Urinary bladder-containing incarcerated inguinoscrotal hernia: a case report.

Inguinoscrotal hernia containing the urinary bladder is a rare entity found in 1-4% of inguinal hernias, while patients rarely present symptoms of urinary dysfunction. We present the case of a 79-year-old Caucasian male with acute renal dysfunction and incarcerated inguinoscrotal hernia containing the entire urinary bladder. The patient presented in the surgical emergency department due to an incarcerated right inguinoscrotal hernia and deteriorated renal function. Preoperatively, ultrasound imaging was performed, which showed the presence of the whole bladder in the hernia sac. The bladder was repositioned to its anatomic position and hernia was repaired through a modified Lichtenstein technique. In patients with inguinoscrotal hernia and acute urinary tract symptoms, surgeons should be aware of the possibility of inguinal bladder hernia. Preoperative imaging can help in preventing intraoperative bladder damage.

Primary greater omental torsion as a cause of acute abdomen-a rare case report.

Greater omental torsion is a rare entity that can cause acute abdominal pain, may mimick other abdominal pathologies, and is difficult to be diagnosed preoperatively. We present a case of a male patient with greater omental torsion mimicking the symptoms of acute appendicitis. A 31-year-old male patient presented with right scrotal pain, initially treated by the urologists, however, 24 h later, he presented right lower quadrant pain, with characteristics of acute appendicitis. After finding in ischemic inflammatory mass on McBurney incision, an exploratory laparotomy was performed, revealing torsion of the greater omentum. Torsion of the greater omentum can be a cause of acute abdomen and could be misdiagnosed with acute appendicitis. Preoperative diagnosis is not easy and resection of the affected tissue is the preferred treatment of choice.

Acute appendicitis as the first presentation of appendiceal metastasis of gastric cancer-report of a rare case.

Metastatic tumors of the appendix is a rare entity, whereas only limited data involving metastasis arising from gastric cancer has been reported. Herein, the case of gastric adenocarcinoma metastasis presenting as acute appendicitis is reported. A 53-year-old male, with a history of subtotal gastrectomy due to gastric adenocarcinoma 3 years before, was referred to the Emergency Department with symptoms of acute appendicitis. While this condition was confirmed intraoperatively, histology examination and comparison with the previously excised gastric specimen indicated that metastasis of gastric adenocarcinoma to the appendix was present. Metastatic appendiceal carcinoma arising from the stomach is an extremely rare condition, associated with poor prognosis. Aggressive treatment of the solitary lesion may present favorable results.

Warfarin-induced skin necrosis.

Warfarin-induced skin necrosis is an infrequent complication occurring in individuals under warfarin treatment who have a thrombophilic history or after administration of large loading doses of warfarin particularly without simultaneous initial use of heparin. A 62-year-old lady developed skin necrosis 4 days after initiating warfarin therapy of 5 mg daily without initial co-administration of heparin. The patient had a normal clotting profile. Skin necrosis progressed to eschar formation after cessation of warfarin and heparinization stopped expanding. Warfarin was reintroduced at 2 mg daily, initially together with low molecular weight heparin. Autolytic debridement of the necrotic tissue was followed by healing of the cutaneous deficit by secondary intention. Prompt diagnosis and discontinuation of warfarin are crucial for the prognosis.

Patient-related delay in presentation for cutaneous squamous cell carcinoma. A cross-sectional clinical study.

BACKGROUND: Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC. PATIENTS AND METHODS: A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed. RESULTS: Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation. CONCLUSION: Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC.

Development of primary malignant melanoma during treatment with a TNF-α antagonist for severe Crohn's disease: a case report and review of the hypothetical association between TNF-α blockers and cancer.

It is recognized that immunosuppression may lead to reduced immune surveillance and tumor formation. Because of the immunosuppressive properties of tumor necrosis factor (TNF)-alpha (TNF-α) antagonists, it is plausible that these biologics may increase the risk of the occurrence of malignancies or the reactivation of latent malignancies. TNF-α antagonists have gained momentum in the field of dermatology for treating rheumatoid arthritis and psoriasis, and they have revolutionized the treatment of other inflammatory autoimmune diseases such as refractory Crohn's disease. However, there is accumulating evidence that TNF-α inhibitors slightly increase the risk of cancer, including malignant melanoma (MM). The authors herein report the case of a 54-year-old female patient who developed a primary MM during treatment with adalimumab for severe Crohn's disease resistant to successive medical therapies. The patient had been receiving this TNF-α blocker therapy for 3 years before the occurrence of MM. After wide surgical excision of the lesion and staging (based on Breslow thickness and Clark level), evaluation with a whole-body computed tomography scan was negative for metastatic disease. The long duration of the adalimumab therapy and the patient's lack of a predisposition to skin cancer suggest an association between anti-TNF-α drugs and melanocytic proliferation. The authors also review the literature on the potential association between anti-TNF regimens and the occurrence of malignancies such as melanocytic proliferations. There is a substantial hypothetical link between anti-TNF-α regimens such as adalimumab and the potential for cancers such as melanoma. However, the risk of malignancy with biological therapy remains to be established, and most of the relevant studies have lacked the statistical power and randomization required for large clinical trials. Further long-term controlled clinical trials and registries are required to investigate this potentially serious association.

Interleukin-1 associations in inflammatory bowel disease and the enteropathic seronegative spondylarthritis.

PURPOSE: This study aims to investigate any associations of the proinflammatory cytokine IL-1 in treated patients with inflammatory bowel disease (IBD) and the enteropathic seronegative spondylarthritis (eSpA). METHODS: Thirty-four patients with Crohn's disease (CD), 26 with ulcerative colitis (UC) and 14 patients with SpA participated in the study. Valid clinical indexes, CRP values and the endoscopic and histologic examination were used for the determination of disease activity. IL-1α, IL-1ß, IL-1 receptor antagonist (IL-1Ra) were measured by ELISA. Nonparametric tests were used for continuous and categorical data. RESULTS: Enteropathic SpA diagnosed in 29.4 % CD and 30.8 % UC patients. Active disease had 58.8 % CD (aCD), 76.9 % UC and 50 % SpA patients. Active and inactive CD (iCD) significantly differ on IL-1α levels (11.2 vs. 3.9 pg/ml; p = 0.034). Active and inactive UC significantly differ on IL-1ß (3.7 vs. 2.3 pg/ml; p = 0.054) and IL-1Ra levels (15.9 vs. 12.7 pg/ml; p = 0.023). Active and inactive SpA (iSpA) significantly differ on IL-1Ra (16.9 vs. 14.8 pg/ml; p = 0.033) and marginally on IL-1α levels (20 vs. 3.9 pg/ml; p = 0.06). Patients with aCD/ieSpA exhibited significant differences on IL-1α (p = 0.022) compared to those with iCD/ieSpA. CONCLUSIONS: IL-1α is associated with CD activity, while IL-1ß and IL-1Ra are associated with UC activity in treated patients with IBD. Prominent cytokine in SpAs seems to be IL-1α.

Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis.

Umbilical endometrioma is a rare condition, with an estimated incidence of 0.5%-1% in all patients with endometrial ectopia. Spontaneous abdominal wall endometriosis is an even rarer and more unusual condition with unclear pathogenetic mechanisms. A 44-year-old parous woman presented with an umbilical skin lesion, and no history of bleeding from the umbilical mass or swelling in the umbilical area. The initial clinical diagnosis was granuloma, and excision was planned. Pathology examination revealed endometrial glands with mucinous-type metaplasia surrounded by a disintegrating mantle of endometrial stroma. Clinical examination and magnetic resonance imaging did not reveal pelvic endometriosis lesions, and given that the umbilical endometrioma was totally excised, no further treatment with hormonal therapy was proposed for the patient. Three years after excision, she was free of disease and no recurrence has been observed. Complete excision and histology is highly recommended for obtaining a definitive diagnosis and optimal treatment in spontaneous abdominal wall endometriosis.

Benign post-radiation rectal stricture treated with endoscopic balloon dilation and intralesional triamcinolone injection.

Post-radiation stricture is a rare complication after pelvis irradiation, but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction. Endoscopy has gained an important role in chronic radiation proctitis with several therapeutic options for management of intestinal strictures. The treatment of rectal strictures has been limited to surgery with high morbidity and mortality. Therefore, a less invasive therapeutic approach for benign rectal strictures, endoscopic balloon dilation with or without intralesional steroid injection, has become a common treatment modality. We present a case of benign post-radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection. A 70-year-old woman presented to the emergency room complaining for 2 weeks of diarrhea and meteorism, 11 years after radiation of the pelvis due to adenocarcinoma of the uterus. Colonoscopy revealed a stricture at the rectum and multiple endoscopic biopsies were obtained from the stricture. The stricture was treated with endoscopic balloon dilation and intralesional triamcinolone injection. The procedure appears to have a high success rate and a very low complication rate. Histologic examination of the biopsies revealed non-specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation. All biopsies were negative for malignancy. The patient is stricture-free 12 months post-treatment.

Non-Hodgkin lymphoma and GIST: molecular pathways and clinical expressions.

We report the case of a 64-year-old woman with a gastrointestinal stromal tumor and a diffuse large cell lymphoma. For this case, we conducted a literature review in an attempt to correlate these two neoplasms on a molecular basis. Diffuse large cell lymphoma is a subtype of non-Hodgkin lymphomas. The etiologic factor of these lymphomas is considered to be the mutations or allelic losses of the TP53 tumor suppressor gene and the overexpression of the bcl-2 oncogene. Gastrointestinal stromal tumors are mesenchymal tumors, which are typically defined by the expression of c-KIT (CD117) and CD34 genes in the tumor cells. Although there are references to dispersants in the literature about patients with both non-Hodgkin lymphoma and gastrointestinal stromal tumors, there is no common molecular pathway between these two diseases. In conclusion, there is no indication that these two neoplasms are relevant on a molecular basis.

Tuberculosis in the peritoneum: not too rare after all.

Peritoneal tuberculosis is rare with increased incidence rates in recent years. The absence of characteristic clinical features of the disease often makes its diagnosis difficult and elusive. We present the case of 61-year-old female with peritoneal tuberculosis. The patient suffered from abdominal pain for a period of 5 months prior to admission. The diagnosis was established on the basis of findings from an abdominal computed tomography scan, a chest radiograph and histopathological analysis of the laparoscopic resection of the two masses. The patient was discharged from hospital receiving a fourfold antituberculous treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. A high index of suspicion and a combination of radiologic, endoscopic, microbiologic and histopathological examination achieves diagnostic accuracy and prevents clinical mismanagement.

The histological and immunohistochemical aspects of bile reflux in patients with gastroesophageal reflux disease.

Introduction. The pathogenesis of GERD is strongly related with mixed acid and bile reflux. Benign and malignant esophageal and gastric lesions have been associated with synergetic activity between those parameters. Bile reflux causes reactive gastropathy evaluated with Bile Reflux Index (BRI). The aim was to investigate if the sequence: bile reflux-intestinal metaplasia-GERD-esophagitis, is associated with apoptotic/oncogenetic disturbances. Materials/Methods. Fifteen asymptomatic subjects and 53 GERD patients underwent gastroscopy with biopsies. The specimens examined histologically and immunohistochemically for p53, Ki-67, Bax, and Bcl-2. Results. Elevated BRI score detected in 47% (25/53) of patients with GERD and in 13% (2/15) of controls (P = 0.02). Severe esophageal lesions were significantly more common in BRI (+) patients (14/25) compared to BRI (-) ones (P = 0.0049). Immunohistochemical analysis did not show associations between BRI score and biomarker expression. Conclusions. Bile reflux gastropathy is associated with GERD severity, but not with oncogene expression or apoptotic discrepancies of the upper GI mucosa.

Prognostic relevance of light chain 3 (LC3A) autophagy patterns in colorectal adenocarcinomas.

AIMS: The microtubule-associated protein 1 light chain 3 (LC3A) is an essential component of the autophagic vacuoles, forming a reliable marker of autophagic activity. In a previous study, the authors showed that LC3A immunohistochemistry renders three patterns of autophagic expression in breast carcinomas: diffuse cytoplasmic, perinuclear and 'stone-like' intracellular structures (SLS), each with a distinct prognostic relevance. METHODS: Tumour tissues from 155 patients with stage IIA-III colorectal adenocarcinomas, treated with surgery alone, were assessed immunohistochemically for LC3A. Median values were used as cut-off points to separate groups into low and high autophagic activity. Associations with prognosis and with lactate dehydrogenase-5 (LDH5) were sought. RESULTS: High SLS counts were associated with metastases and poor prognosis, while the prominence of the perinuclear pattern was linked to localised disease and good prognosis. The cytoplasmic pattern was irrelevant. Furthermore, patients with increased SLS numbers, but suppressed perinuclear expression, were associated with LDH5 overexpression and had an extremely poor prognosis (3-year survival 16.5%). The prognosis improved considerably when high SLS counts were accompanied by intense perinuclear expression (3-year survival 67%) and were optimal when SLS numbers dropped below median values, irrespective of perinuclear status (3-year survival 94-100%). Multivariate analysis showed that SLS and perinuclear patterns were independent predictors of death events. CONCLUSIONS: Perinuclear LC3A accumulation in colorectal tumour cells is a marker of good prognosis, presumably reflecting a basal autophagic activity. An abnormal or excessive autophagic response, as indicated by increased numbers of SLS, is linked to metastasis and poor prognosis.

Immunohistochemical study of angiogenesis after local administration of platelet-rich plasma in a patellar tendon defect.

A full thickness defect was made in the central portion of the patellar tendon of 48 New Zealand white rabbits. Platelet-rich plasma (PRP) gel was then applied and filled the tendon defect. The same procedure was performed in the control group, without the application of PRP. Animals were sacrificed after one, two, three, and four weeks. Histological and immunohistochemical analyses using a monoclonal antibody against CD31 were performed. The histological examination showed a superior healing process in the PRP group compared with the control group. Especially in the third week, the tissue formed in the PRP group was more mature and dense with less elastic fibres remaining. Neovascularisation was significantly higher in the PRP group during the first two weeks and significantly lower in the third and fourth weeks (p < 0.0001). Histological examination and study of angiogenesis showed that the application of PRP enhances and accelerates the tendon healing process.

Laparoscopic cholecystectomy in patients with empyematous cholecystitis: an outcome analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder. METHODS: From May 1992 to July 2007, 315 patients with a clinical diagnosis of acute cholecystitis underwent LC. Operative and histopathology reports were used to identify patients with empyema of the gallbladder, to which retrospective chart reviews were applied. Factors associated with conversion and complications were assessed to determine their predictive power. RESULTS: Being male and having high levels of aspartate transaminase (AST), alanine transaminase (ALT), and white blood cells significantly influenced the prediction of empyema. The conversion rate was significantly higher for empyema and acute cholecystitis, but the complication rate did not differ significantly between these conditions. Previous abdominal surgery was an independent risk factor for conversion and complications. Also, temperature >37.5°C, AST >60 IU/l, and ALT >60 IU/l were associated with higher conversion rates. The hospital stay was longer in patients with empyema, while the operation time did not differ between the two groups. CONCLUSION: Empyema of the gallbladder can be encountered in patients with presumed acute cholecystitis. Preoperatively differentiating between simple acute cholecystitis and empyema is difficult, if not impossible. The conversion rate is expected to be higher when empyema is approached laparoscopically than for simple acute cholecystitis or symptomatic cholelithiasis.

Neuropeptide urocortin 1 and its receptors are expressed in the human liver.

The corticotropin-releasing hormone (CRH) system, consisting of CRH, urocortins (Ucns), their receptors CRH(1) and CRH(2), and CRH-binding protein, holds the principal role in mediating the response to stress stimuli. Besides their expression in the brain, CRH neuropeptides and receptors have been found in multiple peripheral sites. We investigated the expression of the CRH system in the human liver, using RT-PCR and immunohistochemistry. Ucn 1 gene transcripts were amplified in all the human liver biopsies examined. Ucn 1 immunoreactivity was localized in hepatocytes. CRH(1) and CRH(2(alpha)) receptor gene expression was also found, and receptor protein had a similar distribution to Ucn 1. Finally, Ucn 1 and CRH receptor expression was demonstrated in hepatic biopsies from a variety of liver pathologies, including primary or metastatic liver carcinoma and cirrhosis. We conclude that the CRH system is expressed by human liver under normal and pathological conditions, Ucn 1 being the major ligand. Further study is required to unfold the biological role of these effectors in liver physiology and pathogenesis, as they may act in an autocrine manner through activation of the CRH receptors expressed locally.

Hypofractionated accelerated radiotherapy, cytoprotection and capecitabine in the treatment of rectal cancer: a feasibility study.

BACKGROUND: This is a report on the feasibility and efficacy of hypofractionated accelerated radiotherapy combined with amifostine cytoprotection (hypoARC) and capecitabine in the treatment of rectal adenocarcinoma. PATIENTS AND METHODS: Twenty-seven patients (pts) received pre- (14 pts) or postoperative (13 pts) conformal radiotherapy with 10 consecutive fractions of 3.4 Gy in 12 days, supported with subcutaneously administered high-dose amifostine (up to 1000 mg) and capecitabine (daily dose of 600 mg/m2 twice a day, 5 days per week for 4 weeks). Ten additional patients with inoperable tumors received a higher dose (15 fractions of 3.4 Gy) as a radical intervention and 5 received a lower dose for palliation. RESULTS: Chemotherapy-related toxicity was minimal and radiation grade 2 diarrhoea and proctitis was noted in 3/42 and 4/42 cases, respectively. No peri- or postoperative complications were noted in patients receiving pre-operative radiochemotherapy. Significant tumor regression was confirmed in post- RT CT-imaging and major histological responses were noted in 85% of cases treated before surgery. Late toxicity (median follow-up 26 months) was negligible. The 2-year local relapse-free survival was 85-90% in patients treated with pre- or postoperative radiotherapy and 35% in patients with inoperable tumors. CONCLUSION: Capecitabine-based hypoARC is feasible with only minimal early and late toxicity and encouraging efficacy.

Laparoscopic cholecystectomy in elderly patients.

BACKGROUND: Surgery for cholelithiasis is more common in ageing patients. The use of laparoscopic cholecystectomy (LC) in older patients may pose problems because of the comorbid conditions that are concomitant with advanced age and may increase the postoperative LC complications and the frequency of conversion to open surgery. The purpose of this study was to evaluate the outcome of LC in the treatment of gallstones in the elderly (> or = 75 years old). METHODS: A retrospective study was conducted in patients who had undergone LC for symptomatic cholelithiasis: out of these, 153 patients were older than 75 years. Conversion rate to open cholecystectomy, complication rate, operative time, and length of stay were compared with those younger than 75 years. Multivariate analysis was used as a control for baseline differences. RESULTS: Conversion rate to open cholecystectomy in elderly was 13.1% vs 5.8% (p<0.001). Complication rate was 3.9% vs 1.6%. Operative time was 50 min vs 45 min. No significant difference was found in the hospital stay of both younger and elderly patients who had underwent a successful LC (p=0.079). The presence of inflammation was the only independent risk factors for conversion (p=0.014) and had a marginal independent effect on the development of complications (p=0.079) among elderly patients. CONCLUSION: Even though older patients are more likely to present with diseases in more advanced states, LC is safe and should be regarded as the gold-standard approach for elderly patients with cholelithiasis.

Dermoid cyst in the hepatoduodenal ligament: report of a case.

We report an unusual case of a mature cystic teratoma, or dermoid cyst, in the hepatoduodenal ligament of a young woman. Mature cystic teratomas are rarely found in extragonadal sites, especially the hepatoduodenal ligament. Surgical resection remains the mainstay of therapy and is required for a definitive diagnosis. Patients who undergo complete resection of a mature cystic teratoma normally have an excellent prognosis.