Takaaki Osako

Successful treatment of a 14-year-old patient with intestinal malrotation with laparoscopic Ladd procedure: case report and literature review

Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

Can carbon monoxide-poisoned victims be organ donors?

The increasing demand for organ allografts to treat end-stage organ failure has driven changes in traditional donor criteria. Patients who have succumbed to carbon monoxide (CO) poisoning, a common cause of toxicological mortality, are usually rejected as organ donors. To fulfill the increasing demand, selection criteria must be expanded to include CO-poisoned donors. However, the use of allografts exposed to high CO concentrations is still under debate. Basic research and literature review data suggest that patients with brain death caused by CO poisoning should be considered appropriate organ donors. Accepting organs from CO-poisoned victims could increase the number of potential donors and lower the death rate of patients on the waiting lists. This review and reported cases may increase awareness among emergency department physicians, as well as transplant teams, that patients dying of CO exposure may be acceptable organ donors.

Non-surgical pneumoperitoneum associated with mechanical ventilation

Dear Editor, Non-surgical pneumoperitoneum from an intrathoracic route is the most frequently reported cause in non-surgical peritoneal air collection. The true incidence of pneumoperitoneum associated with mechanical ventilation is unknown, but current estimates range from rare to 7% of intubated patients in the intensive care unit. This complication may lead to unnecessary laparotomy, however, if correctly diagnosed, it can be observed successfully without surgical intervention. We experienced a patient with subcutaneous emphysema, mediastinal emphysema, and pneumoperitoneum in whom coughing may have had a causative role, which was recognized and was managed without laparotomy. A 40-year-old female was transferred to our hospital due to loss of consciousness following a suicide attempt (hanging) and an overdose of anti-anxiety medicine. Although her vital signs were stable at admission, the patient was intubated, sedated, and ventilated in the intensive care unit, as her Glasgow Coma Scale score was 3 (E1, V1, and M1). Assisted ventilation was used with a fractional inspired oxygen concentration (FiO2) of 0.4 and a positive airway pressure of 5 cm H2O or less. On the second day of admission, she was alert with strong spontaneous breathing on the ventilator. Routine chest and abdominal X-ray revealed pneumothorax and pneumoperitoneum. Computed tomography scan of the chest and abdomen confirmed the presence of free intraperitoneal air without free fluid (Fig. 1). The patient was not symptomatic and had no fever or dyspnea. The abdomen was soft and flat without guarding or distension. Leukocytosis was present, with a white cell count of

A secure “double-check” technique of bedside post pyloric feeding tube placement using transnasal endoscopy

Enteral feeding has become an important means of providing nutritional support to seriously ill patients. Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration. We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2009. Although we achieved a high success rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a ”double-check” transnasal endoscopy through the other nasal passage. After April 2010, we have placed the feeding tube by ”double-check” method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of ”double-check” procedure. We describe our experience with ”double-check” transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.

Role of endogenous IL-18 in the lung during endotoxin-induced systemic inflammation

Overactivated neutrophils are causes of acute lung injury, which is a major clinical problem with significant morbidity and mortality in sepsis. Serum interleukin (IL)‐18 levels correspond to severity of systemic inflammation.

Hemorrhagic shock due to ruptured left and right gastric artery aneurysm

We report a case of hemorrhagic shock due to a ruptured gastric artery aneurysm successfully treated with transarterial embolization. A 72‐year‐old woman with cholangitis presented with hemoperitoneum following a ruptured aneurysm of the gastric artery.

Acute leukemia presenting as bone pain with normal white blood cell count

Dear Editor, Bone pain can occur in leukemia patients when the bone marrow expands from the accumulation of abnormal white blood cells and may manifest as a sharp pain or a dull pain, depending on the location. The long bones of the legs and arms are the most common location to experience this pain. Bone pain is commonly one of the presenting features of acute leukemia in childhood. Bone and joint pain have been reported to occur in 21–59% of children with acute leukemia. However, only 4% of adults with acute leukemia present with musculoskeletal manifestations. These patients often have relatively normal blood cell counts and a lower incidence of organomegaly. This form of presentation can lead to delays in the diagnosis of acute leukemia in adults. We experienced the case of a 41-year-old male with acute leukemia presenting as bone pain with a normal white blood cell count. The patient was transferred to our hospital with complaints of severe back and leg pain and dyspnea for 3 days.Three days prior to the presentation, he felt pain in his left scapula and the pain expanded to back, pelvis, chest, and legs with increasing severity. He had a past history of allergic rhinitis. He was on no medications and denied any significant family history. Upon physical examination, vital signs were within normal limits and physical examination showed no icterus or pale conjunctiva. The patient had no pallor, lymphadenopathy, organomegaly, or rashes, and had a normal body temperature. Laboratory data were as follows; D-dimer, 30.5 (normal range, <0.5) μg/mL; platelets, 63,000 (normal, 15–35) /μL; a normal white blood cell count 60.2 × 10 (normal, 40–90) /μL (segmented neutrophils 35.4%, lymphocytes 41.7%, monocytes 20.3%, eosinophils 2.1%, basophils 0.5%), lactate dehydrogenase, 2,254 (normal, 119–229) U/L; alkaline phosphatase, 292 (normal, 115–359) U/L; C-reactive protein, 20.3 (normal, <0.3) mg/dL. Preliminary radiological investigations of the bones, X-rays of the chest, femur, hip joints, and lumbar spine, echocardiogram, and whole body contrastenhanced computed tomography scans were normal. Based on these examinations, multiple lesions of the bones were less likely. As hematological disorder was suspected, the patient was referred to the hematology department and a powered peripheral blood smear test showed numerous circulating blasts consistent with acute myeloid leukemia.The specimens of the bone marrow aspiration were reviewed by the hematology department, revealing marrow infiltration by acute lymphoblastic leukemia. Following chemotherapy, the patient received an allogeneic bone marrow transplant and prophylactic intrathecal chemotherapy. Metastatic bone disease and infectious causes were high on our differential diagnosis for the differential diagnosis for the symptoms of the patient based on imaging and frequency of these diseases. Bone marrow necrosis, characterized by fever, bone pain, and increased levels of lactate dehydrogenase and C-reactive protein, should be taken into consideration. Bone marrow necrosis, often accompanied with acute leukemia, is a rare clinicopathologic entity defined as the destruction of hematopoietic tissue and marrow stroma with preservation of bone. Leukemia should always be considered in patients with unexplained pain in the back or of the epiphysis of the long bones, or joint pain out of proportion to the severity of existing arthritis when there is no history of trauma. Of note, the absence of markedly abnormal hematological values does not exclude the diagnosis of leukemia.

Usefulness of 3-D computed tomography for diagnosis of abusive head trauma

high efficacy and fewer side-effects, needs to be developed. Sirolimus has recently been reported to be effective for vascular tumors with KMP. In a multicenter, retrospective study, Ji et al. found that 96% of patients (50/52) had a positive response. The mean stabilization period for platelet count was 14 days. They noted high efficacy and rapid improvement in hematopoietic parameters. The present patient, who was resistant to multiple therapies, also had a rapid and dramatic response to sirolimus. Currently, medical treatment with corticosteroids and/or VCR is recommended for managing KMP with vascular anomalies. Sirolimus might become the firstline treatment in the future. The present patient had three episodes of moderate cellulitis during sirolimus treatment. White blood cell count did not decrease and other immunological tests (immunoglobulin and lymphocyte subsets) were also in the age-appropriate normal range during sirolimus treatment. A reduction in skin barrier function might have been caused by atopic dermatitis and skin involvement of the vascular tumor. Such a reduction of the skin barrier may contribute to recurrent skin infection around the tumor. Whether sirolimus treatment was associated with these infections is unclear. Sirolimus has been safely used in the pediatric age group as an immunosuppressant for renal transplants, but the safety of sirolimus, especially in infants, has not been established. Therefore, we need to carefully evaluate immunological function during treatment, and patients with infection-prone lesions need to be kept clean. In conclusion, sirolimus is effective for KMP with vascular tumors, but further prospective studies are required to evaluate the efficacy and safety of sirolimus for infant KMP patients. Acknowledgments

Intraocular Silicone Oil Masquerading as Eye Hemorrhage

An 87-year-old man presented to the emergency department complaining of a frontal head injury. Brain computed tomography scan revealed hyperdensity in the vitreous cavity of the right eye, suggesting intraocular hemorrhage. The patient’s family reported that he had a history of retinal detachment, which was presumably treated by tamponade with silicone oil. Eye examination by an ophthalmologist indicated no vitreous or retinal hemorrhage. Since intraocular silicone oil is being increasingly used for treatment of retinal detachment, emergency physicians must become familiar with its unique characteristic of mimicking hemorrhage in medical imaging.

Successful treatment of pulmonary contusion following chest trauma using poly‐2‐methoxyethyl acrylate, a biocompatible polymer surface coating for extracorporeal membrane oxygenation

We report a patient with life‐threatening lung contusion who was rescued using poly‐2‐methoxyethyl acrylate, a biocompatible polymer surface coating for extracorporeal membrane oxygenation, which enabled reduction of the dose of systemic anticoagulation to prevent circuit thrombosis.