Spontaneous intra-hepatic haemorrhage in a patient with fever of unknown origin.

Polyarteritis nodosa is a systemic necrotising vasculitis that affects the small- and medium-sized arteries. Multifocal aneurysmal formation in the renal, hepatic, and mesenteric vasculature is a hallmark of this condition, and spontaneous aneurysmal rupture may occur, resulting in life-threatening haemorrhage. We describe a 42-year-old man who initially presented with fever of unknown origin. A diagnosis could not be reached at that time despite extensive investigations. The fever subsided spontaneously after 8 weeks, and the patient remained well for 6 years until he was admitted again for evaluation of fever. During his hospital stay, he developed a spontaneous massive intra-hepatic haemorrhage resulting in hepatic rupture and a haemoperitoneum. The bleeding was controlled at emergency laparotomy. An abdominal angiography demonstrated multiple microaneurysms in the hepatic and mesenteric arterial vasculature. The clinical findings suggested polyarteritis nodosa, and the source of bleeding was probably a ruptured intra-hepatic artery aneurysm.

Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study.

BACKGROUND: The great auricular nerve (GAN) is frequently sacrificed during parotidectomy and causes sensory disturbance of the auricle. Our study is to investigate whether GAN preservation can improve the sensory recovery. METHODS: Patients undergoing superficial or total conservative parotidectomy for benign tumours were recruited consecutively from November 1998 to September 2001. Different sensory methods (light touch, two-point discrimination and sharp pain) of the auricle were evaluated by a designated physiotherapist preoperatively as well as at 1, 3, 6 and 12 months postoperatively. The patients and the physiotherapist were blinded to the integrity of the GAN. Long-term subjective assessment was also carried out beyond 2 years postoperatively. RESULTS: A total of 21 patients were recruited for the study. GAN were preserved in 10 patients. The mean follow up was 16 months (12-42 months). There was no difference in sex distribution, type of operation and pathology of parotid tumour between the two groups. No postoperative mortality occurred and postoperative morbidity did not differ between the two groups. Patients with GAN preserved had significantly better light touch and sharp pain recovery at 1 year postoperatively. Subjective assessment of sensory dysfunction also favoured GAN preservation. CONCLUSION: Great auricular nerve preservation minimizes the postoperative sensory disturbance and should be considered whenever tumour clearance is not compromised.

On-table cecoscopy : a novel diagnostic method in acute diverticulitis of the right colon.

PURPOSE: Controversies abound regarding the optimal surgical management in noncomplicated diverticulitis of the right colon, ranging from a conservative approach to diverticulectomy to right hemicolectomy. One of the arguments for resection is to exclude carcinoma. However, there is significant morbidity associated with resection. We aim to introduce on-table cecoscopy as a tool to improve the diagnosis of acute diverticulitis of the right colon, exclude carcinoma, and reduce the rate of resection. METHODS: From October 1999 to June 2000, five patients presented to our unit with suspected acute appendicitis. Intraoperatively, we found a colonic inflammatory mass at either the cecum or the ascending colon. The cecum and ascending colon were mobilized, and bowel clamps were applied to the ascending colon and ileum. A bronchoscope (Olympus(R) BF-P200) was introduced through the appendix stump. To achieve a good endoscopic view, a limited volume of air was introduced through the working channel. RESULTS: After on-table cecoscopy, all the patients were diagnosed as having acute nonperforated diverticulitis of the right colon. They received appendicectomy, and the diverticulitis was managed conservatively. They were treated with a course of cephalosporin and metronidazole. We performed colonoscopy four weeks later and confirmed that none of them had carcinoma of the colon. CONCLUSIONS: On-table cecoscopy is a new, safe, and effective means of diagnosing acute diverticulitis of the right colon. We can confidently exclude carcinoma and reduce the amount of colonic resection in patients with noncomplicated diverticulitis of the right colon.