1α in the liver of infected mice was inflammatory cells, particularly neutrophils. The implication of IL-1α in liver inflammation and necrosis caused by P. chabaudi infection, as well as in weight loss and hypothermia, opens up new perspectives for improving malaria outcomes by inhibiting IL-1 signaling.

Mercurimetric Titration of Chloride in Presenceof Sodium Nitroprusside as Indicator

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].

The Importance of Radio Allergosorbent Testing Early in the Management of Atopic Dermatitis in Children referred to Secondary Care

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].

18F]FDG-PET/CT Texture Analysis in “Hot” Thyroid Nodules: Results of the validation Cohort

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].

Incidence, Prevalence, And Complications of Pressure Ulcers In General Medical and Surgical Units Using A Multidisciplinary Model (Prospective Cohort)

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].

Morphological Characteristics of the Mucous Membrane of the Ileum and Colon before and after Surgical Correction of the Insolvency of the Bauhinia Valve

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].

Outcomes from Different Minimally Invasive Approaches for Infected Necrotizing Pancreatitis

Acute necrotic collections (ANC) and walled-off necrosis (WON), often performed at least two weeks after the onset of symptoms [1], become infected in about one-third of patients [2].