Spontaneous rupture of adrenal haemangioma mimicking abdominal aortic aneurysm rupture

Serious bleeding from a ruptured adrenal mass limits preoperative diagnostics and can necessitate urgent laparotomy to control blood loss. A 45-year old man underwent an emergency laparotomy due to severe retroperitoneal haemorrhage causing hypovolaemia. Detailed retroperitoneal dissection after splenectomy and clamping of the abdominal aorta revealed bleeding from a ruptured haemangioma of the left adrenal gland. Following a left adrenalectomy, the patient returned to a stable haemodynamic state. Adrenal haemangiomas are rare, but may cause spontaneous life-threatening haemorrhage

Pancreas sparing duodenectomy as an emergency procedure

<p>Abstract</p> <p>Background</p> <p>The operative techniques to close extensive wounds to the duodenum are well described. However, postoperative morbidity is common and includes suture line leak and the formation of fistulae. The aim of this case series is to present pancreas sparing duodenectomy as a safe and viable alternative procedure in the emergency milieu.</p> <p>Methods</p> <p>Five patients underwent emergency pancreas sparing duodenal excisions. Re-implantation of the papilla of Vater or the papilla with a surrounding mucosal patch was performed in two patients. In one, the procedure was further supplemented with a duodenocholangiostomy, stapled pyloric exclusion and enterogastrostomy to defunction the pylorus. In another three patients, distal duodenal excisions were done.</p> <p>Results</p> <p>In four patients, an uneventful recovery was made. One patient died following a myocardial infarction. The surgery lasted meanly 160 minutes with average blood loss of approximately 500 milliliters. The mean hospital stay was 12 days. Enteral nutrition was introduced within the 20 hours after the surgery. Long term follow-up of all surviving patients confirmed a good outcome and normal nutritional status.</p> <p>Conclusion</p> <p>Based on the presented series of patients, we suggest that pancreas-sparing duodenectomy can be considered in selected patients with laceration of the duodenum deemed unsuitable for surgical reconstruction.</p

The effect of acetylsalicylic acid dosed at bedtime on the anti-aggregation effect in patients with coronary heart disease and arterial hypertension: A randomized, controlled trial

Background: Acetylsalicylic acid (ASA) is one of the basic drugs used in the secondary prevention ofcoronary artery disease (CAD), and in most cases it is taken in the morning in one daily dose. It is suggestedthat the morning peak of platelet aggregation is responsible for the occurrence of myocardial infarctionsand strokes. Hence, the aim of the study was to observe the effect of ASA (morning vs. evening)dosing on the anti-aggregative effect of platelets in patients with CAD and arterial hypertension (AH).Methods: The study involved 175 patients with CAD and AH. Patients were randomly assigned toone of two study groups, taking ASA in the morning or in the evening. The patients had two visits, onebaseline and another after 3 months from changing the time of ASA dosage. The platelet aggregationwas determined using the VerifyNow analyzer.Results: In the ASA evening group, a significant reduction in platelet aggregation was obtained. Inthe ASA morning group, a significant difference in response to ASA was observed, depending on sex. Inmen, the reactivity of platelets decreased, but in women it increased.Conclusions: In the group of patients with CAD and AH, bedtime ASA dosing is associated witha significant reduction in platelet aggregation. The response to ASA may differ between sexes. The benefitgained by changing the drug administration from the morning to the evening is greater in women

MTARC1 and HSD17B13 Variants Have Protective Effects on Non-Alcoholic Fatty Liver Disease in Patients Undergoing Bariatric Surgery

The severity of hepatic steatosis is modulated by genetic variants, such as patatin-like phospholipase domain containing 3 (PNPLA3) rs738409, transmembrane 6 superfamily member 2 (TM6SF2) rs58542926, and membrane-bound O-acyltransferase domain containing 7 (MBOAT7) rs641738. Recently, mitochondrial amidoxime reducing component 1 (MTARC1) rs2642438 and hydroxysteroid 17-beta dehydrogenase 13 (HSD17B13) rs72613567 polymorphisms were shown to have protective effects on liver diseases. Here, we evaluate these variants in patients undergoing bariatric surgery. A total of 165 patients who underwent laparoscopic sleeve gastrectomy and intraoperative liver biopsies and 314 controls were prospectively recruited. Genotyping was performed using TaqMan assays. Overall, 70.3% of operated patients presented with hepatic steatosis. NASH (non-alcoholic steatohepatitis) was detected in 28.5% of patients; none had cirrhosis. The increment of liver fibrosis stage was associated with decreasing frequency of the MTARC1 minor allele (p = 0.03). In multivariate analysis MTARC1 was an independent protective factor against fibrosis ≥ 1b (OR = 0.52, p = 0.03) and ≥1c (OR = 0.51, p = 0.04). The PNPLA3 risk allele was associated with increased hepatic steatosis, fibrosis, and NASH (OR = 2.22, p = 0.04). The HSD17B13 polymorphism was protective against liver injury as reflected by lower AST (p = 0.04) and ALT (p = 0.03) activities. The TM6SF2 polymorphism was associated with increased ALT (p = 0.04). In conclusion, hepatic steatosis is common among patients scheduled for bariatric surgery, but the MTARC1 and HSD17B13 polymorphisms lower liver injury in these individuals

Uncontrolled postoperative bleeding in woman with pemphigus and undiagnosed acquired haemophilia A

Nabyta hemofi lia A (AHA) jest skazą krwotoczną wywołaną przez nagłe pojawienie się przeciwciał przeciw czynnikowi krzepnięcia VIII u osoby z negatywnym wywiadem w kierunku zaburzeń krzepnięcia krwi. W obrazie klinicznym choroby dominują wynaczynienia krwi, które prowadzą do zgonu nawet w 22% przypadków. Pacjentka w wieku 55 lat z rozpoznaniem pęcherzycy liściastej była hospitalizowana z powodu nasilenia zmian skórnych, pod postacią sączących się nadżerekz tendencją do erytodermii. W trakcie hospitalizacji obserwowano znaczne pogorszenie stanu ogólnego, narastanie niedokrwistości, silne bóle brzucha oraz wydłużenie czasu częściowej tromboplastynypo aktywacji. W badaniu tomografi i komputerowej stwierdzono obecność rozległych krwiaków w obrębie jamy otrzewnej oraz przestrzeni zaotrzewnowej. Chorej przetoczono świeżo mrożoneosocze (FFP) i poddano ją zabiegowi chirurgicznej ewakuacji krwiaków. Dodatkowo w trakcie zabiegu usunięto torbiel jajnika oraz śledzionę z powodu krwawienia w lewej okolicy podprzeponowej. W okresie pooperacyjnym obserwowano uporczywe krwawienie z rany pooperacyjnej mimo codziennych transfuzji FFP. Podejrzenie nabytej hemofi lii A potwierdzono, oznaczając aktywnośćczynnika VIII (20 jm./dl) i stwierdzając obecność inhibitora czynnika VIII w mianie 1,8 jB./ml. Zastosowano rekombinowany aktywny czynnik VII (rFVIIa) i rozpoczęto leczenie immunosupresyjne. Podczas zmniejszania dawki rFVIIa obserwowano nawrót krwawienia. Chora otrzymywała koncentraty omijające inhibitor łącznie przez 39 dni. W trakcie terapii rozpoznano zewnętrzną przetokę moczową oraz obserwowano przetrwałe krwiaki o podobnej lokalizacji i rozmiarze, jakwyjściowo. Po 6 tygodniach leczenia immunosupresyjnego wyeliminowano inhibitor, a chorą poddano operacjom chirurgicznym, których celem było usunięcie zhemolizowanych krwiaków orazrekonstrukcja pęcherza moczowego. W okresie okołooperacyjnym nie obserwowano skłonności do nadmiernych krwawień. Podsumowując, u chorego z obrazem niewyjaśnionej skazy krwotocznej nie należy przeprowadzać żadnych procedur inwazyjnych. W przypadku rozpoznania AHA zabiegi chirurgiczne, o ile to możliwe, należy odłożyć do czasu wyeliminowania inhibitoraAcquired haemophilia A (AHA) is caused by sudden appearance of autoantibodies against factor VIII (FVIII). The disease presents with severe or life-threatening haemorrhage in patients with nopersonal history of bleeding. The mortality in AHA patients is estimated at even 22%. A 55-year-old female was admitted to the local hospital due to exacerbation of pemphigus foliaceus. After admission she presented rapid deterioration of general condition. Laboratory tests revealed rapidly increasing anaemia and prolongation of activated partial thrombin time (APTT). Truncal CT-scan showed extensive haematomas localized intra-abdominally as well as within left iliac and obturatormuscles. The patient received fresh frozen plasma (FFP) followed by surgical intervention. Additionally, an ovarian cyst was removed. Due to unlocalized intraoperative bleeding from leftsubphrenic area a formal splenectomy was performed. The uncontrolled bleeding from postoperative wound was observed after surgery. Daily FFP transfusions did not reduce blood loss and theAPTT was not corrected. Detailed hematological tests revealed decreased factor VIII activity to 20 IU/dl and the presence of antibodies against factor VIII in the titer of 1.8 BU/ml. The AHAwas diagnosed. To control the bleeding recombinant FVIIa was used successfully. Synchronously, the immunosupressive treatment was administered. Due to recurrent bleeding the treatment withby-passing agents was continued for 39 days. During therapy urinary cutaneous fi stula was observed. In the control CT-scan a persistent intraabdominal and intramuscular haematomas were presented (localized similarly as before the treatment). Six weeks of immunosupressive therapy eradicated the FVIII inhibitor. After eradication of FVIII inhibitor a surgical bloodless removal of hematomas and open bladder reconstruction were performed. The additional transfusions of red blood cells and fresh frozen plasma were not necessary. In conclusion, in patients presenting spontaneous bleeding to muscles and/or retroperitoneal space we suggest the delaying of surgical intervention until the detailed coagulation tests have been performed. Ideally, patients diagnosed with AHA should not undergo surgical interventions