Acute diverticulitis in patients under 50 years of age.

Acute diverticulitis typically occurs in patients over 80 years old. The last five years we observed an increased incidence of acute diverticulitis in patients under 50 years. The aim of this study is to evaluate the increased rate of patients under 50 years that are hospitalized due to acute diverticulitis. Also, we aim to confirm the common symptoms for this disease and the laboratory data, the changes in dietary history (Mediterranean diet) and lifestyle and to calculate the differences in the treatment and the severity in the course of the disease, between younger (<50) and older (>50) patients. PATIENTS AND METHODS: From 2003 to 2008, 118 patients were admitted to our Surgical Department for acute diverticulitis. 32 patients were under 50 years old. In the next five year period (2008-2013) the number of patients under 50 that were admitted due to acute diverticulitis doubled to 183 with 102 patients being over 50 years and 61 patients under 50. For all these patients, the medical and dietary history, laboratory and clinical examinations, radiographic and endoscopic findings were recorded. RESULTS: For patients aged over 50 years there is a predominance in male sex. Symptoms were the same in both groups and no difference in treatment was noted. Furthermore, readmission and recurrence rates were the same for both groups. The condition was equally aggressive in both groups. The only difference observed was increased obesity rate for patients under 50 and variation from the traditional Mediterranean diet to western diet habits. CONCLUSIONS: Although our study has limitations it seems that new cases of diverticular disease in patients have increased due to dietary changes, but treatment and severity have remained the same.

Necrotizing fasciitis associated with primary cutaneous B-cell lymphoma. A case report.

Necrotizing fasciitis is a rapidly progressive and life-threatening infection of the deeper skin layers and subcutaneous tissues that moves along the facial planes. OBJECTIVES: We present the rare case of a patient with necrotizing fasciitis associated with high malignancy b-cell lymphoma. Our purpose is to investigate the probable connection between the two pathologies and evaluate the importance of early surgical intervention. CASE REPORT: 51-year old Caucasian woman presented at the E.R. with history of a painful left thigh over a week and fever up to 38,4°C over the last three days. Necrosis of the soft tissues and fascial planes were observed clinically. After the initial treatment and due to the patient's multiple organ dysfunction (septic shock), she was transferred to the ICU were she was intubated resuscitated with IV fluids and given IV antibiotics. 24 hours after the admission it was decided that the patient should undergo surgery and an extensive debridement of the necrotic area was performed. The antibiogram of the blood culture revealed streptococcus pyogenes and she was administered penicillin while intubated and monitored in the ICU until the seventh postoperative day. On the eighth post-day she was transferred back to the surgical department, hemodynamically normal and stable. She was discharged one month later and she was referred to a plastic surgery center for the final reconstruction surgery. CONCLUSIONS: This case highlights that the high index of suspicion and the early aggressive surgical intervention seems to be very critical to improve survival of the patients with necrotizing fasciitis.

Primary small bowel melanoma. A case report and a review of the literature.

Primary malignant melanoma originating from the small intestine is extremely rare. Only a limited number of cases are described in the literature. Most commonly small intestine is affected by metastatic tumors from other primary lesions. We present a case of a 68-years old male diagnosed with primary malignant melanoma as an ulcerated and bleeding mass in the jejunum--located 40 cm away from the Treitz band. In our case the diagnosis was confirmed at laparotomy and enterectomy. Histology revealed a neoplastic infiltration involving the entire intestinal mucosa, with atypia of neoplastic cells and immunoreactivity to HMB45(+), Melan A(+) and S100(+), confirming the diagnosis of melanoma. There was not revealed a primary lesion in the skin, eye, anus, rectum or in other location by the post-operative investigation. An eleven-month close follow-up has not revealed any metastasis. Therefore a definitive diagnosis of primary malignant melanoma was set.

MAG3-F0 scintigraphy in decision making for emergency intervention in renal colic after helical CT positive for a urolith.

UNLABELLED: Patients with renal colic are evaluated with clinical, laboratory, and imaging methods for stratification for emergency decompression, medical treatment, or discharge and follow up. The current standard practice is heavily based on unenhanced helical CT for detecting uroliths. However, the presence of a urolith does not necessarily mean that the kidney is obstructed and requires emergency decompression. In this study, technetium-mercaptoacetyltriglycine (MAG3) diuretic scintirenography was used to detect obstruction in patients with renal colic. The contribution of this test to patient management after positive findings from helical CT was also studied. METHODS: Diagnostic criteria were established on the basis of previous experience with 60 patients who had renal colic and had undergone radiography of the kidneys, ureters, and urinary bladder (KUB) and diuretic Tc-MAG3 scintirenography and were followed up to correlate scintigraphic findings with clinical outcome. Subsequently, 80 patients with renal colic underwent scintigraphy within 12 h of presentation in the emergency room, after abdominal helical CT showed findings positive for calculus and suggestive of obstruction. After therapeutic oral or intravenous hydration and analgesics, diuretic dynamic renal scintigraphy (flow, function, delayed imaging) was performed after intravenous injections of 10 mCi (370 MBq) 99mTc-MAG3 and 40 mg furosemide (at zero time, or F0). Results were available soon after completion of the study and were considered in patient management. Four characteristic patterns of scintirenography, essential in patient stratification and treatment, had been standardized and were used for interpretation of the studies: the unobstructed kidney; the partially obstructed kidney, proximally or distally obstructed, with mild to severe obstruction and impairment of function; the totally obstructed kidney, with arrested renal function; and the unobstructed but dysfunctioning kidney after decompression, or stunned kidney. RESULTS: Among the 80 patients with positive helical CT findings, 56.5% were found to have obstruction by scintigraphy (32.5% partially, 24% completely); the remaining 43.5% did not have obstruction (21% without an indication of recent obstruction and 22.5% with stunned kidneys after spontaneous decompression). Occasionally, findings of preexistent urine extravasation or infection were present. Patients who, by scintigraphy, never had obstruction or had experienced spontaneous decompression did not require admission or emergency intervention; those with complete or severe obstruction required admission and decompression for relief of pain or restoration of function, whereas those with mild obstruction were treated variably with forced fluids, analgesics, or, less frequently, elective surgery. Outcome information from clinical examination, imaging, and interventional findings indicated that this stratification was successful. The test caused no side effects. CONCLUSION: For renal colic, clinical selection, KUB radiography, and even positive helical CT findings were all found to have a low positive predictive value for obstruction (in this study, 35%, 32%, and 56% respectively). Anatomic studies, including helical CT, should be followed by diuretic MAG3-F0 scintirenography to diagnose and quantify or exclude obstruction, detect spontaneous decompression, and appropriately stratify patients for emergency intervention, observation and medical therapy, or further work-up and discharge with referral to the clinic.

Diuretic MAG3 scintigraphy (F0) in acute pyelonephritis: regional parenchymal dysfunction and comparison with DMSA.

UNLABELLED: 99mTc-DMSA late static planar imaging or SPECT is being used for the investigation of focal acute pyelonephritis (APN), especially in children with urinary tract infection (UTI). Diuretic 99mTc-mercaptoacetyltriglycine (MAG3) dynamic scintirenography has been applied in the evaluation of kidney function and structure, frequently to exclude obstruction. However, in children and adults with a clinical picture of APN, diuretic MAG3 scintigraphy with zero time injection of furosemide (MAG3-F0) was observed to display focal parenchymal abnormalities; regional dysfunction (focal parenchymal decrease in early uptake; slow filling in and prolonged late retention of activity); or, less frequently, fixed defects. This observation was further studied both retrospectively and prospectively, and its sensitivity and specificity for APN were compared with those of dimercaptosuccinic acid (DMSA). METHODS: In the retrospective study, for 36 children with UTI and regional parenchymal findings on MAG3-F(0), data were reviewed, analyzed, and compared with the results of concurrent DMSA studies. In the prospective study, for 57 children with clinical and laboratory findings suggestive of APN, the 2 radiopharmaceuticals were used for imaging sequentially and the results of the 2 studies were compared. The criteria for abnormal findings compatible with the diagnosis of APN were, for MAG3-F(0), regional parenchymal dysfunction and fixed focal defects and, for DMSA, focal defects without parenchymal loss. RESULTS: In all groups of patients, most abnormal MAG3-F(0) studies (80%) showed regional parenchymal dysfunction, but in some (20%) a fixed defect was found. Compared with DMSA and when both regional dysfunction and focal defects were considered, MAG3-F(0) was as sensitive as DMSA. Some patients had only MAG3-F(0) abnormalities, suggesting a slightly lower specificity for MAG3-F(0) compared with DMSA (86%); this finding needs further study, because it also raises questions about the sensitivity of DMSA, considering that only a small percentage of patients with clinically suggestive findings had abnormal study findings. In most patients with fixed defects on both DMSA and MAG3-F(0), follow-up studies showed no resolution, suggesting that a fixed defect on MAG3-F(0) may indicate either more severe APN or preexistent scars and that regional dysfunction may be a sign more specific for APN and prognostic of potential recovery. In addition, a pattern more specific for a scar--a fixed defect with a dilated regional calyx--was seen on follow-up MAG3-F(0). CONCLUSION: A fast (25-min) planar dynamic MAG3-F(0) study was found to be as sensitive at depicting focal parenchymal abnormalities in APN as was the 3- to 4-h DMSA routine procedure. The sensitivity and specificity of both studies need further evaluation.