A Case Report of Spontaneous Closure of a Posttraumatic Arterioportal Fistula

As the indications for the nonoperative management (NOM) of hepatic injury have expanded, the incidence of complications of NOM has increased. Among such complications, arterioportal fistula (APF) formation is rare, although dangerous, due to the potential for portal hypertension. Embolization is performed in APF patients with clinical signs suggestive of portal hypertension. Meanwhile, no indications for treatment have been established in APF patients without symptoms, as the natural history of posttraumatic APF is not well understood. We herein report the case of a 35-year-old female with severe hepatic injury (Grade IV on the Organ Injury Scale of the American Association for the Surgery of Trauma) due to a traffic accident. Her hemodynamic state remained stable, and an enhanced CT scan obtained on admission showed no extravasation of contrast medium, pseudoaneurysm formation, or APF; therefore, NOM was selected. Although the patient’s physical condition was stable, an enhanced CT scan obtained 13 days after the injury showed APF in segment 8 of the liver. Although embolization was considered, the APF was not accompanied by portal dilatation suggestive of portal hypertension; hence, strict observation was selected. Consequently, follow-up CT performed on day 58 after the injury revealed spontaneous closure of the APF

The investigation of posttraumatic pseudoaneurysms in patients treated with nonoperative management for blunt abdominal solid organ injuries.

Posttraumatic pseudoaneurysms (PAs) have been recognized as the cause of delayed hemorrhage complicated with nonoperative management (NOM), although the need for intervention in patients with small-sized PAs and the relationship between the occurrence of PAs and bed-rest has been also unclear.The purpose of this study was to investigate the clinical history of small-sized PAs (less than 10 mm in diameter) which occurred in abdominal solid organs, and to analyze the relationship between the occurrence of PAs and early mobilization from bed.Sixty-two patients who were successfully managed with NOM were investigated. Mobilization within three days post-injury was defined as "early mobilization" and bed-rest lasting over three days was defined as "late mobilization." A comparison of the clinical factors, including the duration of bed-rest between patients with and without PAs detected by follow-up CT was performed. Furthermore, a multiple logistic regression model analysis on the occurrence of PAs was performed.PAs were detected in 7 of the 62 patients. The One patient with PAs measuring larger than 10 mm received trans-arterial embolization, and the remaining six patients with PAs smaller than 10 mm were managed conservatively. Consequently, no delayed hemorrhage occurred, and the PAs spontaneously disappeared in all of the six patients managed without intervention. The multiple regression model analysis revealed that early mobilization was not a significant factor predicting new-onset PAs.Small PAs can be expected to disappear spontaneously. Moreover, early mobilization is not a significant risk factor for the occurrence of PAs

Idiopathic Adrenal Hematoma Masquerading as Neoplasm

We report herein a case of idiopathic adrenal hematoma. A 59-year-old Japanese man was referred to our hospital for evaluation of a 7.0 cm mass in the right upper abdominal cavity. The tumor was suspected to originate from either the posterior segment of the liver or the right adrenal gland. His chief complaint was weight loss of 8 kg over the previous 6 months. He had no past medical history and took no medications, including no anticoagulants. Laboratory data were almost normal except for a slight elevation of PIVKA-II. The origin of the tumor was found to be the adrenal gland, as angiography revealed the blood supply to the mass to derive from the right superior and inferior adrenal arteries. A fine needle biopsy of the lesion was unable to confirm the diagnosis. Open right adrenalectomy was performed. The histopathological findings of the surgical specimen revealed a hematoma with normal adrenal tissue. In the absence of any obvious etiology, the diagnosis was idiopathic adrenal hematoma

Protocol for the management of abdominal solid organ injuries.

<p>Protocol for the management of abdominal solid organ injuries.</p

Comparison of the clinical characteristics between the patients with and without new-onset of pseudoaneurysms.

<p>¹BP; blood pressure.</p><p>²GCS; Glasgow coma scale.</p><p>³OIS; organ injury scale.</p><p>⁴CT; computed tomography.</p><p>⁵ISS; injury severity score.</p><p>⁶PT; pro-thrombin activity.</p><p>⁷Early mobilization; defined as mobilization from the bed within three days post-injury.</p><p>Comparison of the clinical characteristics between the patients with and without new-onset of pseudoaneurysms.</p

Clinical characteristics and outcomes of the patients with PAs.

<p>¹TAE; trans-catheter arterial embolization.</p><p>Clinical characteristics and outcomes of the patients with PAs.</p

Clinical characteristics of patients successfully treated with nonoperative management for blunt abdominal trauma.

<p>¹BP; blood pressure.</p><p>²Shock indicates patients whose systolic blood pressure was less than 90 mmHg or whose shock index (systolic pressure/heart rate) was < 1.0.</p><p>³GCS; Glasgow coma scale.</p><p>⁴OIS; organ injury scale.</p><p>⁵CT; computed tomography.</p><p>⁶ISS; injury severity score.</p><p>⁷PT; pro-thrombin activity.</p><p>⁸NOM with TAE; patients who were treated with nonoperative management with trans-catheter arterial embolization.</p><p>Clinical characteristics of patients successfully treated with nonoperative management for blunt abdominal trauma.</p

Usefulness of intestinal fatty acid-binding protein in predicting strangulated small bowel obstruction.

BACKGROUND: The level of intestinal fatty acid-binding protein (I-FABP) is considered to be useful diagnostic markers of small bowel ischemia. The purpose of this retrospective study was to investigate whether the serum I-FABP level is a predictive marker of strangulation in patients with small bowel obstruction (SBO). METHODS: A total of 37 patients diagnosed with SBO were included in this study. The serum I-FABP levels were retrospectively compared between the patients with strangulation and those with simple obstruction, and cut-off values for the diagnosis of strangulation were calculated using a receiver operating characteristic curve. In addition, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Twenty-one patients were diagnosed with strangulated SBO. The serum I-FABP levels were significantly higher in the patients with strangulation compared with those observed in the patients with simple obstruction (18.5 vs. 1.6 ng/ml p<0.001). Using a cut-off value of 6.5 ng/ml, the sensitivity, specificity, PPV and NPV were 71.4%, 93.8%, 93.8% and 71.4%, respectively. An I-FABP level greater than 6.5 ng/ml was found to be the only independent significant factor for a higher likelihood of strangulated SBO (P =  0.02; odds ratio: 19.826; 95% confidence interval: 2.1560 - 488.300). CONCLUSIONS: The I-FABP level is a useful marker for discriminating between strangulated SBO and simple SBO in patients with SBO

Results of the blood examinations.

<p>a: SBO indicates small bowel obstruction</p><p>WBC: white blood cell; Plt: platelet; ALP: alkaline phosphatase; LDH: lactic dehydrogenase; CK: creatine phosphokinase; CRP: C-reactive protein; LA: lactic acid; I-FABP: intestinal fatty acid-binding protein.</p

Comparison of the diagnostic usefulness of the blood biochemical markers for predicting strangulated small bowel obstruction.

<p>Numbers in parentheses represent 95% confidence intervals.</p>a<p>ROC indicates receivor operating characteristics.</p>b<p>PPV indicates the positive predictive value.</p>c<p>NPV indicates the negative predictive value.</p><p>WBC: white blood cell; Plt: platelet; ALP: alkaline phosphatase; LDH: lactic dehydrogenase;</p><p>CK:creatine phosphokinase; CRP: C-reactive protein; LA:lactic acid; I-FABP: intestinal fatty acid-binding protein</p