BACKGROUND:Splenic rupture is the most common injury in blunt abdominal trauma at any age. The grade of rupture, haemodynamic stability and, in the case of operative treatment, the experience of the surgeon all play an important role in preserving the spleen. Due to its important immunological function preservation of the spleen should be the goal.PATIENTS:From January 2000 to August 2009 five children (4 male/1 female) with isolated grade IV or V splenic rupture, according to the Organ Injury Score (OIS), were treated operatively. At the time of the trauma the patients were 8.8 ± 3.8 (mean ± standard deviation; range, 6–15) years old. Four patients with an OIS grade IV rupture were primarily treated with partially spleen-saving surgery: one resection of 2⁄3 of the spleen including the splenic vessels, one hemisplenectomy and two lower pole resections; in one patient with an OIS grade V rupture splenectomy was performed immediately.RESULTS:In one patient treated with a spleen-preserving approach (hemisplenectomy) the remainder of the spleen had to be removed due to acute bleeding on the first postoperative day. This patient needed two units of blood transfused following the second operation. There were no other complications. The two patients with splenectomy and resection of ⅔ of the spleen developed a transient thrombocytosis indicating impaired clearance of the spleen. In a follow-up involving ultrasonography (median 13, range 1-101 months) all patients managed with partially spleen-saving surgery showed a large remnant spleen with arterial perfusion.CONCLUSION:The majority of primarily partially spleen-preserving operations result from OIS grade IV ruptures of the spleen. Use of a partially spleen-saving surgical approach was successful in ¾ of these patients. Low morbidity and documented perfusion of the remnant spleen at long-term follow-up indicate that a spleen-preserving technique is warranted if an operative approach is required.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

HISTORY AND CLINICAL FINDINGS A 35-year-old man, for 8 years known to have hereditary angio-oedema with recurrent cutaneous swellings and occasional attacks of gastrointestinal pain, developed very painful, colic-like upper abdominal symptoms and frequent vomiting. INVESTIGATIONS Routine laboratory tests were normal, except for leucocytosis of 18,200 WBC/microliter. The plasma concentrations of C1-esterase inhibitor (5.6 mg/dl) and of complement factor C4 (10.0 mg/dl) were reduced. Computed tomography revealed about 500 ml free fluid, a perihepatic effusion and definite oedematous thickening of the ileal wall. TREATMENT AND COURSE During conservative treatment with infusions and no food by mouth the symptoms regressed. Abdominal ultrasonography was normal (no free intraabdominal fluid). Since discharge (now more than 15 months ago) the patient has been on danazole medication (200 mg/d). CONCLUSION Recurrent gastrointestinal colics are typical of for hereditary angio-oedema and can imitate an acute abdomen. Concurrent ascites has only recently been described. Appropriate instruction of the patient and his/her medical practitioner is important to avoid unnecessary laparotomy.

Hämangiome des Gastrointestinaltraktes sind im Kindes- wie im Erwachsenenalter sehr selten. In der vorliegenden Arbeit wird ein Kind mit uncharakteristischen abdominellen Schmerzen und diagnostisch nachgewiesener Stenosierung im terminalen Ileum vorgestellt. Bei der Laparotomie zeigten sich ausgedehnte hämangiomatöse Veränderungen in der Ileocöcalregion. Im Resektat wurde histologisch ein hamartomatöses venöses Hämangion nachgewiesen. In der Diskussion wird auf die Problematik der Klassifizierung und Diagnostik solcher Veränderungen eingegangen.

A case of malignant nodular melanoma (MM), metastatic to the small intestine and the gallbladder, is reported. A 48-year-old male patient underwent excision of the primary tumor (pT3, Nx, Mx; Clark-Level IV) at the lateral foot in 1991. He refused aftercare examinations, After readmission 2 1/2 years later, he presented with recurrent abdominal pain, nausea, vomiting, and weight loss. Symptoms increased, and in the brain a solitary metastasis was detected and excised. In the following, there was an ileus of the small intestine, Resections of parts of the small intestine and a cholecystectomy were performed. On histologic examination there were metastases of the MM in the small intestine and in the gallbladder, which had not been detected by ultrasound. The postoperative period was without any complications. Half a year later, once more metastasis of the brain without clinical symptoms was detected, and a combined radiochemotherapy was started. The patient died 6 months later, nearly 3 1/2 years after excision of the primary tumor.

Hemangiomas of the gastrointestinal tract are very rare in both children and adults. The following case history describes a child with uncharacteristic abdominal pain and stenosis of the terminal ileum. Intraoperatively we found an enlarged hamartomatous alteration of the ileocecal region. The histological analysis showed a hamartomatous venous hemangioma. Problems concerning classification and diagnosis are discussed.

This report presents the cases of two female patients aged 54 and 57 years, both with colon involvement of type 1 neurofibromatosis. The first woman had a polypoid neuronal hyperplasia containing small Wagner-Meissner corpuscles, which had allowed identification of the neuronal nature of the lesion in a small mucosal biopsy specimen taken previously. The second patient had an idiopathic megacolon of the sigmoid, which had to be extirpated because of acute obstruction and ileus. Morphological examination revealed a typical. plexiform neurofibroma of the bowel wall and neuronal hyperplasia of the colonic mucosa and submucosa, which had obviously caused disordered gut mobility leading to functional stenosis and extreme dilatation of prestenotic bowel parts. Gastrointestinal neurofibromatosis is rare and is characterized morphologically by neuronal hyperplasia of the mucosa and submucosa, sometimes containing small aggregates of ganglion cells by which it can easily be identified. However, in the majority of cases the increase of proliferating mucosal nerve fibres can only be confirmed by S-100 protein immunostaining. Furthermore, solitary, multiple and plexiform neurofibromas are found, but only the last, which arises from mesenteric or subserosal nerves, is virtually pathognomonic for neurofibromatosis. Gastrointestinal neurofibromas are usually late manifestations of the disease, but in exceptional cases they can be the initial sign of neurofibromatosis in patients who have no external stigmata that arouse suspicion, The occurrence of gastrointestinal neurofibromas should therefore lead to a careful search for other features of NF-1 in the affected patients and in their families.

Spilled gallstones abandoned intraperitoneally may cause serious complications. The following case history describes a patient who had undergone a laparoscopic cholecystectomy elsewhere 2 years previously, and who had to have a laparotomy because of a pararenal abscess caused by spilled gallstones. fatal sepsis ensued and the patient died on the 6th postoperative day.

A 50-year-old woman complained of upper abdominal pain for several weeks, getting worse and radiating towards the left shoulder in the 24 hours preceding her hospital admission. Plain X-ray film of the abdomen revealed plaque-like calcifications projecting onto the tail of the pancreas. Ultrasound imaging demonstrated splenic rupture with free intra-abdominal fluid. During an emergency laparotomy the spleen was removed. At first the postoperative course was uneventful. But epigastric pain recurred a few days after discharge. Serum amylase and lipase concentrations were elevated (280 U/l and 553 U/l, respectively). Endoscopic retrograde cholangiopancreatography revealed chronic pancreatitis with a 3 cm pseudocyst in the tail of the pancreas. A papillotomy was performed, after which the symptoms rapidly regressed and the pancreatic enzyme concentrations fell. This was thus a case of spontaneous splenic rupture associated with previously undiagnosed chronic pancreatitis with inflammatory papillary stenosis and pseudocyst in the pancreatic tail.

A 50-year-old woman complained of upper abdominal pain for several weeks, getting worse and radiating towards the left shoulder in the 24 hours preceding her hospital admission. Plain X-ray film of the abdomen revealed plaque-like calcifications projecting onto the tail of the pancreas. Ultrasound imaging demonstrated splenic rupture with free intra-abdominal fluid. During an emergency laparotomy the spleen was removed. At first the postoperative course was uneventful. But epigastric pain recurred a few days after discharge. Serum amylase and lipase concentrations were elevated (280 U/l and 553 U/l, respectively). Endoscopic retrograde cholangiopancreatography revealed chronic pancreatitis with a 3 cm pseudocyst in the tail of the pancreas. A papillotomy was performed, after which the symptoms rapidly regressed and the pancreatic enzyme concentrations fell. This was thus a case of spontaneous splenic rupture associated with previously undiagnosed chronic pancreatitis with inflammatory papillary stenosis and pseudocyst in the pancreatic tail.

Von 1/82–3/88 wurden 55 Patienten wegen Colitis ulcerosa stationär behandelt. 9mal lag eine Notfallsituation vor, davon 7mal ein toxisches Megacolon. Immer erfolgte hier im Ersteingriff die Entfernung des toxischen Organs (4mal mit Rektumblindverschluß, 3mal mit Sigma-schleimfistel). 2 Patienten verstarben direkt postoperativ. In 3 Fällen konnte eine kontinuitätswieder-herstellende ileoanale Pouchoperation durchgeführt werden. Die gegenüber primär elektiven Pouchoperationen hierbei erhöhte Komplikationsrate ist mitbedingt durch die Schwere der Grunderkrankung und stattgehabte Voroperation.

The pattern of operation injuries of the arterial vessels which may occur during hip surgery is illustrated by this summary of our own cases. Injuries of the femoral vessels seem to be preventable if the Hohmann-retractor is carefully placed on the anterior margin of the acetabular rim under digital control. Furthermore drilling damage of the iliac vessel appears to be avoidable. However, the replacement manoeuvre of the artificial acetabulum can be associated with massive bleeding despite greatest care. Under these circumstances immediate surgical intervention through an inguinal retroperitoneal approach is mandatory.