[Ileo-colic intussusception in adult secondary to a large neoplasia of the lower caecal fundus]

Intussusception is rare in adults, accounting for 1 to 5 % of mechanical bowel obstructions. It is due to pathologic lead point within the bowel which is malignant in up to 77 % of cases. Benign lesions may also be responsible for intussusception (polyp, Meckel diverticulum). The lead point is pulled forward by normal peristaltism, prolapsing the affected segment of bowel into another segment. The most common presentation in adults is intermittent abdominal pain and bowel obstruction (nausea, vomiting, inability to pass gas or stools). Abdominal scanner is the key exam for the diagnosis and the treatment is always surgical resection.

A Rare Case of Retroperitoneal Abscess Caused by Nephro-Colic Fistula Resulting from Staghorn Calculus

BACKGROUND Nephro-colic fistulas are uncommon, generally caused by local inflammation, trauma, or neoplasia affecting the kidney or the colon. Their association with a coralliform stone is described in a few case reports, but their management is difficult and differs quite a lot, depending on the clinical situation. We report an atypical clinical case of a reno-colic fistula associated with a staghorn calculus. This case adds to the literature an iconography rarely found. CASE REPORT A 68-year-old woman presented to the Emergency Department with respiratory symptoms and chronic abdominal pain. The biological results showed a high inflammatory syndrome. The radiological assessment revealed a retroperitoneal and left retro-renal abscess, attributed to a left nephro-colic fistula associated with the partial passage of a lithiasis within the colonic lumen. Colonoscopy confirmed the diagnosis. Multiple recurrences of diverticulitis in this region could be the origin of the complication. First, the patient was treated with antibiotic therapy and radiological drainage. Second, she benefited from a left nephrectomy, left segmental colectomy, and splenectomy. The clinical and radiological evolution were favorable after surgery. The follow-up was disrupted by hospitalizations in the Cardiology Department for cardiac decompensation. CONCLUSIONS Kidney stones along with local inflammatory phenomena can be the cause of a nephro-colic fistula. Due to the lack of guidelines in such cases, their diagnosis and management are difficult to ascertain. Surgery is the right course of treatment.

[Not Available]

In this case report, a four-week-old boy, who since birth had suffered from constipation and infantile colic, presented with seizures, myoclonic jerks and irritability after being fed with a herbal mixture of star anise the day prior to admission. Chinese star anise is a globally used spice and a herbal remedy for infantile colic. The quick recovery of the boy and normal paraclinical findings supported the assumption of star anise intoxication. The frequent use of complementary medicine in children warrants awareness to inform families of the potential dangers of this home remedy.

Gastro-colic Fistula-associated Hypersplenism Causes Pancytopenia in a Patient with Crohn's Disease

A 24-year-old woman was admitted to our hospital due to abdominal pain and a high fever. She was diagnosed with ileocolonic Crohn's disease (CD), complicated with a gastro-colic fistula and splenomegaly. After initial treatment with an infliximab-biosimilar, all blood cell line counts markedly decreased. Three-dimensional reconstructed computed tomography revealed splenic vein narrowing. Thus, her pancytopenia was deemed to have likely been caused by hypersplenism. Surgery was performed, and clinical remission was maintained without pancytopenia. This is the first report of a CD patient with pancytopenia caused by hypersplenism that was triggered by gastro-colic fistula-associated splenic vein obstruction.

Clostridioides (Clostridium) difficile-associated disease, epiploic foramen entrapment, and gastric rupture in a Thoroughbred racehorse: case report and literature review

Epiploic foramen entrapment (EFE) is a common cause of small intestinal colic in horses and may lead to intestinal strangulation. Strangulating intestinal obstruction impairs the gastrointestinal outflow and can lead to secondary gastric rupture and endotoxemia. Clostridioides difficile can cause enterotyphlocolitis with colic in horses of all ages, and the process is commonly referred to as C. difficile-associated disease (CDAD). Here we report the results of the postmortem examination of a 7-y-old Thoroughbred racehorse with concurrent CDAD, EFE, and gastric rupture that was euthanized following a history of colic over several days. A segment of distal jejunum and proximal ileum had passed through the epiploic foramen, and the intestinal wall was thickened and dark-red. The remaining small intestinal loops were distended and filled with blood-tinged contents. Peritonitis had resulted from escape of gastric contents into the abdominal cavity through a tear in the major curvature of the stomach. Histologically, the incarcerated segment had acute transmural hemorrhage with congestion and mucosal necrosis; neutrophilic infiltrates with fibrin thrombi were in the mucosa of the non-incarcerated small intestinal segments. C. difficile toxins were detected in the small intestinal contents, and C. difficile was isolated from the small intestine, colon, and cecum.

Tailoring diagnosis and treatment in symptomatic gallstone disease

BACKGROUND

There is a lack of consensus in selecting patients who do or do not benefit from surgery when patients present with abdominal pain and gallbladder stones are present. This review aimed to give an overview of results from recent trials and available literature to improve treatment decisions in patients with uncomplicated cholecystolithiasis.

METHODS

First, an overview of different symptom criteria for laparoscopic cholecystectomy in patients with uncomplicated cholecystolithiasis is given, based on national and international guidelines. Second, treatment outcomes (absence of biliary colic, pain-free state, biliary and surgical complications) are summarized, with data from three clinical trials. Finally, personal advice for treatment decisions in patients with uncomplicated cholecystolithiasis is provided, based on recent trials, the available literature, and expert opinion.

RESULTS

This review describes different guidelines and criteria sets for uncomplicated cholecystolithiasis, provides an overview of outcomes after cholecystectomy, and advises on treatment decisions in patients with abdominal pain and gallbladder stones. After cholecystectomy, biliary colic is resolved in 95 per cent of patients. However, non-specific abdominal pain persists in 40 per cent. Irritable bowel syndrome and functional dyspepsia significantly increase the risk of persistent pain. Age, previous abdominal surgery, baseline pain score on a visual analogue scale, pain characteristics, nausea, and heartburn are part of the SUCCESS criteria, and are associated with clinically relevant pain reduction after gallbladder removal.

CONCLUSION

The surgical community can now give more personalized advice on surgery to improve care for patients with abdominal pain and uncomplicated cholecystolithiasis.

Is there an association between infantile colic and subdural hemorrhage?

We present the hypothesis that subdural hemorrhages during childbirth might be associated with so-called three-month colic, whereby an infant cries intensively and repeatedly during its first three months. A traditional interpretation is that this infantile crying is associated with nutrition and is accordingly "a gut issue", but this is probably not the whole explanation. It has also been suggested that infantile crying can trigger a caregiver to shake the baby to make it stop crying, thereby inflicting a subdural hemorrhage. A mechanism-based argument supporting our hypothesis would be that the bilateral film-thin subdural hemorrhage associated with a high percentage of deliveries might cause meningeal irritation and in some cases also symptoms as inconsolable crying. An epidemiological argument is that infantile crying is more frequent among first-born, male and premature babies; these categories have also an increased incidence of subdural hemorrhage. Moreover, preventive programs for managing infantile crying have had no effect on the incidence of alleged shaken baby cases. As infantile crying is currently considered unexplained, it is reasonable to explore the proposed hypothesis and strategies which refute or corroborate it. We suggest that a cohort study of premature, first born and male babies with and without infantile crying are examined with brain MRI scan soon after delivery with clinically and MRI follow up during 3-6 months.

Clinical Efficacy Of Lactase Enzyme Supplement In Infant Colic: A Randomised Controlled Trial

OBJECTIVE

To determine the efficacy of lactase enzyme supplement in infant colic.

METHODS

The double-blind randomised clinical trial was conducted from November 2014 to June 2017 at Kharadar General Hospital, Karachi, and comprised infants aged 0-6 months with infant colic, excessive crying lasting at least 3 hours a day on at least 3 days a week for at least 3 weeks. The subjects were randomised into intervention group A which received lactase enzyme Colibid, and placebo group B. Five drops of intervention preparation were received by all the infants before each feed for two weeks. Confidentiality of active agent and placebo was maintained through drug codes. The duration of crying was recorded at baseline then after first and second weeks of intervention. The two groups were compared with level of significance set at p<0.05.

RESULTS

There were 104 subjects with 52(50%) in each of the two groups Overall, 50(48.1%) were boys. At baseline, all (100%) the subjects had infant colic or excessive crying. After two-week intervention, significant improvement was seen in the duration of crying in group A 45(86.5%) compared to group B 31(59.6%) (p<0.05).

CONCLUSIONS

Significant improvement was seen in the duration of crying in infants who received lactase enzyme supplement..

Unusual presentation of cyathostomiasis in an adult Thoroughbred mare

A recently purchased 16-year-old Thoroughbred mare with a history of recurrent colic and low body weight, also had lameness in 3 limbs, pain at the sacro-iliac joint, and increased corneal opacity of the right eye. Response to supportive therapy was poor and euthanasia was elected. A postmortem examination and histopathology confirmed cyathostomiasis within the large colon and cecum and chronic anterior uveitis of the right eye.

Symptomatic Cholilithiasis and Cholecystectomy for a 9-Month-Old Infant: A Case Report

BACKGROUND

Symptomatic cholilithiasis is rare in children. Thus, a high degree of suspicion is required for diagnosis. Once a child is diagnosed with symptomatic cholilithiasis, cholecystectomy is required to relieve the symptoms and prevent complication.

CASE DETAILS

A 9-month-old infant from Addis Ababa presented to the Pediatric Department of ZewdituMemorial Hospital on January 30, 2015 with irritability, abdominal pain. On workup, she was found to have gall stones, and her condition was at last attributed to biliary colic after months of follow-up in the Department of Pediatrics. She underwent cholecystectomy on the 31st of July 2015 and discharged with improved results. This is the first report of symptomatic cholilithiasis and cholecystectomy in Ethiopia at 9 months of age.

CONCLUSION

Cholilithiasis is rare in infants, and one should have a high index of suspicion for diagnosis. Cholecystectomy should be done as in adults if symptomatic.

Infant Colic

This article reviews the evidence for an association between infant colic and migraine. Infant colic, or excessive crying in an otherwise healthy and well-fed infant, affects approximately 5%-19% of infants. Multiple case-control studies, a cross-sectional study, and a prospective cohort study have all found an association between infant colic and migraine. Although infant colic is often assumed to have a gastrointestinal cause, several treatment trials aimed at gastrointestinal etiologies have been negative. Teaching parents how to respond best to inconsolable crying may be helpful and important for preventing shaken baby syndrome. Given accumulating evidence for a connection between infant colic and pediatric migraine, future studies should examine migraine-oriented treatments for infant colic. Infant colic should be moved into the main body of International Classification of Headache Disorders (ICHD-III beta) as one of the "Episodic syndromes that may be associated with migraine."

Impact of colic pain as a significant factor for predicting the stone free rate of one-session shock wave lithotripsy for treating ureter stones: a Bayesian logistic regression model analysis

Purpose

This study was conducted to evaluate colic pain as a prognostic pretreatment factor that can influence ureter stone clearance and to estimate the probability of stone-free status in shock wave lithotripsy (SWL) patients with a ureter stone.

Materials and Methods

We retrospectively reviewed the medical records of 1,418 patients who underwent their first SWL between 2005 and 2013. Among these patients, 551 had a ureter stone measuring 4–20 mm and were thus eligible for our analyses. The colic pain as the chief complaint was defined as either subjective flank pain during history taking and physical examination. Propensity-scores for established for colic pain was calculated for each patient using multivariate logistic regression based upon the following covariates: age, maximal stone length (MSL), and mean stone density (MSD). Each factor was evaluated as predictor for stone-free status by Bayesian and non-Bayesian logistic regression model.

Results

After propensity-score matching, 217 patients were extracted in each group from the total patient cohort. There were no statistical differences in variables used in propensity- score matching. One-session success and stone-free rate were also higher in the painful group (73.7% and 71.0%, respectively) than in the painless group (63.6% and 60.4%, respectively). In multivariate non-Bayesian and Bayesian logistic regression models, a painful stone, shorter MSL, and lower MSD were significant factors for one-session stone-free status in patients who underwent SWL.

Conclusions

Colic pain in patients with ureter calculi was one of the significant predicting factors including MSL and MSD for one-session stone-free status of SWL.

Intestinal ischemia-reperfusion injury in horses: pathogenesis and therapeutics

This article discusses the potential role of oxidative injury to the intestinal tract of horses and the therapeutic approaches that have been investigated to decrease cellular damage secondary to ischemia-reperfusion (IR) injury. Equine colic is a major concern for horse owners and veterinary practitioners. Strangulating and obstructive lesions of the small and large intestines commonly require intervention in patients via exploratory celiotomy. However, the application of information from experimentally induced IR injury in horses to clinical cases of naturally occurring equine colic is not clear. Thus, while the exact mechanisms and clinical significance of intestinal IR are being defined and may be matters of academic debate, a review of the available information may provide knowledge of potential underlying pathophysiologic mechanisms contributing to intestinal injury in equine colic. This information may allow clinicians to offer additional therapeutic strategies for horses with strangulating obstruction of the small or large intestine. Further clinical study of the therapeutic options for horses with naturally occurring disease is warranted.

[Examination of horses with acute colic: clinical and legal aspects]

The article provides hands-on advice and scientific background information regarding the management of the equine acute colic patient. It summarizes essential information on the patient's history, clinical examination, and legal aspects. The scope of the history is based on the clinical appearance of the patient. In horses with violent and barely controllable signs of pain, it is limited to colic-associated information such as onset, course and severity of colic signs, and the last time of defecation, as well as prior therapeutic intervention. In these patients, the clinical examination is focussed primarily on the assessment of cardiovascular parameters, rectal temperature, and the patient's behaviour. The nasogastric intubation is an essential part of the examination of a horse with colic to prevent a gastric rupture due to gastric distension. Transrectal palpation is equally important and should always be performed unless there are important reasons to object to this procedure. In most cases, a thorough patient history and clinical examination of an acute colic patient allows the examining veterinarian to make a tentative diagnosis and a prognostic evaluation. This helps with the decision to start a conservative or a surgical therapy. Due to the existing obligatory documentation requirement and the duty to inform patient owners, it is of utmost importance to promptly document one's findings, therapeutic measures, consultations, and information of the patient owner in written form. This supports further therapy and it can also be of relevance in a potentially resulting lawsuit.

Acute abdominal pain during an Antarctic cruise--a case report

A 21-year-old female crew member experienced a number of medical conditions during a summer cruise to the Antarctic Peninsula. At one point symptoms and signs strongly suggested acute appendicitis. She was monitored and treated conservatively on board and recovered uneventfully without surgery. Later she had a biliary colic attack and then an allergic reaction to the pain medication given. The pre-employment medical fitness certificate cannot always be trusted regarding previous history of allergies and medical conditions.

Inverted takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a transient acute left ventricular dysfunction characterized by left ventricular apical akinesis and ballooning without obstructive coronary disease described predominantly in post-menopausal women in the setting of acute emotional or physical stress. Recent reports have described isolated transient basal akinesis (inverted takotsubo cardiomyopathy) in mostly female patients with acute neurologic disorders or pheochromocytoma. We describe a rare case of a 78-year-old male with inverted takotsubo cardiomyopathy in the setting of acute abdominal pain attributed to biliary colic. A review of published literature reveals that inverted takotsubo cardiomyopathy precipitated by acute stress rather than an acute neurologic disorder appears to be an extremely rare presentation in a male patient. We discuss the relevant literature regarding incidence and reported gender distribution of inverted takotsubo cardiomyopathy.

Do horses suffer from irritable bowel syndrome?

Irritable bowel syndrome (IBS) in man is not a single entity but has several causes. One of the most common forms has similarities with colic and laminitis in horses. Undigested food residues may pass from the small intestine into the colon where bacterial fermentation produces chemicals that lead to disease. In horses the consequences may be disastrous, but in healthy humans such malabsorption may not be harmful. After events such as bacterial gastroenteritis or antibiotic treatment, an imbalance of the colonic microflora with overgrowth of facultative anaerobes may arise, leading to malfermentation and IBS. It is not known whether such subtle changes may likewise be present in the microflora of horses who are susceptible to colic and laminitis. Metabolomic studies of urine and faeces may provide a suitable way forward to identify such changes in the horse's gut and thus help to identify more accurately those at risk and to provide opportunities for the development of improved treatment.

Post-anaesthetic myelopathy in a 3-year-old Friesian gelding

A 3-year-old Friesian stallion was referred to the Department of Equine Sciences at Utrecht University with signs of colic. Laparotomy was performed and the stallion was castrated bilaterally because of an incarcerated inguinal hernia. Intestinal resection was not performed. Eight days postoperatively, the horse showed signs of severe colic and was admitted for re-laparotomy. After resection of 1.5 m of strangulated jejunum and severe intraoperative hypotension, bradycardia, and electrolyte disorders, the horse showed problems during recovery with signs of hindquarter paralysis. There was no pain perception in the hind limbs and there were no patellar or anal reflexes. The muscles of the hindquarters and the long extensor muscles of the back were soft and not painful on palpation. No improvement was seen 60 minutes after intravenous injection of corticosteroids. Because of the tentative diagnosis of post-anaesthetic myelopathy and its poor prognosis, and the fact that the horse was restless and did not accept being lifted with a sling system, the horse was euthanized with the owner's consent. Post-anaesthetic myelopathy is a rare neuropathological condition in the horse. Because of its low incidence, knowledge about its aetiology and contributing factors is rather limited. This case report presents the clinical observations and the anaesthetic protocol and compares this case with previously reported cases in the literature.

Are horses that undergo an exploratory laparotomy for correction of a right dorsal displacement of the large colon predisposed to post operative colic, compared to other forms of large colon displacement?

REASON FOR PERFORMING STUDY

It is a clinical impression that horses diagnosed with a right dorsal displacement (RDD) of the large colon, are more likely to suffer from recurrent episodes of colic post operatively, compared to other forms of nonstrangulating large colon displacement.

OBJECTIVES

To investigate whether the type of nonstrangulating large colon displacement identified at exploratory laparotomy would influence long-term outcome.

HYPOTHESIS

Horses identified with a RDD of the large colon at exploratory laparotomy would be more likely to experience recurrent episodes of post operative colic than other types of displacement.

MATERIALS AND METHODS

Medical records for horses undergoing an exploratory laparotomy, from 2000-2008, for a nonstrangulating large colon displacement were reviewed. Data retrieved included: subject details, previous medical history, details of current episodes of colic, results of preoperative examination, surgical findings and procedures, post operative management and complications. Follow-up information was obtained by reference to computerised clinical records and by telephone questionnaire administered to the horse's owner or carer, and included details of any colic episodes exhibited by the horse after discharge and whether a repeat celiotomy had been required to resolve the colic episodes.

RESULTS

There were 165 surgeries identified, in 154 horses. It was found that those horses with RDD were significantly more likely to experience recurrent episodes of colic requiring veterinary intervention post operatively compared to other types of displacement.

CLINICAL RELEVANCE

Long-term prognosis and likelihood of post operative complications is an important consideration for both owners and veterinarians.

The role of family therapy in mediating adverse effects of excessive and inconsolable neonatal crying on the family system

Prolonged and inconsolable new infant crying is 1 of the most challenging tasks for parental caregivers to ameliorate and manage. As parent(s) attempt to meet the stressors associated with this situation, multiple subsystems within the family may be adversely affected. Lasting interactional difficulties often result, interfering with the healthy development of parent-child and parent-parent dyads. This article examines these risks to the family system, suggests an important role for intervention by family practitioners, and presents recommendations for intervention by clinicians.

[Encephalopathy and Alzheimer type II astrocytes in a post laparotomy recumbent horse]

A 13-year-old Standardbred gelding was referred for evaluation of continuous abdominal pain. Rectal examination revealed a dislocated large colon (Dislocatio coli ad dextram). The horse showed muscle fasciculations and appeared lethargic. It was sent to surgery because of persistent colic. In transit the gelding showed an unstable walk and immediately prior to surgery a wide-based stance in the hindlimbs. Laparotomy revealed a retroflexion of the large colon and a secundary mesenterial volvulus. After surgery the horse remained recumbent. Due to the comatose state and poor prognosis the gelding was euthanized after 15 hours of recumbency. Necropsy indicated hyperaemic meninges, edema of gliacells and submeningeal tissue with vacuolization and loss of several cerebellar Purkinjecells as well as multiple conglomerates of Alzheimer type II astrocyte groups within the grey matter. Further findings included marked hepatolipidosis, multiple gastric ulcers, small intestinal hyperaemia with mild mononuclear inflammation, tapeworm-infestation of the caecum and moderate chronic enteritis with eosinophilic component in the large intestine. To the best of our knowledge, this was the first case of a horse with colic and concurrent encephalopathy without primary liver disease described in a German-speaking country.

Myonecrosis in three horses with colic: evidence for endotoxic injury

Three horses with colic, clinical evidence of endotoxaemia and high serum activities of creatine kinase and aspartate aminotransferase were examined postmortem. The horses were diagnosed with severe ulcerative colitis, pyloric ulceration and stenosis with colonic sand impaction, and colonic obstruction due to faecaliths. There was no gross or histological evidence of muscle trauma. Their semimembranosus muscles had scattered acute to subacute segmental necrosis of the myofibres, suggestive of endotoxin-induced muscle injury.

Update on infantile colic and management options

Infant colic is a common but poorly defined and understood clinical entity and, while several causative factors have been suggested, a unifying theory of its pathogenesis is still required. Food hypersensitivity/allergy and gut dysmotility are the lead contenders for causative factors of infantile colic. Additional confounders and covariables include psychological and social factors. Although the available data fail to provide insight into the exact triggers of infantile colic, these do allow for the hypothesis that certain infants are predisposed to dietary protein intolerance and disturbed gut motility, such as visceral hypersensitivity/ hyperalgesia, in the first few weeks of life. These processes lead to distress and altered perceptions, where normal stimuli (ie, intestinal distension) are misinterpreted as painful events. This review discusses a number of interventions, including pharmacological agents, which are based on the perceived pathogenesis; however, it is likely that infants with colic will require a multifactorial management strategy. Healthcare providers must offer support, reassurance and empathy to the caregiver, and adopt a biopsychosocial approach to the infants and their families by considering any underlying medical diseases in addition to examining the family unit. In a small subset of infants with colicky behavior, a specific medical disorder such as gastroesophageal reflux or milk protein allergy may be identified. While the vast majority of infants with colic will recover uneventfully, some may be at risk for the later development of behavioral problems and atopy/allergy.

Rapid Extracorporeal Shock Wave Lithotripsy for Proximal Ureteral Calculi in Colic versus Noncolic Patients

OBJECTIVES

In delayed extracorporeal shock wave lithotripsy (ESWL) treatment, increasing stone impaction is associated with delayed stone clearance. Whether colic patients treated by rapid ESWL have the same time to stone clearance as noncolic patients, which supports the thesis that stones in both groups are nonimpacted, has not been investigated yet, and was the objective of this study.

METHODS

A total of 82 patients were prospectively enrolled and treated with piezoelectric ESWL for a solitary proximal ureteral stone. Of these, 56 patients experienced at least one colic episode compared with 26 noncolic patients. Hydronephrosis has been assessed with the use of ultrasound and intravenous urography (IVU). Time to stone clearance after the first ESWL and stone-free rates after a follow-up period of 3 mo were recorded.

RESULTS

In colic and noncolic patients, mean stone size was 7.8mm (p=0.7). Ultrasound-detected hydronephrosis was present in 88% versus 39% (p<0.0001), whereas IVU-detected hydronephrosis was present in 60% versus 7.7% (p=0.0001). Mean number of impulses applied was 8000+/-4000 versus 6700+/-3400 (p=0.1). Mean time to stone clearance was 9.5+/-12.1 d versus 4.6+/-3.8 d (p=0.1). Colic and noncolic patients were considered as treatment success in 83% and 81% after 3 mo of follow-up (p=0.9).

CONCLUSIONS

Treatment outcome and time to stone clearance after rapid ESWL in colic patients compared with noncolic patients is comparable and independent of concomitant hydronephrosis. This finding suggests an absence of significant impaction in proximal ureteral stones treated within 24h after a first colic episode, enforcing the concept of performing rapid ESWL in patients harbouring proximal ureteral stones.

The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis

OBJECTIVE

To prospectively define the role of the double J-stent placement following ureteroscopic stone therapy in providing a pain-free postoperative period for patients with persisting loin pain and documented hydronphrosis.

MATERIAL AND METHODS

The study cohort consisted of 27 patients (mean age: 38.59 years; range: 22-60 years) who had undergone ureteroscopic intervention due to ureteral stone. All of the patients reported loin pain which did not respond to medical therapy associated with various degrees of hydronephrosis documented by ultrasound and/or an excretory urogram. The patients were randomized to either a stented (18 patients) or stentless (nine patients) group following semirigid ureteroscopy (7.5/12 Fr) for the treatment of ureteral calculi (pneumatic lithotripsy). The mean diameter of the stones was 7.7 mm (range: 3-13 mm). Intra-operative balloon ureter orifice dilatation was routinely performed. All patients were evaluated between 0 and 6 days postoperative for loin pain and lower urinary tract symptoms.

RESULTS

Nine patients had loin pain in the first few days following the operation and were in need of intramuscular and/or intravenous analgesics. Of these, four were stented patients (4/18; 22.2%) and five were stentless patients (5/9; 55.5%). Lower urinary tract symptoms were not clinically significant and did not affect the quality of life in terms of loin pain, with the exception of one patient in whom the stent had dropped into the bladder.

CONCLUSION

We believe that stenting in patients with documented hydronephrosis manifesting in persisting renal colic is recommended. As ureteroscopic therapy may aggregate the edema of ureter mucosa, double J-stent placement may play an important role in offering patients a postoperative period free of loin discomfort. However, further prospective trials should be designed to evaluate the criteria for stentless ureterorenoscopy.

Detecting early kidney damage in horses with colic by measuring matrix metalloproteinase -9 and -2, other enzymes, urinary glucose and total proteins

Background

The aim of the study was to investigate urine matrix metalloproteinase (MMP-2 and -9) activity, alkaline phosphatase/creatinine (U-AP/Cr) and gamma-glutamyl-transpeptidase/creatinine (U-GGT/Cr) ratios, glucose concentration, and urine protein/creatinine (U-Prot/Cr) ratio and to compare data with plasma MMP-2 and -9 activity, cystatin-C and creatinine concentrations in colic horses and healthy controls. Horses with surgical colic (n = 5) were compared to healthy stallions (n = 7) that came for castration. Blood and urine samples were collected. MMP gelatinolytic activity was measured by zymography.

Results

We found out that horses with colic had significantly higher urinary MMP-9 complex and proMMP-9 activities than horses in the control group. Colic horses also had higher plasma MMP-2 activity than the control horses. Serum creatinine, although within reference range, was significantly higher in the colic horses than in the control group. There was no significant increase in urinary alkaline phosphatase, gamma-glutamyltranspeptidase or total proteins in the colic horses compared to the control group. A human cystatin-C test (Dako Cytomation latex immunoassay^® based on turbidimetry) did not cross react with equine cystatin-C.

Conclusion

The results indicate that plasma MMP-2 may play a role in the pathogenesis of equine colic and urinary MMP-9 in equine kidney damage.

Preoperative administration of hydroxyethyl starch or hypertonic saline to horses with colic

BACKGROUND

Hypertonic saline and hydroxyethyl starches have been proposed as alternatives to isotonic crystalloids for reversal of hypovolemia in horses with colic. However, no direct comparison of these fluids has been performed in a clinical setting.

HYPOTHESIS

Preoperative administration of hypertonic saline or pentastarch would produce similar effects on intra operative hemodynamics in horses with colic.

ANIMALS

Thirty horses requiring colic surgery were enrolled in this prospective, randomized, open-label clinical trial. Inclusion criteria were owner consent, and at least 2 of 3 clinicopathologic abnormalities: packed cell volume >45%, plasma total solid concentration >8.0 g/dL, and blood lactate concentration >2.5 mM.

METHODS

Study horses were randomly assigned to receive 4 mL/kg hypertonic saline or pentastarch before induction of anesthesia. Hemodynamic measurements were recorded every 30 minutes during anesthesia. Cardiac output (CO) was measured by the lithium dilution method. CO and stroke volume (SV) were indexed by body weight. Data were analysed using repeated measures analysis of variance (ANOVA). Post hoc comparisons were performed using the Bonferroni test.

RESULTS

Cardiac index (CI) was higher in the pentastarch group compared with the hypertonic saline group from 30 to 150 minutes after induction (P = .04). SV index was higher in the pentastarch group at 30 (P = .025) and 60 minutes (P = .04). Mean arterial pressure of horses in both groups was lower at 90 minutes compared with 30 and 60 minutes.

CONCLUSIONS AND CLINICAL IMPORTANCE

Preoperative administration of pentastarch results in better CI than hypertonic saline, for 150 minutes after anesthetic induction. The effect of this improved global blood flow on regional perfusion or clinical outcome remains to be elucidated.

Neurologic signs and hyperammonemia in a horse with colic

A 23-year-old Thoroughbred gelding was referred for the evaluation of acute onset of ataxia and depression, and a 2-day history of fever. On physical examination, the gelding was profoundly depressed and 10-12% dehydrated. The horse appeared very unstable, with a wide-based stance in the hind limbs, severe symmetric ataxia in all 4 limbs, and proprioceptive deficits in both hind limbs. Nasogastric intubation produced 4 L of brown, fetid reflux, and rectal examination revealed mild small intestinal and cecal distention. Hematologic abnormalities included neutropenia with toxic change, compatible with acute inflammation and endotoxemia, and prolonged coagulation times. Serum biochemical abnormalities included prerenal azotemia. metabolic acidosis, and electrolyte abnormalities consistent with enteritis. Blood ammonia concentration was markedly increased (406 micromol/L; reference interval 4-49 micromol/L), however, serum bile acids concentration and hepatic enzyme activities were within reference intervals. Histopathologic examination of a liver biopsy revealed no abnormalities and results of tests for several infectious agents were negative. Clinical signs resolved with correction of the dehydration and electrolyte abnormalities and with antibiotic therapy. The horse was diagnosed with hyperammonemic neuropathy associated with gastrointestinal disease. In such cases, hyperammonemia is caused by increased production of ammonia by organisms in the gastrointestinal tract in combination with increased gut permeability that facilitates ammonia absorption.

Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal.

AIMS

To examine the diagnostic accuracy of clinical predictors of pathological GOR in infants with persistent crying.

METHODS

One hundred and fifty-one infants (82 male; median age 2.5 months, range 0.5-8.2 months) with persistent crying were prospectively studied. Crying and fussing were charted for 24 h, and parents completed a validated questionnaire on reflux symptoms. All infants underwent oesophageal 24-h pH monitoring.

RESULTS

Twenty-seven (17.9%) infants had pathological GOR with a fractional reflux time (FRT) >10%. There was no significant association between total crying duration per 24 and FRT (P = 0.84) or the number of reflux episodes (P = 0.68). Pathological GOR was more common in infants under 3 months, compared to older infants (P = 0.04). Feeding difficulties were significantly associated with pathological GOR (P = 0.02). Backarching was not increased in infants with GOR (P = 0.30). Pathological GOR was significantly associated with the frequency of regurgitation (P = 0.04), but not with vomitus volume (P = 0.62). Regurgitation more than 5 times daily was the most specific reflux symptom (specificity 70.9%), but was a poor predictor of pathological GOR (positive predictive value 22.2%). In the absence of frequent regurgitation or feeding difficulties, pathological GOR was unlikely (negative predictive value 87-90%).

CONCLUSIONS

Investigation and treatment of GOR in infants with persistent crying should be primarily directed at infants presenting with frequent regurgitation or feeding difficulties.

A comparison of traditional and quantitative analysis of acid-base and electrolyte imbalances in horses with gastrointestinal disorders

The purpose of this study was to compare traditional and quantitative approaches in analysis of the acid-base and electrolyte imbalances in horses with acute gastrointestinal disorders. Venous blood samples were collected from 115 colic horses, and from 45 control animals. Horses with colic were grouped according to the clinical diagnosis into 4 categories: obstructive, ischemic, inflammatory, and diarrheic problems. Plasma electrolytes, total protein, albumin, pH, pCO2, tCO2, HCO3-, base excess, anion gap, measured strong ion difference (SIDm), nonvolatile weak buffers (A(tot)), and strong ion gap were determined in all samples. All colic horses revealed a mild but statistically significant decrease in iCa2+ concentration. Potassium levels were mildly but significantly decreased in horses with colic, except in those within the inflammatory group. Additionally, the diarrheic group revealed a mild but significant decrease in Na+, tCa, tMg, total protein, albumin, SIDm, and A(tot). Although pH was not severely altered in any colic group, 26% of the horses in the obstructive group, 74% in the ischemic group, 87% in the inflammatory group, and 22% in the diarrheic group had a metabolic imbalance. In contrast, when using the quantitative approach, 78% of the diarrheic horses revealed a metabolic imbalance consisting mainly of a strong ion acidosis and nonvolatile buffer ion alkalosis. In conclusion, mild acid-base and electrolyte disturbances were observed in horses with gastrointestinal disorders. However, the quantitative approach should be used in these animals, especially when strong ion imbalances and hypoproteinemia are detected, so that abnormalities in acid-base status are evident.

Mesenteric Arterionecrosis in Natural and Experimental Equine Endotoxaemia

To test the hypothesis that mesenteric arterionecrosis (MA) occurs in horses with naturally occurring endotoxaemia (ET) and in those with experimentally induced ET, the mesentery and gastrointestinal tract of 21 Thoroughbred racehorses (15 with spontaneous colic suspected to be due to ET, and six with experimentally induced ET) were examined. MA, which occurred in 13 of the 15 horses with spontaneous colic and in all six of the cases of experimental ET, was morphologically similar in the two groups of animals. This suggested that the pathogenesis of the MA was fundamentally similar in the two groups, and that MA is a pathognomonic feature of equine ET. In addition to histolysis of the arterial walls associated with infiltration of blood components, changes were noted in the medial smooth muscle including formation of many intracellular vacuoles within single smooth muscle cells, cytoplasmolysis, necrosis with granules and vacuoles, and coagulation necrosis; similar changes have been observed in cases of prolonged angiospasm or vasoconstriction. It is suggested that the effects of sustained arterial contraction leading to intimal and medial damage influence the pathomorphogenesis of MA.

Enamel opacities in 8-year-old Icelandic children in relation to their medical history as infants

OBJECTIVES

Opacities in tooth enamel were found in 34% of 8-year-old Icelandic children in 1970. This study aimed to measure the current prevalence of non-fluorotic enamel opacities in the maxillary incisors and to determine if their occurrence was related to significant events in the medical history.

DESIGN

The prevalence of demarcated enamel opacities was recorded photographically by calibrated examiners.

SETTING

Subjects lived in Reykjavík, Iceland.

SAMPLE AND METHODS

A random sample of 290 children aged eight years was examined in 1997-8. Parents were asked if the child had a history of (i) colic as an infant and/or (ii) repeated middle-ear infection.

RESULTS

Demarcated white enamel lesions, not resembling fluorosis, were seen in 41% of children (teeth photographed wet) rising to 51% (teeth photographed dry). Enamel hypoplasia was seen in 11% of wet teeth and 15% of dry teeth. Parents of 94/288 children (32.6%) reported that their child had infant colic and 52/94 (55.3%) had received medication. Three episodes or more of middle-ear infections per year were reported for 123/290 (42.4%) children. Significant association was seen between the presence of demarcated enamel opacities and a history of otitis media. Diffuse enamel opacities, assumed to be fluorosis, were not associated with events reported from the medical history.

CONCLUSIONS

Non-fluoride opacities of teeth are still prevalent in Icelandic children especially those with a history of infections in infancy. Without a careful diagnosis these opacities might be confused with fluorosis.

Emergency ultrasound and urinalysis in the evaluation of flank pain

OBJECTIVES

To determine the sensitivity and specificity of limited emergency ultrasonography of the kidney in diagnosing renal colic.

METHODS

This was a prospective observational trial from December 2001 to December 2003 at a suburban emergency department. Patients who presented with flank pain suspicious for renal colic were enrolled. Exclusion criteria included fever, trauma, known current kidney stone, unstable vital signs, and inability to provide consent. All patients underwent sequential emergency ultrasonography and computed tomography of the kidneys and bladder. Data were analyzed using chi-square analysis. The primary outcome was the sensitivity and specificity of ultrasonography. Results were also stratified for presence of hematuria.

RESULTS

Fifty-eight of the 104 patients enrolled in the study were diagnosed with renal colic. The overall sensitivity and specificity of bedside ultrasonography for the detection of hydronephrosis were 86.8 (95% confidence interval [CI] = 78.8 to 92.3) and 82.4 (95% CI = 74.1 to 88.1), respectively. In patients with hematuria, hydronephrosis by emergency ultrasonography demonstrated a sensitivity and specificity of 87.8 (95% CI = 80.3 to 92.5) and 84.8 (95% CI = 73.7 to 91.9), respectively. In 55 of the cases, the initial computed tomograph was read by a resident and later re-read by an attending physician. Using the reading of the attending physician as the criterion standard resulted in a sensitivity and specificity of 83.3 (95% CI = 73.2 to 88.0) and 92.0 (95% CI = 79.9 to 97.6), respectively.

CONCLUSIONS

Emergency ultrasonography of the kidneys shows very good sensitivity and specificity for diagnosing renal colic in patients with flank pain and hematuria.

Use of plasma ionized calcium levels and Ca2+ substitution response patterns as prognostic parameters for ileus and survival in colic horses

OBJECTIVE

Hypocalcaemia is a common finding in horses with enterocolitis and severe gastrointestinal disorders. The aims of this study were to investigate in colic horses 1)the parameters related to hypocalcaemia, 2)the influence of hypocalcaemia on outcome and 3)the possible beneficial effect of Ca2+ substitution.

DESIGN

Randomized controlled trial.

SETTING

Intensive care unit.

PATIENTS

One hundred forty-four horses that were admitted with an acute abdomen during a 1.5 year period were enrolled and daily evaluated for clinical criteria and whole blood ionized Ca2+ levels. Colic horses with hypocalcaemia were randomly assigned to receive Ca2+.

INTERVENTIONS

Analysis of heparinised whole blood samples. Horses that were assigned to be treated received 400 mEq Ca2+ diluted in 10L of Ringer's lactate solution every 24 h until low reference range limits were obtained or until death.

MEASUREMENTS AND MAIN RESULTS

88% of all colic patients showed blood ionized Ca2+ levels below the reference range at the time of admission. Multivariable analysis revealed that the presence of reflux, signs of endotoxaemia, increased Packed Cell Volume (PCV), alkalinization of pH and the interaction PCV/pH all predispose colic horses to low ionized Ca2+ levels at the time of admission. The Odds for developing ileus during hospitalization are +/- 11.94 times larger for horses in the "very low" calcaemia interval, in comparison with normocalcaemic horses. The Odds for fatal outcome are respectively +/- 9.82 and 8.33 times larger for horses in the "very low" and "low" calcaemia interval. Ca2+ substitution increased the probability of survival, provided that Ca2+ levels could be normalized. The lack of an upward calcaemia response, despite repetitive Ca2+ substitutions, can be guarded as a poor ominous sign.

CONCLUSIONS

Hypocalcaemia in colic horses is of prognostic relevance both with regard to survival as to the probability of development of ileus during hospitalization. This study shows the importance of routine measurement of ionized calcium levels in colic horses. Moreover, correction of hypocalcaemia seems to improve clinical outcome.

Prevalence and risk factors associated with outcome of surgical removal of pedunculated lipomas in horses: 102 cases (1987-2002)

OBJECTIVE

To determine the prevalence of pedunculated lipomas and identify risk factors affecting postoperative complications and survival in horses at a veterinary teaching hospital undergoing surgery for colic caused by pedunculated lipomas.

DESIGN

Retrospective study.

ANIMALS

102 horses with a diagnosis of pedunculated lipoma.

PROCEDURE

Age, breed, weight, and sex of horses with pedunculated lipomas were compared with the total equine hospital population and the population of horses admitted for abdominal surgery during the same period. Follow-up information was obtained by reevaluation or contact with owners via telephone or written request.

RESULTS

Prevalence of pedunculated lipomas as a reason for abdominal surgery in horses, compared with the population of horses with and without lipomas admitted for abdominal surgery, was 10%. Castrated male Saddlebred and Arabian horses > 14 years old were identified as being at risk for developing pedunculated lipomas. Postoperative complications were detected in 72% of horses with pedunculated lipomas. Variables associated with low survival rates included surgery before 1992, heart rate > 80 beats/min, abnormal color of abdominal fluid, pale mucous membranes, surgery requiring intestinal resection, and inability to attain a mean arterial pressure > or = 100 mm Hg. Horses undergoing surgery from 1992 to 1996, weighing < 409 kg (900 lb), or requiring jejunojejunal anastomosis had a high survival rate.

CONCLUSIONS AND CLINICAL RELEVANCE

Although many of the variables reflected the health of the horse at the time of surgery, results may help veterinarians recognize risk factors associated with development of pedunculated lipomas and better predict the outcome of horses undergoing surgery for colic caused by pedunculated lipomas.

[Evaluation of operative risk in emergency treatment of neoplastic left colon obstruction: personal experience]

AIM OF THE STUDY

To analyse the risk factors in the treatment of intestinal obstruction due to colorectal carcinoma. The treatment of neoplastic obstruction of the right colon until the splenic flexure is well defined: right hemicolectomy, enlarged right hemicolectomy. Otherwise the treatment of the obstruction due to left colon carcinoma beyond left flexure is not standardized.

MATERIAL AND METHODS

The Authors report on a consecutive series of 15 patients, classified according to Colorectal Tumours Emergencies Score (CTES), based on the analysis of 4 risks factors: colic, perforation, serum albumin, concurrent cardiovascular disease, chronic renal insufficiency. Each patient has been ranked in three classes of risk: low (CTES < 4), moderate (CTES 4-12), and high (CTES > 12).

CONCLUSIONS

Referring to this classification the Authors consider the choice of surgical treatment. When general conditions of the patient permit, it seems preferable to perform primary anastomosis.

[Modification of nephritic colic and 24-hour calcium excretion in urine in primary hyperthyroidism after parathyroidectomy]

We documented the frequency of nephritic colic in patients with primary hyperparathyroidism, and determined its modification after the parathyroidectomy; we also studied laboratory parameters such as calcium, phosphorus and parathyroid hormone in serum, and the excretion of Cao 24h, previous and later to the intervention. At sight of the results it is possible to be concluded that the parathyroidectomy is useful in the treatment of the kidney stone disease produced by the primary hyperparathyroidism.