A patient with a hyperechoic band-shaped structure in the right hepatic vein.

Cement (polymethylmethacrylat) is frequently and increasingly used in vertebral surgery. Complications can occur by spillage of this material; however the vast majority of the patients remain free of symptoms and do not require any specific therapy.Internists, gastroenterologists and radiologists regularly performing abdominal ultrasound and computed tomography should be aware of this complication.A case of spillage of cement in the right hepatic vein is presented.

Endoscopic procedures in patients under clopidogrel or dual antiplatelet therapy: a survey among German gastroenterologists and current guidelines.

BACKGROUND: Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy. METHODS: A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK. RESULTS: 73 (33 %) chief gastroenterologists returned completed questionnaires, 35 (48 %) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85 %) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41 %) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49 %) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5 %) in the case of combined antiplatelet therapy. However, in emergency situations more than 60 % of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44 %) under clopidogrel monotherapy, but only in 4 (5.5 %) under dual antiplatelet therapy. CONCLUSION: Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.

Spontaneous intramural small-bowel hematoma secondary to anticoagulant therapy: a case series.

Spontaneous small-bowel hematomas most commonly involve the jejunum, followed by the ileum and duodenum, and occur in patients who receive excessive anticoagulation with phenprocoumon/warfarin or who have additional risk factors for bleeding. We report three cases of intramural small-bowel hematoma, all complications of treatment with phenprocoumon, which nowadays is used extensively for therapeutic and prophylactic purposes. Diagnosis can be readily attained by sonography and confirmed using computed tomography. Early diagnosis is crucial because most patients can be treated successfully without surgery. Based on this experience and data from the literature, conservative treatment is recommended for intramural intestinal hematomas, when other complications needing laparotomy have been excluded.

Safety of endoscopic sphincterotomy in patients under dual antiplatelet therapy.

BACKGROUND/AIMS: Dual antiplatelet therapy has to be used for at least one month after placement of bare metal coronary stents and for a minimum of one year after placement of drug eluting stents. Because of the higher risk of bleeding, guidelines strongly recommend to delay elective surgery until dual antiplatelet therapy is terminated. However, no data are available regarding the bleeding risk in patients on combined aspirin/clopidogrel therapy undergoing high-risk endoscopic procedures, such as emergency endoscopic biliary sphincterotomy. METHODOLOGY: We retrospectively analyzed the medical reports of patients who had to undergo endoscopic retrograde cholangiography with endoscopic sphincterotomy (ES) while on dual antiplatelet therapy in our unit between January 2009 and December 2011. RESULTS: In our series, ES was safely performed in eight consecutive patients on dual antiplatelet therapy with no evidence of bleeding. CONCLUSION: ES may be safely performed in patients on dual antiplatelet therapy.

[Partial thrombosis of the inferior vena cava in a patient with non-Hodgkin lymphoma and history of lumbar spine surgery]. / V.-cava-inferior-Thrombose bei Patientin mit Non-Hodgkin-Lymphom und stattgefundener Wirbelsäulenoperation.

Complete or partial thrombosis of the inferior vena cava is usually due to pre-existing malformation of the vessel, malignant tumors, ascending thrombosis, or thrombophilic disorders. We report the case of an 81-year-old woman, in whom a partial thrombosis of the vena cava was observed in the CT scan when re-staging was performed after six cycles of R-CHOP because of high-grade malignant non-Hodgkin lymphoma. Before chemotherapy was started, the patient had undergone an operation of the lumbar spine using cement augmentation. Retrospective analysis showed that cement had penetrated a segmental vein and spilled into the vena cava leading to formation of an adhering blood thrombus. The patient was free of symptoms and anticoagulation was started. Spillage of cement frequently occurs in the process of vertebroplasty and kyphoplasty and may result in serious sequelae. As these procedures are increasingly being used, physicians should be aware of these complications if a patient presents with thrombosis of the caval vein or signs of pulmonary embolism.

[Acute haemoperitoneum due to spontaneous tumour rupture as first manifestation of hepatocellular carcinoma]. / Akutes Hämoperitoneum bei einer spontanen Tumorruptur als Erstmanifestation eines hepatozellulären Karzinoms.

HCC rupture with potentially fatal haemoperitoneum is not an infrequent complication of primary hepaotcellular carcinoma with a prevalence between 2.9 and 26 % and must be considered in the differential diagnosis in all patients with acute haemoperitoneum. Spontaneous tumour rupture is the most common cause, although the pathogenesis of it is not completely understood. Because of the high mortality of an emergency tumour resection, it appears that a two-stage treatment approach with emergency TAE and subsequent elective hepatic resection is the safest and most effective strategy for the management of this life-threatening situation. Despite all therapeutic efforts, the prognosis of this severe complication still remains poor. We report on a 82-year-old patient with spontaneous tumour rupture as the first manifestation of liver cell carcinoma. Our patient represents an exception because his spontaneous HCC rupture occurred without concomitant liver cirrhosis. According to our knowledge this case report is the first publication on spontaneous HCC rupture without pre-existing liver cirrhosis.