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1.
JGH Open ; 3(5): 381-387, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31633042

RESUMO

BACKGROUND AND AIM: Regional differences in gallstone (GS) composition are well documented in the Indian subcontinent. The reasons for the same are unknown. Etiopathogenesis of GS remains elusive despite advances in instrumentation. This was an in-depth analysis of the chemical, structural, and elemental composition of GS with special reference to synchroton studies. METHODS: We used high-end sensitive analytical complementary microscopic and spectroscopic methods techniques, such as X-ray diffraction, scanning electron microscopy, Fourier transform infrared, synchrotron X-ray fluorescence spectroscopy (SR-XRF), and 2D and 3D synchrotron microtomography (SR-µCT), to study the ultra structure and trace element composition of three major types of GS (cholesterol, mixed, and pigment). SR-XRF quantified the trace elements in GS. RESULTS: The cholesterol GS (monohydrate and anhydrate) were crystalline, with high calcium content. The pigment GS were amorphous, featureless, black, and fragile, with high calcium bilirubinate and carbonate salts. They had the highest concentration of iron (average 31.50 ppm) and copper (average 92.73 ppm), with bacterial inclusion. The mixed stones had features of both cholesterol and pigment GS with intermediate levels of copper (average 20.8 ppm) and iron (average 17.78 ppm). CONCLUSION: SR-µCT has, for the first time, provided cross-sectional computed imaging delineating the framework of GS and mineral distribution. It provided excellent mapping of cholesterol GS. SR-XRF confirmed that pigment GS had high concentrations of copper and iron with bacterial inclusions, the latter possibly serving as a nidus to the formation of these stones.

2.
Cureus ; 11(12): e6317, 2019 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-31938608

RESUMO

We describe a case of a symptomatic mucocele of the esophagus following surgical isolation of the diseased esophagus, which needed surgical resection. A 33-year-old male presented to us with shock, high-grade fever, and breathlessness five days after the onset of sudden, severe lower chest and upper abdominal pain preceded by an episode of retching and vomiting. He was initially managed elsewhere by right intercostal drainage for right-sided pleural effusion, broad-spectrum parenteral antibiotics, and total parenteral nutrition. CT chest showed a right loculated pleural effusion and distal oesophageal perforation with active contrast leak into the right pleural space. He was subsequently referred to us in view of suspected Boerhaave's syndrome and clinical worsening. In view of hemodynamic instability with uncontrolled sepsis, he was planned for surgery. Intraoperatively, there was a 4 cm long distal oesophageal perforation, 4 cm above the esophagogastric junction on the right, with an unhealthy apex, communicating with a large abscess cavity in the right pleural space with thick purulent contents. End cervical esophagostomy with esophagogastric junction stapling and feeding jejunostomy was performed in addition to transhiatal drainage of the abscess at the lower end of the esophagus and the placement of an additional intercostal drain. The postoperative period was uneventful, and he was discharged. After two months, he was assessed for possible esophagectomy and gastric pullup. Dense adhesions at thoracoscopy precluded any esophageal delineation and dissection. Attempted transhiatal dissection of the esophagus was unsuccessful in view of cicatrization, and it was decided to forego esophagectomy and proceed with bypass alone by a retrosternal gastric pull-up and cervical esophagogastrostomy. He was discharged following an uneventful postoperative period of recovery. Three months later, the patient presented with complaints of pain in the chest for three weeks, associated with hiccups. He was diagnosed to have a mucocele of the remnant esophagus based on a CT scan. The esophageal mucocele was excised by a transthoracic approach and, he was relieved of the pressure symptoms. Following the esophageal exclusion procedure, a mucocele of the remnant esophagus can develop due to the accumulation of secretions leading to subsequent dilatation. Small mucoceles are usually asymptomatic and often go unnoticed. However, in rare cases, it may enlarge to cause compression symptoms such as respiratory distress, chest pain, cough, hiccups, and an inability to swallow. Cross-sectional imaging clinches the diagnosis, and definitive surgery consists of surgical resection by a transthoracic approach.

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