A diagnostic challenge: primary omental torsion and literature review - a case report

A case report of omental torsion, which is a rare differential diagnosis of the acute abdomen. Intraoperative diagnosis and treatment by resection are the current management of choice, however with increasing use of pre-operative imaging this may need to be reconsidered.     

Eosinophilic ascites: A diagnostic and therapeutic challenge

Eosinophilic gastroenteritis(EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.     

Intrahepatic cholangiocarcinoma: A diagnostic and therapeutic challenge

Objectives: Intrahepatic cholangiocarcinoma (ICC) is a rare tumor of the liver. The diagnosis and treatment of it are difficult. The present study reviewed the diagnostic pathways and operative results for ICC. Methods: A retrospective analysis was made of the clinical presentation, diagnostic pathways, and operative results of 20 patients with ICC who underwent hepatectomy from 1997 to 2004 in our institute. Results: The patients were predominantly female (female : male = 15:5), and ranged in age from 41 to 74 years (median 59.8). Abdominal pain was the main presenting symptom, and hepatomegaly was the commonest physical sign. Diagnosis relied mainly on ultrasound or computed tomography. Without biopsy, only two patients were correctly diagnosed with ICC before surgery. The median size of the tumor was 6 cm (range 1.6–12 cm). Major hepatectomy was carried out in 80% of patients. The operative mortality and morbidity were 15% and 40%, respectively. The median follow up was 18.3 months. Thirteen patients (65%) had recurrences at one or more sites, including, in decreasing frequency, the liver, abdominal lymph node, lung, bone, or skin. The median survival was 17.3 months and the 1‐year, 3‐year, and 5‐year survival rates were 60%, 45%, and 10%, respectively. Conclusions: The poor survival of patients with ICC was mainly due to the delay in diagnosis and the aggressive nature of the disease. The diagnosis of ICC relies on a high index of suspicion as there is no reliable tumor marker and imaging results are usually inconclusive. Radical hepatectomy remains the only chance of cure for ICC. The role of lymph node dissection, liver transplantation, and adjunctive chemotherapy in the treatment of patients with ICC remains to be determined.     

Self-inflicted hand injuries: diagnostic challenge and treatment

Self-inflicted injuries are probably more common than is generally appreciated. Three patients with self-inflicted hand injuries are described. A delay in making the correct diagnosis resulted in severe hand disability in 2 of the patients. Early diagnosis of this entity, combined with prompt psychotherapy, prevented disability in the third. The pertinent literature is reviewed and the importance of early diagnosis and psychotherapy is stressed.     

Tenosynovial osteochondroma of the hand. A case report and brief review

A 61-year-old man presented with a slowly growing, painless mass over the dorsum of his right hand. Roentgenography, computed tomography, and a radionuclide bone scan revealed a soft-tissue mass with mineralization but no bone or joint involvement. Routine laboratory tests and a chest roentgenogram were negative. A biopsy was inconclusive. The mass was removed en bloc and was diagnosed as synovial osteochondroma arising from the extensor tendon sheaths. The patient has been symptom-free 16 months postoperation. The literature indicates that these tumors occur almost exclusively in the hands or feet and are thought to develop by metaplasia from the mesenchymal cells of the synovial membrane; mineralization and ossification of the tumor are secondary. The actively growing tumor is often cellular and may show atypical cytologic features. Such microscopic characteristics should not be interpreted as evidence of a low-grade chondrosarcoma. A review of the literature failed to disclose a case with malignant transformation, although several lesions had recurred, some more than once. For this reason, complete removal of the involved synovia is of great importance.     

Necrotizing fasciitis. A diagnostic and therapeutic challenge

A case of necrotizing fasciitis of the upper limb caused by group A streptococcal infection and a case with an abscess of the hand caused by staphylococcus aureus, are presented. The anatomo-pathological and clinical differences between the two different types of infection are underlined and stress is laid on the excruciating pain, the high temperature and the rapidly spreading inflammatory-necrotizing evolution of the first case. More than the anatomo-pathological findings of a necrotic area the authors consider more important, the rapidity and the severity of the infection, that can evolve into a toxic shock-like syndrome, and the microbiological isolation of the streptococcus type A. On the basis of personal experience and of an accurate review of the literature, a therapeutical protocol is proposed based on an aggressive surgical approach, prompt specific antibiotic treatment and daily control of the lesions.     

Sarcoid tenosynovitis in the hand. A case report and literature review

We report a case of involvement of a finger flexor tendon by sarcoidosis. A review of twelve cases suggests that this is a rare manifestation of the illness that most often affects the finger extensors at the wrist. It tends to present in established sarcoidosis and is associated with a higher than usual incidence of polyarthritis. The main differential diagnosis would be tuberculous tenosynovitis. We suggest that a histological spectrum exists running from a predominantly cellular picture to one of fibrotic nodules, perhaps explaining previously described instances of pseudo-tumour. We would recommend tenosynovectomy in conjunction with corticosteroid therapy as the treatment of choice.     

Pacinian neurofibroma of the hand: a case report and literature review

Pacinian neurofibroma is a rare, benign tumor not associated with von Recklinghausen's disease (neurofibromatosis). Histologically, it is composed of a proliferation of structures resembling normal pressure receptors. A case of pacinian neurofibroma of the hand in a 4-year-old child is presented, along with a review of the literature.     

Vibrio hand infections: a case report and review of the literature

A case of Vibrio vulnificus infection of the hand is presented. The role of Vibrio species as primary pathogens in infections associated with exposure to a marine environment is discussed.     

Actinomadura pelletieri mycetoma from the Transvaal. A case report

The osteophilic red grain mycetoma due to Actinomadura pelletieri is rare in southern Africa. This report describes an elderly patient with extensive bone involvement in which lymphatic spread to the inguinal lymph nodes had occurred. The diagnosis and management are discussed.     

Intestinal angiodysplasia--a diagnostic and therapeutic challenge

During an eight-year period we have treated 10 patients for intestinal angiodysplasia complicated by major hemorrhage. This condition represents a degenerative, acquired lesion mostly in elder people consisting of thin-walled vessels of venous origin. Angiodysplasias are usually multiple and predominantly localized in the right colon. Besides localizing the bleeding source the exclusion of concomitant lesions capable of bleeding but not responsible for hemorrhage represents the main diagnostic problem. Segmental colectomy for angiodysplasia is rarely followed by rebleeding when preoperatively the site of hemorrhage has reliably been identified, mainly by angiography. Today the colonoscopic electro- or lasercoagulation of vascular ectasia represents a valuable alternative therapeutic procedure. Subtotal colectomy should be used only as a last resort.     

Nontuberculous mycobacterial peritonitis during continuous ambulatory peritoneal dialysis: case report and review of diagnostic and therapeutic strategies

Nontuberculous mycobacteria (NTM) are responsible for an increasing proportion of mycobacterial disease. Peritonitis due to NTM is an unusual but treatable complication of continuous ambulatory peritoneal dialysis (CAPD). Its presentation is similar to that of typical bacterial peritonitis, but special culture techniques are required to avoid a delay in diagnosis. Successful treatment depends on early catheter removal, drainage of fluid collections, and appropriate use of antimicrobial agents. We report a case of Mycobacterium fortuitum peritonitis in a patient undergoing CAPD, and review all previously reported cases. Diagnostic and therapeutic strategies are summarized based on available literature.     

Masson's tumor of the hand: a case report and brief literature review

Masson's tumor, more accurately termed intravascular papillary endothelial hyperplasia, is a benign lesion commonly confused with angiosarcoma. We present a case of a Masson's lesion arising on the left thumb of a 63-year-old woman and a review of historic and current literature regarding differential diagnosis and management. Masson's tumor is a completely benign lesion in cutaneous instances and can be adequately treated with excision alone.     

Fournier's gangrene: diagnostic approach and therapeutic challenge.

OBJECTIVE: To identify the prognostic variables and to assess the role of aggressive management in patients with Fournier's gangrene. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 11 patients (9 men and 2 women) with Fournier's gangrene admitted between April 1986 and December 2000. INTERVENTIONS: Early aggressive debridements. MAIN OUTCOME MEASURES: Postoperative course, hospital stay, outcome, morbidity, and mortality. RESULTS: The mean age was 65 years (range 17-90) and the mean (SD) duration of hospital stay was 35 (8) days (range 8-62). The aetiology was identified in 8 patients and idiopathic in 3. Predisposing factors (diabetes, n = 4; heart failure, agranulocytosis, and alcohol misuse, n = 1 each) were identified in 6 patients. All patients except one had raised serum glucose concentrations and low serum albumin values. On admission the white cell count was >15 x 10(9)/L in 10, serum sodium <135 mmol/L, mean (SD) serum creatinine 124 (27) micromol/L, and C-reactive protein >150 mg/L was found in all patients. 3/9 male patients required partial excision of the scrotum. Temporary faecal diversion was done for 3 patients. A mean of 3 aggressive repeated debridements (range: 3-6) were required. Nine patients survived and two patients died. CONCLUSION: Rapid and accurate diagnosis remains the key to achieving a successful outcome. Abnormal laboratory variables on admission may suggest the diagnosis. Early, repeated, aggressive debridement is essential for a successful outcome.     

Isolated right segmental hepatic duct injury: A diagnostic and therapeutic challenge

Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmentai hepatic duct can be particularly difficult to diagnose in that results of endoscopie retrograde cholangiography (ERC) are usually interpreted as ‘normal’ with no leaks demonstrated. The aim of this study was to describe a single institution’s experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholccystcctomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopie retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmentai biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en-Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal inlury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopie retrograde cholangiogram. Management begins with percutaneous access or the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy. Presented at the Fortieth Annual Meeting of The Society tor Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.