Case series of Cryptogenic Multifocal Ulcerating Stenosing Enteritis (CMUSE).

BACKGROUND AND STUDY AIMS: Small bowel ulceration poses a limited, but difficult differential diagnosis. The most common causes are Crohn's disease (CD), NSAID-associated enteritis, lymphoma, cytomegaly virus infection and tuberculosis. A less known and relatively novel differential diagnosis is cryptogenic multifocal ulcerative stenosing enteritis (CMUSE). PATIENTS AND METHODS: ive patients referred for balloon-assisted enteroscopy for various reasons showed endoscopic features of CMUSE. These findings and, when available, medical imaging were reviewed in order to increase general knowledge on CMUSE. RESULTS: Five patients, 3 males and 2 females, with a mean age of 39±5 years, underwent balloon-assisted enteroscopy. Typical short, circular, ulcerative stenoses were detected in the jejunum in 2 and in the ileum in 3 patients. The number of stenoses ranged from 1 to 7 per patient. Histopathology revealed nonspecific granulocyte inflammation without specific CD findings. Stenoses were often missed on pre-enteroscopy CT or MRI enteroclysis due to their short length. Treatment consisted of endoscopic balloon dilation in 3, corticosteroids in 3, azathioprine in 1 and anti-TNFα biologicals in 3 patients. 3 patients needed additional surgery because of ongoing symptomatic small bowel stenosis or retained wireless videocapsule. CONCLUSION: In patients with short, ulcerative small intestinal stenoses CMUSE is an important but often neglected differential diagnosis. The pathophysiology and relationship to CD are subject of ongoing debate, but specific endoscopic characteristics, different histopathological findings and lack of clear abnormalities on CT or MRI enterography suggest that CMUSE is a distinct albeit rare chronic inflammatory bowel disease.

Predictors for extensive nodal involvement in breast cancer patients with axillary lymph node metastases.

PURPOSE: Various prediction models have been developed to predict the risk of having no additional axillary metastases in patients with a positive sentinel lymph node biopsy (SLNB), thereby disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). However, in the post-Z0011 trial era it is important to identify all patients with extensive nodal involvement for whom axillary treatment might still be beneficial. Therefore, the aim of this study is to identify factors predicting extensive nodal involvement (≥3 positive nodes) in the axilla, with the emphasis on the method of axillary staging: node positivity by UGLNB versus SLNB. METHODS: All patients diagnosed with invasive breast cancer between January 2006 and December 2011 at the Máxima Medical Center were included. Univariate and multivariate logistic regression analyses were performed. RESULTS: We included 302 cases, representing 301 node positive patients, of whom 177 cases had 1 or 2 positive lymph nodes and 125 cases had ≥3 positive lymph nodes. Multivariate analyses showed that a positive UGLNB (OR = 5.10; 95%CI = 2.78-9.36), lymphovascular invasion (OR = 3.60; 95%CI = 1.79-7.23) and a larger tumor size (OR = 1.03 per mm increase; 95%CI = 1.00-1.06) were significantly associated with extensive nodal involvement in patients with invasive breast cancer. CONCLUSION: This study shows that a positive axilla, determined by UGLNB, is the most important factor for predicting further extensive nodal involvement. Hence, the role of axillary staging by ultrasound should be redefined since it might play an important role in selecting patients who may still benefit from axillary treatment.

The role of ultrasound-guided lymph node biopsy in axillary staging of invasive breast cancer in the post-ACOSOG Z0011 trial era.

BACKGROUND: Axillary status in invasive breast cancer, established by sentinel lymph node biopsy (SLNB) or ultrasound-guided lymph node biopsy, is an important prognostic indicator. The ACOSOG Z0011 trial showed that axillary dissection may be redundant in selected sentinel node-positive patients, raising questions on the applicability of these conclusions on ultrasound positive patients. The purpose of this study was to evaluate potential differences in patient and tumor characteristics and survival between axillary node positive patients after ultrasound (US group) or sentinel lymph node procedure (SN group). METHODS: Patients diagnosed with invasive breast cancer at the Máxima Medical Center between January 2006 and December 2011 were studied. RESULTS: In total, 302 node-positive cases were included: 139 and 163 cases in the US and SN groups, respectively. Patients in the US group were older at diagnosis (p < 0.001), more often had palpable nodes (p < 0.001), mastectomy (p < 0.001), larger tumors (p < 0.001), higher tumor grade (p = 0.001), lymphovascular invasion (p = 0.035), a positive Her2Neu (p = 0.006), and a negative hormonal receptor status (p = 0.003). Also, they were more likely to have more lymph nodes with macrometastases (p < 0.001), extranodal extension (p < 0.001), and involvement of level-III-lymph node (p < 0.001). Finally, they showed a worse disease-free survival [hazard ratio (HR) = 2.71; 95 % confidence interval (CI) = 1.49-4.92] and overall survival (HR = 2.67; 95 % CI = 1.48-4.84) than the SN group. CONCLUSIONS: These results suggest that ultrasound-positive patients have less favorable disease characteristics and a worse prognosis than SN-positive patients. Therefore, we conclude that omitting an ALND is as yet only applicable, as concluded in the Z0011, in patients with a positive SLNB.

[Mesenteric panniculitis in a man with abdominal pain, fever and diarrhea]. / Mesenteriale panniculitis bij een man met buikpijn, koorts en diarree.

In a 64-year-old white male with abdominal pain, fever, diarrhoea and weight loss there were radiological signs of mesenteric panniculitis: thickening of the small bowel loops, an infiltrate above the bladder and in the lower right abdomen an ileum loop with a spiculated border, and streaky strands emanating from the mesenteric fat in the lower abdomen. The clinical signs resolved spontaneously with conservative treatment in 3 weeks and after 3 months the radiological abnormalities had disappeared completely. The pathogenesis of mesenteric panniculitis is unknown. The prognosis is favourable. In advanced cases of the disease, anti-inflammatory or immunosuppressive medication may be beneficial.

Focal intraperitoneal fat infarction.

Focal intraperitoneal fat infarction, e.g. epiploic appendagitis and segmental omentum infarction, may mimic almost every acute abdominal condition. The symptoms of this benign and self-limiting disease will disappear without treatment. The etiology, symptoms, diagnosis (mainly with ultrasound and CT scan) and course of the disease are being described. An atypical case history with uneventful recovery without medical or surgical treatment is presented.

[Epiploic appendicitis]. / Appendicitis epiploica.

A 50-year-old woman presented with sudden onset of localised pain in the right and later the left lower abdomen, without other complaints. Only tenderness in the left lower abdomen was noted at physical examination. The ESR (25 mm/1st hr) and C-reactive protein (25 mg/l) were slightly elevated. The ultrasound (US) revealed a solid ovoid non-compressible hyperechoic mass (diameter 26 mm) at the point of maximum tenderness. The CT scan confirmed the presence of this lesion which appeared to be an infarction of an epiploic appendix with subsequent inflammation, called primary epiploic appendagitis. On conservative therapy the pain resolved in four weeks. The follow-up US and CT showed disappearance of the lesion after 35 days. When epiploic appendagitis is suspected, an US followed by CT is helpful to confirm the diagnosis and to avoid unnecessary treatment with antibiotics or operation.

Parathyroid hormone-related protein (PTH-rP)-associated hypercalcemia in a patient with an atypical chronic lymphocytic leukemia.

We describe a patient with an atypical chronic lymphocytic leukemia (CLL) of the mixed cell type with a hypercalcemia due to parathyroid hormone-related protein production by the malignant B cells. On regard of the elevated serum calcium level without overt lytic bone lesions we found elevated serum levels of PTH-rP and demonstrated the presence of PTH-rP on the malignant lymphocytes. PTH-rP-related hypercalcemia in CLL is very rare. The role in PTH-rP in humoral hypercalcemia of malignancy is discussed.

Biochemical investigation of fetal renal maturation in early pregnancy.

The objective of this study was to evaluate the biochemical indices of normal fetal kidney maturation in early pregnancy. Urea, creatinine, gamma-glutamyltransferase, and beta 2-microglobulin levels were measured on paired samples of amniotic and coelomic fluids and maternal serum collected at the time of pregnancy termination in a group of woman with pregnancies between 8 and 11 wk, or on paired samples of amniotic fluid and maternal serum collected from woman undergoing early transabdominal amniocentesis between 11 and 16 wk. Before 11 wk of gestation (n = 12), significantly lower concentrations of creatinine and beta 2-microglobulin, and higher concentration of gamma-glutamyltransferase were found in amniotic fluid compared with both maternal serum and coelomic fluid. Significant positive correlations were found between gestational age (8-16 wk) and amniotic fluid (n = 47) levels of urea (r = 0.45; p < 0.01), creatinine (r = 0.68; p < 0.001), gamma-glutamyltransferase (r = 0.71; p < 0.001), and beta 2-microglobulin (r = 0.69; p < 0.001). The maternal serum levels of the corresponding variables did not varied significantly. The abrupt increase in creatinine, gamma-glutamyltransferase, and beta 2-microglobulin amniotic fluid concentrations after 10 wk of gestation provides biochemical evidence for the maturation of the fetal renal glomerular function at a time when the reabsorption capacity of the proximal tubular cells is not established. We suggest that this important variation in the amniotic fluid composition, unrelated to any comparable changes in the maternal serum, reflects the fetal kidney development from the mesonephros to the metanephros.

Percutaneous gallbladder drainage in emphysematous cholecystitis.

Emphysematous cholecystitis is a serious disorder with a high mortality and morbidity. We report successful drainage of the gallbladder in a male diabetic patient with emphysematous cholecystitis in whom surgery was considered contraindicated because of his poor cardiac status.

Trypsin activity. A new marker of acute alcoholic pancreatitis.

A normal serum amylase level is found in up to 32% of patients with acute alcoholic pancreatitis. This underlines the need for more sensitive diagnostic tests in this frequent cause of pancreatitis. Animal and human studies have shown that chronic alcohol consumption leads to important modifications in trypsinogen metabolism. The present work has prospectively analyzed admission serum trypsin activity with a new biochemical test and usual markers such as amylase, lipase, and immunoreactive trypsin in 32 attacks of acute pancreatitis. Seventeen were due to alcohol and 15 to other causes, including 11 with gallstone pancreatitis. High trypsin activity (median: 235 units/liter; range: 165-853) was found in all patients with acute alcoholic pancreatitis even when the amylase level was normal on admission (3/17: 18%). Trypsin activity did not differ between nonalcoholic pancreatitis (N = 15): 84 units/liter (42-98), alcoholic controls (N = 15): 77 units/liter (40-122), and healthy controls (N = 62): 81 units/liter (15-143). The difference was not related to the severity of disease or circulating alpha 2-macroglobulin, alpha 1-protease inhibitor, or immunoreactive trypsinogen levels. Lipase/amylase ratio was less discriminant than trypsin activity between alcoholic and nonalcoholic diseases. We conclude that serum trypsin activity seems specific to acute alcoholic pancreatitis and should be included in new prospective studies assessing biochemical testing of alcohol-related pancreatic diseases.

Relationship between protein concentrations in embryological fluids and maternal serum and yolk sac size during human early pregnancy.

Coelomic fluid (n = 57), amniotic fluid (n = 61) and maternal serum (n = 81) were obtained from normal pregnancies between 7.7 and 13.9 weeks and assayed for total protein, alpha-fetoprotein (alpha FP), albumin and pre-albumin. The mean concentration of total protein in matched samples was 18 times higher in maternal serum than in the coelomic fluid and 54 times higher in the coelomic fluid than in amniotic fluid. The concentrations of total protein, albumin and pre-albumin decreased and that of alpha FP increased in maternal serum with advancing gestation. The yolk sac volume and the concentrations of total protein in the coelomic and amniotic fluids increased with gestational age. No difference was found for the crown-rump length, yolk sac volume and protein concentration in the coelomic fluid between two groups presenting with low and high maternal serum pre-albumin concentrations. Before 11 weeks gestation, significant correlation was only found between yolk sac volume and coelomic fluid concentration of pre-albumin as evaluated by both electrophoresis and immunonephelometry. These results suggest that during the first trimester of normal pregnancy, the placental metabolism and transfer rate of proteins is not directly influenced by the concentrations of protein in the maternal circulation and that the transfer of proteins through the amniotic membrane is limited. These results also indicate that during that period the secondary yolk sac may contribute to the protein content of the exocoelomic cavity, and that the embryo and its yolk sac and subsequently the fetus are the main source of the proteins present in the amniotic fluid.

Determination of protein pattern in embryonic cavities of human early pregnancies: a means to understand materno-embryonic exchanges.

Exocoelomic and amniotic fluids were obtained by selective puncture under ultrasound guidance in normal human pregnancies between 5 and 13 weeks of gestation. Evaluation of the protein patterns in the exocoelomic fluid showed qualitative and quantitative changes with advancing gestation. During the second month of gestation, three electrophoretic bands were found with mobility compatible with albumin, alpha 1-globulin and beta-globulin and composed of at least eight proteins including: pre-albumin, albumin, alpha-fetoprotein (alpha-FP), alpha 1-protease inhibitor, haptoglobin, ceruloplasmin, transferrin and immunoglobulin-G, as revealed by immunoblotting. Protein patterns obtained between 9 and 13 weeks were comparable in exocoelomic fluid and in maternal serum except for the presence of alpha-FP in the alpha 1-globulin band. At the same gestational age, protein electrophoresis of amniotic fluid revealed four bands corresponding to albumin, alpha-FP, haptoglobin and transferrin. Creatinine levels were significantly lower (P less than 0.01) in amniotic fluid than in exocoelomic fluid, and alpha-FP levels were similar in both exocoelomic and amniotic fluids. These results suggest that the exocoelomic fluid is a transudate of the maternal serum except for the presence of high levels of alpha-FP, that amniotic and exocoelomic cavities are separated by a non-permeable membrane and that the secondary yolk sac plays an important role in early protein synthesis and transfer.

Biochemical composition of exocoelomic fluid in early human pregnancy.

Exocoelomic fluid (N = 25) and amniotic fluid (AF) (N = 17) were retrieved by transvaginal puncture from 30 normal pregnancies being terminated for psychosocial reasons between 5-13 weeks of gestation. Biochemical analyses were performed on each sample including concentrations of urea, total protein, potassium, sodium, creatinine, hCG, and alpha-fetoprotein (AFP). The results were compared with values in maternal serum obtained at the same time. Significant correlations were found between gestational age and concentrations of urea (P less than .005), total protein (P less than .05), and hCG (P less than .001) in the exocoelomic fluid. Significantly (P less than .05) higher total protein levels were found in the exocoelomic fluid during the third month of pregnancy compared with the second month. Urea concentration and hCG levels were significantly (P less than .005 and P less than .001, respectively) lower in the exocoelomic fluid during the third than during the second month of gestation. Significantly higher protein (P less than .001 and P less than .001), potassium (P less than .005 and P less than .05), sodium (P less than .001 and P less than .05), and creatinine (P less than .01 and P less than .001) concentrations were found in the maternal serum compared with exocoelomic fluid and AF, respectively. The concentration of hCG was significantly (P less than .001) higher in exocoelomic fluid and significantly (P less than .001) lower in AF than in maternal serum. The AFP level was significantly (both P less than .001) lower in the maternal serum than in both fluids.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonography in the diagnosis of acute appendicitis.

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.

Mass concentration of creatine kinase MB isoenzyme and lactate dehydrogenase isoenzyme 1 in diagnosis of perioperative myocardial infarction after coronary bypass surgery.

Recent advances in methodology allow the mass concentration of creatine kinase MB isoenzyme (CK-MB), and of lactate dehydrogenase isoenzyme 1 (LD1) to be determined quickly and easily as routine, emergency tests. We evaluated these tests as diagnostic criteria of perioperative myocardial infarction (PMI) after coronary bypass surgery. These tests were compared with the usual measurements of CK-MB activity by immunoinhibition and LD1 by electrophoresis and with other biological markers of myocardial infarction such as total CK, total LD, and aspartate aminotransferase. Sixty-one patients who underwent coronary bypass grafting were followed pre- and postoperatively by enzyme determinations and electrocardiography; a subgroup was monitored by myocardial scintigraphy. CK-MB mass appeared to be the best marker of PMI during the first 48 h, although LD1 was the marker of choice from days 2 to 4.

Concentration of tobramycin given by aerosol in the fluid obtained by bronchoalveolar lavage.

Whereas previous studies have used only bronchial secretions and sputum, in the present study, bronchoalveolar (BAL) fluid was analysed for tobramycin levels after aerosolization of this antibiotic. In 20 adult patients with a variety of lung disorders, the concentration of tobramycin obtained in the first aliquot of the bronchoalveolar fluid varied from less than 0.1 to 9.2 micrograms ml-1 (mean 2 +/- 2.26 micrograms ml-1) with 18 samples above 0.4 micrograms ml-1. In most of the cases, the concentration of tobramycin achieved values of tobramycin in excess of the minimal inhibitory concentration for most of the microorganisms. Thus, sampling fluids by the bronchoalveolar technique offers a suitable method to study antibiotic levels at the site of broncho-pulmonary infection. These results may help explain why aerosol antibiotic treatment appears to be useful in selected patients, especially in cystic fibrosis patients chronically infected with Pseudomonas aeruginosa.

Red blood cell destruction in single-needle dialysis.

A high incidence of hemolytic episodes has been documented by increased lacticodeshydrogenase levels after dialysis. When symptomatic, these episodes presented frequently with nausea and abdominal or back pain occurring typically in the last hour of the dialysis session. A prospective study, comparing two different access devices (needle and catheter) and three double-pump systems, demonstrated the critical role of the access device configuration. In addition, the neccessity to monitor the pressures in the arterial and venous lines when working with high blood flow rates is also stressed. By comparison, red blood cell destruction is negligible in conventional double-needle dialysis.