Iron deficiency anaemia over the last decades - Osler's disease diagnosed by Doppler and contrast-enhanced ultrasound.

CASE REPORT: A 72-year-old woman with a 30-year history of iron deficiency anaemia was admitted for fatigue and increasing weakness. On physical examination, the patient appeared dyspneic and pallor. The tongue showed angiodysplasias. Laboratory analysis showed a microcytary anaemia with an iron deficiency. Firstly a routine ultrasound examination (iU22, Philips Medical Systems) was performed. A left accessory artery, a dilated common hepatic artery and ectatic tortuous intrahepatic liver arteries were found. A contrast-enhanced ultrasound (CEUS) detected two intrahepatic arteriosystemic shunts in the left liver lobe. Endoscopy revealed multiple angiodysplasias of the stomach and the duodenum, 4 isolated angiodysplasias in the colon and telangiectasias in the oropharyngeal region. The angiodysplasias were treated with argon plasma coagulation. Osler's disease was diagnosed based on the Curacao criteria. CONCLUSION: Transabdominal B-mode sonography in combination with colour Doppler, pulsed wave Doppler and contrast-enhanced ultrasound is a very important tool to detect hepatic vascular malformations. It is an excellent procedure for the screening of patients with an iron deficiency anaemia. For the first time, we have demonstrated CEUS as an additional approach in the diagnosis of liver involvement in patients with Osler's disease.

[Ultrasonographic diagnosis of a biliary-digestive fistula with gallstone ileus]. / Sonographische Diagnose einer biliodigestiven Fistel mit Gallensteinileus.

HISTORY AND CLINICAL FINDINGS: A 72-year-old woman was admitted to the hospital with upper abdominal pain, nausea, vomiting, and obstipation. INVESTIGATIONS: Percutaneous ultrasound found aerobilia, a biliary-digestive fistula, and an ileus with gallstones within the small bowel. The findings were confirmed at computed tomography. TREATMENT AND COURSE: A gallstone ileus on the basis of a biliary-digestive fistula was diagnosed. The patient was treated by surgery and with antibiotics. CONCLUSION: This case report demonstrates that percutaneous ultrasonography should be used as the first imaging procedure in the diagnosis of acute abdominal pain. This procedure makes it possible to detect a gallstone ileus. It is important also to define various intestinal structures accurately.

Severe gastrointestinal disease due to HIV-1-seronegative AIDS.

An HIV-1 seronegative man presented with odynophagia, dysphagia, diarrhea, tenesmus and a 50-lb weight loss. A large esophageal ulcer and a rectal fissure were identified endoscopically. Stool samples and biopsy specimens from the esophageal ulcer, duodenum, colon and rectum were negative for pathogens. Seronegative AIDS was suspected, and high levels of HIV-1 mRNA (> 242,000 copies/mL) were detected. The esophageal ulcer responded to oral steroids and the HIV-1 infection to highly active anti-retroviral therapy (HAART). The virus isolated from the patient and an HIV-1 seropositive, asymptomatic, female sex worker with whom he had recently terminated a one-year heterosexual relationship showed sequence homology, indicating her as the source of his virus. The unusual presentation of severe gastrointestinal disease in an HIV-1 seronegative man with HIV-1 viremia underscores the importance of including AIDS in the differential diagnosis of wasting syndrome (i. e., B-type symptoms such as fever, night sweats, weight loss) in patients who are HIV-1 seronegative but at risk for AIDS.

Feasibility of double-balloon enteroscopy-assisted chromoendoscopy of the small bowel in patients with familial adenomatous polyposis.

BACKGROUND AND STUDY AIMS: Patients with familial adenomatous polyposis (FAP) are at increased risk of developing duodenal and jejunal adenocarcinomas. The aim of this study was to assess the usefulness of double-balloon enteroscopy- (DBE-) assisted chromoendoscopy for the detection and characterization of small-bowel polyps in patients with FAP. PATIENTS AND METHODS: We performed a prospective evaluation of patients with clinically and genetically proved FAP who were enrolled in an endoscopic surveillance program. DBE was performed using a Fujinon intestinoscope (FN 450P 5/20; Fujinon Corp., Omiya, Japan), and chromoendoscopy was performed using indigo carmine. The severity of small bowel polyposis was based on the Spigelman-Saurin classification. RESULTS: Nine patients underwent DBE-assisted chromoendoscopy. Small-bowel polyps (including papillary adenomas) were detected in seven patients (88 %). The mean depth of small-bowel insertion was 180 cm (range 120-320 cm). The mean Spigelman-Saurin score was 4.6 (range 0-8). Jejunal polyps were detected in six patients (67 %). Chromoendoscopy aided in the detection of additional polyps in two patients. In one patient the polyps were flat and only visible with chromoendoscopy (biopsy confirmed these to be adenomas). Jejunal polyps and advanced neoplasms were more frequent in patients with APC gene mutations in exon 15. The following endoscopic therapies were performed: polypectomy (n = 1), duodenal mucosectomy (n = 1), and ablation therapy with argon plasma coagulation (n = 2). CONCLUSIONS: DBE was found to be a helpful method for the evaluation of small-bowel polyps in patients with FAP. DBE-assisted chromoendoscopy was of further assistance for the detection of jejunal polyps.

[Sonographic diagnosis of a liver abscess caused by an enterohepatic fistula in a patient with Crohn's disease]. / Sonographische Diagnose eines Leberabszesses infolge einer enterohepatischen Fistel bei einem Patienten mit Morbus Crohn.

Liver abscesses in patients with Crohn's disease are rare. We report on a patient with Crohn's disease and a liver abscess of the left lobe caused by an enterohepatic fistula. With treatment of antibiotics and Infliximab the abscess showed complete regression. Percutaneous drainage of the liver abscess was not performed because the abscess was shown not to be completely liquefied at echo-enhanced ultrasound. This case report demonstrates the usefulness of percutaneous conventional and echo-enhanced ultrasound for the diagnosis of liver abscesses. Furthermore, this case also shows that enterohepatic fistulas can be diagnosed precisely with percutaneous ultrasound.

Enfermedad de Crohn asociada a arteritis de Takayasu / Crohn's disease associated with Takayasu's arteritis

Paciente de sexo femenino, de 26 años de edad, portadora de enfermedad de Crohn (EC) se presenta con aumento de su dolor abdominal, frémito abdominal y disminución de los pulsos periféricos. La tomografía computada y la arteriografía revelaron estenosis oclusivas que incluían las arterias subclavia izquierda, celíaca, renal y mesentérica superior, así como también aorta abdominal. Estos hallazgos son consistentes con arteritis de Takayasu. La paciente fue revascularizada para sortear las lesiones oclusivas de las arterias celíaca y mesentérica superior y las estenóticas de la aorta abdominal. Controles posteriores demuestran que la paciente permanece asintomática desde el punto de vista cardiovascular a los 3 años de la cirugía, habiendo presentado un empuje de su enfermedad inflamatoria intestinal.

A 26-year-old woman with Crohn's disease presented with increase of her abdominal pain, abdominal fremitus and decrease in peripheral pulses. The CT scan and the angiography revealed occlusive stenosis of several arteries: left subclavian, celiac, renal, superior mesenteric and abdominal aorta. This findings were consistent with Takayasu's arteritis. The patient underwent surgical revascularization to bypass the occlusive lesions in celiac and superior mesenteric arteries, and the stenosis in abdominal aorta. Subsequent controls showed that she remains free of cardiovascular symptoms three years after surgery but presents progression of her inflammatory bowel disease.

Comparison of 13C- urea blood test to 13C-breath test and rapid urease test for the diagnosis of Helicobacter pylori infection / Comparación entre el test de urea marcada con 13C- en sangre, test de urea marcada con 13C- en aire espirado y el test rápido de ureasa para el diagnóstico de la infección por Helicobacter pylori

At present, the available methods to diagnose active H. pylori infection are endoscopy with biopsy for histology, culture, rapid urease tests, 13C or 14C urea breath test, urine antibody and the stool antigen test. The aims of this study were to simplify the 13C urea test by measuring 13C in blood rather than breath, and to evaluate the usefulness of the 13C urea blood test for the diagnosis of H. pylori infection. Patients who underwent upper endoscopy for standard clinical indications (e.g. dyspepsia, abdominal pain) were enrolled. A total of 161 patients (93F, 68M, mean age 47 +/- 14.2) were evaluated; 50 (31%) of them were H. pylori positive, and 111(69%) were H. pylori negative. H. pylori infection was diagnosed with a rapid urease test (CLO-test) and 13C urea breath test (UBT). Performance characteristics for the 13C urea blood test for diagnosis and evaluation of H. pylori eradication were calculated using UBT and CLO as gold standards. The fifty H. pylori-positive patients were treated with triple antibiotic therapy for two weeks. Four weeks after finishing antibiotic therapy patients were retested with a commercial UBT and urea blood test. The 13C blood test had sensitivities of 92 and 98% and specificities of 96 and 100% as compared with urea breath test and CLO, respectively. We conclude that the 13C urea blood test is highly sensitive and specific for the initial diagnosis and control of eradication of H. pylori infection.

Los métodos diagnósticos disponibles para la identificación de la infección activa por H. pylori son endoscopia con biopsia para histología, test rápido de ureasa y/o cultivo, test del aire espirado con urea marcada con 13C o 14C, anticuerpos anti- H. pylori en orina y test de antígeno en materia fecal. La finalidad del presente estudio fue simplificar el test de aire espirado con urea marcada con 13C, midiendo 13C en sangre en vez de en el aire espirado y evaluar su eficacia para el diagnostico de la infección por H. pylori. Pacientes a los que se les realizó esofagogastroduodenoscopía con indicaciones de dispepsia y/o dolor abdominal fueron incluidos en el estudio. 161 pacientes (93 del sexo femenino y 68 masculino, edad media 47±14.2) fueron evaluados; 50 (31%) de ellos fueron H. pylori positivos, y 111 (69%) fueron negativos. La infección por H. pylori fue diagnosticada con test rápido de ureasa y test del aire espirado on urea marcada con 13C. Usando estos tests como referencia, se evaluó la eficacia del test de sangre con urea marcada con 13C para el diagnóstico y evaluación de la erradicación del H. pylori. Los 50 pacientes positivos para la infección con H. pylori fueron tratados con triple plan de antibióticos por 2 semanas. Cuatro semanas luego de finalizado dicho tratamiento, los pacientes fueron nuevamente testeados con test de aire espirado con urea marcada con 13C y urea marcada con 13C en sangre. El test en sangre con urea marcada con 13C tuvo sensitividad de 92% y 98% y especificidad de 96% y 100% comparado con UBT y test de ureasa respectivamente. Concluimos que el test en sangre con urea marcada con 13C es altamente sensible y especifico para diagnostico inicial y control de la erradicación de la infección por H. pylori.

Differentiation of cystic pancreatic lesions by echo-enhanced sonography with pulse inversion imaging - presentation of case reports.

UNLABELLED: Echo-enhanced sonography is useful for differential diagnosis of pancreatic tumours. We present several criteria for the differentiation of cystic pancreatic lesions with this procedure using three selected patients. Cystadenomas frequently show many vessels along the fibrotic strands. On the other hand, cystadenocarcinomas are poorly and chaotically vascularised. "Young pseudocysts" frequently show a highly vascularised wall. However, the wall of "old pseudocysts" is poorly vascularised. CONCLUSION: Cystic pancreatic masses have a different vascularisation pattern when examined by echo-enhanced sonography. These characteristics can be useful for their differential diagnosis, but histology is still the "gold standard."

[Benign or malignant thrombosis of the jugular vein? - Differentiation with colour-Doppler sonography]. / Benigne oder Maligne Jugularvenenthrombose? - Dopplersonographische Unterscheidung.

Thrombosis can lead to physical impairment and cost-intensive investigations. In some cases, a thrombosis is caused by infiltration of an adjacent tumour. It is therefore important to differentiate between a benign or malignant thrombosis. We report the case of a woman with a malignant thrombosis of the jugular vein. She was hospitalised for suspected malignant disease of unknown origin. Her family doctor had made the diagnosis of a "partially organised thrombosis". At sonography, vessels with an arterial blood flow were detected in the thrombus. A carcinoma of the thyroid gland was therefore suspected and confirmed by histology. This case report demonstrates that the differentiation between a benign and malignant thrombosis is possible with colour-Doppler sonography.

[Ptosis and ophthalmoplegia as predominant signs of multiple myeloma]. / Ptosis und Ophthalmoplegie als Leitsymptome eines multiplen Myeloms.

HISTORY AND ADMISSION FINDINGS: A 59-year-old woman was diagnosed as having solitary bone plasmacytoma of the sternum which was resected. Five month later she presented with a pathological fracture of the clavicle. On examination she had a ptosis and an ophthalmoplegia. INVESTIGATIONS: A mass in the clivus extending into the left sphenoid sinus as well as multiple osteolytic lesions in the skull were shown by cranial MRI. Skeletal survey showed multiple osteolytic lesions. Laboratory test did not show any specific abnormalities. DIAGNOSIS, TREATMENT AND COURSE: The biopsy taken from the mass at the sphenoid sinus demonstrated plasmacytoma. The diagnosis of multiple myeloma was based on the histological evidence of plasmacytoma and the occurrence of multiple lytic bone lesions although no infiltration of bone marrow and none of the specific laboratory findings were present. The patient underwent local radiotherapy with 30 Gy followed by systemic chemotherapy. The symptoms regressed completely under this therapy. CONCLUSION: Various cranial nerve syndromes such as the superior orbital fissure syndrome are most often caused by tumors at the skull base. Knowledge of the histological entity is essential for the correct diagnosis and the appropriate therapy because rare tumors like multiple myeloma may also cause such syndromes.