Severe early onset preeclampsia secondary to bilateral ureteral obstruction reversed by stenting.

BACKGROUND: Severe early onset preeclampsia might be reversed by correction of an underlying pathophysiologic condition. CASE: A 22-year-old nullipara with a history of antivesicoureteral reflux surgery in childhood presented at 23 weeks' gestation with severe headaches, hypertension, proteinuria, edema, and acute renal failure. Severe preeclampsia was diagnosed, and bilateral distal ureteral obstruction was documented by cystoscopy, fluoroscopy, and retrograde pyelography. Bilateral ureteral stent placement completely resolved the preeclampsia and prolonged pregnancy until term. CONCLUSION: Pregnant women with a history of antireflux surgery in childhood might be at risk for acute renal failure and severe preeclampsia caused by bilateral ureteral obstruction. Ureteral stent placement might reverse obstruction, renal failure, and preeclampsia.

[Postoperative recurrent ulcer after gastric resection--results of surgical treatment]. / Postoperatives Rezidivulcus nach Magenresektion--Ergebnisse der chirurgischen Behandlung.

Within a 10-year period, 50 patients with postoperative ulcer recurrence after gastric resection were treated; 31 of these had one, 8 two, 5 three and 6 four previous gastric operations. Ulcer recurrence was attributed to surgery-related causes in 78% of the cases; excessively large gastric remnant 56%, anastomotic stenosis 18%, loop problems 4%. Some 22% of the patients had causes independent of previous surgery: abuse of non-steroidal antirheumatics (NSAR) 10%, hyperacidity of normal gastric remnant 6%, Zollinger-Ellison-Syndrome 6%. The most important co-factor of ulcer genesis was chronic abuse of NSAR (38% of the total series). The interval between onset of complaints of ulcer disease and the last ulcer-dependent operation amounted on average to 13.8 (0.5-36) years. The definitive treatment of recurrent ulceration was surgery in 34 cases-indicated by ulcer complications (73.5%) or failure of medical therapy (26.5%)-and conservative treatment in 16 cases. Surgery comprised 21 re-resections, 7 thoracic truncal vagotomies 4 total gastrectomies 1 Whipple procedure and 1 enucleation of gastrinoma (hospital mortality 0%). During the follow-up period (median 7.1 years, follow-up rate 96%), the cumulative ulcer re-recurrence rate was 57% for the conservatively treated group and 17.6% for the patients treated by surgery (p < 0.05). In none of the eight patients who died during long-term follow-up was the cause of death ulcer-related.

[Radioiodine therapy of functional autonomy of the thyroid gland. Treatment results in view of pretreatment scintigraphic diagnosis and early response of triiodothyronine levels to treatment]. / Die Radiojodtherapie der funktionellen Schilddrüsenautonomie. Behandlungsergebnisse unter Berücksichtigung der Autonomieform und des frühen posttherapeutischen Trijodthyroninspiegels.

AIM: The goal of this retrospective study was to evaluate the results of radioiodine therapy of thyroid autonomy with respect to the underlying scintigraphic pattern, administered I-131 doses and pretherapeutic Tc-99m and I-131 uptake. Furthermore, early post-therapeutic free triiodothyronine (FT3) levels were measured during the first 6 weeks after radioiodine therapy with respect to a FT3-increase. PATIENTS AND METHODS: Thyroid autonomy in 632 patients was followed for at least 3 months (mean 10.9 months). The patients were divided into several groups based on scintigraphic pattern of unifocal (UA), a multifocal (MFA), a focal/disseminated (FDA) and a disseminated (DA) autonomy. The early effects of therapy on thyroid function were assessed by evaluation of FT3 values of 786 patients during the 1st, 2nd, 3rd, 4th and 6th week after therapy. RESULTS: Successful elimination of thyroid autonomy as defined by normalization of FT3 and TSH levels was observed in 92.1% (582/632) of the patients. In 2.2% (14/632) of the patients, immunogenic hyperthyroidism following I-131 therapy was observed. There was no significant difference in the success rates in patients with UA and MFA of 94.9% and 96.1%, respectively, using similar target doses based on the amount of autonomous tissue. The success rate in MFA (96.6%) was similar if target dose was calculated based on the volume of the whole thyroid gland. Compared to MFA (96.6%), however, FDA and DA were associated with significantly lower success rate with 82.7% and 75.5%, respectively, although the target doses were not significantly different. Considering the quantitative Tc-99m uptake prior to therapy, there was no significant difference in the success rate for Tc-99m uptake < or = 3% and > 3%, while the success rate in patients with I-131 uptake of < or = 50% was significantly higher (p = 0.032) than in those with an uptake of > 50%. The determination of FT3 levels during the first 6 weeks after radioiodine therapy revealed a dependence of the FT3 decrease and FT3 increase on the scintigraphic pattern and thyroid function. Patients with FDA and DA with hyperthyroidism showed an increase of FT3 (> 2 to 14.7 pmol/l) in 11 to 18% of the cases, during the first 2 weeks after therapy which occurred significantly more frequently in patients with FDA and DA than in UA and MFA. A similar increase in FT3 level in patients with FDA and DA compared to patients with UA and MFA was observed in 317 patients with euthyroid pretherapeutic hormone levels. A decrease in FT3 level following radioiodine therapy was observed significantly more often and earlier in patients with UA and MFA with hyperthyroid values than in patients with FDA and DA during the first 6 posttherapeutic weeks. Concerning patients with euthyroid FT3 levels, the decrease in FT3 level was observed significantly more frequently in patients with UA and MFA only after 6 weeks following radioiodine therapy. CONCLUSION: In contrast to the multifocal autonomy (MFA), the target dose of 150 to 200 Gy based on total thyroid volume did not result in a comparably high success rate of approximately 95% in disseminated and focal/disseminated types of thyroid autonomy. Therefore, an increase of target dose of 200 to 300 Gy is recommended. The transient FT3 increase particularly observed in FDA and DA in the first weeks following radioiodine therapy makes short-term controls of thyroid function necessary, especially in patients with cardiac risk, in order to initiate necessary therapy.

Effects of vaginal hysterectomy on anorectal sensorimotor functions--a prospective study.

BACKGROUND: While bowel and bladder dysfunction are recognized consequences of a radical hysterectomy, the effects of a simple hysterectomy on anorectal sensorimotor functions, particularly rectal sensation, vary among studies and the effects on rectal compliance remain unknown. Our aims were to prospectively evaluate anorectal sensorimotor functions before and after a hysterectomy. METHODS: Anal pressures, rectal compliance, capacity, sensation, and bowel symptoms were assessed before, at 2 months, and at 1 year after a simple vaginal hysterectomy for benign indications in 19 patients. Rectal staircase (0-44 mmHg, 4-mmHg steps), ramp (0-200 mL at 50, 200 and 600 mL min(-1)) and phasic distentions (8, 16, and 24 mmHg above operating pressure) were performed. KEY RESULTS: Anal resting (63 ± 4 before, 56 ± 4 mmHg after) and squeeze pressures (124 ± 12 before, 124 ± 12 mmHg after), rectal compliance and capacity (285 ± 12 before, 290 ± 11 mL 1 year after), and perception of phasic distentions were not different before vs after a hysterectomy. Sensory thresholds for first sensation and the desire to defecate were also not different, but pressure and volume thresholds for urgency were somewhat greater (Hazard ratio = 0.7, 95% CI [0.5, 1.0]) 1 year after (vs before) a hysterectomy. Rectal pressures were higher (P < 0.0001) during fast compared with slow ramp distention; this rate effect was greater at 1 year after a hysterectomy, particularly at 100 mL (P = 0.04). CONCLUSIONS & INFERENCES: A simple vaginal hysterectomy has relatively modest effects (i.e., somewhat reduced rectal urgency and increased stiffness during rapid distention) on rectal sensorimotor functions.

Dysfunctional urinary voiding in women with functional defecatory disorders.

BACKGROUND: While pelvic floor dysfunction may manifest with bladder or bowel symptoms, the relationship between functional defecatory disorders and dysfunctional voiding is unclear. Our hypothesis was that patients with defecatory disorders have generalized pelvic floor dysfunction, manifesting as dysfunctional urinary voiding. METHODS: Voiding was assessed by a symptom questionnaire, a voiding diary, uroflowmetry, and by measuring the postvoid residual urine volume in this case-control study of 28 patients with a functional defecatory disorder (36 ± 2 years, mean ± SEM) and 30 healthy women (36 ± 2 years). KEY RESULTS: Women with a defecatory disorder frequently reported urinary symptoms: urgency (61%), frequency (36%), straining to begin (21%), or finish (50%) voiding, and the sense of incomplete emptying (54%). Fluid intake and output, the minimum voided volume, and the shortest duration between voids measured by voiding diaries were higher (P < 0.05) in patients than in controls. Uroflowmetry revealed abnormalities in seven controls and 22 patients. The risk of abnormal voiding by uroflowmetry was higher in patients (OR 8.0; 95% CI, 2.3-26.9) than in controls. Patients took longer than controls (P < 0.01) to attain the maximum urinary flow rate (12 ± 2 VS 4 ± 0 s) and to empty the bladder (29 ± 4 VS 20 ± 2 s), but the maximum urinary flow rate and postvoid residual volumes were not significantly different. CONCLUSIONS & INFERENCES: Symptoms of dysfunctional voiding and uroflowmetric abnormalities occurred more frequently, suggesting of disordered urination, in women with a defecatory disorder than in healthy controls.