Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage.

GOALS: The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage. BACKGROUND: Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula. STUDY: We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test. RESULTS: In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage. CONCLUSION: CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.

Comprehensive Evaluation of Diagnostic and Treatment Strategies for Idiopathic Spinal Subarachnoid Hemorrhage.

BACKGROUND: Idiopathic spinal subarachnoid hemorrhage (IS-SAH), defined as spinal SAH without apparent cause, is extremely rare. The objective of the present study was to establish a consensus on the diagnosis and management of IS-SAH. METHODS: We enrolled 5 consecutive cases of IS-SAH at our institution, and we enrolled 19 previously published cases as a literature review. The patient presentations, diagnostic test findings, treatment strategies, and outcomes were retrospectively assessed. Possible causes of spinal SAH were basically excluded by multimodalities, including brain and spinal digital subtraction angiographies. RESULTS: IS-SAH usually developed in middle-aged people around 55 years old and typically presented with acute migrating back pain. Lumbar puncture and spinal magnetic resonance imaging demonstrated xanthochromia or an abnormal intensity area around the spine in all study patients who underwent these diagnostic tests. All of the patients from our institution were discharged with 1 patient (20%) complaining of neurologic dysfunction at discharge, and 1 patient (5.3%) in the published cases died during hospitalization and 5 (26.3%) complained of neurologic dysfunction at discharge. In addition, the surgical findings in 1 case from our institution suggested that one of the mechanisms of IS-SAH is a bleeding from a microvessel around the spine, and we newly propose spinal drainage as one of the treatment options in patients with IS-SAH based on our experience. CONCLUSIONS: We summarized our experience of 5 cases of IS-SAH with a literature review. We demonstrated that spinal drainage could be one of the treatment options in patients with IS-SAH.

Impact of Noninvasive Conservative Medical Treatment for Symptomatic Isolated Celiac Artery Dissection.

BACKGROUND: There is no definite consensus regarding the management of symptomatic isolated celiac artery dissection (ICAD), and the effect of conservative medical treatment has never been evaluated. METHODS AND RESULTS: We enrolled 13 consecutive symptomatic ICAD patients without signs of arterial rupture between 2006 and 2015. All patients received noninvasive conservative medical treatment. The epidemiology, radiological findings and prognostic effect of conservative medical treatment on outcomes were retrospectively assessed. ICAD usually developed in middle-aged men around 50 years old who had a history of smoking. The patients typically presented with acute continuous epigastric pain at rest and with abdominal tenderness on physical examination. On enhanced computed tomography at presentation, the false lumen was found to be double-barreled in 2 patients (15.4%), partially thrombosed in 1 (7.7%), and completely thrombosed in 10 (76.9%). Dissection of associated branches was found in the left gastric artery in 1 patient (7.7%), common hepatic artery in 5 (38.5%), and splenic artery in 7 patients (53.8%). Malperfusion was not found in the stomach or liver but was found in the spleen in 4 patients (30.8%). During a median follow-up period of 376 (165-602) days, all patients were alive without any antiplatelet, anticoagulant, endovascular or surgical treatment. CONCLUSIONS: Symptomatic ICAD without arterial rupture can be safely treated with conservative medical therapy over the short term. (Circ J 2016; 80: 1445-1451).

Baseline disease is a more important predictor of intestinal necrosis than CT findings in patients with acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a potentially fatal vascular emergency, and several computed tomographic (CT) findings have been introduced to determine the presence of intestinal ischemia or necrosis, although the most useful finding is unknown. METHODS: We retrospectively analyzed data of 43 consecutive patients with AMI who were treated during the period from 2006 to 2015. Study patients included both superior mesenteric artery dissection (n = 29) and thrombosis (SMAT, n = 14). Epidemiological data, CT findings, and the primary end point defined as the composite of intestinal ischemia or necrosis based on surgical finding and in-hospital mortality were investigated. The classification and regression tree was used to assess determinants of the primary end point, and area under the curve of receiver operating characteristics was used to evaluate discriminating accuracy. RESULTS: In total, the primary end point occurred in 27.9% (0.0% in superior mesenteric artery dissection and 85.7% in SMAT). Classification and regression tree demonstrated that the baseline disease was the only and strong determinant of the primary outcome (P< .001), which was also confirmed by the highest area under the curve of 0.968 (95% confidence interval, 0.924-1.000). CONCLUSIONS: The baseline disease rather than CT findings is the most important determinant of the primary end point. In patients with AMI, SMAT should undergo exploratory surgery and subsequent surgical treatment without delay.

Unusual Adverse Event of Tetanus: Rectus Sheath Hematoma.

Tetanus is a nervous system disorder characterized by muscular spasms and autonomic hyperactivity, such as unstable blood pressure. We herein report a case of tetanus in a patient in shock complicated with a rectus sheath hematoma caused by rupture of a pseudo-aneurysm of the inferior epigastric artery. A rectus sheath hematoma might be misdiagnosed as unstable blood pressure associated with autonomic hyperactivity, which is usually observed in patients with tetanus. The possibility of the occurrence of bleeding complications should be considered if a patient with tetanus has severe and persistent blood pressure reduction.

Association Between Converting Asystole From Initial Shockable ECG Rhythm Before Extracorporeal Cardiopulmonary Resuscitation and Outcome.

BACKGROUND: Initial electrocardiogram (ECG) rhythm is a predictor of outcomes in out-of-hospital cardiac arrest (OHCA) in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). However, ECG rhythm often changes before ECPR, and the consequence of this change remains unclear. This study aimed to assess the relationship between the conversion of ECG rhythm from initial shockable rhythm before ECPR and mortality. PATIENTS AND METHODS: This was a retrospective cohort study of OHCA patients with initial shockable rhythm who underwent ECPR between January 2010 and September 2020. Patients were classified into two groups: asystole (patients whose ECG rhythm converted to asystole at any time before initiating ECPR) and non-asystole (patients whose ECG rhythm did not convert to asystole at any time before initiating ECPR) groups. The primary outcome was in-hospital mortality. RESULTS: A total of 102 patients were included in the study; in-hospital mortality rate was 46.1% (n = 47) and 76 (74.5%) patients had unfavorable neurological outcomes (Cerebral Performance Category: 3-5). There were 33 and 69 patients in the asystole and non-asystole groups, respectively. The mortality rates in the asystole and non-asystole groups were 69.7% and 34.8%, respectively (P = 0.001). On multivariable analysis, the asystole group showed a significant association with mortality (odds ratio, 5.42; 95% confidence interval, 2.11-15.36; P < 0.001). CONCLUSION: Conversion to asystole before ECPR at any time in patients with OHCA is associated with mortality in patients with an initial shockable ECG rhythm.

[Case of caesarian section in a patient with a giant mediastinal tumor].

Administering anesthesia to a patient with a mediastinal tumor may lead to respiratory difficulty with relatively high morbidity and mortality. A 35-year-old pregnant woman with a large mediastinal tumor was scheduled for caesarian section. Chest roentgenography revealed a large mediastinal tumor. General anesthesia was selected to cope with possible worsening of dyspnea and coughing which could be more likely to occur during spinal anesthesia. Mechanical ventilation caused no trouble. When she started spontaneous breathing after the operation, dyspnea suddenly developed and SpO2 began to fall. Emergency bronchofiberscopy revealed almost total occlusion of the right main bronchus due to extrinsic compression.

Serial Follow-Up Evaluation With Computed Tomography After Conservative Medical Treatment in Patients With Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection.

OBJECTIVE: There is no detailed information available about trend in the morphological change after conservative medical treatment in patients with symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD). METHODS: We enrolled 27 consecutive patients with symptomatic SISMAD who underwent conservative medical treatment between 2006 and 2015. The long-term prognosis, natural history, and serial follow-up computed tomography (CT) findings of risk factors of rupture such as arterial diameter and false lumen enhancement were retrospectively assessed. RESULTS: Spontaneous isolated superior mesenteric artery dissection usually developed in middle-aged men around 50 years old who had a history of smoking. Follow-up CT was performed at 1 to 6 months, 7 to 12 months, and after 12 months. Superior mesenteric artery (SMA) maximum diameter was 10.3 mm (quartile 9.5-11.3) on initial CT and expanded in 47.1% patients during 1- to 6-month follow-up, which decreased over time ( P < .001 at 7- to 12-month follow-up, P = .001 after 12-month follow-up). On the other hand, false lumen enhancements were revealed in 9 (33.3%) patients on initial CT. The size of false lumen enhancement was expanded in the longest diameter in 35.3% patients and in shortest diameter in 29.4% during 1- to 6-month follow-up. However, the size of false lumen decreased in all patients after 12-month follow-up. All patients were alive without arterial aneurysm rupture and hospital readmission during the median of 523 days (170-799) study period. CONCLUSION: We demonstrated that both SMA maximum diameter and false lumen enhancement were transiently expanded in some patients during 6-month follow-up, but no longer expanded after 12-month follow-up. Patients with symptomatic SISMAD could be treated medically with scheduled careful follow-up CT evaluations.