Evidence Of Perforation Research Articles

Pneumatosis cystoides intestinalis after fluorouracil chemotherapy for rectal cancer

Pneumatosis cystoides intestinalis (PCI) is a relatively rare condition characterized by intraluminal gas in the gastrointestinal tract. Several chemotherapeutic agents have been reported to be associated with PCI, although fluorouracil-related PCI is extremely rare. We report a case of a 76-year old man who received adjuvant chemotherapy for rectal cancer with fluorouracil (FU) and leucovorin (LV). After 1 cycle of the treatment, he presented with diarrhea and abdominal pain. Abdominal radiogram revealed the presence of free air under the diaphragm and intramural gas in the intestine. Laparotomy was performed, showing a suspected diagnosis of perforation in the gastrointestinal tract. Intraoperative findings revealed penumatosis of the intestine without evidence of perforation. He was treated supportively and his symptoms improved. In conclusion, we should consider the possibility of PCI occurring in patients with malignancies during chemotherapy treatment.

Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial

Objective:Acute otitis media (AOM) is common in children, yet the optimal management of ear pain associated with AOM has not been well studied. We set out to determine the efficacy...

Complicated appendicitis in children: a clear role for drainage and delayed appendectomy

Introduction Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. Methods A retrospective review of all children undergoing appendectomy over a 5-year period was performed. Results We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy. Conclusion In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.

Polypectomy devices

Polypectomy devices

Akzidentielle und suizidale Verätzungen des oberen Gastrointestinaltraktes

Caustic ingestion can cause sever damages. Immediate management should be directed to airway securing, intravenous fluid replacement and pain relief. Early endoscopy is regarded as the most appropriate method based on which further clinical decisions are made. The effectiveness of dilution by milk or water has not been proven and might aggravate the damage. The use of systemic corticosteroids should also be abandoned as they do not prevent the development of strictures and may cause serious adverse effects. The most important prognostic factor concerning early mortality is the delayed diagnosis and therapy of full thickness esophageal or gastric necrosis. Patients with evidence of perforation require immediate surgery. Since it can be very difficult to classify the exact extent of damage intraoperatively according to the endoscopic findings, a resection of all high grad damaged segments should be performed in doubt. Reconstructive surgery should not be performed earlier then 4 months after the initial event. The used technique depends on the extent of the initial damage and surgery. Development of strictures is the most important physical consequence in burned areas in survivors. Short strictures are mainly treated by endoscopic dilatation. In cases of higher graded strictures, when repeated dilatations are often ineffective, early resection should planned. Because of the high incidence of esophageal cancer among victims of caustic strictures, routine endoscopic follow up is recommended.

The role of diagnostic laparoscopy in micropremmies with suspected necrotizing enterocolitis

The timely diagnosis of perforations or dead gut can be extremely difficult in micropremmies with necrotizing enterocolitis. A negative laparotomy is just as detrimental as failure to recognize early perforation in this group of patients. We have been exploring the role of microlaparoscopy using a needlescope to determine if this modality is feasible and useful in the surgical management of these patients. We report our technique and initial experience with needlescopic diagnosis. Four patients (weight >500 to <1000 g) with abdominal distension and clinical sepsis not responsive to aggressive medical treatment were included in this study. None had radiologic evidence of pneumatosis or perforation. There was no absolute surgical indication for laparotomy except for strong suspicion of a surgical cause. Needlescopic diagnosis was performed in all these patients. There was no evidence of perforation or bile in the abdominal cavity in one patient. This patient improved on medical management, avoiding a laparotomy. The rest had bile or fibrin in the abdominal fluid with a localized perforation, and in each case we performed a microlaparotomy directly over the site of perforation to create a stoma. Needlescopic diagnosis is feasible and appears to be safe, even in critically ill micropremmies less than 1000 g. The technique can provide useful information for surgical decision-making and allows for precise placement of a microlaparotomy incision over the site of perforation, thus minimizing the trauma from open surgery in this special group of patients. We are currently expanding its role in patients with overt perforations to determine if we can limit the extent of surgical exploration without compromising the adequacy of surgical management.

Gastrointestinal tract perforation in children due to blunt abdominal trauma.

Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine (4.9 per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only five of 27 (19 per cent) with a further six of 27 (22 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time from admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (from head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.

Spontaneous Colonic Perforation without Dilatation in a Patient with Ulcerative Colitis (UC) and the Role of Imaging Modalities in the Diagnosis of Colonic Perforation

Describe an uncommon complication in a patient with UC. 64 year old, non-compliant female, with an 8-year history of UC currently on Asacol presents to the EC with 3 days of flue like symptoms, intermittent lower abdominal pain, nausea, vomiting, and diarrhea. Physical examination was unremarkable except for mild abdominal distention and mild tenderness in the lower quadrants. Labs showed a WBC 22.4, Hg 11.0, BUN 17, and Cr 2.0. Acute abdominal series (AAS) was worrisome for distal mechanical SBO without free air. Clinical condition deteriorated as the patient was being prepped for CT. CT abdomen and pelvis 6 hours following the AAS showed severely dilated bowel loops with inflammatory changes in the small bowel mesentery and evidence of perforation with free fluid without again free air. Patient underwent exploratory surgery, revealing a perforated sigmoid colon. Free colonic perforation without dilatation in patients with UC is uncommon. Free perforation occurred in only 7/702 patients with UC (1%) without toxic dilatation seen at Mount Sinai Hospital (1960–1981). These 7 patients represented 30% (7/23) of all colonic perforations seen in patients with UC. Classic physical signs of peritonitis were absent in 6/7 patients. All had a marked deterioration in general condition after perforation. Mortality was high (57%). Comparatively longer histories of colitis, prolonged current attacks, and slightly greater delays between presumed perforation and operation were characteristics of these patients. Several studies have evaluated the use of various imaging studies in the diagnoses of visceral perforation. One study showed that combined radiography, US and CT showed signs of perforation in 71% of cases. When free air was absent (1/3 of cases), free intraperitoneal fluid was the only radiological finding. Another study showed that CT demonstrated the presence of free intraperitoneal gas in more patients than an AAS (92% vs. 74%). Possibility of free perforation in UC must be considered in fulminating cases, even in the absence of colonic dilatation. Careful clinical monitoring and early surgical intervention may be the keys to reducing mortality. AAS is still the primary tool to evaluate for visceral perforation. Free air when present may be detected in nearly 100% of cases. When there is no free air detected and symptoms persist, CT should be performed after at least 6 hours interval to allow the radiological picture to change.

A mixed radiolucency with dispersed calcified bodies of the right posterior mandible and ascending ramus

CLINICAL PRESENTATION A 66-year-old white man was referred by his general dentist for diagnosis and treatment of a painless swelling of the right posterior mandible that was discovered during routine radiographic examination. The patient’s medical history was significant for a diagnosis of tachycardia 4 years earlier. Intraoral examination revealed a 3-cm mass involving the right mandibular alveolar ridge adjacent to the distal aspect of second molar tooth to the retromolar area. The well-circumscribed mass was pink with an intact overlying mucosa and was firm to palpation without tenderness (Fig 1). Imaging studies were obtained. Both routine tomograms and computed tomography (CT) views revealed an intraosseous multilocular radiolucency with welldefined borders and diffusely scattered, internal radiopacities involving the posterior mandible with extension into the ascending mandibular ramus (Fig 2 and Fig 3). The calcified material varied from tiny flecks to irregular masses roughly 1 cm in size. Focal cortical thinning was observed, however no evidence of perforation was identified.

Pseudoperforation during kissing balloon angioplasty

We describe a case of apparent perforation during kissing balloon angioplasty of a bifurcation lesion. There was no evidence of perforation on follow-up angiography or via intravascular ultrasound. Possible etiologies include minimal perforation that immediately sealed postdeflation or forced contrast into the microvascular bed via a proximal side branch.

SPLENIC HEMATOMA FOLLOWING ROUTINE COLONOSCOPY

Colonoscopy is a safe and well-tolerated procedure with few complications. We present an unusual complication of routine colonoscopy diagnosed 3 days after the procedure. A 48 year old female with no significant past medical history was evaluated for increasing sharp, left upper abdominal pain which began abruptly two days ago. She denied nausea, vomiting, diarrhea, melena or bright red blood in stools. Three days earlier patient had undergone a colonoscopy for work up of her anemia. The colonoscopy was reported to be normal and no biopsy was performed. On physical examination she was pale and short of breath. She was afebrile, tachycardiac, tachypneic, hypoxic and hypoten-sive. There was tenderness in the left upper quadrant with hypoactive bowel sounds. Heme occult was negative for any blood in stools. She had a low hemoglobin (7.6gm/dl) and leucocytosis (16300cells/mcl). Comprehensive blood panel including coagulation and liver functions were normal. Obstruction series was grossly normal without evidence of perforation. A CT scan of her abdomen showed a large collection of fluid in the upper left quadrant surrounding the spleen. In view of the temporal relationship between the development of these signs and symptoms after colonoscopy, diagnosis of splenic rupture was made. She was managed with aggressive fluid resuscitation, blood transfusion, and broad-spectrum antibiotics. She responded very well to supportive measures. Splenic trauma is a rare complication of colonoscopy. There are very few case reports of this complication in literature. Predisposing factors are splenomegaly, inflammatory bowel disease, intra-abdominal adhesions due to prior surgeries and use of anticoagulation therapy. However, this complication has occurred in the absence of these predisposing factors, during an otherwise seemingly uneventful diagnostic colonoscopy. The presumed mechanisms of splenic rupture during colonoscopy are direct trauma to the spleen, excessive traction on the splenocolic ligament, and decrease in the relative mobility between the spleen and the colon due to preexisting adhesions. The clinical manifestations mimic those of intra-abdominal hemorrhage. Onset of symptoms is variable and has ranged from 4 hours to about 36 hours after procedure. However, asymptomatic rupture of spleen has also been described. As occurrence of splenic rupture and the associated circumstances are often unpredictable. A high index of suspicion is the key to the diagnosis of this rare but potentially lethal complication.

Mesenteric venous thrombosis

Mesenteric venous thrombosis is a rare condition associated with a high rate of morbidity and mortality. There have been no randomized trials, but most recent authors advocate the combination of a high clinical index of suspicion combined with noninvasive imaging with computerized tomography to make the diagnosis. When there is no evidence of perforation or peritonitis the condition is best managed conservatively with anticoagulation treatment.

Acute oral selenium intoxication with ten times the lethal dose resulting in deep gastric ulcer

A 48-year-old woman presented after taking 2000 mg of selenium dioxide, corresponding to 10 times the experimental lethal dose in animals. She presented with mildly altered consciousness and hematemesis. Endoscopy revealed mucosal damage throughout the oral cavity, esophagus, and stomach. There was no evidence of perforation. After intubation and gastric lavage, hemodialysis was performed. The patient was discharged uneventfully on the 16 th day. This case highlights a very rare acute selenium intoxication. Serum and urinary selenium levels and serum glutathione peroxidase activities during the patient's course were followed, as well as the mucosal corrosive damage caused by the selenium.

In vivo evaluation of the effects of gravitational force (+Gz) on over-the-wire stainless steel Greenfield inferior vena cava filter in swine.

This study was done to determine the effect of exposure to gravitational force (acceleration stress) on in vivo over-the-wire stainless steel Greenfield inferior vena cava filters. Fifteen pigs underwent venous cut down and placement of a stainless steel Greenfield filter. A 4-week observation period simulated realistic convalescence and allowed sufficient time for epithelialization. Ten pigs were exposed to acceleration stress in a centrifuge (3G run for 15 sec followed by rest until return to baseline heart rate, then a 9G run for 15 sec), with inertial loading in a head-to-tail direction (+Gz). Fluoroscopy during acceleration stress allowed assessment for filter migration. Five pigs were not exposed to acceleration stress. AP and lateral abdominal radiographs were obtained at post-filter placement, convalescence, and centrifuge exposure to determine the position and integrity of the filter. All 15 IVCs were resected and evaluated for gross or histological injury to the vessel wall. IVC filter placement was technically successful in all 15 pigs. Radiographic measurements were limited secondary to differences in pig positioning. Fluoroscopy showed no filter migration. All filters were securely attached to the vena cava by the hooks without gross evidence of perforation or hemorrhage. There were varying degrees of fibroplasia involving the hooks and tip of the filters in both the control and experimental groups. Histologically, there was evidence of prior hemorrhage at the level of the hooks, which was similar between the control and experimental groups. It is concluded that Greenfield filter position and vena caval integrity at the implantation site is unaffected by high acceleration stress.

Endoscopic transpapillary gallbladder drainage for closure of calculous gallbladder perforation and cholecystoduodenal fistula

VOLUME 56, NO. 5, 2002 GASTROINTESTINAL ENDOSCOPY 753 Current affiliations: Department of Medicine, Division of Gastroenterology and Hepatology, Department of Surgery, Division of Gastroenterologic and General Surgery, and Department of Radiology, Division of Interventional Radiology, Mayo Medical Center, Rochester, Minnesota. Reprint requests: Todd H. Baron, MD, FACP, 13400 E. Shea Blvd., Scottsdale, AZ 85259. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/4/129217 doi:10.1067/mge.2002.129217 noted. A 10F stent was placed across the stricture into the intrahepatic biliary system, after which the jaundice resolved. Abdominal CT was normal. The patient remained well for 4 weeks but then presented with recurrent right upper quadrant pain, fever, and leukocytosis with normal biochemical parameters of liver function, and he was referred to our institution. Abdominal CT revealed new, marked bowel wall thickening of the proximal and mid portions of the duodenum, as well as thickening of gastric antrum and pylorus. Extensive stranding was seen in the mesenteric fat around the proximal duodenum and gallbladder fossa; the gallbladder wall was thickened with a new adjacent fluid collection. There was a suggestion of a small connection between the gallbladder and duodenal lumen. Radiographic study of the upper GI tract with water-soluble contrast revealed an edematous duodenum without evidence of perforation or fistula. ERCP was repeated because of suspected gallbladder perforation. The previously placed biliary stent was Figure 1. Retrograde cholangiogram showing endoscopically placed biliary catheter in gallbladder (GB). Note markedly irregular contour of gallbladder with extravasation of contrast into fluid collection identified on CT. Endoscopic transpapillary gallbladder drainage for closure of calculous gallbladder perforation and cholecystoduodenal fistula

Perforations and fistulae in gastrointestinal tuberculosis

Background: Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies. Material and Methods: A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae. Results: Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression. Conclusion: Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Perforations and fistulae in gastrointestinal tuberculosis

Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies. A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae. Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression. Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Safety and efficacy of manual stepping and overlapping of β-emitter for diffuse in-stent restenosis lesions

Background: The effects of overlapping β-emitter sources on the treatment of in-stent restenosis (ISR) lesions as a result of manual stepping are unknown. Methods and results: In the BETA WRIST (Beta Washington Radiation for In-stent Restenosis Trial), 17 out of the 50 patients who received radiation treatment had diffuse ISR in native coronaries that required manual stepping of the β-emitter ( 90Y) source in order to cover the lesion and the edges. Fourteen of those patients received radiation with an overlap of up to 3 mm in the middle of the stented segment. The prescribed dose was 20.6 Gy to a distance of 1.0 mm from the surface of the inflated balloon, and the calculated dose to the vessel wall at the overlapped area did not exceed 75 Gy. There was no difference in late total occlusion (7.1% vs. 9.0%, P=NS) and target lesion revascularization (28.5% vs. 27.2%, P=NS) between patients with stepping and those without stepping. At 6 months, there was no evidence of perforation or aneurysm at the overlapped segments. Quantitative coronary angiographic (QCA) analysis revealed significantly reduced late loss in the overlapped segment compared to the adjacent segment ( P=.04). Serial (postradiation vs. follow-up) IVUS measurement showed larger mean lumen cross-sectional area (CSA) ( P=.0035) and smaller mean intimal hyperplasia (IH) CSA ( P=.0010) in the overlapped segment compared to the adjacent segment. Conclusion: Manual stepping of β-emitter source with a short overlapped segment is safe for diffuse ISR. Further increase in lumen dimension and reduction in IH formation are observed at the overlapped segment.

Transmural Atrial Insulating Lesions Using Epicardially Applied Radiofrequency Energy Coupled With Saline Irrigation

The Maze procedure has been demonstrated to eliminate atrial fibrillation (AF) refractory to medical management. The procedure, however, is technically difficult and requires prolonged cardiopulmonary bypass (CPB). We investigated the use of epicardially applied radiofrequency (RF) energy delivered using a saline-irrigated probe to functionally reproduce the linear lesions of the surgical Maze procedure. The goals of this study were to safely produce transmural atrial insulation lines without CPB and to investigate whether they could retain their electrical insulation properties and structural integrity over an acute time period. Baseline pacing thresholds were measured on the atria of six swine. Then, circular insulating lesions ( n = 11) were created around each pacing site using a saline-irrigated RF probe and specifically designed radiofrequency generator. Pacing thresholds were repeated at the same atrial sites, and in adjacent areas, immediately following lesion creation and at 7 days. At sacrifice the areas of interest were removed for histopathology. Pacing thresholds increased from 0.9 - 0.09 V to 9.59 - 0.87 V immediately following lesion formation ( p < .05) and remained supraphysiologic at 4.05 - 0.36 V after 7 days ( p < .05). Thresholds from outside the lesions were unchanged from baseline. There was no evidence of perforation and histologic analysis demonstrated transmural necrosis with advancing granulation tissue. Our data suggest that epicardially applied RF energy coupled with saline irrigation can produce transmural electrical insulation lines for up to 7 days. However, the decreasing trend in thresholds toward baseline suggests further investigation is needed to verify insulation line continuity over a chronic time period. These lines were created safely and efficiently without CPB, and may be applicable to a minimally invasive Maze procedure.

Twin-endoscope scissors resection (T-ESR): a new minimally invasive technique for performing colonic mucosectomy.

Piecemeal resection is currently the safest method for the endoscopic removal of large sessile colonic polyps. However, this method has its limitations, including the quality of the specimen received for histopathology and the need for early follow-up due to the possibility of incomplete resection and recurrence. New methods enabling en bloc resection would be advantageous in these respects. We developed a new technique that uses endoscopic scissors and two endoscopes to perform mucosal resection in a porcine model. So far, the technique has been evaluated in two animals. The resection of intact mucosal specimens measuring 1.5 x 1 cm and 2.2 x 3.5 cm was achieved, with no procedural or late hemorrhage and no clinical or radiological evidence of perforation. After further development and evaluation, this technique should be suitable for the resection of large sessile colonic polyps in humans.