Chien-Heng Lin

Emergent Transcatheter Arterial Embolization in Hemodynamically Unstable Patients With Blunt Splenic Injury

RATIONALE AND OBJECTIVES Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. MATERIALS AND METHODS In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. RESULTS Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. CONCLUSIONS TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Children with Chest Pain Visiting the Emergency Department

BACKGROUND Chest pain is a common complaint in children visiting the emergency department (ED). True organic problems like cardiac disease are rare. We assess and analyze the etiology of chest pain among children visiting a pediatric ED in one medical center. METHODS We retrospectively reviewed the medical records of children with chest pain who visited our ED between September 2002 and June 2005. Any case of trauma-associated chest pain was excluded from this study. RESULTS A total of 103 patients (64 boys, 39 girls; mean age, 13 years; age range, 4-17 years) were enrolled into this study; 101 patients had chest radiograms (98.1%). Pneumonia was identified in five patients and pneumothorax in three. Eighty-seven patients had electrocardiogram study (84.5%) and four of them showed abnormalities. Additional diagnostic tests were performed in 64 patients (62.1%), including complete blood count analysis and echocardiography. Echocardiograms were performed in 15 (14.6%) patients. Six of them showed minor abnormality. Panendoscopy was done in six (5.8%) patients, and gastroesophageal reflux was found in three. Eleven (10.7%) patients were admitted to hospital because of pneumonia, pneumothorax or arrhythmia. Overall, idiopathic chest pain was the most common diagnosis (59.2%). Other associated disorders were pulmonary (24.3%), musculoskeletal (6.7%), gastrointestinal (5.8%), cardiac (2.0%) and miscellaneous (2.0%). CONCLUSION The most common cause of chest pain prompting a child to visit the ED is idiopathic chest pain. Careful physical examination can reveal important clues and save much unnecessary examinations.

Wandering spleen with torsion and gastric volvulus.

Wandering spleen, defined as a spleen without its usual peritoneal attachments, is a rare entity, particularly in children. It usually occurs in those aged 20 to 40 years, and most cases occur in women. Patients usually become symptomatic when torsion of the splenic pedicle occurs. Gastric volvulus, like wandering spleen, is also related to anomalies of intraperitoneal visceral attachments. However, cases of wandering spleen associated with gastric volvulus are rare. We report a case of wandering spleen with torsion and gastric volvulus. The patient was a 4-year-old girl who presented with acute intractable vomiting and abdominal pain. Exploratory laparotomy was performed under the impression of wandering spleen with torsion. The gastric volvulus was found intraoperatively. Following splenectomy and gastropexy, Haemophilus influenza type b and pneumococcus vaccination and prophylactic antibiotics were given. She recovered uneventfully and had no signs of illness or ongoing infection at 1-year follow-up after the operation.

Computed tomographic imaging in determining the need of embolization for high-grade blunt renal injury.

BACKGROUND It is well documented that transarterial embolization (TAE) can successfully stop bleeding in renal trauma patients and reduce the failure rate of conservation treatment. However, there is no consensus on the indications for TAE. The aim of this study was to evaluate the criteria for computed tomography (CT) to predict the need for TAE for patients with high-grade blunt renal trauma. METHODS Of the 137 patients with blunt renal trauma between 2005 and 2010, 81 had a high-grade injury (grade ≥3) with stable hemodynamics, who were treated conservatively, were included in the study. CT criteria included contrast extravasation (CE), perirenal hematoma rim distance (PRD), and extent of hematoma. The patients were divided into two groups according to the extent of hematoma on CT, as either Group 1 with localized hematomas or Group 2 with extensive hematomas. We compared the CT and angiographic findings and examined the correlation between patient management and outcome. The CT criteria, alone or in combination, for predicting the subsequent requirement for TAE were evaluated. RESULTS Of the 81 patients, 35 were in Group 1 and 46 were in Group 2, with 35 having CE. The 22 patients who received TAE were all in Group 2 and had CE. Mean PRD was larger for the patients who received TAE than for those who did not. CE, extent of hematoma, and PRD correlated significantly with the need for TAE (all p < 0.001). Overall, the combination of CT criteria for CE and extent of hematoma showed the highest accuracy for predicting the need for TAE. CONCLUSION CE, extent of hematoma, and PRD were simple and sensitive indicators of patients who required TAE. The combination of CE criteria and extent of hematoma markedly increased the predictive value for predicting the need for TAE. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Preoperative Diagnosis of Right Paraduodenal Hernia by Multidetector Computed Tomography

Right paraduodenal hernia is an unusual congenital malformation that causes intestinal obstruction. It is seldom diagnosed preoperatively and a small bowel follow-through series is the best diagnostic method. However, multidetector computed tomography (MDCT) can be an alternative diagnostic method. We report the first case of right paraduodenal hernia that was diagnosed preoperatively by MDCT. A 15-year-old boy presented with right lower abdominal pain, nausea and vomiting. Abdominal MDCT with coronal reformation images clearly revealed encapsulated small bowel loops in the right side of the abdomen and displacement of the ascending colon to the left side. He received surgical repair and recovered uneventfully.

Child With Ataxia Telangiectasia Developing Acute Myeloid Leukemia

An 11-year-old boy, who was diagnosed as having ataxia telangiectasia (AT) at 5 years of age, was referred to our hospital because of a right submandibular progressive enlarged mass for 2 months. He also suffered from being unstable to stand and recently had twisting of the trunk and tremor in all areas of his body. On physical examination, the patient looked pale and had multiple cervical lymphadenopathies and telangiectasia of the bulbar conjunctiva. His gums easily bled, and he had mild gingival hypertrophy. No hepatosplenomegaly or mucocutaneous petechiae were noted. Neurologic examination revealed nystagmus, squint, dysarthric speech, diminished reflexes, dysmetria, and ataxic gait. Laboratory investigations showed leukocytosis, anemia, and thrombocytopenia (WBC count 28,500/ L; platelets 59,000/ L; hemoglobin 5.2 g/L; hematocrit 27.5%). Biochemistry tests revealed ALT of 27 U/L, AST of 29 U/L, blood urea nitrogen of 9 mg/dL, creatinine of 0.5 mg/dL, and lactate dehydrogenase of 352 U/L. The -fetoprotein level was high (242 ng/mL). There were decreased levels of immunoglobulin (Ig) A (6.67 mg/dL) and IgE ( 0.1 mg/dL). Electrophysiologic study showed mild to moderate motorpredominant spinal motor pathology with sensory involvement. Brain magnetic resonance images revealed isolated cerebellar atrophy with small size of vermis (Fig 1). The ventricles were all normal. Analysis of the ATM gene revealed compound heterozygous mutation (2413 C to T, arg805ter; 1402-3 del AA, lys468fs). Bone marrow examination showed hypercellularity with an excess of blastic cells (80% to 85%) with primitive nuclear morphology, little cytoplasm, easily discernible nucleoli, and distinct nuclear membrane and markedly depleted hematopoietic cells (Fig 2). These blasts were positive in peroxidase stain (Fig 3) but negative in periodic acid-Schiff stain. Flow cytometric analysis of the bone marrow aspirate revealed the following: CD13, 42.51%; CD33, 77.33%; CD34, 43.64%; HLA-DR, 34.71%; and negative for Band T-cell markers. The karyotype of the bone marrow cells was 45,XY, 7, 10,t(12;14)(p11.2;q32), 14, 22. Acute myeloid leukemia (AML) was diagnosed. After AML was diagnosed, the patient received chemotherapy according to the Taiwan Pediatric Oncology Group AML-97A protocol. Induction treatment consisted of cytarabine (100 mg/m, continuous infusion, days 1 to 7) and idarubicin (9 mg/m, intravenous push, days 1 to 3). Intrathecal methotrexate (15 mg) was administered on day 1. However, the patient did not achieve remission after two courses of induction therapy and consequently died as a result of severe pneumonia. Fig 2.

Meckel's Diverticulum Induced Intrauterine Intussusception Associated with Ileal Atresia Complicated by Meconium Peritonitis

Intrauterine intussusception with a leading point of Meckels diverticulum is a rare cause of ileal atresia, which may cause bowel obstruction and perforation. We report such a case complicated by meconium peritonitis. The fetal ultrasonogram revealed ascites, dilated bowel loops and intra-abdominal calcification at a gestational age of 30 weeks. The patient was delivered at 37 weeks and laparotomy was performed to manage the intestinal obstruction. The operative findings showed that Meckels diverticulum had induced intussusception associated with the ileal atresia with meconium peritonitis. The ileum was resected with end-to-end anastomosis. The postoperative course was uneventful. In this patient, ascites and intraperitoneal calcification were caused by ileal atresia, which may have been induced by intrauterine intussusception.

Comparison of Pigtail Catheter With Chest Tube for Drainage of Parapneumonic Effusion in Children

BACKGROUND The use of thoracostomy tube for drainage of parapneumonic effusion is an important therapeutic measure. In this study, we compared the effectiveness and complications between chest tube and pigtail catheter thoracostomy for drainage of parapneumonic pleural effusion in children. METHODS We retrospectively reviewed the medical records of children with parapneumonic effusion during the period of July 2001 through December 2003. Patients who received thoracostomy with either chest tube or pigtail catheter were enrolled into this study. Medical records, such as age, sex, clinical presentation, subsequent therapies, hospital stay, laboratory data, and complications, were collected and compared between these two methods of intervention. RESULTS A total of 32 patients (17 boys and 15 girls; age range, 2-17 years; mean age, 14 years) were enrolled into the study. Twenty patients were treated with traditional chest tubes, whereas 12 patients were treated with pigtail catheters. In the chest tube group, drainage failure occurred in one patient and pneumothorax occurred in two patients. In the pigtail catheter group, drainage failure occurred in two patients, but no case was complicated with pneumothorax. There were no significant differences in either drainage days or hospitalization days between the chest tube group and pigtail catheter group (6.0 ± 2.6 vs. 5.9 ± 3.8, p=0.66; 12.5 ± 5.6 vs. 17.3 ± 8.5, p=0.13). CONCLUSION The effectiveness and complications of the pigtail catheter were comparable to those of the chest tubes.

Rapidly Progressive Pancreatic Lipomatosis in a Young Adult Patient with Transfusion- dependent Myelodysplastic Syndrome

Pancreatic lipomatosis is defined as deposition of fat cells in pancreatic parenchyma. Although the etiology of this condition is still unclear, it is not uncommon in the elderly, obese individuals, and a variety of transfusion-dependent hematologic diseases such as beta-thalassemia major. Pancreatic lipomatosis associated with transfusion-dependent myelodysplastic syndrome (MDS) has never been reported. We present a 17-year-old male patient with transfusion-dependent MDS. He received transfusion of a total of 345 units of blood in a period of 18 months but without iron chelating agent. Progressive fatty replacement of the pancreas parenchyma was found by a series of computed tomography images over seven hospital admissions due to repeated infections. Bone marrow biopsy revealed hemosiderin deposition. Because of his poor response to induction chemotherapy, stem cell transplantation was suggested, but the patient died of sepsis before the therapeutic procedure could take place. Although most patients with pancreatic lipomatosis have neither clinical symptoms nor abnormal laboratory data, it may cause endocrine and exocrine pancreas dysfunction. In this reported case, mild exocrine dysfunction was noted on the last admission. Clinicians should be cautious of hemosiderin deposition after large amount of blood transfusion and chelating therapy should be given to avoid iron overload.

Rapid pre-operative diagnosis of ileal hernia through the foramen of Winslow with multi- detector computed tomography, enabling successful laparoscopic reduction

Internal hernias through the foramen of Winslow are extremely rare. Prompt diagnosis and early surgical reduction are vital to prevent bowel gangrene and avoid resection. We report a case of ileal hernia through the foramen of Winslow in a 48-year-old woman. She presented to the emergency department with acute epigastric pain, and rapid and definitive pre-operative diagnosis of internal hernia of ileum through the foramen of Winslow without ischaemia was made by means of multi-detector computed tomography. Emergency laparoscopic bowel reduction was performed. The postoperative course was uneventful, and the patient recovered rapidly.