Mirizzi syndrome and gallstone ileus: An unusual presentation of gallstone disease

We discuss the case of a man with an unusual complication of gallstone disease. An 85-year-old patient presented to the emergency department with a 3-week history of abdominal pain in the right upper abdominal quadrant. Thoracoabdominal radiography demonstrated that the whole extrahepatic biliary tree, including the common bile duct, common hepatic duct, gallbladder, and left and right hepatic ducts, were visibly delineated by air. The operative findings revealed a small shrunken gallbladder, a fistula between the gallbladder fundus and the gastric antrum, and a cholecystohepatic fistula, corresponding to Mirizzi syndrome, type II. A large gallstone was found impacted in the jejunum. This patient seems to have developed initially a cholecystohepatic fistula. Due to the acute inflammatory process, the stone eroded through the gallbladder wall and into the gastric antrum, passing from the antrum into the small bowel, where it became impacted. We suggest that the natural history of Mirizzi syndrome does not end with a cholecystobiliary fistula but that the continuous inflammation in the triangle of Calot may result in a complex fistula involving not only the biliary tract but also the adjacent viscera

Multilocal programming and applications

Preprint versionMultilocal programming aims to identify all local minimizers of unconstrained or constrained nonlinear optimization problems. The multilocal programming theory relies on global optimization strategies combined with simple ideas that are inspired in deflection or stretching techniques to avoid convergence to the already detected local minimizers. The most used methods to solve this type of problems are based on stochastic procedures and a population of solutions. In general, population-based methods are computationally expensive but rather reliable in identifying all local solutions. In this chapter, a review on recent techniques for multilocal programming is presented. Some real-world multilocal programming problems based on chemical engineering process design applications are described.Fundação para a Ciência e a Tecnologia (FCT

Antimicrobial therapy for acute cholangitis: Tokyo Guidelines

Antimicrobial agents should be administered to all patients with suspected acute cholangitis as a priority as soon as possible. Bile cultures should be performed at the earliest opportunity. The important factors which should be considered in selecting antimicrobial therapy include the agent’s activity against potentially infecting bacteria, the severity of the cholangitis, the presence or absence of renal and hepatic diseases, the patient’s recent history of antimicrobial therapy, and any recent culture results, if available. Biliary penetration of the microbial agents should also be considered in the selection of antimicrobials, but activity against the infecting isolates is of greatest importance. If the causative organisms are identified, empirically chosen antimicrobial drugs should be replaced by narrower-spectrum antimicrobial agents, the most appropriate for the species and the site of the infection

The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification

Background Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas. Methods We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome. Results Cholecystoenteric fistula was associated with Mirizzi syndrome (p < 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (p < 0.0001), and female gender was associated with Mirizzi syndrome (p < 0.0001). Conclusion When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula

Some discussions on functionalist housing and its economics in Romania by Lhe late 1950s and early 1960s

This paper proposes an analysis of the Romanian architectural practices in the late 1950's and early 1960's by considering the availability of financial resources. I premise that echoes of Moscow's approaches to the built environment overlapped the Bucharest politicians' priorities, whose lack of constancy in economic decision-making exacerbated itself as the urban construction programs advanced. From the Romanian authorities' point of view, therefore, raising the mass housing profitability could save important financial resources for other investments in heavy industry, while maintaining the appearance of a social state. Similarities between Soviet and Romanian modernist building projects suggested a coherent approach to housing throughout the bloc. However, this article will show that functionalist architectural modernism -cheap and fast to erect- also proved beneficial for Gheorghe Gheorghiu-Dej's economic plans, which questions urban construction projects' political agendas and the professional tensions between architects and economists. Therefore, investigating the functionalist architecture opens up several lines of inquiry: to what extent Nikita Khrushchev's housing program was transferred in Romania; the tortuous policies of the Romanian state's leadership in the field of housing as well as how local bureaucratic or professional actors appropriated, interpreted and adjusted such programs; and, the economic costs of the new functionalist approach to urban dwelling. In this way, this article reads the making of functionalist mass housing programs by the late 1950s to assess the Soviets' part in building the Romanian cities. To this end, the article contributes to the recent scholarly literature on multiple modernities

Barrett's esophagus can develop after antireflux surgery

BACKGROUND: Surgical treatment in patients with gastroesophageal reflux disease (GERD) without Barrett's esophagus (BE) is an excellent alternative therapy to medical treatment, preventing the development of complications and the appearance of BE. PURPOSE: To determine the newly developed BE in a group of patients without BE prior to surgery, the patients were submitted to a late subjective and objective follow-up. METHODS: From 115 non-BE patients submitted to surgery and followed up for a long period, 12 (10.4%) developed intestinal metaplasia after operation. They were submitted to endoscopic, histologic, manometric and functional studies (24-h pH and Bilitec). RESULTS: The 12 patients had an average of 5 endoscopies after surgery with several biopsy samples. Symptoms of recurrent reflux were present in only 10 patients (83%) at a mean of 80 months after surgery. The mean follow-up was 135 months. Four patients showed the absence of pathologic reflux measured by 24-h pH and Bilitec monitoring, while 8 had the presence of abnormal acid reflux. There were no significant differences between endoscopic, histologic and functional studies comparing patients with the presence or absence of pathologic reflux. The time of appearance to intestinal metaplasia from cardiac or oxynto-Cardiac mucosa was 58-90 months. Four patients showed regression of intestinal metaplasia to cardiac mucosa after intensive medical treatment. CONCLUSIONS: Antireflux surgery in patients without BE does not prevent the late appearance of BE in near 10% of the cases, provided that a long-term follow-up is performed and several endoscopic and histologic evaluations are repeated. Near 2/3 of these patients showed the presence of acid reflux, while 1/3 showed no abnormal reflux. With this method of follow-up, metaplastic changes from cardiac to intestinal metaplasia and from intestinal metaplasia to low-grade dysplasia can be documented, as well as regression from intestinal metaplasia to cardiac mucosa

Severe sepsis caused by Aeromonas hydrophila in a patient using tocilizumab: a case report

<p>Abstract</p> <p>Introduction</p> <p><it>Aeromonas </it>species do not commonly cause disease in humans. However, when disease is seen, it often occurs in patients with underlying immunosuppression or malignancy and has a high fatality rate.</p> <p>Case presentation</p> <p>A 72-year-old Japanese woman with rheumatoid arthritis treated with tocilizumab (which has an immunosuppressive effect) presented with severe epigastric pain. She had a fever with chills, hypotension and jaundice. She was diagnosed with acute suppurative cholangitis and treated with cefoperazone-sulbactam and an endoscopic drainage was performed. Jaundice was slightly improved, but the shock state and inflammatory reactions were prolonged as typical of septic shock. On the second day after admission, an electrocardiogram showed ST segment elevation and echocardiography showed ventricular wall dysfunction. Coronary arteries were patent in coronary angiography and she was diagnosed with stress-induced cardiomyopathy. Blood cultures showed <it>Aeromonas hydrophila</it>. A stool culture was negative for <it>A. hydrophila</it>. On day six, her white blood cell count and neutrophils were normalized and cefoperazone-sulbactam treatment was halted. Left ventricular function normalized on day twelve and a laparoscopic cholecystectomy for cholelithiasis was performed on the 16th day of hospitalization. A culture from the bile showed <it>A. hydrophila</it>. Eighteen days after surgery, tocilizumab treatment was restarted and there were no complications. Two months after restarting tocilizumab, our patient is stable without any serious events.</p> <p>Conclusion</p> <p>We present a rare case of <it>A. hydrophila </it>sepsis and acute suppurative cholangitis in an elderly patient with gallstones and rheumatoid arthritis using tocilizumab. This clinical course may suggest that preemptive treatment for cholelithiasis prior to using molecular-targeting agents might be feasible in elderly patients.</p