Post-Traumatic Retroperitoneal Hematoma Caused by Superior Rectal Artery Pseudoaneurysm.

BACKGROUND Pseudoaneurysms are a known pathology commonly recognized after disruption of the vascular wall leads to the development of a hematoma. Although pseudoaneurysms are common, occurrence in the location of the superior rectal artery is exceedingly rare, has been documented in the literature only 7 times, and can be extremely dangerous. Patients can present with vague abdominal complaints, pain, gastrointestinal bleeding, and development of hematomas, and can progress to hemodynamic instability related to hypovolemia. This phenomenon requires swift recognition and patient management, as well as stabilization, to achieve desired results and minimize morbidity and mortality. CASE REPORT We report the case of a 79-year-old man who presented after minor trauma with gastrointestinal bleeding and was diagnosed with a retroperitoneal hematoma. Although he was stabilized and discharged, conventional angiography diagnosing and treating his causative superior rectal artery pseudoaneurysm was not completed until a second traumatic event resulted in recurrent presentation with worsened symptoms and retroperitoneal hematoma enlargement. CONCLUSIONS Superior rectal artery pseudoaneurysm is a rarely-reported phenomenon, usually occurring after a traumatic event. It can lead to significant anemia, hypovolemic shock, blood transfusion, and other serious consequences. It can be difficult to diagnose given its location and obscurity. However, upon diagnosis, swift treatment is recommended, for which a variety of both surgical and endovascular approaches have been employed to prevent exsanguination.

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

INTRODUCTION: Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. METHODS: This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. RESULTS: Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. CONCLUSIONS: The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Potential sites of virus latency associated with indigenous pseudorabies viruses in feral swine.

Free-ranging feral swine (Sus scrofa) are known to be present in at least 32 states of the USA and are continuously expanding their range. Infection with pseudorabies virus (PRV) occurs in feral swine and the primary route of transmission in free-living conditions seems to be venereal. Between 1995 and 1999, naturally infected feral swine and experimentally infected hybrid progeny of feral and domestic swine, were kept in isolation and evaluated for occurrence of latent PRV indigenous to feral swine in sacral and trigeminal ganglia and tonsil. Sacral ganglia were shown, by polymerase chain reaction (PCR) amplification of the thymidine kinase (TK) gene of PRV, to be the most frequent sites of latency of PRV. Nine (56%) of 16 sacral ganglia, seven (44%) of 16 trigeminal ganglia, and five (39%) of 13 tonsils from naturally infected feral swine were positive for PCR amplification of TK sequences of PRV. These tissues were negative for PRV when viral isolation was attempted in Vero cells. DNA sequencing of cloned TK fragments from the sacral ganglia of two feral swine, showed only one nucleotide difference between the two fragments and extensive sequence homology to fragment sequences from various domestic swine PRV strains from China, Northern Ireland, and the USA. The hybrid feral domestic swine, experimentally inoculated with an indigenous feral swine PRV isolate by either the genital or respiratory route, acquired the infection but showed no clinical signs of pseudorabies. Virus inoculated into either the genital or respiratory tract could, at times, be isolated from both these sites. The most common latency sites were the sacral ganglia, regardless of the route and dose of infection in these experimentally infected hybrids. Nine of 10 sacral ganglia, six of 10 trigeminal ganglia, and three of 10 tonsils were positive for PCR amplification of TK sequences. No virus was isolated from these tissues in Vero cells. The demonstration of the sacral ganglia as the most common sites of latency of pseudorabies viruses indigenous to feral swine, supports the hypothesis that these viruses are primarily transmitted venereally, and not by the respiratory route as is common in domestic swine, in which the trigeminal ganglia are the predominant sites of virus latency.

Reflux anuria after prophylactic ureteral catheter removal: a case description and review of the literature.

In an attempt to reduce iatrogenic ureteral injury, urologists are frequently called on for placement of prophylactic ureteral catheters in difficult pelvic surgeries. Reflux anuria, which may be more appropriately termed catheter-induced obstructive anuria, has been reported as a complication of ureteral catheter placement and is characterized by the absence of urine output after ureteral manipulation because of edema and obstruction. We report a case of obstructive anuria after bilateral ureteral catheter removal and review the literature regarding this rare complication. Medline was searched for all relevant case reports, case series, and trials that included prophylactic ureteral catheters and described complications of their use. Published series report varying incidence of obstructive anuria after prophylactic ureteral catheter removal from 0% to 7.6%. There are no proven strategies for prevention of obstructive anuria after prophylactic ureteral catheter removal, but staged removal has shown a trend toward reduced incidence. When encountered, most cases of anuria after catheter removal resolved with medical management alone; however, indwelling stent placement has been advocated while ureteral edema resolves.