Cytomegalovirus infection as a rare cause of colitis

A 62 year-old-man with low anterior rectal resection and protective ileostomy, for low rectal neo and neoadjuvant QT +RT. Then ileostomy closure without incidences. On the 3rd postoperative day, he started with fever peaks and diarrhea. An abdominal CT scan showed diffuse thickening of the wall of the descending colon compatible with colitis and colonoscopy showed deep rectal ulcers with punch-like morphology with hyperemic mucosa with erythematous stippling of erosive appearance, showing this ulcerative pattern with numerous lesions and intensely edematous and congestive mucosa covered with abundant fibrinopurulent exudate in the descending colon. Biopsies and stool cultures were negative, but serologies were positive for CMV. Suspected CMV infection in a immunosuppressed by chemotherapy patient, he was treated with ganciclovir. The patient presented clinical improvement, without fever or diarrhea and improvement of the punch ulcers in the endoscopic controls, so he could be discharged from the hospital with follow-up in the outpatient consulting offices.

Uncommon causes of acute appendicitis: foreign bodies in the cecal appendix

A 50-year-old woman with a history of hysterectomy for endometrial cancer in 2015 visited because of abdominal pain for 1 week and fever simultaneous with her third dose of the COVID-19 vaccine. Physical examination revealed a mobile mass in the right iliac fossa, and laboratory testing showed C-reactive protein at 3 mg/dL, with no further changes. Ultrasound results were consistent with an appendiceal inflammatory mass, and a CT scan revealed an appendicolith as likely cause. The patient was subjected to laparoscopy, which found inside the mass a metallic piece (dental prosthesis) that perforated the appendiceal lumen at the mid portion of the appendix. Appendectomy was completed and the patient was discharged on the third day post-procedure.

Safety of propofol sedation administered by an endoscopy team for outpatient colonoscopy

Sedation during colonoscopy increases comfort and reduces unexpected patient movement. Colorectal cancer (CRC) screening colonoscopies performed under propofol sedation controlled by our endoscopy team (ET) were retrospectively studied for eight months.

Management of duodenal perforations after endoscopic retrograde cholangiopancreatography

OBJECTIVE

To describe our experience regarding post-endoscopic retrograde cholangio-pancreatography (ERCP) perforations and its conservative management.

MATERIAL AND METHODS

Retrospective study of the therapeutic management of post-ERCP perforations occurred over the period 2012-2017 in our hospital.

RESULTS

There were 12 perforations after ERCP, with choledocholithiasis being the main indication for the test (66.6%). In 9 cases (75%) an initial conservative attitude was attempted, but only 3 of them (25%) managed to solve the problem with broad-spectrum antibiotics, parenteral nutrition and close monitoring of the patient.

DISCUSSION

Management of post-ERCP perforations must be individualized for each patient, depending on the clinical situation. Surgery remains the best option for the treatment of post-ERCP perforations, although conservative medical management is an option to be assessed, assuming that if it fails, delaying surgery is associated with high morbidity and mortality rates.

Twisting of sleeve gastrectomy: two ways of clinic presentation

Laparoscopic sleeve gastrectomy is an increasingly widespread bariatric surgical technique thanks to its good outcomes and apparent simplicity. However, complications may arise, including hemorrhage, gastric fistula, and stenosis, which can be either organic or functional. Functional stenosis is caused by gastric tube twisting. We present two cases of patients who underwent laparoscopic sleeve gastrectomy and who were subsequently diagnosed with gastric twisting. Both cases required conversion to laparoscopic gastric bypass. Accompanying symptoms may vary but they commonly include early satiety, epigastric pain associated with food intake, gastroesophageal reflux and early vomiting. Although diagnose is mainly clinical, it requires high suspicion since endoscopy and gastrointestinal studies are not conclusive. The principal therapeutic options are endoscopic dilatations, serotomy and conversion to gastric bypass.

Intussusception After Bariatric Surgery

A case of bowel intussusception in a 43-year-old woman with a history of Roux-en-Y gastric bypass surgery is presented.

Esophageal perforation by a Sengstaken balloon

Iatrogenic esophageal perforations are rare but associated with a high morbidity and mortality. Secondary to placing a Sengstaken ballon are even more extraordinary because of the infrequency which this measure is used to control upper gastrointestinal bleeding. Therefore, we think it is of interest to communicate this complication, to remember the need to check the correct placement of the Sengstaken ballon before insufflation, since it would help further decrease this complication.

Management of non-surgical pneumoperitoneum

Percutaneous endoscopic gastrostomy (PEG) is the best approach to feeding patients not eligible for oral nutrition who have a functioning digestive system. Pneumoperitoneum after PEG is a relatively common complication. As regards management, the most important decision is whether conservative therapy or an exploratory laparotomy should be indicated. We report the case of a patient with giant pneumoperitoneum following PEG, who was successfully managed with percutaneous air drainage.

Small bowel mesenchymal tumors: description of two unusual cases

We present two cases of intestinal ileal GIST who developed complications of nonspecific signs and required to be operated urgently, providing unusual images of tumors because of its characteristics.

Laparoscopic adrenalectomy for nonfamilial adrenal medullary hyperplasia

Sporadic adrenomedullary hyperplasia may mimic pheochromocytoma. Laparoscopic adrenalectomy is recommended for the management of this entity.

Background and Objectives:

Sporadic adrenomedullary hyperplasia (AMH) is characterized by a medical history of hypertension, excessive catecholamine excretion, and histomorphometric evidence of increased adrenomedullary tissue relative to the cortex in the absence of multiple endocrine neoplasia. The aim of this study was to perform a retrospective analysis of patients after laparoscopic adrenalectomy for AMH, an early form of sporadic adrenal medulla–related endocrine hypertension, as well as to update our understanding of the clinical features and management of this clinicomorphologic entity.

Methods:

We performed a retrospective review of the medical records of patients operated on between 2007 and 2011 at Reina Sofia University General Hospital, Murcia, Spain, with a diagnosis of AMH. Patient characteristics, diagnostic studies, surgical procedures, and histologic findings were analyzed.

Results:

Seven hypertensive patients with intermittent adrenergic crises were found to have AMH (3 men and 4 women; mean age, 44 years). Catecholamine levels were increased. Radiologic studies included 1 or more of the following: magnetic resonance imaging, computed tomography, positron emission tomography imaging with fluorodeoxyglucose, dihydroxyphenylalanine–positron emission tomography–computed tomography, Octreoscan (Mallinckrodt Pharmaceuticals, St. Louis, MO, USA) and ¹²³I-metaiodobenzylguanidine scintigraphy. Laparoscopic adrenalectomy was performed in all cases. One patient underwent bilateral adrenalectomy because of persistent symptomatology after unilateral adrenalectomy. Surgery was associated with normalization of catecholamine hypersecretion and complete disappearance of symptoms, as well as the reduction or abstention of antihypertensive therapy.

Conclusions:

Sporadic AMH is a clinicomorphologic entity that may mimic pheochromocytoma clinically. Recent advances in diagnostic and surgical methods have changed the management and outcome of this unusual disease. Laparoscopic adrenalectomy may be recommended as the gold standard in the treatment of this entity. Definitive diagnosis is provided by histologic study.

Acute mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter

Mediastinitis is a complication generally associated with thoracic surgery. Its occurrence after placement of a central venous catheter is uncommon, and only a few cases have been reported. An 83-year-old man who had mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter is presented. The signs and symptoms, diagnosis, and treatment of this unusual complication are described. This complication should be included in the differential diagnosis of mediastinitis in patients with a central venous catheter in place who have not had thoracic surgery.

Penile paraffinoma after subcutaneous injection of paraffin. Treatment with a two step cutaneous plasty of the penile shaft with scrotal skin

OBJECTIVE

To report a rare case of penile paraffinoma caused by the subcutaneous or intra-urethral injection of foreign substances containing long-chain saturated hydrocarbons. These were injected in order to increase the penis size which generated a chronic granulomatous inflammatory reaction. This is a rare practice in the western world.

METHODS

We present the case of a 32-year-old Bulgarian male who presented with a two-year history of elastic, slightly painful penis swelling after subcutaneous liquid paraffin injection. The proposed treatment was excision of the affected tissue and penile reconstruction in a two-stage procedure.

RESULTS

The operative procedure was successful and the patient had good aesthetic and functional results. Paraffin and other materials injected into the penis can produce many complications. Foreign body granuloma, skin necrosis, penile deformity, chronic and unhealed ulcer, painful erection, and the inability to achieve a satisfactory sexual relationship are some of the resulting complications. Intralesional or systemic steroids have been used in primary sclerosing lipogranuloma resulting in the disappearance of the granuloma, but in our opinion the treatment of choice should be radical excision, and, if necessary, secondary reconstruction of the penis.

CONCLUSION

The injection of foreign substances to enhance penis size is currently an unjustifiable practice. However, it is still carried out, especially in Eastern Europe and Asia. In most cases surgical treatment is needed to treat the complications and the best modality seems to be radical excision together with follow-up.

[Non-obstructive enterolithiasis: report of two cases]

Enterolithiasis, or coprolithiasis, stones formed mainly in the intestine, is uncommon in humans and is generally associated with intestinal stasis. This entity is highly common in some animals, such as horses. Enterolithiasis is usually asymptomatic but may lead to intestinal occlusion and should be considered as a possible cause of this event. We report two cases of enterolithiasis, in which the diagnosis was established by simple abdominal radiography and computed tomography. Although both patients had factors favoring the development of enterolithiasis, a genetic substrate predisposing them to this uncommon clinical entity cannot be excluded.

Quality evaluation of total parenteral nutrition in an acute care setting

OBJECTIVE

To analyse the degree of compliance with internationally accepted standards defined for total parenteral nutrition (TPN) quality control in our hospital. The problems of quality which exist must be detected and possible solutions put into practice.

PATIENTS AND METHOD

Retrospective study of critically ill patients treated with TPN during two years in a university teaching hospital (n=92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were evaluated both individually and gathered in three categories: appropriate, safe and accurate TPN. Three summary/indicators were also established which assessed simultaneous compliance with all the criteria in each group. Criteria compliance was compared to standards values. Patient (age, sex, diabetes) and process (TPN indication, patient's outcome, type of diet used) variables were analysed (using logistic regression models) as factors potentially associated with compliance with the quality criteria. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria, paying particular attention to those criteria which presented the highest percentage of errors in the study carried out using a Pareto analysis.

RESULTS

Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% in adjusted TPN, 38% in safe TPN and 94% in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR: 9.4) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9). The absence of metabolic complications was influenced (P<0.05) by the use of standardized diets (OR: 0.3). Effects of the change: the simultaneous compliance with all the criteria of a group improved in all three groups, but this was statistically significant in the 'appropriate' TPN and 'safe' TPN groups. The criteria analysed individually improved after the corrective measures in five of the six criteria which had been below standard in the first evaluation.

CONCLUSIONS

The correct understanding and application of the indications, physiology and potential complications of TPN constitute the hub of the improvement process.

Presentation of Degos syndrome as acute small-bowel perforation

Malignant atrophic papulosis is an uncommon vasculopathy affecting multiple systems and frequently associated with a poor prognosis. We describe a 56-year-old patient with this rare disorder whose death was the result of intestinal involvement. Clinical diagnostic features of malignant atrophic papulosis as well as the main therapeutic approaches suggested in the literature are presented herein.