Effects of the Concomitant Use of Low-dose Clarithromycin with an Anti-TNFα Antibody in a Patient with Intestinal Behçet Disease.

A 66-year-old Japanese male with a history of Behçet disease exhibited oral and genital ulcers, and a round deep ileocecal ulcer. He was treated with a combination of mesalazine and 20 mg/day of prednisolone (PSL), but was only partially responsive to PSL and we were not able to reduce the steroid dosage. Adalimumab was also administered. However, the ulcer was not completely responsive, and weaning the patient off PSL remained impossible. In contrast, additional treatment with clarithromycin completely healed the refractory active ulcer and left only a scar. Furthermore, the ulcer has since maintained the scar stage despite successfully weaning the patient from PSL.

Ileocecal endometriosis: diagnosis and management.

OBJECTIVE: Ileocecal endometriosis is rare. Symptoms range from no symptoms, cramps, vomiting, to acute intestinal obstruction. Our objective was to review our cases, clarify, and resume its most appropriate management focusing on the factors to determine diagnosis. This is a retrospective study by revision of medical charts of all ileal endometriosis cases of our unit from 2006 to 2014. CASE REPORT: Seven cases were found; three (43%) had previous endometriosis laparoscopic diagnosis, four (57%) had partial bowel obstruction episodes, three (43%) had chronic pelvic pain, and one developed acute intestinal obstruction in postoperative ileostomy closure. In three (43%), the diagnosis was made with magnetic resonance imaging (MRI) and double contrast barium enema, in one (14%) only with MRI, and the other three (43%) during surgery. All patients underwent resection of the ileum and evolved favorably. CONCLUSION: Variability in symptoms hinders diagnosis. The gold standard for diagnosis is MRI, but clinical suspicion optimizes imaging test diagnosis. Segmental resection should be indicated in the majority of the cases.

A case of ileocecal actinomycosis treated by preoperative antibiotic treatment to reduce mass size followed by surgical resection.

A 65-year-old woman presented to a nearby clinic with a painful mass in the right lower abdominal region. She was suspected of having an appendiceal tumor on abdominal computed tomography (CT) and was referred to our hospital for surgery. Blood testing revealed increased inflammatory markers. Contrast-enhanced abdominal CT revealed a mass with poorly defined margins in the ileocecal region, which was adjacent to the external iliac vessels. A barium enema revealed unilateral wall deformities in the cecum through to the terminal ileum, whereas lower gastrointestinal endoscopy showed no clear epithelial tumor component. The patient was clinically diagnosed with ileocecal actinomycosis and treated with high-dose penicillin G. On day 15 of treatment, contrast-enhanced abdominal CT showed a reduction in mass size. On day 26, right hemicolectomy (D3) with combined resection of the external iliac vein (which could not be separated from the mass) was performed. Pathological examination revealed granulation tissue with granules of actinomyces, with filamentous bacteria detected by Grocott staining. With no evidence of malignancy, the final diagnosis of ileocecal actinomycosis was made. This report presents a case of clinically suspected ileocecal actinomycosis treated by preoperative antibiotic treatment to reduce mass size, followed by surgical resection.

Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults? A Randomized Controlled Trial.

OBJECTIVE: We hypothesized that immediate laparoscopic surgery for appendiceal abscess would result in faster recovery than conservative treatment. BACKGROUND: On the basis of the retrospective studies, conservative management of appendiceal abscess is recommended as a first line treatment, but some controversy exists. METHODS: Sixty adult patients diagnosed with appendiceal abscess were randomly assigned to either laparoscopic surgery (n = 30) or conservative treatment (n = 30). Hospital stay, recurrences, additional interventions, and complications within 60 days from randomization were recorded. RESULTS: There was no difference in hospital stay: 4 days (interquartile range: 3-5 days) in the laparoscopy group versus 5 days (3-8) in the conservative group, P = 0.105. Patients in the laparoscopy group had 10% risk for bowel resection and 13% risk for incomplete appendectomy. There were significantly fewer patients with unplanned readmissions in the laparoscopy group: 1 (3%) versus 8 (27%), P = 0.026. Additional interventions were required in 2 (7%) patients in the laparoscopy group (percutaneous drainage) and in 9 (30%) patients in the conservative group (surgery), P = 0.042. Recurrent abscesses and failure to respond to conservative treatment were the main reasons for additional interventions. Open surgery was required in 3 (10%) patients in the laparoscopy group and in 4 (13%) patients in the conservative group. Postoperative complications occurred in 3 patients in laparoscopic group versus 2 patients in the conservative group. The rate of uneventful recovery was 90% in the laparoscopy group versus 50% in the conservative group, P = 0.002. CONCLUSIONS: Laparoscopic surgery in experienced hands is safe and feasible first-line treatment for appendiceal abscess. It is associated with fewer readmissions and fewer additional interventions than conservative treatment with comparable hospital stay.

Pharmacokinetics and oral bioavailability of amoxicillin in chicken infected with caecal coccidiosis.

Chicken infected with caecal coccidiosis (Eimeria tenella) was used to evaluate the effect of coccidiosis on the pharmacokinetic and bioavailability of amoxicillin. The level of amoxicillin was estimated by high-performance chromatography (HPLC) to calculate the pharmacokinetic parameters and oral bioavailability. For i.v. injection of amoxicillin, Vd and CL were 0.29 and 0.27 (mg/kg)/(µg/mL)/h, respectively. Compared with healthy chicken, intravenous injection of amoxicillin in the infected chicken showed higher distribution and elimination constants, delayed clearance and statistically significant higher AUC and MRT. Oral administration in healthy chicken was accompanied by rapid absorption and high bioavailability with Tmax , Cmax and F about 1.03 h, 3.26 µg/mL and 40.2, respectively. Furthermore, oral administration in the infected chicken produced higher mean absorption time, delayed Tmax, lower Cmax, smaller AUC value and lower bioavailability (16.76). Based on these results, monitoring and adjustment of amoxicillin dosing could be practiced during the presence of coccidiosis. The measured Cmax values suggest the administration of 1.3-folds of the normal dose to maintain the normal maximal serum concentrations of amoxicillin in chicken infected with caecal coccidiosis.

Caecal diverticulitis: a rare cause of right iliac fossa pain.

We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.

Recurrence of acute appendicitis after non-operative treatment of appendiceal abscess in children: a single-centre experience.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the incidence of recurrence of acute appendicitis after initial successful non-operative treatment of appendiceal abscess in children. METHODS: This study was an observational cohort study of children treated non-operatively for appendiceal abscess at a large tertiary referral centre from 2006 to 2010. The primary outcome was recurrence of acute appendicitis. Secondary outcome variables were re-admission and interval appendectomy. RESULTS: Eighty-nine patients were discharged after successful non-operative treatment of appendiceal abscess. The median age was 10.1 (1.3-16.3) years. Nine patients underwent surgery during the follow-up period. Five patients were re-admitted with ongoing symptoms leading to an appendectomy. They all returned shortly after discharge and are considered failures of initial treatment. Two of 82 patients returned with a new episode of acute appendicitis during the trial period. Hence, the recurrence rate was 2.4 % during 5.1 years of follow-up. CONCLUSION: Our data support the strategy of not performing an interval appendectomy after successful non-operative treatment with antibiotics of an appendiceal abscess in children.

[Successful conservative treatment of coecal perforation in a patient with Ogilvie's syndrome]. / Vellykket konservativt behandlet caecumperforation ved Ogilvies syndrom.

The case report describes a 37-year-old woman who was diagnosed with Ogilvie's syndrome after caesarean section. Conservative treatment was initiated with minimal effect, and the patient was subsequently treated with IV neostigmine. A computed tomography of the abdomen revealed enlarged peritoneal cavity. However the patient was clinically unaffected without fever or signs of peritonitis. The perforation was managed with a conservative approach including antibiotics and close observation of the patient. After nine days the patient was discharged with normal gastrointestinal function and without further reported complications.

Effect of acute ethanol treatment on biochemical and histopathological factors in rat liver in an experimental sepsis model.

The aim of this study was to investigate the contribution of acute alcohol in sepsis-related liver damages using a Cecal Ligation and Puncture (CLP) model. Rats were divided into 7 groups (5 rats/group): control (saline-injected), sham-operated, CLP, ethanol (1.0 and 2.0 g/kg b.w) and CLP+ethanol. The CLP+ethanol group received a single dose of ethanol following sepsis induction. Sepsis induction caused early changes in lipid peroxidation products in liver, whereas ethanol alone (2.0 g/kg b.w) resulted in a significant increase (~21%) in lipid peroxidation, which was further increased (~57%) in CLP rats treated with alcohol. CLP operation and alcohol treatment exhibited additive effects on plasma catalase, liver glutathione and glutathione S-transferase (GST), which were primarily suppressed due to ethanol. Hepatic cytochrome P4501A1, which was elevated in CLP rats, was reversed in the CLP+ethanol group. Plasma tumor necrosis factor-α was markedly elevated (~85%) in septic rats, but was unaffected in septic rats having received ethanol. Histopathological observations revealed that inflammatory reactions in liver in response to CLP operation are not intensified by ethanol administration. On the basis of biochemical and histopathological results, it can be concluded that acute ethanol treatment is responsible for early changes in oxidative stress, which may lead to polymicrobial sepsis-related organ damage.

Sildenafil treatment attenuates lung and kidney injury due to overproduction of oxidant activity in a rat model of sepsis: a biochemical and histopathological study.

Sepsis is a systemic inflammatory response to infection and a major cause of morbidity and mortality. Sildenafil (SLD) is a selective and potent inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase PDE5. We aimed to investigate the protective effects of sildenafil on caecal ligation and puncture (CLP)-induced sepsis in rats. Four groups of rats were used, each composed of 10 rats: (i) 10 mg/kg SLD-treated CLP group; (ii) 20 mg/kg SLD-treated CLP group; (iii) CLP group; and (iv) sham-operated control group. A CLP polymicrobial sepsis model was applied to the rats. All groups were killed 16 h later, and lung, kidney and blood samples were analysed histopathologically and biochemically. Sildenafil increased glutathione (GSH) and decreased the activation of myeloperoxidase (MPO) and of lipid peroxidase (LPO) and levels of superoxide dismutase (SOD) in the septic rats. We observed a significant decrease in LPO and MPO and a decrease in SOD activity in the sildenafil-treated CLP rats compared with the sham group. In addition, 20 mg/kg sildenafil treatment in the sham-operated rats improved the biochemical status of lungs and kidneys. Histopathological analysis revealed significant differences in inflammation scores between the sepsis group and the other groups, except the CLP + sildenafil 10 mg/kg group. The CLP + sildenafil 20 mg/kg group had the lowest inflammation score. Sildenafil treatment decreased the serum tumour necrosis factor (TNF)-α level when compared to the CLP group. Our results indicate that sildenafil is a highly protective agent in preventing lung and kidney damage caused by CLP-induced sepsis via maintenance of the oxidant-anti-oxidant status and decrease in the level of TNF-α.

Success of medical therapy in a rare case of cecal ameboma.

INTRODUCTION: Colitis caused by Entamoeba histolytica (EH) is prevalent in developing countries. Clinical presentation ranges from mild diarrhoea episodes to dysentery and liver abscess. Ameboma, a complication caused by EH invasion of the intestinal wall, is a rare presentation of amebiasis, occurring approximately in 1.5% of cases. Because of its insidious and variable clinical presentation only few cases are diagnosed previous to surgical intervention. We report a 52 years old Mexican-mestizo female, presenting with a pain-less right lower quadrant abdominal mass and diagnosed of cecal ameboma prior to surgery by colonoscopy and histopathologic examination. The present case highlights the importance of early diagnosis and medical therapy with antiparasitic drugs in order to avoid complications that could lead these patients to unnecessary surgical management.

Solitary caecal ulcer syndrome: our experience with this benign condition.

AIM: Solitary caecal ulcer syndrome is rare. We describe our experience of 10 patients with the condition. METHOD: A prospectively collected database of patients undergoing colonoscopy or surgery with histology reporting a solitary caecal ulcer was reviewed from 1999 to 2008. Patients with known carcinoma of the colon, cytomegalovirus infection, amoebiasis, inflammatory bowel disease, immunosuppression and history of nonsteroidal anti-inflammatory drug use were excluded. RESULTS: Ten patients were found to have a solitary caecal ulcer. All were of Chinese ethnicity, of median age 61 years. The most common presenting symptoms were haematochezia and right-sided abdominal pain. Histological findings included ulceration sharing some features of solitary rectal ulcer syndrome, but with differences to suggest a different aetiology. CONCLUSION: Solitary caecal ulcer syndrome should be included in the differential diagnosis of lower gastrointestinal haemorrhage, right iliac fossa pain or when computed tomography imaging demonstrates caecal wall thickening. The diagnosis can only be made on histopathological examination.

Intestinal schistosomiasis associated with intussusception: a case report.

We report a case of intestinal schistosomiasis associated with iliocaecal intussusception resulting from obstructions of the terminal part of the ileum by schistosome egg-induced fibrosis. A 7-year-old boy presented with the history of abdominal pain and difficulties in passing stool for two months. Ultrasound examination revealed doughnut signs characterized with multiple concentric rings at the lateral abdomen, and the bowel loop appeared distended. Exploratory laparatomy confirmed intussusception of the terminal part of the ileum into the caecum, extending to the ascending colon. Hemicolectomy and end-to-end iliocolostomy was performed. Histological examination of the resected bowel revealed Schistosoma mansoni eggs within the mucosa, submucosa of the ileum, caecum and ascending colon, granulomatous inflammation with foreign body giant cells accompanied by fibrosis and eosinophilic infiltrate into the mucosa. Postoperatively, the patient recovered well. There may have been a synergistic effect of schistosomiasis with other underlying conditions, leading to intussusception. In conclusion, it is important to consider S. mansoni infection as a differential diagnosis for intestinal obstruction in endemic areas.