Different Kynurenine Pathway Dysregulation in Systemic Sclerosis in Men and Women.

Systemic sclerosis (SSc), a predominantly female-affected systemic autoimmune disease, requires tailored treatment strategies contingent on organ involvement and symptom severity. Given SSc's inflammatory nature, the involvement of the kynurenine pathway (KP) in its pathophysiology is underexplored. Our study aimed to investigate sex-related differences in KP activation among SSc patients and assess the impact of angiotensin-converting enzyme (ACE) inhibitors and estimated glomerular filtration rate (eGFR) on KP metabolite concentrations. We enrolled 48 SSc patients and 53 healthy controls, quantifying KP metabolites (tryptophan (TRP), kynurenine (KYN), and kynurenic acid (KYNA)) in serum via high-performance liquid chromatography. Separate multivariate analyses of covariance (MANCOVAs) for women and men were performed to ascertain mean differences between patients and healthy controls while correcting for age. For our secondary objective, we conducted a MANCOVA to explore disparities in ACE inhibitor users and non-users among patients, with BMI correction. Our findings revealed decreased TRP concentrations but increased KYNA/TRP ratio and KYN/TRP ratio in both male and female SSc patients compared to their respective controls. Unlike women, SSc males exhibited higher KYN concentrations and decreased KYNA/KYN ratio relative to their controls. Additionally, SSc patients using ACE inhibitors had higher serum KYNA levels than non-users. Notably, we established a significant correlation between eGFR and KYNA in SSc patients. These results indicate differential KP activation in male and female SSc patients, with males demonstrating heightened KP activation. While ACE inhibitors may influence the KP in SSc patients, further research is necessary to comprehensively understand their impact on symptoms and prognosis in the context of these KP alterations.

A Review of the Health Benefits of Food Enriched with Kynurenic Acid.

Kynurenic acid (KYNA), a metabolite of tryptophan, is an endogenous substance produced intracellularly by various human cells. In addition, KYNA can be synthesized by the gut microbiome and delivered in food. However, its content in food is very low and the total alimentary supply with food accounts for only 1-3% of daily KYNA excretion. The only known exception is chestnut honey, which has a higher KYNA content than other foods by at least two orders of magnitude. KYNA is readily absorbed from the gastrointestinal tract; it is not metabolized and is excreted mainly in urine. It possesses well-defined molecular targets, which allows the study and elucidation of KYNA's role in various pathological conditions. Following a period of fascination with KYNA's importance for the central nervous system, research into its role in the peripheral system has been expanding rapidly in recent years, bringing some exciting discoveries. KYNA does not penetrate from the peripheral circulation into the brain; hence, the following review summarizes knowledge on the peripheral consequences of KYNA administration, presents data on KYNA content in food products, in the context of its daily supply in diets, and systematizes the available pharmacokinetic data. Finally, it provides an analysis of the rationale behind enriching foods with KYNA for health-promoting effects.

Thromboelastometry as an Ancillary Tool for Evaluation of Coagulation Status after rFVIIa Therapy in a Pregnant Woman with Severe Hypoproconvertinemia-A Case Series and Review of the Literature.

Introduction: Factor VII (FVII) deficiency is a rare hemorrhagic diathesis. In females, heavy menstrual and postpartum bleeding can appear as a consequence of its deficiency. Supplementation of the recombinant FVIIa is widely accepted. The supplementation effect in FVII-deficient subjects is difficult to predict, and severe hemorrhage has been described even when FVII levels after supplementation were within normal ranges. The aim of this report is to present the application of thromboelastometry to control the coagulation status in a patient with severe FVII deficiency during pregnancy and delivery, supplemented by rFVIIa per protocol complicated with life-threatening venous thromboembolism. Methods: Rotational thromboelastometry (ROTEM) was performed in 16 pregnant women: in one 28 year old primigravida at 35 weeks of pregnancy with congenital FVII deficiency after rFVIIa administration and 15 healthy women at 38 gestational weeks. The results were compared. Results: The thromboelastometry results showed significant shortening of the clotting time in the extrinsic and the intrinsic pathway in the hypoproconvertinemia patient after rFVIIa administration in relation to healthy pregnant women. A significant reduction in maximum lysis of the clot after FVII supplementation was observed. Conclusions: The thromboelastometry results showed a significant hypercoagulable state with hypoproconvertinemia. Thrombotic complications after delivery might be prevented by the reduction in rFVIIa guided by thromboelastometry. Thromboelastometry performed on a pregnant woman with factor VII deficiency during the supplementation of rFVIIa in peripartum time might be helpful in order to determine an individual, effective dosage regimen of rFVIIa to ensure full correction of clotting disorders without the tendency to develop thrombosis, but further studies are needed.

Protection from phototoxic injury during laparoscopic surgery in patients with erythropoietic protoporphyria.

Erythropoietic protoporphyria is a hereditary defect in heme synthesis, causing protoporphyrin deposition and phototoxic reactions after exposure to light, especially at a wavelength of about 400 nm. Sensitivity to light may cause postoperative complications. Therefore, in open surgery protective filters are employed on surgical luminaires. The dangers of laparoscopy are little understood and the intensity of the light used can be high. To protect against phototoxic injury, we inserted an OG 530 filter in the video track. This filter blocks wavelengths below 470 nm. Three cholecystectomies and one sigmoidectomies were performed laparoscopically. The procedures were uneventful, and the patients suffered no adverse reactions, including phototoxic symptoms. The filter had a moderate influence on color perception and caused no significant restrictions on working conditions. We consider that it is appropriate to develop a relevant design to meet the suitable requirements for a durable filter holder in the laparoscopic video track.

Unexpected content of kynurenine in mother's milk and infant formulas.

Mother's milk is widely recommended as complete food for the offspring in earliest postnatal time. However, the knowledge about detailed composition and the physiological role of bioactive components of breast milk is incomplete. Therefore, the aim of our study was to determine the content of kynurenine (KYN) in human breast milk during lactation and to explore the effects exerted by intragastric KYN administration from birth to weaning on physical and psychomotor development of adult rats. We found that KYN is consistently present in human milk and its content gradually increased from day 4 to 28 after delivery and that it is present in commercial baby formulas in amounts noticeably exceeding its physiological range. Animal studies showed that KYN supplementation resulted in a marked elevation of absorptive surface of rat intestine and in enhanced expression of both, aryl hydrocarbon receptor and G protein-coupled receptor 35 in the intestinal tissue in rats. Moreover, we discovered that KYN administration from birth to weaning resulted in neurobehavioral changes in adult rats. Therefore, we postulate that further research is required to thoroughly understand the function of KYN in early developmental stages of mammals and to ensure the safety of its presence in baby food products.

[Porcelain gallbladder with suspected gallbladder cancer. Case report and review of the literature]. / Porcelanowy pecherzyk zólciowy z podejrzeniem raka pecherzyka zólciowego. Opis przypadku i przeglad literatury.

Gallbladder calcification known as porcelain gallbladder (PGB) is most often asymptomatic disease developing in consequence of chronic inflammatory process in the course of other gallbladder diseases (gallstone disease). In the past PGB was reported to be associated with carcinoma of gallbladder, with the incidence of 30%, nowadays recent studies suggesting a rate of 6%. Patients with PGB due to malignancy risk undergo , prophylactic cholecystectomy although as recent studies show part of them could avoid it. AIM: Presentation of a case of a patient with calcification of the gallbladder wall and suspicion of gallbladder cancer and a review of the literature. A CASE REPORT: A 66-year-old woman was admitted with a diagnosis of PGB and concomitant diseases with a high risk of adverse events. PGB was detected through incidentally 4 months earlier, during the diagnosis of abdominal pain caused by the sigmoid volvulus. Computed tomography revealed enlarged (125mm x 57mm) PGB and abnormal tissue components into the fundus of gallbladder- suspected malignancy. No detected lymphadenopathy and growing cancer into liver, or invading, nearby organs. The patient underwent open extended (radical) cholecystectomy. Gallbladder was excised with fused part of greater omentum and adjacent, wedge-shaped part of liver parenchyma. Lymphadenectomy of the hepatoduodenal ligament and resection of cystic duct stump was also performed. There was no postoperative complication, patient was discharged six days after the surgery. No gallbladder cancer was found in the histopathological examination. There were fund cholecystolithiasis, chronic cholecystitis with hyalinization and calcification of the wall, chronic limphadenitis and glandular epithelium in the stump of the cystic duct. RESULTS: Patient with PGB and suspicion of gallbladder cancer was treated with open extended cholecystectomy. Histopathological examination has not revealed gallbladder cancer. CONCLUSIONS: Open extended cholecystectomy has proven to be an effective and safe treatment for a patient with a porcelain gallbladder at high risk of cancer.

Local recurrence of the atypical fibrous histiocytoma - a case report.

Atypical fibrous histiocytoma (AFH) is an uncommon variant of benign skin neoplasm, fibrous histiocytoma. Despite having pseudosarcomatous histological features, atypical fibrous histiocytoma is characterized by a benign clinical course. AIM: The aim of the study was to present the case of local recurrence of atypical fibrous histiocytoma in scar after the primary excision. A CASE REPORT: A 28-year-old woman was admitted due to a slowgrowing 10 mm skin tumor of the left elbow, which has been observed for 18 months. Physical examination revealed that the tumor was covered by normal skin, firm, painless and movable. Tumor was excised and the wound was healed properly. Histopathological examination revealed AFH with normal tissue margins below 1 mm. It was decided to increase the excision. After 4 months patient was admitted for an extended resection. Physical examination showed no abnormalities within the scar. Despite this the primary procedure was radicalized and the scar with margins was excised. Histopathological examination reveals a subcuticular, single-site, 2 mm recurrent atypical fibrous histiocytoma with a surrounding of 2-10 mm normal tissue margin. The patient remains in follow-up the scar reveals no irregularities. The excisional biopsy followed by an extended resection makes a complete recovery. CONCLUSIONS: The probability of a too small surgical margin (<1 mm) could contribute to the local recurrence of atypical fibrous histiocytoma.

Chronic dietary supplementation with kynurenic acid, a neuroactive metabolite of tryptophan, decreased body weight without negative influence on densitometry and mandibular bone biomechanical endurance in young rats.

Kynurenic acid (KYNA) is a neuroactive metabolite of tryptophan. KYNA naturally occurs in breast milk and its content increases with lactation, indicating the role of neonatal nutrition in general growth with long-term health effects. KYNA is also an antagonist of ionotropic glutamate receptors expressed in bone cells. The aim of this study was to establish the effects of chronic KYNA supplementation on bone homeostasis in young rats, using mandible as a model bone. Female and male newborn Wistar rats were divided into control and KYNA-administered groups until 60 days of age (25x101 mg/L or 25x102 mg/L in drinking water). Hemimandibles were subjected to densitometry, computed tomography analysis and mechanical testing. Rats supplemented with KYNA at both doses showed a decrease in body weight. There were no effects of KYNA administration and mandible histomorphometry. In males, a significant quadratic effect (P < 0.001) was observed in the densitometry of the hemimandible, where BMD increased in the group supplemented with 2.5x101 mg/L of KYNA. Analysis of mechanical tests data showed that when fracture forces were corrected for bone geometry and rats body weight the improvement of bone material properties was observed in male and female rats supplemented with lower dose of KYNA. This study showed that chronic supplementation with KYNA may limit weight gain in the young, without adversely affecting the development of the skeleton.

α4ß7 Integrin Antagonist Vedolizumab for the Treatment of Refractory Ileitis.

BACKGROUND AND AIMS: Ulcerative colitis (UC) is a superficial diffuse inflammation restricted to the colon and rectum. Inflammation within the small bowel may occur several years after a pancolectomy. The pathogenesis is unknown and seems to be different from Crohn's disease or other causes of diseases of the small intestine, but an association with colectomy due to UC is very likely. METHODS AND RESULTS: We describe the case of a patient with a probable diagnosis of pan-UC accompanied by Sjögren's syndrome and partial IgA deficiency, who developed enteritis after a restorative pancolectomy. For induction and maintenance of remission, the patient was successfully treated with mycofenolate mofetil (MMF) and vedolizumab (VDZ). CONCLUSIONS: We suggest that a previously refractory to standard therapy UC-related enteritis can be treated with combination MMF and VDZ.

Kynurenic acid as the neglected ingredient of commercial baby formulas.

The global increase in resorting to artificial nutritional formulas replacing breastfeeding has been identified among the complex causes of the obesity epidemic in infants and children. One of the factors recently recognized to influence metabolism and weight gain is kynurenic acid (KYNA), an agonist of G protein-coupled receptor (GPR35). Therefore the aim of the study was to determine the concentration of KYNA in artificial nutritional formulas in comparison with its level in human breast milk and to evaluate developmental changes in rats exposed to KYNA enriched diet during the time of breastfeeding. KYNA levels were measured in milk samples from 25 heathy breast-feeding women during the first six months after labor and were compared with 21 time-adjusted nutritional formulas. Animal experiments were performed on male Wistar rats. KYNA was administered in drinking water. The content of KYNA in human milk increases more than 13 times during the time of breastfeeding while its level is significantly lower in artificial formulas. KYNA was detected in breast milk of rats and it was found that the supplementation of rat maternal diet with KYNA in drinking water results in its increase in maternal milk. By means of the immunoblotting technique, GPR35 was evidenced in the mucosa of the jejunum of 1-day-old rats and distinct morphological changes in the jejunum of 21-day-old rats fed by mothers exposed to water supplemented with KYNA were found. A significant reduction of body weight gain of rats postnatally exposed to KYNA supplementation without changes in total body surface and bone mineral density was observed. The rat offspring fed with breast milk with artificially enhanced KYNA content demonstrated a lower mass gain during the first 21 days of life, which indicates that KYNA may act as an anti-obesogen. Further studies are, therefore, warranted to investigate the mechanisms regulating KYNA secretion via breast milk, as well as the influence of breast milk KYNA on mass gain. In the context of lifelong obesity observed worldwide in children fed artificially, our results imply that insufficient amount of KYNA in baby formulas could be considered as one of the factors associated with increased mass gain.

Kynurenic Acid Protects against Thioacetamide-Induced Liver Injury in Rats.

Acute liver failure (ALF) is a life-threatening disorder of liver function. Kynurenic acid (KYNA), a tryptophan metabolite formed along the kynurenine metabolic pathway, possesses anti-inflammatory and antioxidant properties. Its presence in food and its potential role in the digestive system was recently reported. The aim of this study was to define the effect of KYNA on liver failure. The Wistar rat model of thioacetamide-induced liver injury was used. Morphological and biochemical analyses as well as the measurement of KYNA content in liver and hepatoprotective herbal remedies were conducted. The significant attenuation of morphological disturbances and aspartate and alanine transaminase activities, decrease of myeloperoxidase and tumor necrosis factor-α, and elevation of interleukin-10 levels indicating the protective effect of KYNA in thioacetamide (TAA) - induced liver injury were discovered. In conclusion, the hepatoprotective role of KYNA in an animal model of liver failure was documented and the use of KYNA in the treatment of ALF was suggested.

Prevalence of malnutrition in various political, economic, and geographic settings.

BACKGROUND: Disease-related malnutrition (DRM) represents a critical public health concern. Therefore, Fight Against Malnutrition (FAM) should be a state priority, but the degree to which this is true appears to differ considerably among European countries. The aim of this study was to put the problem into perspective by comparing the prevalence of malnutrition in countries from opposite parts of the continent. METHODS: Six countries-Croatia, Estonia, Greece, Lithuania, Poland, and Turkey-participated in the study. A short questionnaire was used to assess DRM: its prevalence, the current situation in hospitals, regulations for reimbursement, and general healthcare circumstances. Data from ESPEN's NutritionDay 2006 were used to broaden the perspective. RESULTS: At admission in October 2012, 4068 patients were assessed. The study was performed in 160 hospitals and 225 units with 9143 beds. The highest proportions of patients with 3 or more points on the Nutritional Risk Screening 2002 were observed in Estonia (80.4%) and Turkey (39.4%), whereas the lowest were in Lithuania (14.2%). The provision of nutrition support was best in Turkey (39.4% required intervention, 34.4% received intervention) and Poland (21.9% and 27.8%, respectively). Nutrition support teams (NSTs) are active in some countries, whereas in others they virtually do not exist. CONCLUSION: The prevalence of malnutrition was quite high in some countries, and the nutrition approach differed among them. It could be the result of the lack of reimbursement, inactive or nonexistent NSTs, and low nutrition awareness. Those facts confirmed that the continuation of FAM activities is necessary.

Solid-pseudopapillary neoplasm of the pancreas - comparisons between magnetic resonance and histological findings.

Solid-pseudopapillary neoplasm is a rare pancreatic tumor typically observed in young adults. A new case of the tumor was diagnosed in a 22-year-old woman. An abnormal mass connected with the pancreatic body was found on ultrasound and computed tomography. Magnetic resonance revealed weak homogeneous contrast enhancement and a low ADC value (0.824 mm/s2; b1000). Primary radiological diagnosis suggested a solid pancreatic neoplasm, which was confirmed during histopathological assessment after resection of the pancreatic body with preservation of the spleen and normal drainage through the main pancreatic duct. Histological appearance of the solid-pseudopapillary neoplasm corresponded with its radiological morphology.

Kynurenic Acid in the digestive system-new facts, new challenges.

This review provides information on the most recent findings concerning presence, origin, and role of kynurenic acid (KYNA), a tryptophan metabolite, in the digestive system. KYNA is an antagonist of both the ionotropic glutamate receptors and the alpha7 nicotinic acetylcholine receptor, as well as an agonist of G-protein coupled GPR35 receptor. Since the GPR35 receptor is mainly present in the gastrointestinal tract, researchers have concentrated on the digestive system in recent years. They have found that KYNA content increases gradually and significantly along the gastrointestinal tract. Interestingly, the concentration of KYNA in the lumen is much higher than in the wall of intestine. It has been documented that KYNA may have a positive influence on the number of pathologies in the gastrointestinal tract, in particular ulcers, colon obstruction, or colitis. Future studies might determine whether it is advisable to supplement KYNA to a human organism.

Cardiovascular aspects of psoriasis: an updated review.

Psoriasis, a systemic inflammatory disease, is associated with enhanced atherosclerosis and risk of cardiovascular (CV) disease, which may account for higher morbidity and mortality rates in psoriatic patients. It especially applies to younger psoriatic patients with more severe disease, reducing their life expectancy. The aim of the study was to review the literature on CV disease in psoriasis as well as the pathogenic mechanisms shared between psoriasis and atherosclerosis. Moreover, case-control and cohort studies published between 2006 and 2011 were selected for meta-analysis. The meta-analysis indicates elevated risk of cardiovascular events in psoriatic patients in relation to non-psoriatic controls (OR 1.28; 95% CI 1.18-1.38). It is suggested that the treatment of the inflammatory processes involved in the pathogenesis of both psoriasis and atherosclerosis may be beneficial in reducing the CV risk in psoriatic patients. Further in-depth investigations, including prospective studies, are needed to enable more effective management of psoriatic patients in the future.

Main dietary compounds and pancreatic cancer risk. The quantitative analysis of case-control and cohort studies.

OBJECTIVE: Estimation of the role of main dietary compounds in the risk of developing pancreatic cancer. RESEARCH METHODS AND PROCEDURES: Literature published till 2010 was reviewed and selected for further analysis. The used terms were: red meat, minced meat, ham, bacon, sausages, white meat, poultry, vegetables, fish, eggs, fruits, lifestyle, diet, pancreatic cancer and pancreatic neoplasm. The collected data were meta-analysed with calculation of combined relative risk and 95% confidence interval as well as studies heterogeneity. RESULTS: A meta-analysis of 11 case-control studies indicates that red meat ingestion elevates pancreatic cancer risk by 48% (95% CI=1.25-1.76). The vegetables and fruit reduce the risk by 38% (95% CI=0.54-0.73) and 29% (95% CI=0.59-0.84), respectively. The pooled analyses of 10 cohort studies do not show significant relations between main dietary compound ingestion and pancreatic cancer risk. CONCLUSION: The red meat intake is associated with elevated risk of pancreatic cancer in contrast to vegetables and fruit ingestion. The ingestion of red meat, vegetables and fruit in cohort studies was not influenced on pancreatic cancer risk. The role of fish, poultry and eggs was not significant in both case-control and cohort studies, thus further studies were needed.

The possum scoring system and complete blood count in the prediction of complications after pancreato-duodenal area resections.

UNLABELLED: The introduction of markers which help in the identification of patients prone to suffer from postoperative complications enables to recognize them more easily and thus, treat them more effectively. THE AIM OF THE STUDY was to evaluate complete blood count indicators, as well as preoperative results obtained on the basis of the POSSUM and P-POSSUM scoring systems, considering the prediction of complications after surgical resections in the pancreato-duodenal area. MATERIAL AND METHODS: A prospective 30-day non-interventional clinical study was conducted on a group of 65 patients who underwent scheduled surgery, due to pancreatic head cancer or chronic pancreatitis. Total pancreatoduodenectomy was performed in 24.1% of patients, while the remaining were subject to hemi-pancreatoduodenectomy. The authors evaluated the preoperative complete blood count parameters, as well as the risk of complications and mortality using the audit POSSUM and P-POSSUM scoring systems. RESULTS: Postoperative complications were observed in 32.4% of patients. The white blood cell count and platelet count in the preoperative period were statistically lower in the group of patients with postoperative complications, in comparison to patients without diagnosed complications. Higher severity scores obtained by means of the P-POSSUM scoring system, as well as higher mortality during the perioperative period can be ascribed to patients who suffered postoperative complications. However, no correlation was found between the occurrence of complications and gender, age, type of resection, preoperative hemoglobin level, absolute lymphocyte count, or numerical value representing the patient's general condition (POSSUM) and predicted postoperative morbidity. CONCLUSIONS: The absolute white blood cell count and total platelet count during the preoperative period may be considered as an indicator of the higher risk of complications during pancreato-duodenal area resections. The usefulness of the POSSUM and P-POSSUM scoring systems is limited. However, the surgical severity index and calculated mortality coefficient risk can facilitate the identification of patients threatened with postoperative complications.

Recommendations for the management of trauma or surgery-related massive blood loss.

UNLABELLED: Exsanguination is an underestimated cause of treatment failures in patients with severe trauma or undergoing surgery. In some patients the primary dysfunction of blood clot formation is a direct cause of a massive blood loss. Patients without previous coagulation disorders are at risk of coagulopathy following intraoperative or post-traumatic bleeding, where the local haemostasis does not warrant bleeding cessation. THE AIM OF THE STUDY: was to assess the therapeutic value of various components of a complex interdisciplinary approach, based on the opinion of the experts treating patients with massive bleeding. MATERIAL AND METHODS: The study was conducted by anonymous questionnaire, using the analogue representation of the argument strength. The results were analyzed based on the techniques of descriptive statistics. The argument was considered a key parameter, when the median value of strength was located in the highest quartile. RESULTS: It was found that the arguments of the highest strength for the risk of developing the posthaemorrhagic coagulation disorders are: loss of more than one third of blood volume, fluid therapy in an amount greater than 35 ml/kg, administration of more than 5 units of packed red blood cells, insufficient supply of fresh frozen plasma and platelets in proportion to packed red blood cells, severe acidosis and hypothermia. The most important tests for post-haemorrhage coagulopathy are: anatomically non-localized bleed, abnormal values of the standard coagulation parameters and fibrinogen level below 1 g/L. In the treatment of post-haemorrhagic coagulopathy the team of experts pointed out the benefits of antifibrinolytic drugs, concentrates of prothrombin complex and recombinant activated coagulation factor VII. CONCLUSIONS: Multidisciplinary therapeutic management of bleeding patients is associated with employment of appropriate treatment methods to achieve the best possible outcome. Factors influencing the development of coagulopathy, the methods of diagnosis and proposed techniques of treatment may facilitate therapeutic decisions in bleeding patients requiring massive transfusion of blood components.

T-tube duodenocholangiostomy for the management of duodenal fistulae.

BACKGROUND: The tube decompression of the duodenum through an additional point of access of the duodenal wall or occasionally via the leak site decreases morbidity and mortality in patients with duodenal fistula. The objective of this paper is to present the detailed technique and clinical benefits of simplified duodenal and biliary decompression achieved by transampullary insertion of a T-tube with one-step duodenal closure for the prevention and/or treatment of duodenal leak. METHODS: The duodenocholangiostomy using T-tube with laterally perforated long duodenal limb was performed preventively in 4 patients and as a secondary procedure for septic duodenal leak in another selected 12. The mean output from the fistula, length of hospital stay, incidence of pancreatitis, as well as any postoperative septic events was recorded. The nutritional schedule during the in early postoperative period also was analyzed. RESULTS: The outcome was favorable for all patients. The mean length of hospital stay was 19 days. Septic events, such as wound or urinary tract infections, were observed in 30% of patients. Serum amylase and lipase activity was increased in two patients without a clinical picture of pancreatitis. Mean volume of T-tube duodenocholangiostomy drainage was approximately 500 ml per day during the first postoperative week. Enteral feeding was commenced 10-52 (mean, 21) hours after surgery and was followed by the initiation of normal diet on average 5 days postoperatively. CONCLUSIONS: Duodenocholangiostomy performed for duodenal decompression may be a promising alternative to classical tube duodenostomy for selected patients; however, further studies should be made to evaluate fully its practical value.

Spontaneous rupture of adrenal haemangioma mimicking abdominal aortic aneurysm rupture.

Serious bleeding from a ruptured adrenal mass limits preoperative diagnostics and can necessitate urgent laparotomy to control blood loss. A 45-year old man underwent an emergency laparotomy due to severe retroperitoneal haemorrhage causing hypovolaemia. Detailed retroperitoneal dissection after splenectomy and clamping of the abdominal aorta revealed bleeding from a ruptured haemangioma of the left adrenal gland. Following a left adrenalectomy, the patient returned to a stable haemodynamic state. Adrenal haemangiomas are rare, but may cause spontaneous life-threatening haemorrhage.