Peter J. Barcia

Tuberculous peritonitis : Do not miss it

Incidence of tuberculosis is sharply rising in the United States, and tuberculous peritonitis is often diagnosed late in the course of the disease, resulting in undue patient morbidity and mortality. PURPOSE: Purpose of this study was to better identify which clinical, laboratory, radiologic, and invasive procedures were most useful in diagnosing tuberculous peritonitis. METHODS: All cases of tuberculous peritonitis diagnosed between 1982 and 1994 were reviewed retrospectively to discern which laboratory, radiographic, and procedural tests were helpful in diagnosing the condition. RESULTS: Twenty-eight cases of tuberculous peritonitis were diagnosed during the studied period. Two patients were not diagnosed until autopsy. Patients from all socioeconomic classes and multiple races ranged in age from 3 to 69 (mean, 29.5) years. Most patients presented with a chronic wasting illness, mild abdominal pain, and fever. Purified protein derivative was only positive in 5 of 16 patients. Chest radiographs were suggestive of pulmonary tuberculosis (TB) in five patients. Ultrasound examination of the abdomen was helpful in five patients, and computed tomographic scan was suspicious in 16 of 17 patients. Sputum for acid fast bacillus (AFB) smear was positive in 3 of 14 patients, and paracentesis for AFB smear was positive in 1 of 8 patients. Routine blood work was not helpful. Laparoscopy was diagnostic in five of seven patients. Laparotomy and tissue biopsy of characteristic tissue for AFB smear and culture was diagnostic in 20 of 20 patients. Once diagnosed, all patients responded rapidly to empiric antituberculous medical therapy, except one patient with miliary TB who died shortly after diagnosis. A trend in earlier diagnosis was noted in recent years and is felt to be the result of an elevated index of suspicion. CONCLUSIONS: TB peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. It is essential that the clinician suspect the disease in appropriate patients. Tests frequently associated with TB such as chest radiograph and purified protein derivative are not sensitive in detection of TB peritonitis. Computed tomographic scan is the most useful radiographic study. Mini laparotomy with tissue biopsy for smear and culture is the most sensitive and specific diagnostic procedure.

Primary segmental infarction of the omentum with and without torsion.

Summary Primary segmental infarction of the omentum simulates acute appendicitis and other acute abdominal disorders. Early operation is almost always undertaken at which time the correct diagnosis is made. When other viscera are found to be normal at exploration, the omentum should be inspected specifically for infarction, especially if serous or serosanguineous fluid is present. Resection of the involved portion of the omentum, usually the right lower edge, leads to prompt recovery without complications. Two types of primary infarction are described, usually separately, depending on whether or not torsion is present. This report adds seven cases to the present collective experience of approximately 276 cases, 188 with and 88 without torsion. Our review shows that the two types have identical clinical characteristics. It is recommended that the condition be reported as a single entity, which should eliminate some of the confusion involved in studying this condition. Since early operation is usually undertaken, the natural clinical course of the disease is not well known. One of our patients, in whom operation was deferred for six weeks, is of particular interest in that he demonstrated the late findings of primary segmental infarction of the omentum.

Complications of small dose prophylactic heparinization

The observations reported herein on the use of prophylactic small dose heparinization are in no way intended to diminish its value but are reported and reviewed so that certain precautions may be exercised in its use. In fact, the apparent difference in the incidence of pulmonary emboli in the controls and heparinized patients may lend credence to its value. The large controlled series now being studied at various medical centers will help to confirm or deny the value of this factor in the prevention of emboli. Careful preoperative scrutiny of the patient and meticulous intraoperative hemostasis remain important factors when a patient is receiving small dose heparin therapy. Other factors such as concomitant medications, weight of the patient, frequency and technic of administration and dosage must be considered. Additionally, monitoring the hemostatic mechanism with serial hematocrit determinations and laboratory coagulation tests appears to be an important adjunct in small dose prophylactic heparinization.

Gastric trichobezoar as a manifestation of child abuse1

The human trichobezoar, or hairball of the gastrointestinal tract, is rare and unusual. It is thought to be a symptom of an underlying behavioral disorder. Surgical removal of a trichobezoar is straightforward, but the causative behavior must be addressed to prevent recurrence. We provide the first report of a patient with a trichobezoar as a manifestation of child abuse and advocate a multimodal treatment approach. (Curr Surg 58:202-204)

Multiple Transections of the Thoracic Aorta Secondary to Blunt Trauma

Abstract A patient is described who underwent the first successful repair of multiple traumatic aortic transections. Reported postmortem series reveal multiple tears occurring in 19 to 25% of all patients with blunt aortic rupture, and a review of the literature shows 3 patients who survived long enough to receive medical attention but died prior to or during operation. An unrecognized massive hemorrhage from a concomitant tear in the abdominal aorta caused 1 of these 3 patients to exsanguinate during repair of his thoracic aorta. These experiences point up the need for thoracic and abdominal aortography to rule out multiple tears.

Uncommon cause of a right upper quadrant abdominal mass in the newborn: Acute cholecystitis

What appears to be the first reported case of an otherwise-asymptomatic newborn with a mass in the right upper quadrant of the abdomen and no signs of biliary disease is presented. At exploration, acute acalculous cholecystitis was found, probably secondary to cystic duct obstruction.

Determination of heat gain in the inferior vena cava during thermodilution measurements

The measurement of blood flow in the inferior vena cava (IVC) by thermodilution may be useful in the determination of hepatic venous blood flow (HVBF), but is subject to major errors. The most serious error is gain of heat from the abdominal viscera by the cool thermodiluent bolus as it moves up the IVC. The determination or elimination of this heat gain is necessary for accurate IVC blood flow measurement. By comparison of the area under the curve (AUC) for cardiac output following femoral vein injection of the thermodiluent bolus to the AUC following right ventricular injection of the thermodiluent, it is possible to quantitatively determine the unidirectional heat gain by the bolus at it moves up the IVC. The heat gain varied from 0 to 40% of the thermodiluent injected. The factors that aggravated the heat gain were a low cardiac output (below 4000 ml/mn), a large thermodiluent calorie load (over -40 calories), and possibly a slow transit time. The error due to heat gain may be effectively eliminated by keeping the size of the thermodiluent bolus below 40 negative calories.