Idiopathic Splenic Artery Pseudoaneurysm Rupture as an Uncommon Cause of Hemorrhagic Shock.

Splenic artery pseudoaneurysms are infrequently encountered but critical to recognize. Limited literature to date describes associations with pancreatitis, trauma, and rarely peptic ulcer disease. Hemorrhage and abdominal pain are the most common manifestations. There is typically overt gastrointestinal blood loss but bleeding can also extend into the peritoneum, retroperitoneum, adjacent organs, or even a pseudocyst. Most patients with ruptured splenic artery pseudoaneurysms present with hemodynamic instability. Here, we describe a patient recovering from acute illness in the intensive care unit but with otherwise no obvious risk factors or precipitants for visceral pseudoaneurysm. He presented with acute onset altered mental status, nausea, and worsening back and abdominal pain and was found to be in hypovolemic shock. The patient was urgently stabilized until more detailed imaging could be performed, which ultimately revealed the source of blood loss and explained his rapid decompensation. He was successfully treated with arterial coiling and embolization. Thus, we herein emphasize the importance of prompt recognition of hemorrhagic shock and of aggressive hemodynamic stabilization, as well as a focused diagnostic approach to this problem with specific treatment for splenic artery pseudoaneurysm. Finally, we recommend that multidisciplinary management should be the standard approach in all patients with splenic artery pseudoaneurysm.

A modern series of percutaneous intracavitary instillation of amphotericin B for the treatment of severe hemoptysis from pulmonary aspergilloma.

BACKGROUND: Pulmonary aspergillomas may cause life-threatening hemoptysis. The treatment of this condition is problematic because poor pulmonary function often precludes definitive surgical resection. METHODS: We retrospectively reviewed all patients hospitalized at our institution for hemoptysis associated with an aspergilloma over an 8-year period and who underwent percutaneous intracavitary instillation of amphotericin B (ICAB). ICAB consisted of catheter placement into the aspergilloma cavity with subsequent instillation of 50 mg amphotericin B in 20 mL 5% dextrose solution daily for 10 days. RESULTS: ICAB was attempted for 23 distinct episodes of severe hemoptysis in 20 individual patients. Catheter placement was successful in 21 of the 23 episodes (91%), and of these, ICAB instillation was successfully completed in 20 episodes (95%). In these 20 episodes, hemoptysis ceased by hospital discharge in 17 of 20 patients (85%) and in all 18 who survived until a follow-up visit 1-month after treatment. Pneumothorax occurred in six of 23 (26%) catheter placement attempts without long-term complications. Recurrence of serious hemoptysis occurred after six of 18 episodes for which follow-up was available. Potential risk factors associated with severe, recurrent hemoptysis were a size increase or reappearance of the aspergilloma on a chest CT scan (P = .001), bleeding diathesis (P = .08), and lack of bronchial artery embolization during index hospitalization (P = .07). CONCLUSIONS: Our data suggest that ICAB is an effective short-term treatment to control severe hemoptysis caused by pulmonary aspergilloma. The long-term benefit of this procedure is unknown. We identified several potential risk factors for recurrent hemoptysis after ICAB that could be examined prospectively in future trials.

An unusual pediatric case of chronic constipation and rectosigmoid prolapse diagnosed by video defecography.

Rectal prolapse is a relatively common, benign condition in the pediatric population. Conservative management usually results in resolution of the problem. Persistent rectal prolapse with chronic constipation suggests more serious underlying pathologic condition that may be challenging to diagnose. We present a case of severe recurrent rectal prolapse with chronic constipation in a 13-year-old boy. Using video defecography, an unusual radiographic modality in children, a functional sigmoid obstruction was observed that was not found on more routine imaging studies. Laparoscopic sigmoidectomy provided an excellent outcome in this patient who previously had a lifestyle-limiting, chronic condition.

The utility of the chest radiograph in diagnosing exacerbations of pulmonary sarcoidosis.

BACKGROUND AND OBJECTIVE: To quantify the CXR using a profusion of small lung opacities score in patients with pulmonary exacerbation of sarcoidosis. In particular, the study sought to determine whether the CXR changes were a reliable indicator of disease exacerbation. METHODS: The study recruited patients with an exacerbation of pulmonary sarcoidosis, who were attending a university medical centre sarcoidosis clinic. Pulmonary exacerbation was defined as worsening pulmonary symptoms, thought to be related to sarcoidosis, that responded to an increase in corticosteroid dose. A subset of patients were identified who met the criteria of spirometric decline of >or=10% in FVC or FEV(1) from the previous (baseline) visit. Patients required a baseline CXR and spirometry and had CXR and spirometry performed at the initial assessment. Two International Labour Organisation B readers interpreted the CXR in a blinded manner. RESULTS: All study patients (n = 36) were African American; there were 24 patients in the 'spirometric decline' subgroup. Agreement between the B readers was moderate (kappa = 0.54, P < 0.01). The mean profusion score increased, or worsened by 1.38 points (SD = 3.60, P = 0.008) for the exacerbation group while the 'spirometric decline' group worsened by an average of 1.80 points (SD = 3.81, P = 0.031). There was too much variation for a cut-off to be identified that would reliably diagnose exacerbations. There was no significant correlation between FVC or FEV(1) and profusion score. CONCLUSIONS: The CXR International Labour Organisation profusion score is not a reliable test to detect pulmonary exacerbations of sarcoidosis. However, a CXR may be useful to exclude other diagnostic possibilities.