Massive Gastrointestinal Bleeding and Obstruction of the Ureter Caused by the Migration of a Swallowed Toothpick from the Sigmoid Colon – A Case Report

In this study, a case of an ingested toothpick partially migrating from the sigmoid colon, causing massive lower gastrointestinal bleeding due to arterial-colic fistula, and stricture of the left ureter is presented. A 70-year-old male was admitted to the emergency department after having feces mixed with fresh and coagulated blood for the past two days. Computed tomography and retrograde ureteropyelography showed the stricture of the left ureter, 1.5 cm below the branching of iliac artery, without any signs of malignancy. Colonoscopy showed fresh blood in the rectum and sigmoid colon up to the neoplasm like granulation tissue mixed with fresh and coagulated blood, which almost obstructed the lumen. Explorative laparotomy showed a foreign body (toothpick) perforating the sigmoid colon through the mesenterial wall, and being stocked with one-third into the left internal iliac artery, causing arterial-colic fistula. The remaining part of the toothpick was surrounded by granulation tissue and chronic inflammatory process, pressing on the distal third of the left ureter. We conclude that a swallowed toothpick may cause a significant gastrointestinal injury with a wide variety of clinical manifestations, and it must be treated with caution. The imaging studies are often inadequate in detecting toothpicks, and thus, we insist on a physical examination, as the best indicator of injury

Colobronchial fistula following a partial resection of the colon

We report a case of colobronchial fistula as a late consequence of the resection of the colon due to relapse of the gastrointestinal stromal tumor (GIST). A 54-year-old man experiencing pain in the left upper abdominal region underwent doublecontrast barium enema which revealed a fistulous channel between the splenic flexure of the colon and the bronchial tree. Fiberoptic bronchoscopy, after an extensive washout and aspiration of barium sulphate, confirmed the existence of a fistula in left lower subsegmental bronchi. The patient underwent left lower lobectomy, resection of the colobronchial fistula and resection of the splenic flexure of the colon. A year after the operation, the multidetector computed tomography (MDCT) showed neither signs of malignant abdominal disease, nor signs of pathological changes in the lung bases

Colobronchial fistula following a partial resection of the colon

We report a case of colobronchial fistula as a late consequence of the resection of the colon due to relapse of the gastrointestinal stromal tumor (GIST). A 54-year-old man experiencing pain in the left upper abdominal region underwent doublecontrast barium enema which revealed a fistulous channel between the splenic flexure of the colon and the bronchial tree. Fiberoptic bronchoscopy, after an extensive washout and aspiration of barium sulphate, confirmed the existence of a fistula in left lower subsegmental bronchi. The patient underwent left lower lobectomy, resection of the colobronchial fistula and resection of the splenic flexure of the colon. A year after the operation, the multidetector computed tomography (MDCT) showed neither signs of malignant abdominal disease, nor signs of pathological changes in the lung bases

Posttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleeding

Posttraumatic hepatic artery pseudoaneurysm is a rare, but life threatening condition which should be considered in patients with a history of blunt abdominal trauma who present with abdominal pain or gastrointestinal bleeding. We report a case of a patient with such a pseudoaneurysm discovered five months after a bicycle accident resulting in hepatic rupture that was treated conservatively. The patient presented with fatigue, dizziness, inability to tolerate major exertion and gastrointestinal bleeding. After extensive diagnostic procedures, a right hepatic artery pseudoaneurysm was found. The condition was treated successfully with transcatheter coil embolization

Use of modified multidetector CT colonography for the evaluation of acute and subacute colon obstruction caused by colorectal cancer

Kompjutorizirana tomografska kolonografija je minimalno invazivna dijagnostička metoda kojom se pregledava lumen debelog crijeva, kao i kolonoskopijom i irigografijom s dvostrukim kontrastom, ali istovremeno i stijenka debelog crijeva, tkivo uz stijenku s limfnim čvorovima, kao i drugi organi u trbuhu. U slučajevima akutne i subakutne opstrukcije debelog crijeva, kao korisne dijagnostičke metode navode se nativna snimka trbuha, irigografija, standardni CT trbuha i kolonoskopija. O mogućoj primjeni CT kolonografije u takvih bolesnika nema podataka u dostupnoj literaturi. CILJ: U prospektivnom ispitivanju i uz korištenje modificiranog protokola ocijeniti tehničku izvedivost multidetektorske kompjutorizirane tomografske kolonografije (MDCTC) u bolesnika sa sumnjom na akutnu ili subakutnu opstrukciju debelog crijeva uzrokovanu kolorektalnim karcinomom, te pri tome ocijeniti točnost metode u utvrđivanju postojanja, lokalizacije, veličine i proširenosti karcinoma, kao i prikaza debelog crijeva proksimalno i distalno od opstrukcije. METODE: Istraživanje je odobrilo Etičko povjerenstvo KBC Split, a bolesnici su potpisali informirani pristanak. U 50 bolesnika (14 žena, 36 muškaraca; raspon 31-93 godine; medijan 70 godina) u kojih se na osnovi kliničkih simptoma i nativne snimke trbuha sumnjalo na opstrukciju debelog crijeva uzrokovanu karcinomom učinjena je kolonografija na 16-slojnom CT uređaju. Debelo crijevo je čišćeno klizmama mlake vode. Nakon nativnog skeniranja trbuha u pronaciji, bolesnicima je intravenski dano 100-140 ml kontrasta, a skeniranje u supinaciji je učinjeno u portalnoj, venskoj fazi. Parametri CT protokola bili su: kolimacija 16 x 0,75 mm; 120 kV; 100-300 mA; vrijeme rotacije 0,5 s; rekonstrukcijska debljina sloja 1 mm s pomakom od 0,7 mm. Kirurški i patohistološki nalaz su služili kao zlatni standard. Točnost metode je određivana za T (tumorska invazija crijevne stjenke), N (zahvaćenost limfnih čvorova) i M (metastaze) proširenost. REZULTATI: U 48/50 bolesnika distenzija crijeva je bila uzrokovana opstrukcijom, od kojih je u 44 (91%) uzrok opstrukcije bio kolorektalni karcinom (13 žena, 31 muškarac; raspon 31-87 godina; medijan 71 godina). MDCTC je točno locirala sve karcinome i uspješno otkrila sve netumorske uzroke distenzije crijeva. Ukupna točnost za T proširenost je bila 91,5%, za N 72,7% i za M 90%. Točno su prikazana i tri (6,8%) sinkrona tumora. ZAKLJUČAK: MDCTC je tehnički izvediva i neinvazivna dijagnostička metoda u slučajevima akutne i subakutne opstrukcije debelog crijeva, s visokom točnošću pri evaluaciji debelog crijeva i procjeni proširenosti kolorektalnog karcinoma, što omogućava planiranje optimalnog kirurškog postupka.Computed tomographic colonography is a minimally invasive technique that provides information about the lumen of the colon, like a colonoscopy or double-contrast barium enema, but also about the colon wall, pericolic tissue, lymph nodes, and other extracolonic pathology. In cases of acute and subacute colon obstruction, a plain abdominal radiograph, a contrast enema, a standard abdominal CT, and a colonoscopy have been reported as valuable diagnostic tools. The role of CT colonography in cases of acute or subacute colonic obstruction has yet to be evaluated. PURPOSE: The purpose of the study was to prospectively evaluate the technical feasibility of the multidetector computed tomographic colonography (MDCTC) in patients in whom acute or subacute colon obstruction caused by colorectal cancer was suspected, using a modified procedure protocol, and also to establish the accuracy of MDCTC regarding the presence, location, size, and staging of the cancer, as well as colon evaluation proximal and distal to obstruction. METHODS: This prospective study was approved by Ethic Commitee of University Hospital Center Split; all participants gave written informed consent. On the basis of the clinical symptoms and a plain x-ray film of the abdomen, a 16 row CT colonography was performed in 50 patients (14 women, 36 men; range, 31-93 years; mean age, 70 years) if acute or subacute bowel obstruction was suspected. The colon was cleansed with lukewarm water enemas. Scans were performed in precontrast prone-position and in supine position after the administration of 100-140 ml of contrast agent intravenously in a single portal venous phase. Computed tomography parameters were: slice collimation, 16 x 0.75 mm; kV, 120; mAs, 100-250; rotation time of 0.5 s; reconstructed thickness 1.0 mm at intervals of 0.7 mm. The surgical and pathologic findings served as standards of reference. The accuracy of the method was assessed for T (tumor invasion of colon wall), N (nodal involvement), and M (metastases) staging. RESULTS: In 48 of 50 patients, colon distention was caused by obstruction, and in 44 (13 women, 31 men; range 31-87 years; mean age, of 71 years) of these 48 patients (91%) obstruction was caused by colorectal cancer. MDCTC correctly located all the tumors and successfully revealed all noncancer causes of colon distention. The overall accuracy for T, N and M staging was 91,5%, 72,7% and 90%, respectively. Three (6.8%) synchronous colorectal cancers were correctly revealed by MDCTC. CONCLUSION: MDCTC is a technically feasible and noninvasive method applied in cases of acute and subacute bowel obstruction, with a high accuracy in colon evaluation and in colorectal cancer staging, which allows the planning of the optimal surgical procedure

Use of modified multidetector CT colonography for the evaluation of acute and subacute colon obstruction caused by colorectal cancer

Kompjutorizirana tomografska kolonografija je minimalno invazivna dijagnostička metoda kojom se pregledava lumen debelog crijeva, kao i kolonoskopijom i irigografijom s dvostrukim kontrastom, ali istovremeno i stijenka debelog crijeva, tkivo uz stijenku s limfnim čvorovima, kao i drugi organi u trbuhu. U slučajevima akutne i subakutne opstrukcije debelog crijeva, kao korisne dijagnostičke metode navode se nativna snimka trbuha, irigografija, standardni CT trbuha i kolonoskopija. O mogućoj primjeni CT kolonografije u takvih bolesnika nema podataka u dostupnoj literaturi. CILJ: U prospektivnom ispitivanju i uz korištenje modificiranog protokola ocijeniti tehničku izvedivost multidetektorske kompjutorizirane tomografske kolonografije (MDCTC) u bolesnika sa sumnjom na akutnu ili subakutnu opstrukciju debelog crijeva uzrokovanu kolorektalnim karcinomom, te pri tome ocijeniti točnost metode u utvrđivanju postojanja, lokalizacije, veličine i proširenosti karcinoma, kao i prikaza debelog crijeva proksimalno i distalno od opstrukcije. METODE: Istraživanje je odobrilo Etičko povjerenstvo KBC Split, a bolesnici su potpisali informirani pristanak. U 50 bolesnika (14 žena, 36 muškaraca; raspon 31-93 godine; medijan 70 godina) u kojih se na osnovi kliničkih simptoma i nativne snimke trbuha sumnjalo na opstrukciju debelog crijeva uzrokovanu karcinomom učinjena je kolonografija na 16-slojnom CT uređaju. Debelo crijevo je čišćeno klizmama mlake vode. Nakon nativnog skeniranja trbuha u pronaciji, bolesnicima je intravenski dano 100-140 ml kontrasta, a skeniranje u supinaciji je učinjeno u portalnoj, venskoj fazi. Parametri CT protokola bili su: kolimacija 16 x 0,75 mm; 120 kV; 100-300 mA; vrijeme rotacije 0,5 s; rekonstrukcijska debljina sloja 1 mm s pomakom od 0,7 mm. Kirurški i patohistološki nalaz su služili kao zlatni standard. Točnost metode je određivana za T (tumorska invazija crijevne stjenke), N (zahvaćenost limfnih čvorova) i M (metastaze) proširenost. REZULTATI: U 48/50 bolesnika distenzija crijeva je bila uzrokovana opstrukcijom, od kojih je u 44 (91%) uzrok opstrukcije bio kolorektalni karcinom (13 žena, 31 muškarac; raspon 31-87 godina; medijan 71 godina). MDCTC je točno locirala sve karcinome i uspješno otkrila sve netumorske uzroke distenzije crijeva. Ukupna točnost za T proširenost je bila 91,5%, za N 72,7% i za M 90%. Točno su prikazana i tri (6,8%) sinkrona tumora. ZAKLJUČAK: MDCTC je tehnički izvediva i neinvazivna dijagnostička metoda u slučajevima akutne i subakutne opstrukcije debelog crijeva, s visokom točnošću pri evaluaciji debelog crijeva i procjeni proširenosti kolorektalnog karcinoma, što omogućava planiranje optimalnog kirurškog postupka.Computed tomographic colonography is a minimally invasive technique that provides information about the lumen of the colon, like a colonoscopy or double-contrast barium enema, but also about the colon wall, pericolic tissue, lymph nodes, and other extracolonic pathology. In cases of acute and subacute colon obstruction, a plain abdominal radiograph, a contrast enema, a standard abdominal CT, and a colonoscopy have been reported as valuable diagnostic tools. The role of CT colonography in cases of acute or subacute colonic obstruction has yet to be evaluated. PURPOSE: The purpose of the study was to prospectively evaluate the technical feasibility of the multidetector computed tomographic colonography (MDCTC) in patients in whom acute or subacute colon obstruction caused by colorectal cancer was suspected, using a modified procedure protocol, and also to establish the accuracy of MDCTC regarding the presence, location, size, and staging of the cancer, as well as colon evaluation proximal and distal to obstruction. METHODS: This prospective study was approved by Ethic Commitee of University Hospital Center Split; all participants gave written informed consent. On the basis of the clinical symptoms and a plain x-ray film of the abdomen, a 16 row CT colonography was performed in 50 patients (14 women, 36 men; range, 31-93 years; mean age, 70 years) if acute or subacute bowel obstruction was suspected. The colon was cleansed with lukewarm water enemas. Scans were performed in precontrast prone-position and in supine position after the administration of 100-140 ml of contrast agent intravenously in a single portal venous phase. Computed tomography parameters were: slice collimation, 16 x 0.75 mm; kV, 120; mAs, 100-250; rotation time of 0.5 s; reconstructed thickness 1.0 mm at intervals of 0.7 mm. The surgical and pathologic findings served as standards of reference. The accuracy of the method was assessed for T (tumor invasion of colon wall), N (nodal involvement), and M (metastases) staging. RESULTS: In 48 of 50 patients, colon distention was caused by obstruction, and in 44 (13 women, 31 men; range 31-87 years; mean age, of 71 years) of these 48 patients (91%) obstruction was caused by colorectal cancer. MDCTC correctly located all the tumors and successfully revealed all noncancer causes of colon distention. The overall accuracy for T, N and M staging was 91,5%, 72,7% and 90%, respectively. Three (6.8%) synchronous colorectal cancers were correctly revealed by MDCTC. CONCLUSION: MDCTC is a technically feasible and noninvasive method applied in cases of acute and subacute bowel obstruction, with a high accuracy in colon evaluation and in colorectal cancer staging, which allows the planning of the optimal surgical procedure

Prognostic value of IMP3 immunohistochemical expression in triple negative breast cancer

Triple negative breast cancer (TNBC) account for 12% to 17% of all breast cancers. It is a heterogeneous group of tumors associated with aggressive clinical course. Insulin-like growth factor II mRNA binding protein 3 (IMP3) belongs to a family of insulin-like growth factor type II (IGF2), which plays a key role in the transmission and stabilization of mRNA, cell growth, and migration during embryogenesis. Increased expression of IMP3 is associated with aggressive behavior of different tumor types, advanced clinical stage, distant metastasis, and shorter overall survival (OS). The study included 118 patients with breast carcinoma diagnosed as TNBC and immunohistochemical staining for estrogen receptors (ER), progesterone receptors (PR), epidermal growth factor receptor 2 (HER2/neu), Ki-67, and IMP3 was performed. Correlations between categorical variables were studied using the chi-square and the Mann–Whitney U test. For survival analysis, the Kaplan–Meier method, log-rank test and the Cox proportional hazard regression model were used. Positive expression of IMP3 protein was present in 35.6% of TNBC. The presence of basal morphology was observed in 46.6% of TNBC. Positive IMP3 expression was connected with larger size of tumor, higher clinical stage, and basal morphology (P=.039, P=.034, P<.001). Disease-free survival and OS were significantly shorter in IMP3 positive TNBC. According to results of our study IMP3 expression can be used as negative prognostic factor for triple negative breast carcinomas. Targeting IMP3 molecule could be an effective approach to the management of a triple negative breast cancer with new immunological therapies, which does not yet exist for this group of tumors