A child with hypertension and ambiguous genitalia – an uncommon variant of congenital adrenal hyperplasia: a case report

Deficiency in 11β-hydroxylase as a cause of congenital adrenal hyperplasia is uncommon. It should be considered in the differential diagnosis of hypertension with virilization in any prepubescent child.

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Thyrotoxic and pheochromocytoma multisystem crisis: a case report

Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously de...

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A case of an anomalous biliary tract diagnosed preoperatively

Abstract

We describe a 48-year-old man with cholecystolithiasis whose preoperative magnetic resonance cholangiopancreatography (MRCP) scan showed that the right accessory hepatic duct branching from the cystic duct dominated an anterior segment of the right hepatic lobe. We observed the right accessory hepatic duct using intraoperative cholangiography, and we were able to perform laparoscopic cholecystectomy without injuring it. He had no complication after discharge, and a drip-infusion cholangiography-computed tomography (DIC-CT) scan demonstrated that the right accessory hepatic duct was intact, and it dominated an anterior segment of the right hepatic lobe. During laparoscopic cholecystectomy, a bile duct injury is the most challenging perioperative complication. We selected MRCP preoperatively; however, if it is necessary for us to observe an anomalous biliary tract more precisely, we recommend selecting DIC-CT endoscopic retrograde cholangiopancreatography. Additionally, we think a bile duct injury can be avoided with intraoperative cholangiography, even if there is an anomalous biliary tract.

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Venous occlusion test applied to the tributaries of the superior mesenteric veins of the pancreas head infiltrated by tumor

Abstract

A 64-year-old white woman presented with cholestatic jaundice, weight loss and a solid lesion in the pancreas head. At multislice computed tomography, a superior mesenteric vein (SMV) and one of it tributaries showed signs of tumor infiltration. At surgery, a venous occlusion test applied to the infiltrated tributary of the SMV showed immediate venous congestion in two-thirds of the distal small intestine. No reconstruction attempt was made due to the small size of the vessel. A biliodigestive anastomosis and lymph node biopsy was performed. The herein assessed case report suggests that the ileal tributary occlusion test applied to patients presenting pancreatic adenocarcinoma, with invasion of the tributaries of the SMV, may be effective in contraindicating resection procedures.

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Wide rectal duplication cyst in an adult resected by anterior approach: efficacy and recurrence

Abstract

Alimentary tract duplications are uncommon congenital abnormalities usually diagnosed and treated in childhood. Rectal involvement is extremely rare. We report the case of a 22-year-old female who presented with chronic abdominal and perianal pain; feeling of rectal fullness. Workup revealed a rectal duplication cyst. The patient underwent a complete transabdominal excision of the cyst: an hybrid laparoscopic and laparotomic technique was adopted. The hybrid isolated anterior abdominal approach is safe and feasible even for the treatment of wide rectal duplication cysts. Real recurrence in rectal duplication cysts is uncommon when the first operation was performed with radical intent.

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Intra-articular lipoma of the hip

Intra-articular lipoma of the hip is a rare entity, with only two reports published in the English-language literature. We present a case of successful arthroscopic resection of an intra-articular peripheral compartment lipoma in a 69-year-old woman with a coincident labral tear. This woman presented with left hip pain that developed gradually over 2 years and increased over 2 months. MRI showed a fat-intense mass in the anterior aspect of the hip joint, convincing for intra-articular lipoma. Physical examination in the operating room reproduced decreased range of motion and evidence of impingement but with a soft endpoint. Arthroscopy revealed an anterior intrasubstance labral tear, which was debrided. The mass was excised and confirmed as true lipoma on histology. The soft endpoint on examination illustrates that a large lipoma of the hip joint can cause clinical symptoms of impingement in the absence of bony abnormality or trauma.

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The cause of the stroke: a diagnostic uncertainty

A 39-year-old man with a history of sickle cell disease (SCD) presented with left leg weakness. He had a normal CT head and CT angiogram, but MRI head showed multiple acute bilateral cortical infarcts including in the right precentral gyrus. The MRI findings were more in keeping with an embolic source rather than stroke related to SCD, although it could not be ruled out. He also had an echocardiogram which revealed a patent foramen ovale. He was treated with antiplatelet therapy and also had red blood cell exchange transfusion. His symptoms improved significantly and he was discharged with follow-up as an outpatient and a cardiology review.

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An unusual case of abdominal pains

Description

A 55-year-old African American man presented to the emergency room with 3 days of new-onset right-sided flank and abdominal pains. His abdominal pains were dull in nature, constant, moderate in severity (approximately 6 out of 10) and radiated to his back and right flank regions. There were no aggravating factors but the patient reported temporary relief with over-the-counter acetaminophen. The pains were associated with mild nausea and vomiting but he denied diarrhoea, constipation, weight loss, fevers or other associated symptoms. His only known medical history was hypertension, controlled with lisinopril. Surgical, social and family history were unremarkable. Other than abdominal pains, a complete review of systems was negative. His blood pressure was 117/78 mm Hg and his pulse was 82 bpm. His physical examination revealed right flank and right lower quadrant abdominal pain without rebound or guarding.

He underwent an abdominal CT scan which showed a 5.2 cmx4.2 cm hypodensed solid right...

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Obesity-related hypogonadism: a reversible condition

Obesity is associated with hypogonadism. While this association is widely accepted, the underlying mechanisms remain unclear. Furthermore, obesity is a risk factor for hypogonadism and conversely hypogonadism may be a risk factor for obesity. We present the case of a morbidly obese man aged 30 years with hypogonadotrophic hypogonadism that underwent a Roux-en-Y gastric bypass operation. Following the surgical treatment of his obesity, the testosterone level returned to normal with improvements in hypogonadal symptoms, which allowed discontinuation of exogenous testosterone therapy. This case report demonstrates reversal of hypogonadism following weight loss with restoration of gonadal function.

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An umbilical bleeding nodule

Description

A 23-year-old woman was referred to the dermatology department through the 2-week wait pathway under clinical suspicion of malignant melanoma in the umbilical region. She presented with a 4-month history of a painful and intermittently bleeding nodule on the umbilical area. The lesion was more prominent during her menstrual cycles and bled. She was otherwise in good general health and denied a history of abdominal or gynaecological surgery. There was no known medical history of endometriosis.

On physical examination, she presented with approximately 1.5 cm soft, brown, well-circumscribed nodule on the inferior aspect of the umbilical area (figure 1). Based on her medical history and examination findings, umbilical endometriosis was suspected. A cutaneous biopsy was performed, which showed endometrial glands and stroma without atypia and scattered siderophages (figure 2). The patient was referred to the gynaecology team for further investigation. Ultrasound studies and abdominal/pelvic...

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Antenatal thoracoamniotic shunting in congenital cystic adenomatoid malformation

Description

This case report describes a baby who was diagnosed antenatally with a significant left-sided congenital cystic adenomatoid malformation.

Following diagnosis of a fluid-filled, macrocystic structure on the left side of the chest, the mother was referred at 27 weeks' gestation to her regional fetal medicine unit for assessment and ongoing management. Fetal MRI demonstrated a cyst measuring 6.7 mm x 4.3 mm, associated with mediastinal shift and affecting cardiac contractility. Scalp oedema and ascites noted at this time indicated evolving fetal hydrops.

At 28 weeks, thoracoamniotic shunt was inserted to drain the lesion. By 29 weeks, the cyst had decreased in size, now 5.1 mm x 3.4 mm. Cardiac function, oedema and ascites had all improved.

Subsequent scans showed that the shunt, initially placed successfully, had completely migrated into the cyst. Further drainage was completed at 37+3 weeks, with 90 mL of fluid needle aspirated.

Labour was induced, and baby was delivered at 37+4...

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The Implementation of a Preoperative Transthoracic Echocardiography Consult Service by Anesthesiologists.

We describe a preoperative transthoracic echocardiography consult service led by anesthesiologists. The implementation process and the patient cohort are described. Preoperative transthoracic echocardiographic examinations were mostly performed in patients undergoing intermediate- or high-risk noncardiac surgery and in patients with a higher calculated mortality risk. All transthoracic echocardiographic examinations were interpreted by anesthesiologists. (C) 2017 International Anesthesia Research Society

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A Limitation of Intensive Care Unit Sedation Using Volatile Anesthetics.

No abstract available

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Physiologic Considerations in Trauma Patients Undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta.

Resuscitative endovascular balloon occlusion of the aorta is a new procedure for adjunctive management of critically injured patients with noncompressible torso or pelvic hemorrhage who are in refractory hemorrhagic shock, ie, bleeding to death. The anesthesiologist plays a critical role in management of these patients, from initial evaluation in the trauma bay to definitive care in the operating room and the critical care unit. A comprehensive understanding of the effects of resuscitative endovascular balloon occlusion of the aorta is essential to making it an effective component of hemostatic resuscitation. (C) 2017 International Anesthesia Research Society

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A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta.

BACKGROUND: The incidence of placenta accreta (PA) has increased from 0.8 to 3.0 in 1000 pregnancies, driven by increased rates of cesarean deliveries (32.2% in 2014) of births in the United States. The average blood loss for a delivery complicated by PA ranges from 2000 to 5000 mL, frequently requiring substantial transfusion medicine support. We report our own institutional multidisciplinary approach for managing such patients, along with transfusion medicine outcomes, in this setting over a 5-year period. METHODS: We reviewed records for patients referred to our program in placental disorders from July 1, 2009, to July 1, 2014. A placental disorders preoperative checklist was implemented to ensure optimal management of patients with peripartum hemorrhage. RESULTS: Of 136 patients whose placentas were reviewed postpartum, 21 had PA, 39 had microscopic PA, 17 had increta, 17 had percreta, and 42 had no accreta (of which 11 had placenta previa). For each subtype, the percentage of patients receiving blood products were 71% (PA), 28% (microscopic PA), 82% (increta), 82% (percreta), and 19% (no accreta). Among patients with PA or variants, 89% of patients with PA or variants underwent postpartum hysterectomy, compared to only 5% of patients with no or microscopic PA. CONCLUSIONS: Based on our experience and on the findings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will benefit from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identified predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to sufficient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices. (C) 2017 International Anesthesia Research Society

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In Response.

No abstract available

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Perioperative Venous Thromboembolism: A Review.

Venous thromboembolism (VTE) is a significant problem in the perioperative period, increasing patient morbidity, mortality, and health care costs. It is also considered the most preventable of the major postoperative complications. Despite widespread adoption of prophylaxis guidelines, it appears that morbidity from the disease has not substantially changed within the past 2 decades. It is becoming clear that current prophylaxis efforts are not sufficient. Using more potent anticoagulants may decrease the incidence of VTE, but increase the risk for bleeding and infection. Much has been learned about the pathophysiology of venous thrombogenesis in recent years. Beyond the "traditional coagulation cascade," which anticoagulants modulate, there is a growing appreciation for the roles of tissue factor, monocytes, neutrophils, neutrophil extracellular traps, microvesicles, and platelets in thrombus initiation and propagation. These recent studies explain to some degree why aspirin appears to be remarkably effective in preventing thrombus propagation. Endothelial dysfunction, traditionally thought of as a risk factor for arterial thrombosis, plays an important role within the cusps of venous valves, a unique environment where the majority of venous thrombi originate. This suggests a role for newer treatment modalities such as statins. Not all patients have an equal likelihood of experiencing a VTE, even when undergoing high-risk procedures, and better tools are required to accurately predict VTE risk. Only then will we be able to effectively individualize prophylaxis by balancing the risks for VTE against the risks associated with treatment. Given the different cell types and pathways involved in thrombogenesis, it is likely that multimodal treatment regimens will be more effective, enabling the use of lower and safer doses of hemostatic modulating therapies such as anticoagulants, antithrombotics, and antiplatelet medications. (C) 2017 International Anesthesia Research Society

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