Acute liver failure secondary to metastatic liver infiltration: case report and review of the literature.

We present the case of a patient who died from multiple organ failure due to acute liver failure as a result of malignant hepatic infiltration by an adenocarcinoma. A review of the literature revealed that the clinical picture, laboratory examination, and imaging studies do not contribute to the diagnosis of this rare cause of liver failure. Therefore, liver biopsy should be considered early in the process, as this diagnosis is a contraindication for orthotopic liver transplantation.

Extensive propagation of a pancreatic pseudocyst along the lower limb through the sciatic foramen.

The extremely rare extensive propagation of a giant retroperitoneal pancreatic pseudocyst into the posterior compartment of the lower limb as far as the knee is reported. The extension was found producing through the sciatic foramen and the full diagnosis was made by MDCT. A complete healing was progressively obtained in the 78-year old female after a six months period of sequential multidisciplinary therapeutic approach comprising combined medical and surgical intra-abdominal and external drainage.

Spontaneous transhepatic rupture of the gallbladder with massive hemoperitoneum.

Perforation of the gallbladder has an incidence of 1.6 to 2.8% in gallbladder disease. Among these cases transhepatic rupture is a very rare event. We report a case associated with secondary massive hemoperitoneum, free gallstone spillage, partial portal vein thrombosis and secondary pulmonary embolism.

Pylephlebitis complicating peridiverticulitis without hepatic abscess: early detection with contrast-enhanced CT of the abdomen.

Pylephlebitis is a very rare and dangerous complication of inflammatory abdominal processes, mainly appendicitis (1) and diverticulitis (2).We describe a case of peridiverticular inflammation leading to a extensive phlebitis of the adjacent sigmoid vein, extending to the inferior mesenteric vein up to the proximal portal vein, with distal embolus into the left portal vein. Contrast CT and multiplanar reconstructions allowed early diagnosis, and with antibiotic and anticoagulation therapy, no liver abscess developed.

Posterior arthroscopic subtalar arthrodesis: ten cases at one-year follow-up.

BACKGROUND: Isolated subtalar arthrodesis is the treatment of choice for several conditions -mostly subtalar arthritis, tarsal coalition and posterior tibial tendon dysfunction- unresponsive to conservative treatment. Arthroscopic procedures are an interesting recent alternative, less invasive than conventional open techniques. Posterior arthroscopy, in prone position, could be more advantageous than the conventional lateral and/or anterior approach. PATIENTS AND METHODS: Ten cases, from 20 to 59-years-old, were prospectively followed up for minimum of one-year (range 12 to 31 months). Arthritis and tarsal coalition were the most common indications. RESULTS: Fusion was observed in all cases at a maximum of nine weeks. Mean average AOFAS score improved from 47 to 78. No complications were noted related to the technique. Only two patients, operated for a symptomatic subtalar coalition, complained of some residual pain due to a lateral submalleolar impingement. Interest of preservation of vascular talar supply and bone grafting are discussed. CONCLUSION: The good results using this innovative technique are encouraging. Long-term randomized studies remain necessary to confirm the reliability of the procedure in these different indications, and the type of bone graft to favour, if really needed. LEVEL OF EVIDENCE: Level IV therapeutic study.

Plantar pressure relief using a forefoot offloading shoe.

AIM: To assess the effectiveness of the Barouk(®) second-generation postoperative forefoot relief shoes during appropriate use of the shoe on healthy subjects. MATERIALS AND METHODS: A convenience sample of 35 volunteer subjects (17 women, 18 men) was recruited to participate in this study. Dynamic foot loading was evaluated with inshoe plantar pressure measurements. Subjects were asked to walk two trials at a self-selected speed: (a) in their mass-produced shoes to assess baseline pressure values, defined as 100% and (b) with the Barouk(®) postoperative shoe on the right foot and their own shoe on the left side. Data analysis was tested for statistical differences with paired Student's t-tests (with p<0.05 as a significance level). RESULTS: The Barouk(®) second-generation postoperative forefoot relief shoes relieved forefoot pressure in all trials. For all 35 volunteers, there was a 79-96% mean peak pressure reduction (p<0.001) of the forefoot except for the fifth metatarsal head during appropriate use of the postoperative shoe. In contrast to the results for the forefoot, a significant increase of the peak pressure values was observed in the heel region. Similar findings were observed for the pressure-time integral values. CONCLUSION: The data of our study provide evidence that the second-generation Barouk(®) shoe relieve pressure of the forefoot with appropriate use.

Tarsal tunnel syndrome and flexor hallucis longus tendon hypertrophy.

Tarsal tunnel syndrome (TTS) defines an entrapment neuropathy of the posterior tibial nerve or one of its branches, within the tarsal tunnel. Numerous etiologies have been described explaining this entrapment, including trauma, space-occupying lesions, foot deformities, etc. We present an unreported cause of a space-occupying lesion in the etiology of TTS, namely the combination of a hypertrophic long distally extended muscle belly of the flexor hallucis longus and repetitive ankle motion. Surgical debulking of the muscle belly in the posterior ankle compartment resolved all symptoms.

Technique and early experience with posterior arthroscopic tibiotalocalcaneal arthrodesis.

Tibiotalocalcaneal arthrodesis is indicated for pain relief in patients with combined arthritis of the ankle and subtalar joint. An arthroscopic posterior approach was designed to improve upon traditional methods by using a minimally invasive technique. The technique involves prone positioning of the patient, one anterolateral and two posterolateral portals, and arthroscopic debridement of both the tibiotalar and posterior talocalcaneal joint. Stabilisation is obtained with a retrograde intramedullary nail, with static interlocking. This article presents illustrative cases and discusses some of the technical advantages and disadvantages over conventional open surgery. For surgeons familiar with posterior ankle or subtalar arthroscopy, this minimally invasive debridement and nailing appears to offer superior exposure, high patient satisfaction and lower postoperative morbidity than traditional methods; fusion is encouraged by preserving the medullary reaming material at the site of the fusion.

Ileal inflammatory fibroid polyp causing ileocolic intussusception.

Inflammatory Fibroid Polyp (IFP) is an extremely rare tumour involving the gastrointestinal tract (GI) and especially the stomach and small bowel. It presents either as a solitary large or sessile lesion arising from the submucosa and despite a large size and sometimes infiltrating growth, the tumour is always benign and has a good prognosis. Histogenesis remains unknown and controversial. We report an ileal case presenting classically and typically with ileocolic intussusception. Diagnosis was made preoperatively with abdominal mdCT. The polyp itself does not have noteworthy radiological signs but must be included in the large essentially histological differential diagnosis of GI tumours.

Carcinoid tumor of the small intestine: MDCT findings with pathologic correlation.

BACKGROUND: MDCT currently frequently represents the first choice modality for imaging in acute or subacute abdominal conditions implicating the small bowel. As a consequence, the MDCT features of intestinal carcinoid tumors and of their peculiar metastatic spread have to be known by abdominal radiologists. PATIENTS AND METHODS: These features are described and illustrated in the retrospective review of seven proven cases of small intestine carcinoids diagnosed and treated in our institution. The findings are described and correlated with gross anatomy specimens. RESULTS: The primary tumour clearly appeared as a contrast-enhancing intraluminal lesion in all cases except in one case in which the primary lesion remained unlocalized and in another in which the primary tumour finally appeared infracted at gross anatomy. The maximal tumoral enhancement was obtained in 3 patients imaged during the acute arterial phase. The diameter of the primary tumour ranged from 1 to 3 cm and all masses were ileal comprising one lesion in the proximal ileum, two in the medium ileum and three in the distal ileum. 6/7 patients had multiple prominent mesenteric nodal metastases, all also appearing as hypervascularised enhancing masses. In 4/7 patients the nodal metastases represented the major finding being much prominent and larger than the primary tumour. Signs of retractile mesenteritis with soft tissue stranding, retraction and stellate pattern of the mesentery were found around the mesenteric metastases in 5/7 patients and direct incarceration of vessels were found in 3 cases. CONCLUSION: The analysis of the arterial phase of MDCT study appears primordial to detect the sometimes very small but intensively enhancing primary tumor and to delineate encasement or direct obstruction of mesenteric vessels frequently caused by enhancing nodal metastases which volume often exceeds that of the primary tumor. Secondary retractile mesenteritis, deformation or ischemia of bowel loops, and hypervascular hepatic metastases are typical associated findings.

Intraabdominal counter clockwise gastric volvulus incarcerated through a defect of the lesser omentum: CT diagnosis.

We report the probably first case of incarcerated intra-abdominal gastric volvulus protruding through a defect of the pars flaccida of the lesser omentum. The 79-year-old woman presented with acute symptoms of upper gastrointestinal occlusion. Plain film radiographs, endoscopy and attempts at opacifying the upper alimentary tract failed to make the correct diagnosis. The definite preoperative diagnosis was achieved by mdCT thanks to high quality multiplanar reconstruction (MPR). In the reported case coronal oblique MPR views and vascular volume rendering views (VR) were of particular interest for the preoperative diagnosis.

Emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report.

This case report describes a sigmoid diverticulitis with torpid development, long-term symptoms of bladder irritability, and an emphysematous epididymitis caused by a direct seminal vesicle fistula. The diagnosis was suggested by scrotal ultrasound visualizing gas in the scrotum; the complex pelvic fistulous tract was specifically delineated by multislice computed tomography. This may be the first reported case of seminal vesicle fistula directly related to colonic diverticulitis and causing emphysematous epididymitis.

Gastric ulcer penetrating the anterior abdominal wall: ultrasound diagnosis.

We report two rare cases of penetration of the anterior abdominal wall by gastric peptic ulcers. The full diagnosis was made by ultrasound, which showed similar findings: sharply delineated, hyperechoic craters clearly traversing the gastric wall and covered by hypoechoic inflammatory components of the abdominal wall. Because ultrasound is increasingly used as a primary procedure for evaluation of abdominal complaints, efforts should be directed toward exploring the accessible portions of the gastric and duodenal walls to detect peptic ulcer disease and its complications.

[Corticosteroid-induced epidural lipomatosis. Efficacy of medical treatment]. / La lipomatose épidurale cortico-induite. Efficacité du traitement médical.

We describe a further case of cauda equina compression secondary to steroid-induced epidural lipomatosis in a patient treated for IBD. The diagnosis was rapidly confirmed by MRI allowing conservative management by corticosteroid withdrawal as well as use of hygiene and dietary measures. Therapeutic efficacy was noted on a clinical basis and confirmed by repeated follow-up MRI exams which showed regression of fat accumulation. Symptomatic epidural lipomatosis is probably underestimated because physicians concerned by steroid treatment are not fully informed about this potentially severe and usually iatrogenic disease. Also, proper medical attention to the first neurological symptom in these patients might help limit therapeutic management to a medical measurer, before requiring surgical decompressive surgery.

Poly-D-glutamic acid induces an acute lysosomal thesaurismosis of proximal tubules and a marked proliferation of interstitium in rat kidney.

Renal damage caused by polycationic peptides is well documented, but renal damage caused by polyanionic peptides is not. During our attempts to inhibit the nephrotoxicity of aminoglycoside antibiotics by polyanionic peptides, we discovered that poly-D-glutamic acid (molecular weight, 20 kd; 250 mg/kg/day subcutaneously for 1 to 4 days) produces an acute thesaurismosis in the proximal tubular cells associated with a marked proliferation of peritubular interstitial cells in rat kidney. Thesaurismotic bodies were easily visualized by light microscopy at the basal pole of proximal tubular cells with the cationic stain Giemsa. By electron microscopy, these bodies appeared membrane-limited, frequently distorted, filled with heterogeneous granular material, accessible to injected peroxidase (a tracer of the endocytic pathway), and generally stainable for the lysosomal enzyme arylsulfatase. Specimens obtained 3 hours after injection of poly-D-glutamic acid and horseradish peroxidase suggested an impairment of endosome and/or lysosome fission, but not fusion. By histoautoradiographic examination after 3H-thymidine incorporation, global labeling indices of cortical cells were increased 11- to 18-fold in poly-D-glutamic acid-treated rats as compared with controls, with > 80% of labeled cells localized in the interstitium. Distal tubular and glomerular cells also showed a moderate proliferation, but proximal tubular cells showed no significant necrosis or proliferation. Although tubular thesaurismosis persisted, interstitial cell proliferation resolved within 7 days after cessation of treatment. We suggest that poly-D-glutamic acid is a convenient tool to induce a rapid and sustained lysosomal storage disorder. It could also help clarify the relationship between insults to tubular cells and proliferation of peritubular cells, two features frequently associated in tubulointerstitial disorders. The mechanism of the thesaurismosis and of the interference with the dynamics of fusion-fission of the endocytic apparatus are addressed in the companion paper.

Mechanism of the thesaurismosis and altered lysosomal dynamics induced by poly-D-glutamic acid in kidney proximal tubular cells.

In the companion paper, we report that a single injection of poly-D-glutamic acid causes an acute lysosomal storage condition and apparently impairs the lysosomal fission dynamics. The present paper addresses the mechanisms of these two alterations using a combination of in vivo and in vitro biochemical approaches. After a single intravenous injection, 14C-poly-D-glutamic acid was rapidly cleared from the plasma and appeared in the urine. Yet, a small but sizable fraction of the injected polymer was taken up by the kidney cortex through a saturable process (Kuptake, 150 mg/kg body wt; uptakemax 96 micrograms/g cortex). Analytical subcellular fractionation of cortex homogenates demonstrated that at initial stages, the 14C label was predominantly associated with subcellular particles of intermediate size and low equilibrium density, and was therefore slowly transferred to larger particles equilibrating at high density, then codistributing with the lysosomal hydrolases. At a concentration of 10 mg/ml (equivalent to its estimated concentration in lysosomes), poly-D-glutamic acid formed micronic aggregates ( > or = 10 microns) when brought to solution at pH < or = 6 in relation to its decreased ionization (pKa of lateral chains approximately equal to 4.25). Finally, 1 day after the injection of poly-D-glutamic acid, the activities of several lysosomal enzymes (hexosaminidase, cathepsin B, acid sphingomyelinase, and sulfatase B), but not of all of them (eg, acid phosphatase), were increased in the kidney cortex. We propose that poly-D-glutamic acid reaches lysosomes by adsorptive endocytosis and becomes concentrated within these organelles because its withstands hydrolysis until it forms aggregates or precipitates, causing a decrease in the fluidity or the deformability ("gelling") of the lysosomal matrix. This should alter the dynamics of intercommunication of these organelles by impairing their fission without a proportionate effect on their fusion properties. In addition, the data suggest that the presence of poly-D-glutamic acid directly or indirectly slows down the degradation of several lysosomal enzymes.