Spontaneous Peritoneal Research Articles

S2686 A Rare but Potentially Fatal Cause of Abdominal Pain: Segmental Arterial Mediolysis

Introduction: Segmental arterial mediolysis (SAM) is a rare disease, defined as a nonatherosclerotic, noninflammatory disruption of the arterial medial layer of a medium- to large-sized artery. We describe a case of a healthy woman with acute onset abdominal pain subsequently found to have spontaneous peritoneal hemorrhage from SAM. Case Description/Methods: A 52-year-old former professional female athlete developed abrupt onset lower abdominal pain with nausea and vomiting. Pain was 10/10 in severity with a sharp and crampy quality. She denied fevers, diarrhea, melena, bloody stool, ill contacts, recent travel, or prior episodes. Past medical history was significant for endometrial polyp, menopause, and iron deficiency. She had no prior surgeries. Family history included colon cancer in her father and ovarian cancer in her mother. Her abdomen was soft with tenderness in the lower quadrants with the remainder of the exam unremarkable. Labs including CBC, BMP, LFT, lipase, beta hCG, troponin, ESR, CRP, serum acetone, urinalysis, and lactic acid were reassuring. CT abdomen and pelvis with and without contrast demonstrated hyperenhancing hepatic lesions suggestive of hemangiomas. Ultrasound of the pelvis with duplex was normal with arterial and venous duplex waveforms to both ovaries. On the second day of hospitalization, she had another episode of abdominal pain with labs demonstrating a hemoglobin drop from 13.7 g/dL to 10.2 g/dL. Repeat CT abdomen pelvis with contrast demonstrated large volume hemorrhagic ascites up to 16 cm in size with concerns for active hemorrhage in the left upper quadrant. Diagnostic angiography was performed by Interventional radiology which did not show active arterial hemorrhage although demonstrated fusiform dilatation of the distal middle colic artery and short segment focal fusiform dilatation of the left colic artery at the splenic flexure suggestive of SAM. She subsequently underwent diagnostic laparoscopy and evacuation of hemoperitoneum with over 1L of unclotted blood evacuated with a mesenteric hematoma noted in the distal transverse and proximal descending mesocolon. The spontaneous peritoneal hemorrhage was thought to be secondary to underlying arterial abnormalities triggered by minor trauma. (Figure) Discussion: Vascular causes of abdominal pain such as segmental arterial mediolysis are uncommon. Awareness of noninflammatory and nonatherosclerotic artery diseases such as SAM need to be recognized since they can be fatal if not treated promptly.Figure 1.: Fig 1 demonstrates a bleeding artery as seen on CT abdomen and pelvis with intravenous contrast. Fig 2 demonstrates the large hemoperitoneum in the left upper quadrant seen on CT abdomen and pelvis.

Spontaneous peritoneal dialysis catheter expulsion: A case series.

There are a significant number of mechanical complications related the peritoneal dialysis (PD) catheter and early diagnosis is key. Between them, the spontaneous extrusion of the catheter is quite uncommon but it should be included among the possible complications of the technique, given that it can be related to frequent situations in PD patients like abdominal wall issues, past immunosuppression or PD fluid leakage. In 25 years our Unit had three cases, probably related to peritoneal fluid leakage, exit site infection and past steroid treatment. Careful examination of abdominal wall preimplantation, adequate break-in period to allow maturation and early detection of exit site infection to start treatment in a timely fashion could help to prevent this rare complication. The complete extrusion of the catheter does not preclude from continuing PD treatment.

Spontaneous Mesotheliomas in F344/N Rats Are Characterized by Dysregulation of Cellular Growth and Immune Function Pathways

Aged male Fischer 344/N rats are prone to developing spontaneous peritoneal mesotheliomas that arise predominantly from the tunica vaginalis of the testes. A definitive cause for the predominance of this neoplasm in F344/N rats is unknown. Investigation of the molecular alterations that occur in spontaneous rat mesotheliomas may provide insight into their pathogenesis as well enable a better understanding regarding the mechanisms underlying chemically induced mesothelioma in rodents. Mesothelial cell function represents a complex interplay of pathways related to host defense mechanisms and maintenance of cellular homeostasis. Global gene expression profiles of spontaneous mesotheliomas from vehicle control male F344/N rats from 2-year National Toxicology Program carcinogenicity bioassays were analyzed to determine the molecular features of these tumors and elucidate tumor-specific gene expression profiles. The resulting gene expression pattern showed that spontaneous mesotheliomas are associated with upregulation of various growth factors, oncogenes, cytokines, pattern recognition response receptors, and pathogen-associated molecular patterns receptors, and the production of reactive oxygen and nitrogen species, as well as downregulation of apoptosis pathways. Alterations in these pathways in turn trigger molecular responses that stimulate cell proliferation and promote tumor survival and progression.

Orchidopexy without ligation of the processus vaginalis is not associated with an increased risk of inguinal hernia

To report our experience using a modified orchidopexy with division and non-ligation of the processus vaginalis. We performed a single-centre retrospective analysis of all patients who underwent orchidopexy between December 2005 and October 2008 at our institution. In the present technique, the processus vaginalis was gently peeled off the spermatic cord structures as high as possible and severed at the level of the internal inguinal ring without its ligation. Postoperative follow-up was routinely offered to all patients. Additionally, we made a special clinical follow-up, ranging from 1 to 69 months (median 34). One hundred and twenty-three patients, aged 1-11 years (median 3), underwent 147 orchidopexies during the study period. Of these, 25 were accomplished using conventional division and ligation of the processus vaginalis, and in the remaining 122 orchidopexies, the processus vaginalis was only divided. Of the 137 testes available at follow-up, 134 were in the scrotum and 3 (2 %) required re-do orchidopexy due to secondary reascent, including 2 treated with division only of the processus vaginalis. None of the patients experienced postoperative hydrocele or inguinal hernia development. Our findings confirm that division without ligation of a patent processus vaginalis is usually followed by spontaneous peritoneal scarring and complete closure of the internal inguinal ring. Present technique is as effective as traditional orchidopexy and saves extra time spent for meticulous closure of the processus vaginalis or peritoneal tears.

Loss of STAT6 promotes autoimmune disease and atopy on a susceptible genetic background

Atopy and autoimmunity are usually considered opposed immunological manifestations. Lyn−/− mice develop lupus-like autoimmune disease yet have coexistent intrinsic allergic traits and are prone to severe, persistent asthma induced exogenously. Recently it has been proposed that the Th2 environment and IgE auto-Abs promotes autoimmune disease in Lyn−/− mice. To examine this apparent contradiction, we derived Lyn−/− mice with a null mutation in STAT6, a regulator of Th2 immunity that integrates signaling from the IL-4/IL-13 receptor complex. Atopy and spontaneous peritoneal eosinophilia, characteristic of Lyn−/− mice, were lost in young Lyn−/−STAT6−/− mice; however, autoimmune disease was markedly exacerbated. At a time-point where Lyn−/− mice showed only mild autoimmune disease, Lyn−/−STAT6−/− mice had maximal titres of IgG and IgA auto-Abs, impaired renal function, myeloid expansion and a highly activated T cell compartment. Remarkably, low level IgE auto-Abs but not IgG1 auto-Abs were a feature of some aged Lyn−/−STAT6−/− mice. Furthermore, aged Lyn−/−STAT6−/− mice showed dramatically increased levels of serum IgE but minimal IgG1, suggesting that class-switching to IgE can occur in the absence of an IgG1 intermediate. The results show that Lyn-deficient mice can overcome the effects of disabling Th2 immunity, highlighting the importance of Lyn in controlling Th2 responses. Our data also indicates that, under certain conditions, STAT6-independent factors can promote IgE class-switching. This work has important clinical implications as many experimental therapies designed for the treatment of asthma or atopy are based on targeting the STAT6 axis, which could potentially reveal life endangering autoimmunity or promote atopy in susceptible individuals.

Spontaneous peritoneal and retroperitoneal hemorrhage, rare serious complication following carotid angioplasty with stent

Carotid artery stenting (CAS) has been accepted as a relatively safe and effective treatment modality for patients with symptomatic severe carotid stenosis. We report a rare case of 75-year-old male with spontaneous peritoneal and perirenal hemorrhage following carotid angioplasty with stent. Because this intraabdominal hemorrhage can cause delayed diagnosis and treatment due to vague symptoms and the lack of suspicion of the hemorrhage, and can induce fatal condition, physicians should be aware that the abdominal hemorrhage could occur as a rare but serious complication after CAS without puncture site problems or iatrogenic injury.

Terlipressin infusion induces Tako-Tsubo syndrome in a cirrhotic man with hepato-renal syndrome

Dr. Di Micoli, Dr. Buccione, Prof. Trevisani: TakoTsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome, is a clinical entity characterized by (1) reversible left ventricular apical wall motion abnormalities, (2) typical electrocardiographic changes and (3) relatively minor elevation of troponine, creatinine-kinase (CK) and CK-MB that mimics an acute myocardial infarction (AMI) without any acute obstructive coronary disease [1]. Typically, the left ventricular imbalance almost always recovers in a period of days to weeks, so that the management and prognosis of this condition are clearly different from those of AMI [2]. TTC is generally observed in post-menopausal women without prior history of heart disease or clear risk factors for coronary artery disease, who have often experienced recent emotional or physical stress, non-cardiac surgery or extracardiac diseases [1]. Recently, TTC has also been described in critically ill patients without prior heart disease admitted to a medical intensive care unit for severe non-cardiac diseases, such as sepsis, acute respiratory failure, systemic inflammatory response syndrome, anaphylaxis and trauma injuries [3, 4]. Herein, we report a case of TTC occurring in a cirrhotic man, waiting for liver transplantation (LT), probably favored by the intravenous infusion of terlipressin, a synthetic analog of vasopressin (AVP), for the treatment of hepato-renal syndrome (HRS). A 67-year-old Caucasian man with hepatitis B virusrelated cirrhosis and ascites, waiting for LT, was admitted to our unit because of the onset of hepatic encephalopathy, and the worsening of renal sodium retention. As a candidate for LT, he had undergone clinical, laboratory and instrumental tests aimed at excluding extrahepatic diseases precluding surgery. Myocardial single photon emission computed tomography had excluded ischemic damage, and trans-thoracic echocardiography had ruled out dyskinesia of ventricular segments and documented a normal (65%) left ventricular ejection fraction (LVEF). On admission, the patient presented with peripheral edema, ascites and grade III hepatic encephalopathy. Daily diuresis was around 200 mL. The ongoing therapy included oral diuretics (furosemide 25 mg b.i.d. and spironolactone 100 mg b.i.d.), lamivudine and tenofovir for HBV infection control, norfloxacine (400 mg/day) for secondary prophylaxis of the spontaneous peritoneal peritonitis, lactulose, and periodic albumin infusion. The serum creatinine was 2.2 mg/dL and blood urea nitrogen 0.9 g/dL, while serum electrolyte concentrations were normal (sodium 138 mEq/L, potassium 3.5 mEq/L, calcium 8.9 mg/dL and magnesium 2.6 mEq/L). The hemoglobin level was 10.4 g/dL, platelet count 134.000/lL, leukocytes 8.0 9 10/mmc, serum bilirubin 18.8 mg/dL, albumin 3.4 g/dL, INR 2.11. A. Di Micoli D. Buccione V. Santi L. Bastagli M. Bernardi F. Trevisani Dipartimento di Medicina Clinica, Alma Mater Studiorum-Universita degli Studi di Bologna, Bologna, Italy

Specific collaboration between rat membrane complement regulators Crry and CD59 protects peritoneum from damage by autologous complement activation

The peritoneal cavity is isolated from the outside and is usually a sterile environment. Patients on peritoneal dialysis (PD) have PD fluid (PDF) infused into the peritoneal cavity. We previously showed that unregulated complement activation could contribute to the development of peritoneal inflammation in yeast peritonitis in PD therapy. In that situation, suppression of local complement activation is essential to protect the host from further injury. The membrane complement regulators (CRegs), Crry, CD55 and CD59, are expressed in the rat peritoneum, especially along the mesothelial cell layer. We investigated CRegs' functional roles in the peritoneal cavity using blocking mAb against each CReg and complement activation in different PDFs. Blockade of any single CReg did not cause spontaneous peritoneal injury in rat. Combined blockade of Crry and CD59 induced focal peritoneal tissue injury and heavy accumulation of inflammatory cells with peritoneal edema at 24 h. Deposits of C3 and C5b-9 were found on the peritoneal surface after combined blocking of Crry and CD59. Systemic complement depletion by cobra venom factor abrogated these inflammatory changes. When combined blockade of Crry and CD59 was performed with PDF of different pH and glucose concentration in rats, the peritoneal injuries were enhanced with lower pH and higher glucose concentration. These results were confirmed by in vitro experiments using primary rat mesothelial cell culture. Rat CRegs, Crry and CD59, specifically collaborate to control complement activation in rat peritoneum. During PD, impairment of CReg might contribute to the development of severe peritoneal inflammation.

Induction of peritoneal endometriosis in nude mice with use of human immortalized endometriosis epithelial and stromal cells: a potential experimental tool to study molecular pathogenesis of endometriosis in humans

To determine whether a mixed population of immortalized human endometriosis epithelial and stromal cells is able to induce peritoneal endometriosis in nude mice. Prospective experimental study. Human immortalized endometriosis epithelial and stromal cells were xenografted into ovariectomized nude mice. Macroscopically, the number of induced endometriosis-like lesions and their color were determined. Microscopically, histomorphology of endometriosis glands and their structure were analyzed, and comparisons were made with tissue from spontaneous endometriosis in women. College of Veterinary Medicine and Biomedical Sciences, Texas A&M University. Seven ovariectomized nude mice. Minimal invasive procedures were performed to administer estrogen pellets and transplant immortalized human endometriosis epithelial and stromal cells into nude mice. Peritoneal endometriosis-like lesions induced in nude mice were characterized and compared with spontaneous peritoneal endometriosis in women. Xenografts of human immortalized endometriosis epithelial and stromal cells into the peritoneal cavity of the recipient nude mice are able to proliferate, attach, invade, reorganize, and establish peritoneal endometriosis. Endometriosis glands at different stages of growth were present in induced endometriosis-like lesions. Proliferating cell nuclear antigen, metalloproteinase 2, estrogen receptor-alpha, cyclooxygenase-2, and prostaglandin E(2) receptors EP2 and EP4 proteins were expressed in both endometriosis glandular epithelial and stromal cells of the induced endometriosis-like lesions. This xenograft model could be used as a potential experimental tool to understand the molecular and cellular aspects of the pathogenesis of endometriosis in humans.

Efficacy of anti-tumor necrosis factor therapy in the treatment of spontaneous endometriosis in baboons

Objective To determine the efficacy of anti-tumor necrosis factor therapy (etanercept) for treating endometriosis in baboons. Design A randomized, placebo-controlled, blinded study using the baboon endometriosis model. Setting Southwest National Primate Research Center. Animal(s) Twelve female baboons with spontaneous peritoneal endometriosis. Intervention(s) Etanercept (n = 8) or sterile water (n = 4) was administered subcutaneously three times per week. Main outcome measure(s) After 8 weeks, the number, color, and surface area of peritoneal lesions was evaluated. Revised American Society for Reproductive Medicine staging was used. Result(s) A statistically significant decrease in red lesion surface area in the treatment group was observed. A trend toward a decrease in the absolute number of red lesions was noted in the treatment group. White and black lesion number and total surface area slightly increased in both groups but failed to achieve statistical significance. Endometriosis was diagnosed in 60% of captive-born baboons with primary infertility. Conclusion(s) These results indicate that etanercept effectively reduces the amount of spontaneously occurring active endometriosis in the baboon.

Spontaneous peritoneal hemorrhage of splenic origin in newborn infants : J. -M. Bouyala and P. Aubrespy. Ann. Chir. Infant. 7:49–54. 1966

Spontaneous peritoneal hemorrhage of splenic origin in newborn infants : J. -M. Bouyala and P. Aubrespy. Ann. Chir. Infant. 7:49–54. 1966