Biliary Peritonitis Caused by Spontaneous Bile Duct Rupture in the Left Triangular Ligament of the Liver after Endoscopic Sphincterotomy for Choledocholithiasis.

Spontaneous bile duct rupture is a rare condition in adults, with only 70 cases reported. Increased bile duct wall pressure may lead to rupture and biliary peritonitis. In this patient, the bile duct ruptured in the hepatic left triangular ligament. A 91-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and endoscopic retrograde biliary drainage (ERBD) placement. One week later, removal of the ERBD and common bile duct stones and an endoscopic sphincterotomy (EST) were performed. Four days later, the patient had abdominal pain, increased inflammatory reaction, and jaundice. Abdominal computed tomography showed ascites, bile duct dilatation and fluid collection under the liver (10 cm in diameter). Emergency surgery was performed to drain the fluid. On laparotomy, encapsulated biliary ascites was seen. To search for the site of the leak, after cholecystectomy, a tube (C-tube) was inserted into the common bile duct via cystic duct stump. Because of uncontrollable bleeding, after packing with surgical gauze, the operation was temporarily stopped. The next day, reoperation was performed. Intraoperative cholangiography with contrast dye revealed the perforation site in the left triangular ligament and a partial resection was performed. Bile excretion from the C-tube was subsequently observed, but the patient's jaundice did not improve. Although endoscopic retrograde cholangiopancreatography revealed that the EST site was normal, ERBD was placed again, and the jaundice gradually improved. Although EST was performed in this case, biliary peritonitis resulting from spontaneous bile duct rupture occurred. This case was very informative because biliary perforation may occur even after EST.

Rectal arterio-venous malformation (AVM) with bleeding of an internal hemorrhoid.

A 38-year-old male with no past history of illnesses visited the out-patient clinic of Nerima Hikarigaoka Hospital complaining of dizziness and persistent anal bleeding. There was a significant anemia on a blood test and colonoscopy showed a thrombus in a markedly swollen internal hemorrhoid. Contrast-enhanced computed tomography (CT) showed a poorly demarcated area with early face enhancement on the right side of the rectum and anal canal. Based on these findings, an arterio-venous malformation (AVM) of the rectum was suspected. Abdominal angiography showed abnormal vessels receiving a blood supply from the bilateral superior rectal arteries. We suspected that the AVM in the rectum was the cause of the hemorrhage from the internal hemorrhoid, and therefore performed embolization of the AVM. Thereafter, the hemorrhage from the internal hemorrhoid stopped completely and the anemia improved to the normal level, without the need for treatment for the internal hemorrhoid. Colonoscopy performed 6 months after embolization showed shrinkage of the internal hemorrhoid. To the best of our knowledge, there are no reports stating a relationship between rectal AVM and internal hemorrhoids. However, we consider that contrast-enhanced CT can be used to detect vessel abnormalities related to severe bleeding of the internal hermorrhoids in patients with internal hemorrhoids and severe anemia.

A study on the correlation between patients' physical characteristics and effective dose of liver computed tomography.

This suggests indicators to be considered in the protocol for setting up equipment and minimizing patient doses by identifying the effective dose and correlations of each equipment company according to a patient's body characteristics in liver CT. The study was conducted with 445 patients who went to the hospital and received liver CT at the diagnostic radiology department of S medical center from 2010 January to June. As the statistical methods, t-test, one-way ANOVA, and Pearson's correlation analysis were used. The study results show that as height, weight, and BMI increased, the effective dose increased with all equipment vendors. Correlations between a patient's body characteristics and the effective dose were shown to be positive with all equipment vendors in regard to weight, BMI, and height, in order.

[Can magnetic resonance imaging of the brain in the acute phase of carbon monoxide intoxication forecast delayed encephalopathy?].

We examined the usefulness of Magnetic Resonance Imaging (MRI) test in the acute phase of carbon monoxide intoxication for forecasting delayed encephalopathy (DE). [Case 1] 26-year-old female. COHb 12%. Takotsubo (Ampulla) cardiomyopathy was supervened. Pallidal disorder was recognized in MRI test in the early stage. Although Prophylactic HBO was performed, DE began. 36 days later, disorder was recognized in large area, such as, in cerebral white matter and callosum, and abnormality was found in WMS-R and MMSE. Since HBO was performed, DE subsided. In MRI test, on the other hand, high signal range in cerebral white matter and callosum were gradually decreased and WMS-R and MMSE were improved. [Case 2] 19-year-old female. COHb 9.4%. The state was considered to be mild but pallidal disorder was found in MRI test at the beginning. DE did not start, then the part of pallidal disorder was narrowed. WMS-R and MMSE showed slightly low level. [Case 3] 19-year-old female. COHb 7.3%. The state was considered to be mild and there was no abnormal findings in MRI test in the early stage. DE did not start. [Case 4] 48-year-old male. COHb 48.9%. Rhabdomylosis was supervened, then ischemic change in a left radiate crown was recognized in the early MRI test. Since the third day, disorientation and restlessness had been developed, so that the patient was transferred to psychiatric department, though it was still difficult to distinguish the case from DE. Although the case is relatively mild, pallidal disorder is recognized in the early MRI test. Pallidal disorder alone can cause memory disorder and cognitive impairment. Even if pallidal disorder alone is recognized in the early MRI test, white matter disorder is developed with time, and then DE begins. If there are no typical carbon monoxide intoxication findings, some cases can be suspected as DE. It is useful to perform serial MRI test in order to prepare for delayed encephalopathy in carbon monoxide intoxication.

[Acyclovir combined with plasma exchange for disseminated varicella-zoster virus infection after bone marrow transplantation].

In 2001, a 45-year-old man with severe aplastic anemia received a bone marrow transplantation from his HLA-identical sister, 2.5 years after which he developed severe liver dysfunction together with abdominal pain, disturbance of consciousness and generalized vesicles. Disseminated varicella-zoster virus infection was diagnosed by the detection of VZV DNA. Acyclovir and plasma exchange rapidly controlled his VZV-related symptoms and signs. Disseminated VZV infection is often fatal, but acyclovir and plasma exchange may be useful for such infection by reducing the circulating viral load.