Osman Nuri Dilek

The role of power Doppler sonography in the evaluation of superficial soft tissue abscesses

OBJECTIVE To evaluate the efficacy of power doppler ultrasonography in depicting increased vasculature and hyperemia around the superficial soft tissue abscess. MATERIALS AND METHODS 21 patients with soft tissue abscess were evaluated with gray scale imaging, color doppler sonography, power doppler sonography and computed tomography. In each case attempts were made using power doppler sonography to demonstrate any areas of increased vascularity around the lesion. The results were compared with computed tomographic findings. RESULTS Peripheral hyperemia and increased vasculature were demonstrated with power doppler sonography in 19 of 21 patients with soft tissue abscess. The hyperemic area demonstrated around the wall of the abscess by power doppler sonography was similar to the enhanced area shown by computed tomography performed after contrast administration. CONCLUSION Power doppler sonography shows increased vasculature and hyperemia in the wall of abscesses. Therefore, power doppler sonography can be used to assist with the diagnosis of superficial soft tissue abscess.

Primary leiomyosarcoma of the breast

Sarcomas of the breast are rare, accounting for about 1% of all malignant breast tumors. Leiomyosarcoma of the breast was an almost unknown tumor until some 20 years ago, and the few previously published cases lacked detailed information. Only 11 well-documented cases of leiomyosarcoma of the breast had been reported in the literature up to February 1992. The clinical features, diagnosis, therapy, and prognosis are discussed here in the light of the previously published literature.

The effect of lymphatic blockage on the amount of endotoxin in portal circulation, nitric oxide synthesis, and the liver in dogs with peritonitis.

This study was performed to investigate the effect of lymphatic blockage on the amount of endotoxin in portal venous blood, nitric oxide synthesis, the release of aspartate aminotransferase (AST) from the liver, hepatic damage, and survival in an experimental model of dogs with peritonitis. The dogs were divided into a control group (group 1), an unligated thoracic duct peritonitis group (group 2), and a ligated thoracic duct peritonitis group (group 3). Peritoneal fluid and blood from the portal vein and femoral artery were taken for peritoneal culture, endotoxin, and AST assay, respectively, and liver biopsies were performed to assess for hepatic damage and for nitric oxide assay. There was a higher bacteria count in the peritoneal fluid from group 3 than in that from group 2 (P<0.0001). Bacteria grew in all of the blood cultures from the group 2 animals, but growth was seen only in blood cultures from four of the group 3 animals. The levels of endotoxin, nitrite, and AST levels in group 3 were significantly increased in comparison with those in group 2 (P<0.0001). Extensive hepatocellular necrosis with hemorrhage was observed in the livers of the group 3 animals, and all of them died within 48 h. The results of this study suggest that the blockage of lymph flow has a negative effect on liver and survival in dogs with peritonitis, and that hepatic damage is directly related to the amount of endotoxin to which the liver is exposed.

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.

E-cadherin, β-catenin adhesion complex and relation to matrilysin expression in pT3 rectosigmoid cancers

E-cadherin/beta-catenin complex has a critical role in cell-cell adhesion. beta-Catenin is a critical component of the highly conserved Wnt signaling pathway that regulates cell proliferation and differentiation. Wnt signaling leads to the stabilization of cytosolic beta-catenin and to translocation to the nucleus, where it binds with T-cell factor and promotes the transcription and changes in target gene expression, including matrix metalloproteinases. In this study, we analyzed paraffin-embedded specimens from 42 patients with pT3 rectosigmoid cancer for E-cadherin, beta-catenin, and matrix metalloproteinase-7(MMP-7, matrilysin) expression using immunohistochemistry. Seventy-four and 79% of tumors expressed beta-catenin and E-cadherin, respectively. Nuclear expression of beta-catenin was detected only in 26.1% of tumors. Forty-five percent of the rectosigmoid cancers showed strong expression of MMP-7. It was revealed that membranous or cytoplasmic beta-catenin expression was significantly related to E-cadherin and MMP-7 expression. No significant association was seen between E-cadherin, beta-catenin, or MMP-7 expression and some clinicopathologic features. Our results may contribute to the functional interaction between beta-catenin and MMP-7. Further studies on Wnt/beta-catenin and MMP-7 gene activity and protein expression are necessary to better understand the pathogenesis of colorectal carcinoma.

Prevalence of cagA and vacA genotypes of Helicobacter pylori isolated from Turkish patients with active or non-active chronic gastritis

Abstract Several virulence factors of Helicobacter pylori may contribute to gastric mucosal damage. In this study, the prevalence of cagA and vacA genotypes of H. pylori was examined in different patterns of chronic gastritis. Oesophagogastroendoscopy was performed in 147 dyspeptic patients. Antrum biopsies were obtained for isolation of H. pylori and for histopathological assessment. H. pylori vacAs1 and cagA genes were directly genotyped in the gastric biopsy specimens by polymerase chain reaction (PCR). A total of 102 dyspeptic patients, all H. pylori-positive by PCR, were included in the study. Of these, 59 had active chronic gastritis and 37 had non-active chronic gastritis. The prevalence of cagA and vacAs1 was higher among patients with active chronic gastritis than among those with non-active chronic gastritis (45.8% vs 21.6% (p = 0.02) and 78.0% vs 40.5% (p < 0.001), respectively). In conclusion, both cagA and vacAs1 genotypes are associated with the activity of chronic gastritis.

A case of esophageal leiomyoma causing left atrial compression.

A 64-year-old woman was admitted to our clinic with progressive dyspnea (New York Heart Association class III) and fatigue for 3 months. Dysphagia for solids more than for liquids was present for 3 years. Transthoracic echocardiography demonstrated extrinsic left atrial compression and impaired left atrial filling because of the compression (Fig. 1). Esophagoscopy revealed a submucosal mass in the distal esophagus. Computed tomography of the chest (Fig. 2) and magnetic resonance imaging of the mediastinum revealed the extra cardiac mass located in the wall of the distal esophagus, compressing the left atrium. The patient was referred for surgical treatment. Enucleation of the mass was performed by thoracotomy. Histophatology confirmed the diagnosis of leiomyoma. The postoperative evolution was uneventful.

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

Effects of Octenidine HCl on Liver Tissue: Could It Be an Alternative Scolicidal for Hidatid Disease?

Octenidine HCl is new topical antiseptic solution for wounds and abdominal washing that has been found to be highly effective for inactivating scolices in an in vitro study. However, the effects of octenidine HCl on the liver are not yet known. The aim of this study was to determine if there are any histopathologic changes after injecting octenidine HCl into the liver. A group of 50 male Sprague-Dawley rats were included in the study and randomly divided into five groups of 10 rats each, as follows: sham group; 0.09% NaCl group; 20% NaCl group; undiluted octenidine HCl group; 1% octenidine HCl group. The scolicidal agents (0.3 ml) were directly injected into the left lobe of the liver (except in the sham group). At 3 and 7 days after the injection, the rats were sacrificed, and the left lobe of the liver was harvested. Liver tissue was scored for degree of necrosis and the diameter of the necrosis examined under light microscopy. The highest scores were found in the undiluted octenidine HCl group, although a similar effect was observed in the 20% NaCl group. There was no necrosis in the sham group, the 0.09% NaCl group, or the 1% octenidine HCl group. All of the injury was coagulation-type necrosis. No mortality was observed throughout the study. The 1% octenidine HCl solution could thus be used as a scolicidal agent in liver tissue, whereas the undiluted form of octenidine and 20% NaCl solutions were shown to cause necrosis when directly injected into liver tissue in our animal model.