Acute haemoperitoneum caused by endometriosis infiltrating the uterine artery - Two case reports and a literature review.

Objective: We report 2 cases of haemoperitoneum due to a bleeding of the uterine artery caused by infiltrating endometriosis. We have also conducted a literature review on endometriosis-related intra-abdominal haemorrhage and wrote a practical guideline on how this entity can be recognized and handled. Patients: Case 1: A 49-year-old multiparous woman presented with intense stabbing pain in the lower abdomen during her menstruation. CT angiography showed a bleeding from a side branch of the internal iliac artery. Laparoscopy was performed and an active bleeding from the right uterine artery was confirmed, clearly caused by infiltrating endometriosis lesions. Haemostasis was achieved by bipolar coagulation. Case 2: A 29-year-old nulliparous woman was admitted for observation because of heavy stabbing pain in the right lower quadrant and presence of free fluid on CT abdomen. The day after the admission, laparoscopy was performed because of a decreasing haemoglobin level. An arterial bleeding from the right parametrium was observed, probably originating from the right uterine artery. Histopathological examination of a biopsy of the right parametrium proved the presence of endometriosis. Haemostasis was achieved by bipolar coagulation. Conclusion: Although endometriosis-related haemoperitoneum is a rare entity, this diagnosis should be considered when a patient presents with an intra-abdominal haemorrhage during menstruation or withdrawal bleeding - especially in case of a history or suspicion of endometriosis. Laparoscopy is the cornerstone of the treatment.

Whipple's disease in a man of North African descent : case report and brief review of the literature.

A 62-year-old man of North African descent presented with weight loss in the past year and diarrhea for three weeks. His medical history included erosive rheumatoid arthritis, treated with methotrexate and adalimumab. Histological examination of a duodenal biopsy showed foamy macrophages in the lamina propria, with PAS-positive cytoplasmatic inclusions. These findings are compatible with Whipple's disease, a rare chronic infectious disease caused by Tropheryma whipplei, an opportunistic bacterium. It is typically seen in middle-aged Caucasian men and the immunocompromised host. The classical presentation of Whipple's disease consists of intermittent migratory arthralgia, followed by intestinal symptoms which typically occur six to seven years later. The clinical image can be very variable, and this complicates the diagnostic process. PAS-staining and PCR are the diagnostic cornerstones. In our case, treatment consisted of a prolonged cure of antibiotics: intravenous ceftriaxone for two weeks, followed by an oral maintenance therapy of doxycycline and hydroxychloroquine for at least one year. A therapeutic dilemma arose as continued anti-TNF blockade was necessary to maintain remission of the rheumatoid arthritis. Lifelong follow-up is necessary because relapse is possible.

Evaluation of the larynx for tumour recurrence by diffusion-weighted MRI after radiotherapy: initial experience in four cases.

Radiotherapy-induced changes in the soft tissues of the neck hamper the early detection of persistent or recurrent tumour by clinical examination and imaging procedures. Diffusion-weighted (DW) MRI is a non-invasive technique capable of probing tissue properties by measuring the movement of water. The purpose of the ongoing study is to examine the usefulness of DW-MRI for differentiation of persistent or recurrent tumour from post-radiotherapeutic sequelae or complications. Four patients, suspected of tumour recurrence after radiotherapy for laryngeal squamous cell carcinoma, were examined using a DW-MRI sequence on a clinical 1.5 T MR system prior to surgery. In two patients, the DW-MRI images showed an asymmetric hyperintense lesion on b1000 images with low apparent diffusion coefficient (ADC)-value, compatible with tumour on histopathology. All surrounding tissue presented high ADC values and absent signal on the b1000 images, histopathologically correlating to post-radiotherapeutic changes. The images of the third and fourth patient showed absent or minimal symmetric hyperintensity of the laryngeal soft tissues on the b1000 images and high ADC-values. In these cases, the histopathological diagnosis of radionecrosis was made and no tumour was found. In all four cases, differentiation of tumoral tissue from radiotherapy-induced tissue alterations was possible with DW-MRI.