Ceftriaxone-induced pancreatitis in a pediatric patient: case report.

We describe the first case of probable ceftriaxone-induced pancreatitis in a 2-year-old child. The patient was admitted to Santobono-pausilipon Children's Hospital with fever, vomiting and diarrhea and was treated with ceftriaxone 700 mg/day by intramuscular route. After the second administration of ceftriaxone, laboratory data revealed an increase in amylase. The patient's abdomen was mildly distended and diffusely painful. Drug-induced pancreatitis was considered and ceftriaxone was immediately discontinued, but after 24 hours laboratory data showed a further increase in amylase and an increase in lipase. Three days after interruption of ceftriaxone, the child's symptoms had improved. based on a) biochemical, clinical and instrumental parameters, b) criteria of drug-induced pancreas disorders and c) the Naranjo adverse drug reaction probability scale, we made a diagnosis of probable ceftriaxone-induced pancreatitis. To our knowledge, this is the first case report of probable primary ceftriaxone-induced pancreatitis in children.

[Role of sonography in the evaluation of parotid gland in HIV+ children undergone highly active antiretroviral therapy (HAART)]. / Ruolo dell'ecografia nello studio della ghiandola parotide in bambini HIV+ sottoposti a terapia farmacologica antiretrovirale combinata. (HAART: "Highly active antiretroviral therapy").

PURPOSE: To evaluate the role of sonography (US) in the evaluation of parotid gland alterations in HIV+ children, in order to show their presence, severity, specificity, relationship with clinical and laboratory data and sensitivity to new drugs. MATERIAL AND METHODS: From June 2000 to December 2000 twenty-two consecutive HIV+ children (12 males and 10 females, mean age 9.7) undergoing HAART were prospectively examined with US. A multi-frequency linear probe (7.5-10 MHz) was used for the examination. The glands were assessed for alterations in gland volume and vasculature, hypoechoic foci, hyperechoic striae, lympho-epithelial cysts and solid nodules and the enlargement of intraparotid and adjacent lympho nodes. The US findings on HIV+ patients were compared with the patients'clinical and laboratory data and with US exams performed on HIV- children. Finally, we made a comparison with US exams performed on the same patients before HAART: RESULTS: In HIV+ children the most frequent US findings were hypoechoic foci (68.2% of patients), hyperechoic striae (68.2%) and the enlargement of intraparotid and adjacent lympho nodes (86.3% and 95.4%, respectively). No relationship between US outline and clinical and laboratory data was found. In the control group (HIV-negative children) hypoechoic foci and hyperechoic striae were rare (4.7% and 14.3%, respectively), while the enlargement of intraparotid and adjacent lympho nodes was very common (76.2% and 100%, respectively). The comparison with US exams performed on the same patients before HAART showed an improvement in 59.1% of patients, no improvement in 13.6% and a worsening in 13.6% (3 patients were lost to follow-up). DISCUSSION AND CONCLUSIONS: US is useful in the study of parotid gland alterations in HIV+ children. The most frequent specific US findings were hypoechoic foci and hyperechoic striae, whereas the enlargement of intraparotid and adjacent lympho nodes was frequent but completely aspecific. The analysis of results did not show any relationship between the US findings and clinical and laboratory data. HAART can be correlated to an improvement and/or a stabilization of the US pattern in most patients.

Niflumic acid and cutaneous reactions in children.

In a case control study of adverse drug reactions in children, the odds ratio of developing a serious mucocutaneous event among users of niflumic acid, adjusted for concomitant use of all other drugs, was 4.9 (95% CI 1.9 to 12.8). Given the availability of safer analgesics and antipyretics, there is no indication, in our opinion, that requires the prescription of substances which bear an increased risk.

[Multiple prostatic biopsies in the "gray zone" of the specific prostatic antigen]. / La biopsia prostatica multipla nella "zona grigia" dei valori dell'antigene prostatico specifico.

PURPOSE: Aim of our study was to identify cases of undetected prostatic cancer in patients with normal findings at digital examination and transrectal US, and prostate specific antigen (PSA) values ranging 4-10 ng/mL. MATERIAL AND METHODS: Two hundred and ninety patients were submitted to transrectal US and random bilateral prostatic biopsy; 3 samples were collected from each side of the gland using 16-Gauge thru-cut needles. Of the 290 patients who gave fully informed consent, we selected 34 whose age ranged 56 to 76 years (mean: 64). Inclusion criteria were PSA 4-10 ng/mL, PSAD cut-off 0.15, free/total PSA ratio 15-25%, and normal findings at digital examination and transrectal US. PSA velocity was calculated collecting 3 blood samples every 30 days for 2 months. RESULTS: Five of the 34 selected patients (15%) had prostatic cancer, and 2 (6%) Pin (1 Pin 1 and 1 Pin 2). As for the other 27 patients, biopsy demonstrated 4 (12%) cases of prostatitis and 23 (62%) cases of BPH. PSA values increased in all patients with positive histology, versus only 6 (22%) of those with negative histology. PSAD was 0.15 or greater in 3 of 7 prostatic cancer patients. Free/total PSA ratio never exceeded the cut-off value. Gleason score ranged 2 to 4. CONCLUSIONS: Our findings confirm that prostatic biopsy can detect tumors also in areas which appear normal at transrectal US and digital examination, and that PSA rate increases in patients with positive histology. Finally, the actual clinical role of prostatic biopsy relative to all other diagnostic imaging techniques remains to be defined.

[Role of color Doppler echography in the visualization of perianal fistulae with injections of physiologic solutions]. / Ruolo dell'eco color Doppler nella visualizzazione delle fistole perianali mediante iniezione di soluzione fisiologica.

PURPOSE: To prove the diagnostic value of color Doppler US in the evaluation of perianal external fistulae, using an endocavitary probe and a saline solution injection, in order to show the location of the fistulae, their extension, possible secondary tracts, residual abscesses and the relationship with adjacent tissues. MATERIAL AND METHODS: From October 1999 to December 1999, thirty-five consecutive patients (21 males and 14 females, mean age 47.5) affected with Crohn's disease were examined prospectively. These patients presented postoperative recurring external perianal fistulae. From this first group, 10 patients (6 males and 4 females, mean age 45) were selected as the external fistula was open. A biplanar transrectal 7.5 MHz probe was used for the examination. First the external opening of the fistula was cannulated with a soft plastic catheter. Then the probe, covered with a lubricated condom filled with US gel, was introduced into the anal canal (males) or the vagina (females). An initial gray-scale US study was performed. Finally the color-box was positioned on the tract, the Pulse Repetition Frequency (PRF) adjusted and the saline solution introduced. The study was completed with axial and linear scans. RESULTS: The mean examination duration was 31 minutes. Only two patients found the examination annoying because of partial anorectal stricture. The wall layers and their thickness were clearly located and distinguished. Gray-scale US showed the local anatomy in all patients. In 4 patients it depicted the primary fistula as a thin hypoecoic line (40%, three intersphinteric and one transphinteric). Color Doppler US detected the fistula in all patients (100%, seven intersphinteric and three transphinteric). Moreover it showed 2 small secondary tracts in 2 patients. No abscesses were found at the time of the examination. In the patients who underwent a second operation, surgical findings showed a good correlation (90-100%) with color Doppler findings. DISCUSSION AND CONCLUSIONS: This study demonstrated a greater diagnostic value of endosonography with color Doppler and saline solution injection as compared to conventional gray-scale endosonography in the evaluation of fistulae. Since this technique is also cost-effective and well tolerated by most patients we conclude that at present it makes an important diagnostic tool in the preoperative assessment of perianal fistulae.

Tubercular epididymitis and orchitis: US patterns.

For several decades tuberculosis has been adequately under control in this country, but there has been recent concern that this disease might be coming back to the forefront, due to the influx of immigrants from developing countries where tuberculosis is still rampant. In the years to come we are expecting an increase in cases of genitourinary lesions of tubercular origin, a disease which had practically disappeared in the Western world. The aim of this pictorial essay is to provide an outline of the typical US images of tubercular epididymitis and orchitis.

US and CT findings of small bowel neoplasms.

Small bowel (SB) neoplasms are very rare tumours, but are still associated with high mortality rates, since the tumour-related symptoms occur late and are non-specific. In addition, endoscopy is not feasible in most cases, and radiological contrast studies do not reach the high accuracy obtained in the evaluation of upper and lower gastrointestinal tract. Cross-sectional imaging, and particularly CT, is becoming increasingly relevant in the diagnosis of these tumours. Both US and CT allow tumour detection, even when performed on an emergency basis, and are capable of showing the lesion as well as possible complications. Moreover, CT offers the possibility of a preoperative staging by evaluating tumour extension through the bowel wall, lymph node involvement and possible metastases. Finally, in most cases a direct correlation between cross-sectional findings and histology can be found, thus permitting tumour characterisation.

[Ultrasonography in the preoperative assessment of candidates for laparoscopic cholecystectomy: examination technique and results]. / L'ecografia nella valutazione preoperatoria dei pazienti candidati a colecistectomia laparoscopica: tecnica d'esame e risultati.

Laparoscopic cholecystectomy needs a more specific preoperative diagnostic approach than open cholecytsectomy. We investigated the role of US in the preoperative assessment of patients candidate to laparoscopic cholecystectomy. Two hundred patients were examined and then submitted to laparoscopic cholecystectomy regardless of US results: the surgical approach had to be changed from laparoscopy to laparotomy only in 10 of them. We focused our study on two major parameters to reduce the surgical risk: the anatomical study of the so-called "Calot's triangle" (the hepatic artery, common duct and cystic duct) and the study of the gallbladder bed and of pericystic structures. In the study of gallbladder walls and bed, US had high sensitivity (100%) and diagnosed no false negatives and 11 false positives of pericholecystitis (94.5% specificity), with a trend toward overstaging; in these 11 cases, gallbladder wall thickening was seen but the organ was not particularly difficult to remove at surgery. In cystic duct studies, we correctly diagnosed 6 abnormalities (3 cystic duct stones, 2 anatomical variants and 1 anatomical variant plus stone), with no false-positive and 2 false-negative diagnoses of abnormal insertion (75% sensitivity and 100% specificity). The common duct was shown along its whole course in 80% of cases; both sensitivity and specificity were 100% in dilatation detection, while the presence of stones was diagnosed with 70% sensitivity and 100% specificity.

The role of preoperative investigations in predicting difficult laparoscopic cholecystectomies. Results in 200 consecutive cases.

BACKGROUND: When we began laparoscopic cholecystectomy (LC) we set up a strict preoperative workup in order to assess whether currently available investigations could help predict difficult laparoscopic procedures. METHODS: Reported here are the results of a prospective trial carried out in our first 200 consecutive patients, who underwent routine intravenous cholangiography (IVC), abdominal ultrasound scan (US), blood tests-namely, markers of biliary stasis (MBS)-and preoperative endoscopic retrograde cholangiopancreatography (ERCP) in case of clinically suspected common bile duct stones (CBDS). RESULTS: On the basis of our experience we think that the US findings relate to the difficulty of the laparoscopic procedure more closely than the other preoperative investigations, and the association of US and liver chemistry provides an accurate evaluation of biliary stones. CONCLUSIONS: In agreement with data emerging from the literature, the preoperative investigations do not seem to be useful in predicting biliary and vascular complications, whose prevention lies in the adoption of correct surgical technique and a low threshold for conversion.

Laparoscopic sonography during abdominal laparoscopic surgery: technique and imaging findings.

Laparoscopy is becoming the preferred approach for managing several abdominal disorders. The main limitations of laparoscopic surgery and diagnostic laparoscopy are the loss of the surgeon's tactile feedback and the inability to undertake a complete internal evaluation of solid parenchyma. Probes for laparoscopic sonography have been introduced to compensate for the limitations of laparoscopic surgery and to increase the diagnostic efficacy of laparoscopy [1]. In this article we describe our experience with laparoscopic sonography and illustrate the normal anatomic findings and some applications in biliary surgery and other abdominal laparoscopic procedures.

[Budd-Chiari syndrome in children: case report]. / Sindrome di Budd-Chiari in età pediatrica. Descrizione di un caso.

This work aims at describing a particular case of Budd-Chiari syndrome in a ten-year-old girl. In our patient, the subjective and objective features of this disease, which is already rare during childhood, are associated with a well-assessed polyposis in the blind intestine (intestinum caecum). In our opinion, a possible connection between these two pathological events, a connection unheard of in the literature so far, is an interesting issue to be dealt with in this case report. The follow-up of our patient took place at the Pediatric Hospital of the University of Rome "La Sapienza" and lasted an overall period of 6 months. The girl was hospitalized twice and she underwent a large number of radiological and laboratory tests. The therapy consisted only of medical treatment and support measures. Liver transplant is regarded as the only chance to obtain a full recovery, but it has not yet been performed on our patient. It is by comparing those researches carried out on similar cases with the outcome of our personal study, that we come to the conclusion that, as for our patient, the Budd-Chiari syndrome can be classified as an idiopathic syndrome. Moreover, the fact that this syndrome and the polyposis of caecum occur at the same time in a patient can probably be considered as a coincidence.

[Diagnostic imaging in the evaluation of pelvic complications in intestinal diseases]. / Diagnostica per immagini nella valutazione delle complicanze pelviche da malattie intestinali.

During 12 consecutive months, 680 patients with recent pelvic symptoms were examined with ultrasonography (US). In 44 patients we found evidence of intestinal disease; 19 of them exhibited pelvic complications--11 pelvic abscesses, 3 enterovesical fistulas, 2 enterovaginal fistulas and 1 enterovesicle fistula; in 11 cases the inflammation spread to the surrounding organs. Of these 19 patients, 8 had an intestinal disease in their case history, whereas symptom onset was recent in the other 11 patients. In the latter group US yielded the first diagnostic information showing a bowel disease and other diagnostic examinations with different techniques were therefore performed. In 15 patients US indicated which type of bowel disease had caused the pelvic complications, while in 4 patients US showed a bowel disease without differentiating diverticular disease from neoplasms. In all patients US results were compared with X-ray and CT findings. In 17 patients the diagnoses were confirmed at surgery. The results we obtained from this study indicate US as an accurate method to detect not only the various pelvic conditions but also to differentiate pelvic complications of intestinal conditions from diseases originating in the pelvic organs.

[Transrectal echography in the assessment of anastomosis and local recurrence after prior resection]. / L'ecografia transrettale nella valutazione dell'anastomosi e delle recidive locali dopo resezione anteriore.

The value of rectal endosonography was investigated in the follow-up of the patients submitted to anterior resection for rectal cancer. Rectal endosonography was performed on 42 patients who had been operated on two months to five years before; all patients were monitored according to a carefully planned follow-up schedule including clinical and instrumental examinations and laboratory tests. Sixteen patients had altered clinical and laboratory data; 26 were completely asymptomatic. In the latter group, no signs of local recurrences were found, while in 4 cases the rectal wall appeared homogeneously thickened and hypoechoic: this pattern was due to postoperative or post-irradiation hyperemic-edematous phenomena. In 14 of 16 symptomatic patients, a mass was detected--in 9 of them inhomogeneous and hypoechoic and developing mainly in the perirectal perianastomotic tissue and in 5 limited to the rectal wall, in the anastomotic area. In the last 2 cases, no lesions were found. Both the manual and the stapler anastomoses were always demonstrated, which exhibited different US patterns. US findings were compared with histologic results or were clinically checked in the subsequent follow-up. To conclude, rectal endosonography proved to be useful in the postoperative follow-up of this kind of patients even though it did not allow the differential diagnosis between fibrosis and local recurrence.

The hepatic malignant mesenchymoma: a case report.

We report a case of hepatic mesenchymoma in an 8-year-old girl who presented with abdominal pain and ultrasonographic diagnosis of hepatic echinococcosis. Due to the good general condition of the patient and the diagnostic confirmation of liver hydatid disease by the CT scan, antiparasitic therapy with albendazole was started. After 1 month of therapy the girl's general condition worsened as did the ultrasonographic picture. On laparatomy a large cystic mass was observed within the right hepatic lobe and was removed. Pathological examination of the mass excluded an echinococcal cyst and demonstrated a malignant hepatic mesenchymoma.

[Tuberculous inflammation of the testicle: characteristic echographic picture]. / Le flogosi tubercolari del testicolo: quadri caratteristici in ecografia.

During the last 3 years (1987/1990) the authors have performed 562 ultrasound studies of the scrotum in patients ranging 6 months to 76 years of age. All patients were referred with a non-specific clinical suspicion of scrotal pathologies. Only 214/562 patients presenting with signs and symptoms of scrotal inflammation were considered for this study. Among this group of 214 patients, 34 cases of tuberculous epididymo-orchitis were identified. The remaining 180 patients were classified as follows: non-specific inflammation 141, other non inflammatory pathology 39. In the group with findings of tuberculosis, all stages of disease were identified, including miliary forms as well as nodular forms. The patients were closely followed during medical therapy or until surgery was performed to study the course of the disease. For each form of disease specific US findings and differential diagnostic criteria were recognized and will be illustrated in this paper. All diagnosis of tuberculosis were confirmed either at surgery or on the basis of successful response to specific chemotherapy. US diagnosis based on the morphologic and echo texture criteria allowed high diagnostic accuracy: in fact in the whole group of 214 patients with inflammatory disease there were only 1 false positive and 1 false negative diagnoses with a sensitivity of 96.9%, a specificity of 89.9% and a diagnostic accuracy of 98.85%. The paper also stresses the importance of US in the short- and long-term follow-up of the patients undergoing medical therapy.

[Echographic aspects of kidney diseases and comparisons with needle biopsy]. / Aspetti ecografici delle nefropatie mediche e confronti con agobiopsia.

A study of 38 patients who underwent renal biopsy was designed to correlate the sonographic features of the kidney with the histologic changes in various renal parenchymal diseases. This research was performed in order to determine if sonography could be useful in the diagnosis and differentiation of renal parenchymal diseases. The ultrasound examination was based on the evaluation of some codified parameters: renal dimension, parenchymal thickness, cortical echogenicity and medullary dimension. There was no correlation between the specific sonographic features and the type of renal medical disease. In 28 patients (74%) with clinical and histological signs, sonography showed morphostructural alterations of the kidney.

[Role of ultrasonic tomography in the diagnosis of prostatic cysts. Our experience in l3 cases]. / Il ruolo dell'ecotomografia nella diagnosi delle cisti prostatiche. Nostra esperienza in 13 casi.

Authors describe the radiological and echographic methods of investigation of cystic structures in the prostate, remarking the great importance of echotomography. They relate upon their experience in 13 cases of prostatic cyst, a pathological condition which is still poorly known.