Late-Onset Chronic Corneal Fistula Following Phototherapeutic Keratectomy: A Case Report and Importance of Early Detection.

BACKGROUND We report a case of late-onset chronic fistula in a decompensated cornea after multiple ocular surgeries and a recent phototherapeutic keratectomy (PTK). CASE REPORT A 73-year-old woman presented to our service with a past ocular history of bilateral chronic angle closure glaucoma and pseudophakic bullous keratopathy in the left eye. Given a history of long-term uncontrolled glaucoma with advanced disc cupping and poor visual potential, the patient underwent multiple palliative procedures, including, most recently, a PTK. Few years later she presented with a spontaneous late onset of slowly appearing corneal leak on fluorescein staining upon routine clinical examination. Corrected distance visual acuity was hand motion and intraocular pressure (IOP) was 40 mmHg in the affected eye. Serial anterior segment optical coherence tomography (AS-OCT) sections were obtained, which aided in understanding the current presentation and revealed distinctive multilayer corneal changes during the healing process. The patient was successfully managed with cyanoacrylate corneal gluing and ocular hypotensive medications, which halted the corneal leak. CONCLUSIONS We report a case of a rare finding of corneal fistula in an eye with multiple previous ocular surgeries, and provide an explanation of the possible etiopathogenesis. We also highlight the pivotal role of AS-OCT for evaluating such cases and stress the importance of early detection of similar subtle leaks in the setting of a formed anterior chamber, which can often be missed, carrying a risk of infection.

Novel and Effective Almagate Enema for Hemorrhagic Chronic Radiation Proctitis and Risk Factors for Fistula Development.

Radiation proctitis is a common complication after radiotherapy for pelvic malignant tumors. This study was conducted to assess the efficacy of novel almagate enemas in hemorrhagic chronic radiation proctitis (CRP) and evaluate risk factors related to rectal deep ulcer or fistula secondary to CRP. All patients underwent a colonoscopy to confirm the diagnosis of CRP and symptoms were graded. Typical endoscopic and pathological images, risk factors, and quality of life were also recorded. A total of 59 patients were enrolled. Gynecological cancers composed 93.1% of the primary malignancies. Complete or obvious reduction of bleeding was observed in 90% (53/59) patients after almagate enema. The mean score of bleeding improved from 2.17 to 0.83 (P<0.001) after the enemas. The mean response time was 12 days. No adverse effects were found. Moreover, long-term successful rate in controlling bleeding was 69% and the quality of life was dramatically improved (P=0.001). The efficacy was equivalent to rectal sucralfate, but the almagate with its antacid properties acted more rapidly than sucralfate. Furthermore, we firstly found that moderate to severe anemia was the risk factor of CRP patients who developed rectal deep ulcer or fistulas (P= 0.015). We also found abnormal hyaline-like thick wall vessels, which revealed endarteritis obliterans and the fibrosis underlying this disease. These findings indicate that almagate enema is a novel effective, rapid and well-tolerated method for hemorrhagic CRP. Moderate to severe anemia is a risk factor for deep ulceration or fistula.

Enfermedad de zuska. Diagnóstico en atención primaria / Zuska disease. Diagnosis and treatment in primary care

Una fístula es una comunicación anómala patológica que comunica 2 órganos entre sí o con el exterior. Son trayectos fibrosos con revestimiento interno de tejido de granulación, que se extienden desde un orificio interno o primario hasta uno o varios orificios externos o secundarios situados en la piel. La constante recidiva de una mastitis suele ser consecuencia de una fístula entre conductos galactóforos y el límite areola-piel de la mama, llamándose a esto fistulización periareolar recidivante. Para integrar este cuadro en la terminología propuesta, enfermedad de Zuska, es indispensable pensar primero en su existencia para enfocar el tratamiento en su origen. El conocimiento de esta enfermedad y su diagnóstico y tratamiento correctos impedirán las constantes recidivas en forma de mastitis que presentan estas pacientes, evitando así su peregrinaje por distintos especialistas. En este artículo revisamos esta entidad, métodos diagnósticos y tratamiento (AU)

A fistula is an abnormal pathological communication which links two organs together or with the exterior. They are fibrous paths internally coated with granulation tissue, extending from an internal o primary opening to one or more openings located outside or on the skin. The recurrent mastitis that some patients suffer is due to a fistula between a lactiferous duct and the limit of the areola, and this condition is called a recurrent periareolar fistula.To incorporate this clinical condition into the proposed terminology, Zuska disease, is essential to believe in its existence, in order to to treat it from the source. The knowledge of this disease, a proper diagnosis and treatment will prevent the constant recurrence of mastitis as presented by these patients, avoiding their pilgrimage to various specialists. In this article we review this disease, methods of diagnosis and treatment (AU)

Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy.

BACKGROUND: Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life. AIMS: To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients. RESULTS: A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases. CONCLUSION: Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.

Ear trauma caused by a yucca plant leaf spine.

Three uncommon cases of ear trauma caused by a yucca plant leaf spine are presented. One patient presented with tympanic perforation and the second with mixed hearing loss after spontaneous closure. The third patient probably had a perilymphatic fistula with subsequent labyrinthitis and hearing loss. Although the yucca is a ubiquitous plant, to the best of our knowledge, such incidents have not been previously reported.

Post-treatment fistulas in patients with rectal cancer: MRI with rectal superparamagnetic contrast agent.

MRI is the standard modality in the pre- and post-treatment evaluation of patients with rectal cancer, particularly in those cases with locally advanced disease. We routinely employ a superparamagnetic iron oxide (SPIO) contrast enema to distend the rectal lumen and achieve maximal tumor-to-lumen contrast gradient. This practice also allowed the identification of a fistula in 24% of patients treated for rectal cancer. Contrast agent-related low intensity signal could be seen filling the tract and eventually opacifying surrounding organs (i.e., vagina) or collections (i.e., presacral abscess). Fistula formation after radiochemotherapy and surgery for rectal cancer is not uncommon. MRI with dark lumen contrast enema allows an effective demonstration of this complication in a high number of patients.

[Vestibular evoked myogenic potentials]. / Vestibulär evozierte myogene Potenziale.

The recording of vestibular evoked myogenic potentials is a relatively new neuro-otologic method which gives specific information about the function of the sacculus and the inferior vestibular nerve on each side separately. The main indications for this method are vestibular schwannoma and fistula of the labyrinth, involvement of the sacculus or the inferior vestibular nerve in Menière's disease and vestibular neuritis, vertigo of unknown etiology, and forensic questions.

Fístula sigmoidoapendicular de origen diverticular / Sigmoidoappendiceal fistula of diverticular origin: report of one case

Se presenta un caso de fístula sigmoidoapendicular de origen diverticular diagnosticado por enema baritado en el estudio electivo de una paciente anciana, luego de un episodio de diverticulitis tratado en forma médica. El enema baritado es el examen de elección para demostrar este tipo de fístula. El estudio histopatológico permite certificar el origen diverticular de esta condición. Habitualmente la sigmoidectomía más apendicectomía es el tratamiento de elección con resultados satisfactorios. En el caso que se presenta fue necesario realizar una ileotiflectomía por la concomitancia con un cáncer avanzado de ciego. La fístula coloentérica de origen diverticular representa el 1 a 4 por ciento de las indicaciones de cirugía electiva por una enfermedad diverticular del colon sigmoides. Dentro de ellas, la fístula sigmoideo-apendicular de origen diverticular es excepcional y sólo hemos encontrado tres casos documentados de esta rara forma de fístula coloentérica.

Fístula prostatorectal yatrogénica. Reparación con colgajo pediculado de músculo gracilis. Presentación de dos casos / Yatrogenic prostatorectal fistula. Use of gracilis muscle pedicled flap for its reparation. Presentation of two cases

Presentamos dos casos clínicos en los cuales durante la realización de una adenomectomía retropúbica por patología prostática benigna se produce una fístula prostatorectal. Describimos la cirugía de reparación de la misma con colgajo de músculo gracilis o recto interno, y su posterior buena evolución. Presentamos imágenes cistográficas y de enemas opacos que presentan un antes y un después de dicha cirugía. Los pacientes están sin incontinencia ni problemas relacionados con la cirugía de desinserción muscular

We present two cases in which during retropubic prostatectomy for benign prostatic disease a prostatorectal fistula ocurred. We describe its reparation using a pedicled flap of gracilis muscle. We also present cistografic and opaque enema images wich shows the before and after of this surgery. Patients had good outcome without incontinence nor problems related to muscle desinsertion surgery

Can low frequency sound stimulation during posturography help diagnosing possible perilymphatic fistula in patients with sensorineural hearing loss and/or vertigo?

Perilymphatic fistula (PLF) is often difficult to diagnose because of the similar symptomatology, such as vertigo, tinnitus and hearing loss, which is found in several inner ear diseases. We attempted to correlate a positive result of low frequency sound (LFS) stimulation tests in posturography with the presence or absence of a PLF confirmed by transtympanic endoscopy in 209 patients with various inner ear diseases (Meniere's disease ( n=128), vestibulopathy ( n=41), cochleopathy ( n=28) and sudden deafness ( n=12). LFS provoked unsteadiness in posturography without PLF in 24 patients with Meniere's disease, in 5 patients with vestibulopathy, in 3 patients with cochleopathy and in 2 patients with sudden deafness. In one patient, tympanoscopy revealed fistula in the round window membrane that was covered with a fibrinous layer. In four cases there was abnormal light reflex in the round window but without PLF. In eight cases, Hennebert's sign was present with nystagmus, without PLF. We conclude that pathological responses to the LFS test in posturography can also be encountered in other inner ear diseases without PLF.

Resolución de un síndrome de Youssef mediante tratamiento con análogos de GnRH. Caso clínico / Resolution of Youssef's syndrome by treatment with GnRH analogues. Case report

El síndrome de Youssef o menuria tras una fístula vesicouterina ha sido raramente publicado. Este caso difiere de los previamente comunicados en que el tratamiento mediante análogos de la GnRH hizo posible el cese de la menuria y, por tanto, un éxito del tratamiento conservador (AU)

Interposition of fallopian salpinges in the treatment of sigmoidovaginal fistula, secondary to vaginal hysterectomy with failure of previous repair.

A 50-year-old woman, para 4, suffering from uterine fibromatosis and recurrent menometrorrhagia, underwent vaginal hysterectomy with preservation of salpinges. About 15 days after surgery, hydrosoluble contrast enema showed sigmoidovaginal fistula; after about two months there was failure of surgery repair by the rectal endoscopic technique. A month later, we performed repair surgery by the abdominal approach interposing fallopian salpinges between the sigmoid and the vagina. About two months later, a enema showed absence of fistula and today the women is free from disease.

Epigastric appendiceal abscess with spontaneous drainage into the stomach.

The appendiceal abscess is a common complication of acute appendicitis and usually is located in the right lower quadrant of the abdomen. An epigastric appendiceal abscess has never been reported at an unusual location. We experienced an unusual case of a 49-year-old man with an epigastric appendiceal abscess. Initially, this abscess was suspected to be a pancreatic abscess. Abdominal CT scan and barium enema demonstrated a hyperrotated cecum with an appendiceal abscess in the left upper quadrant of the abdomen. An gastroscopy revealed a small fistula-like lesion with purulent coating at the bulging posterior gastric wall. The abscess resolved spontaneously. We believe that the abscess drained into the stomach through a small fistula between the stomach and abscess cavity. There was no recurrence for over 6 months.

Epigastric appendiceal abscess with spontaneous drainage into the stomach

The appendiceal abscess is a common complication of acute appendicitis and usually is located in the right lower quadrant of the abdomen. An epigastric appendiceal abscess has never been reported at an unusual location. We experienced an unusual case of a 49-year-old man with an epigastric appendiceal abscess. Initially, this abscess was suspected to be a pancreatic abscess. Abdominal CT scan and barium enema demonstrated a hyperrotated cecum with an appendiceal abscess in the left upper quadrant of the abdomen. An gastroscopy revealed a small fistula-like lesion with purulent coating at the bulging posterior gastric wall. The abscess resolved spontaneously. We believe that the abscess drained into the stomach through a small fistula between the stomach and abscess cavity. There was no recurrence for over 6 months.

[Colo-uterine fistula, a complication of sigma diverticulitis]. / Fistola colo-uterina, complicanza della diverticolite del sigma.

The colo-uterine fistula is a rare complication of diverticular disease of the colon; the literature review has shown only few well studied cases. The fistula, among the complications of the sigma diverticulitis, is 20% of the observed cases; generally, the bladder is the most involved organ, but also the skin or gut can be interested. If we consider the aetiology of the colo=uterine fistula of the observed case, the presence of the sigma locked stenosis with an endocolic pressure increase, associated with a peridiverticulitis condition, seems to have a relevant rule. The clinical symptomatology is represented by vague abdominal pain localized in particular in the left iliac cavity and by emission of blood, purulent material and stools from the vagina. The diagnosis of colo-uterine fistula is not easily reached: barium enema, Fallopian tube endoscopy and colon endoscopy not always allow to visualize in a right manner the fistula and only the oral administration of non-absorbable substances to be searched in the vaginal tampon, clear each doubt. Regarding the therapy to be carried out, we think that, colic resection en bloc with the uterus is the treatment of choice, while, in emergency, the Hartman operation is the most suitable to avoid the beginning of septic complications.

Colouterine fistula complicating diverticulitis: charcoal challenge test aids in diagnosis.

Fistula formation between a segment of colon and the uterus is an unusual complication of diverticulitis; only 17 cases have been reported in the world literature. We describe a 69-year-old woman with a colouterine fistula secondary to diverticulitis. She presented with a malodorous vaginal discharge that grew multiple enteric organisms on culture. A barium enema revealed colonic diverticula but no fistula tract. Orally administered activated charcoal was seen flowing from the cervical os during a pelvic examination the following day, establishing a diagnosis of colouterine fistula. Pathologic examination of the resected colon and uterus confirmed this diagnosis and determined that diverticulitis was the etiology. From a review of the literature, we conclude that radiographic and invasive procedures cannot be depended upon for diagnosis. Ingestion of activated charcoal may provide a simple, noninvasive approach to the diagnosis of enterouterine fistulas.

System identification of perilymphatic fistula in an animal model.

An acute animal model has been developed in the chinchilla for the study of perilymphatic fistulas. Micropunctures were made in three sites to simulate bony, round window, and oval window fistulas. The eye movements in response to pressure applied to the external auditory canal were recorded after micropuncture induction and in preoperative controls. The main pressure stimulus was a pseudorandom binary sequence (PRBS) that rapidly changed between plus and minus 200 mm of water. The PRBS stimulus, with its wide frequency bandwidth, produced responses clearly above the preoperative baseline in 78 percent of the runs. The response was better between 0.5 and 3.3 Hz than it was below 0.5 Hz. The direction of horizontal eye movement was toward the side of the fistula with positive pressure applied in 92 percent of the runs. Vertical eye movements were also observed. The ratio of vertical eye displacement to horizontal eye displacement depended upon the site of the micropuncture induction. Thus, such a ratio measurement may be clinically useful in the noninvasive localization of perilymphatic fistulas in humans.

Electrocochleography in the diagnosis of perilymphatic fistula: intraoperative observations and assessment of a new diagnostic office procedure.

The intraoperative electrocochleogram (ECochG) was investigated during stapedectomy surgery and during cochleostomy surgery. This provided the justification for obtaining recordings with the oval window (OW) or round window (RW) intact and then when there was a definite fistula. It was noteworthy that no ECochG changes occurred on merely opening the OW or RW, but that marked changes occurred on removing perilymph, even by gentle suction. On raising the intrathoracic pressure and replacing the perilymph, the ECochG potentials usually recovered. Based on these intraoperative observations, an office procedure was designed. The subject was asked to raise the intrathoracic pressure on several occasions and changes in the amplitude of the ECochG potential were noted. An increase of over 15 percent in the action potential (AP), with or without a decrease in the negative summating potential (SP) during the period of raised intrathoracic pressure, was used as the diagnostic criteria for a perilymphatic fistula. A decrease in the AP with or without an increase in the negative SP immediately on relaxing after a period of raised intrathoracic pressure was also treated as a positive diagnostic criterion. Seventy-one normal ears were investigated and a positive result was recorded in two ears (false positive rate: 2.8%). Two hundred and six ears, strongly suspected as having a perilymph leak on the basis of the clinical history and vestibular signs have been investigated over the past 4 years. Ninety positive diagnoses have been reached and 46 of these ears have been surgically explored.(ABSTRACT TRUNCATED AT 250 WORDS)