Enis Dikicier

Intestinal obstruction due to phytobezoars: An update

The term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. Bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction. The clinical findings of bezoar-induced ileus do not differ from those of mechanical intestinal obstruction due to other causes. The appearance and localization of bezoars can be established with various imaging methods. Treatment of choice depends on the localization of the bezoar which makes the clinical findings.

Idiopathic Granulomatous Mastitis: An Autoimmune Disease?

Purpose. This study aimed to investigate the autoimmune basis of idiopathic granulomatous mastitis (IGM) by determining the anti-nuclear antibody (ANA) and extractable nuclear antigen (ENA) levels of patients diagnosed with IGM. Material and Methods. Twenty-six IGM patients were evaluated. Serum samples were analyzed for autoantibodies by indirect immunofluorescence (IIF) using a substrate kit that induced fluorescein-conjugated goat antibodies to human immunoglobulin G (IgG). IIF patterns were read at serum dilutions of 1 : 40 and 1 : 100 for ANA positivity. Using the immunoblot technique, the sera of patients were assayed at dilutions of 1 : 40 and 1 : 100 for human autoantibodies of the IgG class to 15 lines of highly purified ENAs. Results. In the IIF studies for ANA, positivity was identified for four different patterns in the 1 : 40 diluted preparations, for three different patients in the 1 : 100 diluted preparations and only one pattern was identified at the 1 : 320 dilution. In the ENA studies, positivity was identified for four different pattern in the 1 : 40 dilution, and only one pattern was identified at the 1 : 100 dilution. Conclusion. This study was not able to support the eventual existence of an autoimmune basis for IGM.

CT Findings of Patients with Small Bowel Obstruction due to Bezoar: A Descriptive Study

Purpose. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types. Materials and Methods. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. Results. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n = 26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. Conclusions. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis.

Retrospective Review of Pilonidal Sinus Patients With Early Discharge After Limberg Flap Procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

A rare etiology of acute abdominal syndrome in adults: Gastric volvulus - Cases series.

INTRODUCTION Gastric volvulus is a rare surgical emergency with a high mortality rate that requires urgent surgical management. PRESENTATION OF CASE A 19-year-old male and 51-year-old female patient underwent emergency surgery with a prediagnosis of acute abdomen syndrome, and a 60-year-old female patient underwent elective surgery due to diaphragmatic hernia. Abdominal exploration revealed gastric volvulus together with perforation in received emergency surgery patients, and a mesenteroaxial gastric volvulus due to diaphragmatic defect in third patient. DISCUSSION Gastric volvulus is classified into four subgroups depending on the mechanism of development, and organoaxial form is the most common type of gastric volvulus. The most challenging step in diagnosing gastric volvulus is the consideration of this diagnosis. CONCLUSION Preoperative diagnosis is often difficult, and its management involves surgical correction of the pathology followed by institution of resuscitative treatment.

A case of achalasia presented with cardiopulmonary arrest.

Achalasia is a rare disorder characterised by obstruction of the distal oesophagus and subsequent dilation of the proximal oesophagus. Patients generally complain of gastrointestinal symptoms; however, pulmonary symptoms and complications may also occur. A 35-year-old woman was brought to our emergency service complaining of sudden-onset dyspnea that started 15 minutes earlier during dinner. She suffered a cardiopulmonary arrest due to aspiration 5 minutes after being admitted to the emergency room and was intubated. Thoracic computed tomography examination showed that her oesophagus was filled with undigested food. Heller cardiomyotomy and Dor fundoplication was performed via laparotomy with the diagnosis of primary achalasia, and she was discharged as uneventful on the 5th postoperative day.

Acute appendicitis presenting with small intestinal obstruction findings - 2 cases report

Olgu Sunumu / Case Report Altıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 90 Giriş Acute appendicitis is the most common emergency surgical condition in worldwide. Clinical findings of acute appendicitis that are accepted as ‘typical’ are only seen in 60% of all patients. In other patients, various non-typical clinical findings are encountered. Small intestinal obstructions are another surgical situation frequently encountered by emergency departments. Intestinal obstructions are generally seen in their mechanical form, and their etiology is most commonly postoperative adhesions. Acute appendicitis rarely presents in small intestinal obstruction findings. The reason for intestinal obstruction in acute appendicitis is generally adhesions due to periappendicular inflammation or localized/generalized peritonitis due to a perforated appendix. However, since the appendix is a mobile organ, its location may change inside the abdomen, and in cases of inflammation it may adhere to surrounding tissues causing a subsequent mechanical obstruction, as seen in one of the cases in this report. In this article 2 appendicitis cases with intestinal obstruction are reported. Case 1: A sixty-eight-year-old woman with abdominal pain and vomiting complaints consulted the emergency unit on the fourth day of her complaints. No abdominal operation were present in her medical history. Abdominal distension and diffuse tenderness were present in her physical examination, and intestinal sounds were increasing. Leukocytosis was present according to whole blood count, which was 12 x 10/mm. Intestinal-type air-fluid levels were detected by abdominal graphy, and subsequently a computed tomography (CT) scan was performed. According to CT, dilatation was present in all segments of the small intestine, and inflammation was present in the pericecal area (Figure 1a). In operation, perforated appendicitis and a paralytic obstruction secondary to the inflammation in the terminal ileum were determined (Figure 1b). Appendectomy was performed following abscess drainage, and the patient was discharged on the third day postoperation without complications. Case 2. A forty-two-year-old man with abdominal pain and vomiting complaints consulted the emergency unit on the second day of his complaints. Abdominal distension, diffuse tenderness and defance were present in his physical examination, and intestinal sounds were increasing. Small intestinal-type air-fluid levels were detected by direct abdominal graphy. Leukocytosis was present according to the whole blood count, which was 18 x 10/mm. The patient had no medical history of abdominal initiations, and a CT scan with oral contrast material was performed. According to the CT a sudden narrowing was present in the small intestinal lumen of the terminal ileum, and the intestinal segments proximal to this point were dilated (Figure 2a). With a primary diagnosis of acute mechanical obstruction, the patient underwent emergency surgery. During surgical exploration, a long appendix and acute appendicitis were discovered; after leaving the cecum, the appendix wrapped around the ileum loop and mesenterium like a napkin ring, and adhered to the cecum once more. It was determined that the reason for intestinal obstruction was the mechanical pressure exerted by the appendix on the ileal loop (Figure 2b and c). The operation was terminated following appendectomy. The patient was discharged on the third day post-operation without complications. Figure 1: Abdominal CT; a) dilatation was present in all segments of the small intestine, and inflammation was present in the pericecal area (arrows). This appearance suggest that a perforated appendicitis. Intraoperative appearance; b) perforated appendicitis and intense inflammation seen. Figure 2: (a) Abdomen CT; a) It’s the dilatation in proximal intestine segments and partial stricture on ileum level seen (arrow). No inflamation symptom or free fluid in the abdomen. Intraoperative appearance; b-c) It’s the adhesion of long appendix to intestine mesentery depending on inflamation and its ileum segment compAltıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 91 Discussion: Acute appendicitis is the most frequent acute abdominal syndrome etiology of abdominal surgeries. The probability of a person developing acute appendicitis during their lifetime has been calculated as 7%. A careful medical history and a detailed physical examination are the basic tools in the diagnosis of acute appendicitis. The presence of leukocytosis in laboratory test results is a supportive finding in the diagnosis. Despite these diagnostic tools, radiological monitoring is needed for diagnosis in approximately one third of all patients. On the other hand, intestinal obstructions form 20% of all emergency surgical operations and 60% of these involve the small intestine.4 Post-operative adhesions are the most frequent cause of small intestine obstructions in adults, and are the first etiologic diagnosis considered in patients with intestinal obstructions and abdominal surgery history. Clinical findings of intestinal obstruction and leukocytosis were present in both the cases presented in our report upon initial consultation, but neither had a history of abdominal surgery. The presentation of acute appendicitis via intestinal obstruction findings is a rare situation and what is extremely rare is its appearance via a mechanical obstruction. The mechanism involved in these cases was first defined in 1901 and in 1908 it was classified into 3 sub groups: mechanical, septic, and combined types.5 Early and correct diagnosis of patients with mechanical small intestine obstruction is important for reducing morbidity and mortality. If the etiologic factor is acute appendicitis with suppressed clinical manifestations in a patient with delayed diagnosis of mechanical small intestine obstruction, the morbidity and mortality risk will no doubt increase by the hour. It is predicted that results will develop progressively, particularly in patients of advanced age; clinical manifestations occur more often in this age group. The importance of early diagnosis and definitive therapy may be better understood in light of one of our patients, who was in the >65 age group and had no clinical or radiological findings suggesting acute appendicitis. Acute appendicitis-dependent small intestine obstructions may be placed in 2 main categories, paralytic and mechanic, if the combined type comprising both situations together is put aside. Paralytic is the most common etiology, and the physiopathology may be defined as the reduction of peristalsis in the adjacent small intestinal segment caused by peri-appendicular inflammation. The physiopathology of mechanical causes is the mechanical pressure on the adjacent small intestinal segment. The etiology of the obstruction in our first patient was paralytic, whereas in our second patient it was mechanical, which is a very rare, as we mentioned above. Although detailed anamnesis, physical examination, laboratory tests, and conventional graphies aid in the diagnosis of obstruction in patients with obstructional findings, CT is a more sensitive method of diagnosis. The degree (completepartial), the level (small intestine-colon), and the etiology (intra-luminal/extra-luminal) of the obstruction and the presence of other accompanying intra-abdominal pathologies may be determined by CT. Balthazar et al. reported that the sensitivity, specificity, and accuracy of abdominal CT in the diagnosis of mechanical small intestine obstructions are 83%, 93%, and 91% respectively, and they remarked on the superiority of CT, especially in patients with small intestine obstructional findings with no clarified etiology despite clinical-biochemical or radiological examinations. Intestinal obstructional findings, leukocytosis, and intestinal-type air-fluid levels were present in both of our patients upon consultation, but abdominal CT scanning was needed since these findings did not suggest a specific diagnosis. The etiological cause in the first patient was perforated appendicitis, and it was discovered in the preoperative period via CT. In the second patient only obstruction of the terminal ileum level was determined via CT; the real diagnosis was determined during the operation. In conclusion, as the most frequent surgical acute abdominal syndrome etiology, appendicitis may appear with unexpected clinical manifestations depending upon appendix length, location inside the abdomen, and degree of inflammation, in addition to its known classical findings. Conflict of Interest : The authors declare that have no conflict interest Altıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 92

Recurrent intestinal ischemia related to Behçet’s Disease

Behçets disease is a systemic inflammatory disease that may affect multiple organs. However, intraabdominal complications requiring surgical intervention are rare in the natural course of the disease. A 32-year-old male patient with Behçets disease who had been followed for 5 years with a diagnosis of acute abdominal syndrome was operated on twice in 18 days. Intestinal ischemia was identified in different segments of the jejenum during each operation. Recurrent segmental intestinal ischemia within a short time interval is rare, although the gastrointestinal involvement can be seen in the normal course of Behçets disease.

Treatment results of small bowel perforations due to unusual causes

Objectives: Although non-traumatic Small Bowel Perforations (SBPs) are rare, they have high rates of morbidity and mortality in case of late presentation. Aetiological factors vary across different geographical regions. In this paper, SBPs caused by anything other than trauma and other well-known causes are presented and the current literature is reviewed. Methods: The study was conducted at General Surgery Clinics of two different tertiary university hospitals between January 2008 and September 2016. The authors directly involved in managing the patients. This study was approved by the ethical institutional board and was performed at the Department of General Surgery, School of Medicine, Sakarya University. The medical records of patients retained in both hospitals are electronic. Medical records of subjects who had undergone emergency operations with a prediagnosis of acute abdomen in single center, and were determined to have SBPs due to unusual causes, were investigated retrospectively. Patients with aetiological factors such as trauma, mesenteric vascular disease, internal and external hernias, intra abdominal adhesions, inflammatory bowel diseases, and iatrogenic causes were excluded. Results: In total, 35 patients were evaluated, 20 (57.1%) males and 15 (42.9%) females. The mean age of the cases was 51.6 (18–88) years. Mean time until admission at the hospital was 1.4 days (range 0.25–7 days). The most frequent aetiological factors were various malignancies (10 cases, 28.5%) and perforation of Meckel’s diverticulum (8 cases, 22.8%). It was surprising to detect a considerable rate of perforation due to bezoars (6 patients, 17.1%). Conclusions: Post-operative consequences of SBPs due to unusual causes are similar with those related to common, known causes. Factors affecting the clinical course are presentation time and patients’ clinical status in admission, not aetiology.

Choledochal cysts- Classification, physiopathology, and clinical course

Although biliary canal cysts were first described around the 1720s, the aetiology, physiopathology, natural course, and treatment options of the disease remain controversial. These cysts are becoming more common and can now be more easily diagnosed thanks to recent developments in imaging methods. Nevertheless, if left un-diagnosed, the risk of progressive complications such as spontaneous perforation, cholelithiasis, choledocholi-thiasis, cholangitis, secondary biliary cirrhosis, portal hypertension, and development of malignancies should be considered. In this review, we discuss the epidemiology, classification, physiopathology, carcinogenesis, and clinical course of biliary cysts. Introduction Choledochal cysts (CCs) are rare medical conditions, which are congenital cystic dilatations of any portion of the bile ducts, most often occurring in the main portion of the common bile duct. Although choledochal cysts are considered a disorder of childhood and infancy, the ages in reported cases range from newly born to 80 years old; however 60% of such cysts are diagnosed in patients less than 10 years old [1-6]. Epidemiology Choledochal cysts (CCs) are extremely rare with an incidence of about 1/100–150,000 in Western societies. The disease affects 1 in 13,500 live births in the USA and 1 in 15,000 live births in Australia. It is seen more fre-quently in Asians; two out of three cases are of Japanese origin despite the reported incidence of 1/1,000. There is significant female gender predominance (F/M: 3–4/1). The cause of this female and Asian origin predomin-ance is unknown [6]. Classification Alonso-Lej defined three types of biliary dilatations in 1959; this classification system has since been widely accepted. Todani expanded this classification in 1977 and divided the CCs into five subgroups. Todani re-modified the classification to include pancreatic junctional abnormalities, and the resulting system became the final and most commonly used classification method [6] (Table 1) (Figure 1). According to the Todani classifi-cation, CCs are classified as follows: Correspondence to: Mustafa Yener Uzunoglu, Sakarya Üniversitesi Egitim ve Arastırma Hastanesi, Adnan Menderes Cad. Sağlık Sok. No: 195 Adapazarı, 54100, Sakarya, Turkey, Tel: +905056503394, E-mail: drmyuzunoglu@gmail.com