Mural Thickening Research Articles

Extranodal B‐cell lymphoma in the urinary bladder with cytological evidence of concurrent involvement of the gall bladder in a cat

A 15-year-old domestic shorthair cat was presented with severe haematuria, stranguria, anorexia and lethargy of 10 days' duration. Physical examination revealed a large painful urinary bladder and pain in the cranial abdomen. Abdominal ultrasound revealed severe generalised mural thickening of both the gall bladder and the urinary bladder. Lymphoma was diagnosed on cytology of urine sediment and fine-needle aspirates of the gall bladder. Despite a transitory clinical improvement and partial remission following chemotherapy, the cat was euthanased six weeks after initial presentation due to recurrent clinical signs. Post-mortem examination confirmed a B-cell lymphoma in the urinary bladder. This report is the first description of gall bladder and bladder lymphoma in a cat.

Intussusception due to intestinal metastasis from lung cancer

Intestinal metastasis from lung primary is very uncommon and seen at the terminal stage of the disease. Clinically, patients present as perforation or bleeding and rarely as intussusception. We report the case of a 78-year-old man who came with sudden onset of abdominal complaints of four to five days duration. A computerized tomography (CT)--scan abdomen showed mural thickening of short loop of jejunum with ileoileal intussusception. Resection-anastomosis revealed two separate nodules in the small intestine. The patient, a diagnosed case of primary carcinoma of lung seven months ago, had been treated with one cycle of chemotherapy. Histopathology of the small intestinal nodules showed features of adenocarcinoma consistent with the known primary lung cancer. We present this case to arouse a clinical suspicion of intestinal metastasis in known cases of primary lung cancer presenting with the sudden onset of abdominal complaints. Early diagnosis and management improves the survival of these patients.

Adenomyomatosis of the Gallbladder: The “Good Omen” Comet

As emergency physicians perform bedside ultrasound with greater frequency, greater numbers of incidental and potentially unfamiliar sonographic findings will be encountered. Illustrate, discuss, and briefly review literature regarding one such finding and diagnosis in right upper quadrant sonography. A middle-aged woman was evaluated in the Emergency Department for abdominal pain. Limited bedside sonography of the gallbladder revealed mural thickening and comet-tailing. A diagnosis of adenomyomatosis was made. Gallbladder adenomyomatosis can produce ultrasound findings similar to those of more serious and emergent gallbladder diseases. Cognizance of the sonographic details and typical clinical characteristics will allow the emergency physician to appropriately assess and disposition patients with this condition.

A Case of Collagenous Enterocolitis in an Infant

Purpose: Collagenous colitis is where a thick subepithelial collagen layer in the colon is seen on histology. Few cases are reported in children. To date, there have been no cases of collagenous enterocolitis reported in children. We present a case of collagenous enterocolitis diagnosed in a male infant with an unknown neuromuscular disorder who was evaluated for protein losing enteropathy after presenting with hypoalbuminemia and ascites. He had a history of failure to thrive for which an NG tube was used to provide calories. He resided in a nursing facility when he was transferred to our institution with worsening abdominal distention over 1 week. He had been experiencing voluminous, foul-smelling, mucoid stools. On examination, he had a soft, moderately distended abdomen and severe hypoalbuminemia. Imaging studies showed irregular mural thickening of small bowel loops and ascites. His work-up was negative for infectious or renal causes prompting endoscopy. Gross endoscopic findings were duodenal edema with exudative lesions and a nodular rectum. Histology showed thickened subepithelial collagen in the duodenum, sigmoid and rectum. He was trialed on Prednisone 1 mg/kg/day and allowed to continue NG feeds. A few days later, he suffered respiratory insufficiency requiring intubation. Because of his acute decompensation, he was placed on stress-dose Hydrocortisone, feeds were discontinued, and he started parenteral nutrition (PN). Despite being on steroids and having optimal protein in his PN, hypoalbuminemia persisted, requiring daily albumin infusions; his fecal alpha-1-antitrypsin and reducing substances were positive. It was determined that he would require long-term PN. The steroids appeared to provide no benefit so they were subsequently tapered off over a month. He was trialed on Sulfasalazine 40 mg/kg/day while further work-up was ongoing. After a 2 month hospitalization, he eventually stabilized and was transferred back to the nursing facility where he remained NPO and on Sulfasalazine. After a month, a feeding trial was attempted but he developed diarrhea, guaiac positive stools, and hypoalbuminemia, so feeds were discontinued. A trial was reattempted another month later with the same results. Review of the literature shows that common variable immune deficiency, autoimmune enteropathy, and celiac disease may present with subepithelial collagen but work-up has thus far been negative. Presently, the patient remains NPO with PN. Sulfasalazine was discontinued after he was readmitted with acute respiratory failure. A repeat endoscopy was conducted at the time of this abstract submission. Biopsy samples were sent for electron microscopy and further testing is ongoing.

Intensely Hypermetabolic Extra-Axial Brainstem Tumor in Erdheim-Chester Disease

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis characterized by progressive histiocytic proliferation with multiorgan involvement, typically of the kidney, skin, brain, and lung, and less frequently, the heart and retro-orbital tissue. Fluorine-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) plays an important role in the management of this disease. It has been reported that FDG PET imaging allows accurate evaluation of the extent of the disease at baseline, as well as assessment of response to any specific therapy. In this case, a 57-year-old Chinese man presented with functional decline and a urinary tract infection. He had a prior history of xanthogranulomas of bilateral canthal masses. On imaging, he was found to have left hydronephrosis, diffuse urothelial thickening, increased density of the perinephric fat, mural thickening of the descending aorta and soft tissue masses along the posterior wall of the right atrium extending into the region of the interatrial septum and involving the right atrioventricular groove. Histopathology revealed retroperitoneal fibrosis. An IV contrast-enhanced FDG PET scan showed increased activity in a previously unidentified brain stem mass and the shafts of bilateral femora. Varying levels of FDG uptake were seen in the other lesions.

Multidetector CT angiography in Takayasu arteritis

Objective To analyse the spectrum of Takayasu's arteritis (TA) on multidetector CT angiography (MDCTA). Materials and methods A retrospective analysis of the MDCTA findings was performed on 15 patients clinically diagnosed as Takayasu's arteritis. The spectrum and incidence of imaging findings on CTA were compared to studies in literature on catheter angiography in Takayasu's arteritis. Laboratory parameters were available in nine patients. The disease was considered active if erythrocyte sedimentation rate (ESR) levels were elevated and ‘C’ reactive protein (CRP) was positive. An attempt was made to correlate disease activity with the imaging findings. Results Ascending aorta, arch of aorta and descending thoracic aorta were involved in 14 out of 15 (93%) patients. The wall thickness varied between 1 and 10 mm with maximal involvement in arch and descending thoracic aorta. Major neck vessels were involved in 11 (73%) patients with most pronounced changes seen in the brachiocephalic trunk, left common carotid artery (CCA) and left subclavian artery (SCA). Abdominal aorta and its branches were involved in all the 11 (100%) patients in whom abdominal CTA was performed. Celiac axis and SMA were involved in 10 (91%) and seven (64%) patients, respectively while renal artery stenosis was present in five (45%) patients. In six patients, ESR was elevated and CRP was positive indicating active disease. All patients in whom the laboratory parameters were available showed mural thickening in the aorta and at least one of the neck vessels except for one patient with inactive disease who had aortic mural thickening only. Conclusion MDCTA provides information about both the vessel wall and lumen in patients with Takayasu's disease.

The architecture of the left ventricular myocytes relative to left ventricular systolic function

Mural thickening, combined with longitudinal and circumferential shortening, and apical along with basal twisting are critical components of the left ventricular systolic deformation that contribute to ventricular ejection. It is axiomatic that the spatial alignment of the actively contracting aggregates of myocytes must play a major role in the resulting ventricular deformation. The need to conserve functional global myocytic architecture, therefore, is an important aspect of the surgical manoeuvres affecting ventricular mass and geometry. To investigate the influence of the global alignment of the myocytes on ventricular contraction, we used a mathematical model simulating the large deformations produced by systolic contraction of the left ventricle of a human heart. The alignment and meshing of the myocytes within their supporting fibrous matrix cause mechanical anisotropy, which was included in the mathematical model in the form of a unit vector field, constructed from the measured trajectories of aggregated myocytes in an autopsied human heart. The relationship between ventricular structure and ventricular dynamics was assessed by analysing the influence of systematic deviations of the orientation of the myocytes from their original alignment, in longitudinal as well as radial directions, on the distribution of stress and strain within the myocardium, as well as on the ejection fraction. In addition, simplified idealised geometries were used to investigate the influence of the overall geometrical modifications. Left ventricular function proved to be robust with respect to small-to-moderate rotational variations in myocytic alignment, up to 14 degrees , a finding which we attribute to an equalising effect of the non-uniform anisotropic pattern found in a real heart involving substantial local irregularities in the architecture of the aggregated myocytes. Severe deterioration of function occurred only when deviations in alignment exceeded 30 degrees . Our findings substantiate the concept of the myocardial walls representing a continuous three-dimensional meshwork, with the absence of any intermediate structures such as discrete bands or tracts extending over the ventricles, which could be destroyed surgically, thereby adversely affecting systolic function. With appropriate indications, they also support the validity of the surgical procedures performed to reduce ventricular radius and therefore to reduce mural stress.

Mural Inflammation in Crohn Disease: Location-Matched Histologic Validation of MR Imaging Features

To validate proposed magnetic resonance (MR) imaging features of Crohn disease activity against a histopathologic reference. Ethical permission was given by the University College London hospital ethics committee, and informed written consent was obtained from all participants. Preoperative MR imaging was performed in 18 consecutive patients with Crohn disease undergoing elective small-bowel resection. The Harvey-Bradshaw index, the C-reactive protein level, and disease chronicity were recorded. The resected bowel was retrospectively identified at preoperative MR imaging, and wall thickness, mural and lymph node/cerebrospinal fluid (CSF) signal intensity ratios on T2-weighted fat-saturated images, gadolinium-based contrast material uptake, enhancement pattern, and mesenteric signal intensity on T2-weighted fat-saturated images were recorded. Precise histologic matching was achieved by imaging the ex vivo surgical specimens. Histopathologic grading of acute inflammation with the acute inflammatory score (AIS) (on the basis of mucosal ulceration, edema, and quantity and depth of neutrophilic infiltration) and the degree of fibrostenosis was performed at each site, and results were compared with MR imaging features. Data were analyzed by using linear regression with robust standard errors of the estimate. AIS was positively correlated with mural thickness and mural/CSF signal intensity ratio on T2-weighted fat-saturated images (P < .001 and P = .003, respectively) but not with mural enhancement at 30 and 70 seconds (P = .50 and P = .73, respectively). AIS was higher with layered mural enhancement (P < .001), a pattern also commonly associated with coexisting fibrostenosis (75%). Mural/CSF signal intensity ratio on T2-weighted fat-saturated images was higher in histologically edematous bowel than in nonedematous bowel (P = .04). There was no correlation between any lymph node characteristic and AIS. Increasing mural thickness, high mural signal intensity on T2-weighted fat-saturated images, and a layered pattern of enhancement reflect histologic features of acute small-bowel inflammation in Crohn disease.

MR enterography with polyethylene glycol as oral contrast medium in the follow-up of patients with Crohn disease: comparison with CT enterography

To compare magnetic resonance enterography (MRE) and computed tomography enterography (CTE) in detecting inflammatory bowel disease activity (IBD) in patients with Crohn's disease (CD). A total of 29 patients (M 20; F 9; mean age 43.8 ± 15.9) with known CD underwent MRE. MRE was performed at 1.5 T using phased-array sense body coil, after oral administration of 1.5-2 L of PEG solution as oral contrast agent. MRE protocol included T1-weighted, sSShT2, sBTFE and gadolinium-enhanced THRIVE sequences acquired on coronal and axial planes. CTE was performed using a 16 multidetector-row computed-tomography before and after intravenous administration of 120 mL of iodinated contrast. MRE images and CTE scans were reviewed by a radiologist for bowel thickness and enhancement, mesenteric lymph nodes, vascular engorgement, fibrofatty proliferation, fistulas and abscesses. The disease activity was also defined by CDAI > 150. MRE has demonstrated a good sensitivity in detection of CD activity, particularly in depiction of mural thickening, mural enhancement, and vascular engorgement. The level of agreement between the two technique was excellent in evaluating wall thickening with mucosal hyperenhancement (κ = 1), comb (κ = 0.90) and halo signs (κ = 0.86). In detecting fibrofatty proliferation and mesenteric lymph nodes, CTE was superior to MRE (accuracy: P < 0.05), while MRE was superior in visualization of fistulas. MRE is an accurate method in monitoring the activity of CD as compared to CTE and may be considered an alternative to CTE in assessing degree of CD and evaluating therapeutic effectiveness.

Enteroclysis CT and PEG-CT in patients with previous small-bowel surgical resection for Crohn’s disease: CT findings and correlation with endoscopy

The aim of this study was to evaluate the accuracy of multidetector CT in patients with Crohn's disease (CD) relapse after ileocolic resection compared with endoscopy. Thirty-four patients were studied by endoscopy and multidetector CT, after oral administration of polyethylene glycol solution (n = 21) or after administration of methylcellulose via nasojejunal tube (n = 13). In CT examinations we evaluated the presence of mural thickening, target sign, perienteric stranding, comb sign, fibrofatty proliferation and complications. Endoscopic results were classified in accordance with Rutgeerts score (from 0 to 4). The statistical evaluations were carried out by using Fisher's exact text and chi (2) testing (p < 0.05, statistically significant difference). Sensitivity, specificity and accuracy of the CT were 96.9%, 100% and 97%, respectively. We found a statistically significant correlation between an endoscopic score of 4 and the CT signs of target sign, perienteric stranding, comb sign and fibrofatty proliferation, and between scores 1 and 2 and mucosal hyperdensity without or with mural thickening, respectively (p < 0.05). Moreover, only CT identified the presence of jejunal and proximal ileum disease in two and three patients, respectively, and fistulas in three patients. CT is a reliable method in the diagnosis of CD relapse and shows agreement with the approved endoscopic Rutgeerts score.

Calcium Channel Blocker-associated Small Bowel Angioedema

Isolated angioedema of the small intestine is a rare entity. The cases described have been related with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or C1 esterase inhibitor deficiency. We present a case of small intestine angioedema caused by calcium channel blockers (CCBs) and a review of the literature. Over the course of approximately 2 years, a 56-year-old African American woman presented to our hospital with 8 similar episodes of diffuse, intermittent abdominal pain, nausea, vomiting, and diarrhea. The diagnostic workup was extensive and included normal stool studies, anticardiolipin antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, cryoglobulin studies, complement levels, urinary 5-hydroxyindoleacetic acid, and serum markers for inflammatory bowel diseases. A computed tomographic angiogram was normal. Abdominal computed tomographic scans showed prominent mural thickening of different intestinal segments, always involving the ileum. An esophagogastroduodenoscopy showed patchy edematous, violaceous folds in the second portion of the duodenum. Colonoscopy revealed a markedly edematous and erythematous distal ileum. The recurrences subsided after CCBs were discontinued in this patient and reoccurred when they were incidentally restarted. Our case demonstrates that CCBs can cause isolated intestinal angioedema with distinctive endoscopic findings. The discontinuation of the involved medication is the key for both diagnosis and treatment.

A standard echocardiographic and tissue Doppler study of morphological and functional findings in children with hypertrophic cardiomyopathy compared to those with left ventricular hypertrophy in the setting of Noonan and LEOPARD syndromes

Several clinical and echocardiographic studies describe morphological and functional findings in patients with hypertrophic cardiomyopathy. Less is known regarding morphological and functional characteristics of the left ventricular hypertrophy found in the setting of the Noonan and LEOPARD syndromes. To compare non-invasively the morphological and functional findings potentially affecting symptoms and clinical outcome in children with hypertrophic cardiomyopathy as opposed to Noonan and LEOPARD syndromes. We studied by echo-Doppler 62 children with left ventricular hypertrophy, dividing them into two subgroups matched for age and body surface area. The first group, of 45 patients with a mean age of 7.5 +/- 5.2 years and body surface area of 0.9 +/- 0.44 mq, had idiopathic hypertrophic cardiomyopathy. The second group, of 17 patients, all had left ventricular hypertrophy in the setting of Noonan or LEOPARD syndromes. Their mean age was 6.6 +/- 5 years, and body surface area was 0.8 +/- 0.36 mq. In all patients, we assessed the left ventricular maximal mural thickness, expressed as a Z-score, along with any obstructions in the left and right ventricular outflow tracts. In addition, to define left ventricular diastolic function, we used mitral flow and pulsed Tissue Doppler to record the Ea, Aa, Ea/Aa, E/Ea indexes in the apical 4-chamber view at the lateral corner of the mitral annulus. We also measured the diameters of the coronary arteries in the diastolic frame. Compared to those with hypertrophic cardiomyopathy, those with syndromic left ventricular hypertrophy showed a significantly increased Z-score for mural thickness, and a higher prevalence of obstruction in the left ventricular outflow tract. In addition, the patients with Noonan or LEOPARD syndromes showed a significantly decrease of Ea and increase of Aa, with a decreased Ea/Aa ratio, all suggestive of left ventricular abnormal relaxation. Moreover, the E/Ea ratio was significantly increased in these patients. The presence of right ventricular hypertrophy, mainly associated with dynamic obstruction in the outflow tract, was detected in only 5 of the 17 patients with Noonan or LEOPARD syndromes, as was dilation of the coronary arteries. Compared to children with hypertrophic cardiomyopathy, those with left ventricular hypertrophy in the setting of Noonan or LEOPARD syndromes show more ventricular hypertrophy and diastolic dysfunction, due to both abnormal relaxation and reduced compliance. They also exhibit an increased prevalence of obstruction of the left ventricular outflow tract, along with dynamic obstruction of the right ventricular outflow tract and dilated coronary arteries. These morphological and functional findings could explain the different symptoms and clinical events, and potentially define the more appropriate therapeutic options in children with left ventricular hypertrophy of different aetiology.

Comparison of Torsional and Linear Mode Ultrasonic Coagulating Shears for Sealing Veins

Torsional mode ultrasonic coagulating shears are an alternative device to linear mode shears for hemostatic cutting. The aim of this study was to compare the vessel-sealing quality of torsional and linear mode ultrasonic coagulating shears on human veins. Veins were harvested from 15 patients during varicose vein surgery. Each vessel was sealed and cut by both devices at different sites. The seals were either tested for burst pressure or examined microscopically to compare mural thickness, seal length, and extent of coagulation and lateral thermal effect. For veins 2.0-3.0 mm in diameter, the median burst pressure was higher on seals made with torsional mode shears (245, IQR 161-360 mm Hg vs. 133, IQR 101-165 mm Hg; P = 0.001). Similarly, for veins 3.5-4.5 mm in diameter, the median burst pressure was higher with torsional mode shears (149, IQR 118-212 mm Hg vs. 94, IQR 82-126 mm Hg; P = 0.001). There was no significant difference in the median burst pressure for veins 5.0-6.0 mm in diameter (82, IQR 61-132 mm Hg vs. 76, IQR 40-114 mm Hg; P = 0.268). Seals made with torsional mode shears showed significantly greater seal length (517 +/- 300 microm vs. 316 +/- 147 microm; P = 0.016), more tissue coagulation (467 +/- 197 microm vs. 335 +/- 128 microm; P = 0.015), and greater lateral thermal effect (1479 +/- 340 microm vs. 1116 +/- 253 mum; P < 0.001). Torsional mode ultrasonic shears produced more secure seals on veins up to 4.5 mm in diameter. This can be explained by the greater seal length produced by torsional mode shears.

Radiologic testing in Crohnʼs disease

Answer: The diagnosis of CD is usually the result of a constellation of clinical, endoscopic, radiological, and histological findings. CD, a systemic, segmental chronic granulomatous disease affects the terminal ileum and proximal colon in 70% of cases, small bowel alone in 30%–40%, and isolated colonic disease in 20%.1 Radiological studies are important in making the diagnosis of CD, assessing the extent and severity of disease, and defining the response to medical and surgical therapy. The ideal imaging technique should be one that is cheap, readily available, and highly accurate. Traditionally, small bowel follow-through (SBFT) and small bowel enteroclysis have met this criteria and have been the diagnostic tools of choice for small bowel CD.2,3 Although there is controversy as to which technique is superior, local expertise usually determines which of these modalities is preferred. The SBFT requires ingestion of a barium meal, whereas an enteroclysis requires placement of a nasoduodenal tube through which barium and air are passed. The earliest CD lesions detectable on a barium x-ray are aphthous ulcers. In more advanced CD, the ulcers enlarge and coalesce to form stellate, serpiginous, or deep linear ulcers that appear as cobblestoning on barium x-rays. In penetrating CD the deep ulcers form fissures, sinus tracks, and fistulas; these are readily identified by pooling or tracking of barium transmurally. Chronic inflammatory CD results in intramural fibrosis and scarring that is depicted by circumferential thickening of the bowel wall and significant luminal narrowing. Patients with obstructive symptoms often develop bowel dilation proximal to the stricture that connotes a degree of chronicity and “fixed” fibrostenosis. Often luminal narrowing from inflammatory stenosis and fibrostenotic stricture may be difficult to delineate on barium studies. The treatment implications are important, as patients with obstructing fibrotic strictures require surgery, whereas patients with inflammatory stenosis may respond to medications and have return of normal caliber lumen after treatment.2,4–6 Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are the preferred modalities for evaluating extraluminal CD, e.g., abscesses or phlegmon. The most common finding on CT in CD patients is mural thickening, often associated with perienteric inflammatory stranding.6,7 CT scan is the modality of choice for diagnosing and treating intraabdominal abscesses. Many abscesses detected on CT are amenable to percutaneous drainage. This allows for elective definitive medical or surgical therapy and often avoids the need for emergent surgery and ileostomy. Endoscopic ultrasound (EUS) and pelvic MRI have been particularly useful in diagnosing perirectal and perianal fistula and guiding therapy.8,9 EUS is over 90% accurate in identifying perianal fistula and abscesses. Combined with MRI and surgical exam under anesthesia the diagnostic accuracy rates approach 100%. EUS and MRI may delineate which fistula are simple and complex, and which fistula require surgical intervention alone or in combination with medical therapy. Likewise, EUS and MRI may guide infliximab therapy by determining which fistula are completely healed and which persist despite the external skin portion closing. Video capsule endoscopy (CE) is a useful tool in assessing small bowel CD.10 The role of CE in CD has yet to be firmly established. The CE is more sensitive than barium studies at detecting small mucosal defects that may be of little clinical significance.11 It has been our experience that CE may be a useful study in patients with a known diagnosis of CD and persistent symptoms despite normal SBFT. For example, we have detected significant small bowel CD, i.e., inflammatory stenosis, deep ulcers, stricture, in patients with normal SBFT. This finding has led to alteration in treatment and in a few cases surgery. Also, CE may play a role in patients with indeterminant colitis (IC) scheduled for surgery. Patients with IC and small bowel disease on CE should have a permanent ileostomy rather than ileal pouch anal anastomosis. A combination of CT scan with SBFT affords simultaneous evaluation for intraand extraluminal CD while assessing the abdominal viscera. The recent advent of CT enterography and CT enteroclysis has married these modalities in 1 exam.12,13 The patient is administered oral and IV contrast dye simultaneously. The downside to this combined modality From the Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, & Nutrition, University of Pittsburg School of Medicine, Pennsylvania, USA. Copyright © 2008 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.20614 Published online in Wiley InterScience (www.interscience.wiley.com).

Early and midterm outcomes of open stent-graft treatment for distal aortic arch aneurysm

The aim of this study was to investigate early and late outcomes for open stent-graft treatment, which was introduced as a less-invasive technique for thoracic aortic aneurysm of the distal arch, and to clarify the validity of and indications for this treatment. We retrospectively investigated 38 patients with thoracic aortic aneurysm of the distal arch who underwent open stent-graft placement at our hospital between June 2000 and September 2006. Five patients died in hospital (hospital mortality 13.2%). Age at the time of surgery and onset of postoperative paraplegia were identified as risk factors. Four patients (10.5%) had postoperative paraplegia, but no significant risk factors were seen. The size of the aneurysm was clearly reduced in 18 of the 25 patients (75.8%), in whom computed tomography was performed after discharge, and late outcomes were good. Mural thrombus thickness on the stent landing zone of <4 mm was a predictor for aneurysm shrinkage. Seven patients died during the late period, and the 5-year survival rate among hospital survivors was 80.1%. Early outcomes for open stent-graft are not necessarily good, and late survival is also not excellent. Open stent-graft thus cannot be regarded as an ideal technique for all patients with distal aortic arch aneurysm. However, after aneurysm shrinkage was confirmed during the early period, late outcomes were good. Absence of thick mural thrombus on the stent landing zone may represent a good indication for open stentgraft surgery.

Nontraumatic Spontaneous Intramural Small-Bowel Hematoma Caused by Warfarin-Induced Overanticoagulation

Nontraumatic Spontaneous Intramural Small-Bowel Hematoma Caused by Warfarin-Induced Overanticoagulation

Cholangiectasis and Duodenal Diverticulosis in a Farm-Raised Elk (Cervus Elaphus)

A 6-year-old male elk presented in August with a 4-month history of weight loss and a 1-day history of being recumbent and unable to rise. The elk's body condition score was 1.5/5. Hematology and blood chemistry showed an inflammatory leukogram, mild electrolyte abnormalities, and elevated liver enzyme activities. Because of poor prognosis, the owner elected euthanasia. On necropsy, 8 diverticula were in the duodenum distal to the common bile duct, which was dilated and filled with feed material. Many intrahepatic bile ducts were dilated up to 5 cm, were filled with ingesta and gritty material, and had walls thickened up to 1.5 mm. On histologic examination, mural thickening of dilated bile ducts was because of increased fibrous connective tissue with inflammatory cell infiltration and hyperplastic and hypertrophic epithelial lining. Portal tracts diffusely contained hyperplastic bile ducts and had increased amounts of fibrous connective tissue. Abscesses that contained bacteria were scattered throughout the liver. Duodenal diverticula lacked the tunica muscularis, and the muscularis mucosa was hypertrophied. Caudal to some diverticula, the duodenal lumen was narrowed. An additional finding was embolic pneumonia with fungi morphologically and immunohistochemically consistent with Aspergillus spp.

The three‐dimensional arrangement of the myocytes in the ventricular walls

The arrangement of the myocytes aggregated together within the ventricular walls has been the subject of anatomic investigation for more than four centuries. The dangers of analyzing the myocardium on the basis of arrangement of the skeletal myocytes have long been appreciated, yet some still described the ventricular myocardium in terms of a unique band extending from the pulmonary trunk to the aorta. Another current interpretation, with much support, is that the ventricular myocytes are compartmentalized in the form of sheets, albeit that the extent of division, and interrelations, of the sheets is less well explained. Histological examination, however, shows that the only muscular unit to be found within the myocardial walls is the cardiac myocyte itself. Our own investigations show that, rather than forming a continuous band, or being arranged as sheets, the myocytes are aggregated together as a three-dimensional mesh within a supporting matrix of fibrous tissue. Within the mesh of aggregated myocytes, it is then possible to recognize two populations, depending on the orientations of their long axes. The first population is aligned with the long axis of the aggregated myocytes tangential to the epicardial and endocardial borders, albeit with marked variation in the angulation relative to the ventricular equator. Correlation with measurements taken using force probes shows that these myocytes produce the major unloading of the blood during ventricular systole. The second population is aligned at angles of up to 40 degrees from the epicardium toward the endocardium. The correlation with measurements from force probes reveals that these intruding myocytes produce auxotonic forces during the cardiac cycle. The three-dimensional arrangement of the mesh also serves to account for the realignment of the myocytes that must take place during ventricular contraction so as to account for the extent of systolic mural thickening.

Reduced production of digestive proteases and the efficacy of enteral and parenteral nutrition on inflammatory bowel disease

Correlation with CT showed circumfer-ential mural thickening, most marked atC7-T2, measuring up to 1.5 cm. Thedistal esophagus was of normal caliber.Upper endoscopy was reattempted bythe surgical unit in theater under generalanesthetic. Successful passage and dila-tation of the stricture was performed.Esophageal biopsies were taken, whichshowed ulcerated mucosa with nonspe-cific inflammatory changes. There wasno granulomatous inflammation identi-fied. There was no dysplasia or malig-nancy seen.Distinguishing esophageal CDfrom its differentials, in particular refluxesophagitis, can be difficult, as a well-defined diagnostic criteria is yet to beestablished. Noncaseating granulomasoccur in less than 25% of cases

Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma

The authors describe a rare case in which blunt abdominal trauma resulted in mesenteric injury with delayed double ischemic ileal stenosis. Abdominal computed tomography demonstrated stenotic ileal loop with mural thickening. At surgery, a double stenotic bowel loop was found adjacent to a healed defect in the mesentery. Histological examination of the two resected segments showed fibrotic and ischemic lesions within the mesentery. Ischemic intestinal stenosis from mesenteric injury should be considered in the differential diagnosis in patients suffering from intestinal occlusion with a history of blunt abdominal trauma.