Gastrointestinal stromal tumor with hemoperitoneum masquerading as appendicitis.

Gastrointestinal stromal tumor (GIST) is a rare condition with an annual worldwide incidence of 11 to 15 cases per million, with nearly 5000 cases occurring in the United States yearly. This tumor is found often when patients present with intraluminal gastrointestinal hemorrhage. Other manifestations include early satiety and unintentional weight loss. Multislice computed tomography is an appropriate modality used to diagnosis a GIST after clinical suspicion warrants such imaging. Hemoperitoneum secondary to ruptured GIST is rare. Our patient presented with classic appendicitis, but the etiology of his right lower-quadrant pain with peritonitis was found to be hemoperitoneum secondary to ruptured GIST originating from the ileum.

Eosinophilic granuloma of the lung and rib.

Langerhans-cell histiocytosis is characterized by abnormal proliferation of Langerhans cells, and frequently associated with cigarette smoking. A 24-year-old man who underwent excisional biopsy of a pulmonary nodule and segmental rib resection was found to have the eosinophilic granuloma variation of Langerhans-cell histiocytosis.

Predictors of electrocardiographic change, cardiac troponin elevation, and survival after major vascular surgery: a community hospital experience.

Cardiovascular disease is the leading cause of perioperative morbidity and mortality after vascular surgery. The purpose of this study was to identify risk factors for myocardial ischemia after vascular surgery and to investigate a potential association of ischemia with mortality in a community hospital setting. A retrospective review was conducted after 190 major vascular procedures. Electrocardiogram (ECG) results and troponin I levels were obtained serially during the first 24 postoperative hours. Outcomes analyzed were ischemic ECG changes, troponin I level more than 2 ng/mL, 6-month mortality, and overall survival. The authors investigated any association of these outcomes with each other and the type of operation, history of coronary artery disease, diabetes, recent coronary intervention, age older than 70 years, or postoperative symptoms. Twenty-seven (14%) patients experienced ischemic ECG changes. Twenty-one (11%) patients experienced troponin I elevation. Univariate analysis revealed a history of coronary artery disease, diabetes, concerning symptoms, and troponin elevation to be predictive of ECG change (P < 0.05). ECG change and symptoms were predictive of troponin elevation (P < 0.01). Cox multivariate analysis revealed only infrainguinal bypass to predict 6-month mortality (odds ratio = 2.92, P = 0.02). Diabetes was the sole predictor of overall mortality (odds ratio = 1.94, P = 0.001). Nonsustained ischemic postoperative ECG changes during the first 24 postoperative hours do not independently influence 6-month or overall mortality after major vascular surgery. Postoperative troponin elevation likely conveys a mortality risk in the subsequent 6 months. In the community hospital setting, midterm survival rates after vascular surgery equivalent to those in higher volume centers can be achieved. Patients undergoing infrainguinal bypass and diabetics continue to be the most moribund vasculopaths.

Aortoesophageal fistula secondary to reflux esophagitis.

Aortoenteric fistula is a rare cause of massive upper gastrointestinal bleeding and is in the overwhelming majority of cases due to erosion of a suture line of a prosthetic vascular graft into the bowel. We report the case of a massive fatal gastrointestinal hemorrhage from an aortoenteric fistula secondary to erosion from reflux esophagitis. Proper management requires expedient radiographic and endoscopic evaluation, and even with appropriate management mortality remains extremely high.

Aberrant right hepatic artery in laparoscopic cholecystectomy.

INTRODUCTION: Presented herein is a case in which an aberrant right hepatic artery (RHA) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry. CASE REPORT: A 54-year-old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy. Laparoscopic dissection revealed an aberrant right hepatic artery (RHA) anterior to the infundibulum and fundus of the gallbladder. Further dissection revealed the cystic artery to branch laterally off this RHA over the gallbladder fundus anteriorly. The cystic artery then wrapped posterolaterally on the gallbladder's surface to its neck. After the gallbladder was removed, the aberrant RHA was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location. Intraoperative images are included. The procedure was completed laparoscopically without complication. DISCUSSION: The origins and paths of both the cystic and right hepatic arteries have several documented anomalies. We are unaware of any reports of an RHA that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry. CONCLUSION: This case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy. Ligation of this uniquely located aberrant RHA could have led to intraoperative hemorrhage or potential hepatic ischemia.