Significance of ultrasonography of the terminal ileum in moderate Crohn's disease

Background/aim: Crohn's disease (CD) is a chronic granulomatous inflammatory disease of unknown etiology, involving any part of the gastrointestinal tract, and frequently followed by extra intestinal manifestations. The use of ultrasonography plays a significant role in diagnosing this disease, as well as in monitoring the effects of the therapy. The aim of this study was to assess the use of ultrasonographic diagnostics in the patients with moderate serious and the mild form of CD. Methods. The study involved 30 patients both sexes with CD of moderate form determined using the standard diagnostics, according to the Crohn's Disease Activity Index - CDAI ranging from 220−400. The patients were divided into two groups with CDAI > 320 (Ia), and CDAI between 220 and 320 (Ib), respectively. The Control group was made of 19 patients with the mildly active stage of the disease and the CDAI values in the range from 100−220. The patients were submitted to an ultrasonographic examination of the terminal ileum affected with CD in order to determine the length of the affected segment of intestine, the thickness of the wall, the changes of the structure of the wall, the changes of the surrounding mesenterium with the enlarged lymph nodes. CD complications, abscesses, and enteroenteral fistulas were investigated, too. Results. The comparison of the ultrasonographic findings of the three groups revealed that more serious clinical laboratory image of CD significantly correlated with the higher length of the affected segment (p < 0.001), higher thickness of the wall (p < 0.001), the higher number and the larger lymph nodes of the mesenterium (p < 0.001). Only the most serious patients were found to have abscess of the ileocecal area (Ia − 40%). There was no difference found between the groups regarding the occurrence of enteroenteral fistulas. Conclusion. Considering the obtained results and data from the literature, it could be concluded that an ultrasonographic examination of the ileocecal area plays an important role in the diagnostic procedure in the management of a patient with CD. Of particular significance is the possibility to use this examination in monitoring the effects of the therapy in patients with CD

Significance of ligature of early detected insufficient perforated lower extremities veins as a cause of the varicous syndrome

Background/Aim. Perforated veins (PV) connect surface and deep veins net. Insufficient perforated veins (IPV) are considered to be one of the causes of the venous stasis syndrome. Ligating IPV removes increased pressure transmission from the deep veins to the surface veins system and prevents the occurrence of varicosis, as well. The aim of the study was to determine surface veins diameters prior and after the surgical operation on IPV, and to confirm good results of the treatment with this method in removing causes of the surface veins varicosis. Methods. The study included 30 patients of both sexes (25 males and 5 females), mean age 30.10 ± 10.24 years. The patients were classified in accordance with CEAP (clinical severity, etiology or cause, anatomy, pathophysiology) classification as those with the initial varicous syndrome based on IPV. Any of the patients were submitted to color Doppler echophlebography. In case of diameter ≥ 3.5 mm PV were marked as IPV. All of the IPV were divided into two groups, the group I being with ostium in the stem of Vena Saphena Magna (VSM) or Vena Saphena Parva (VSP), while the group II was with ostium in the venous tributors. VSM and VSP diameters at the level of IPV ostium, bellow and above (1 cm) the ostium were measured prior to IPV ligature, and 30 days after the surgical intervention. Results. Comparing the results the highest ligature effects were shown at the level of IPV ostium in the stem of VSM and VSP of both groups (p < 0.0001) with the highest diameter reduction. There was a smaller reduction of diameter in the proximal and distal segment of ostium in the group I, while there was no diameter change in the distal segment of ostium in the group II. Conclusion. Saphenous stem diameter reduction at the level of ostium, proximally and distally of the confluence, confirms the significance of IPV ligature before pronounced varicosis appears

Visceral hybrid reconstruction of thoracoabdominal aortic aneurysm after open repair of type a aortic dissection by the Bentall procedure with the elephant trunk technique: A case report

Introduction. Reconstruction of chronic type B dissection and thoracoabdominal aortic aneurysm (TAAA) remaining after the emergency reconstruction of the ascending thoracic aorta and aortic arch for acute type A dissection represents one of the major surgical challenges. Complications of chronic type B dissection are aneurysmal formation and rupture of an aortic aneurysm with a high mortality rate. We presented a case of visceral hybrid reconstruction of TAAA secondary to chronic dissection type B after the Bentall procedure with the elephant trunk technique due to acute type A aortic dissection in a high-risk patient. Case report. A 62 year-old woman was admitted to our institution for reconstruction of Crawford type I TAAA secondary to chronic dissection. The patient had had an acute type A aortic dissection 3 years before and undergone reconstruction by the Bentall procedure with the elephant trunk technique with valve replacement. On admission the patient had coronary artery disease (myocardial infarction, two times in the past 3 years), congestive heart disease with ejection fraction of 25% and chronic obstructive pulmonary disease. On computed tomography (CT) of the aorta TAAA was revealed with a maximum diameter of 93 mm in the descending thoracic aorta secondary to chronic dissection. All the visceral arteries originated from the true lumen with exception of the celiac artery (CA), and the end of chronic dissection was below the origin of the superior mesenteric artery (SMA). The patient was operated on using surgical visceral reconstruction of the SMA, CA and the right renal artery (RRA) as the first procedure. Postoperative course was without complications. Endovascular TAAA reconstruction was performed as the second procedure one month later, when the elephant trunk was used as the proximal landing zone for the endograft, and distal landing zone was the level of origin of the RRA. Postoperatively, the patient had no neurological deficit and renal, liver function and functions of the other abdominal organs were normal. Control CT after 6 months showed full exclusion of the aneurysm from the systemic circulation without endoleak and good flow through visceral anastomosis. Conclusion. In patients with comorbidities, like in the presented case, visceral hybrid reconstruction of chronic dissection type B with TAAA could be the treatment of choice

Posterior reversible encephalopathy syndrome: A case report

Posterior reversible encephalopathy syndrome (PRES) is characterized by the following symptoms: seizures, impaired consciousness and/or vision, vomiting, nausea, and focal neurological signs. Diagnostic imaging includes examination by magnetic resonance (MR) and computed tomography (CT), where brain edema is visualized bi-laterally and symmetrically, predominantly posteriorly, parietally, and occipitally. Case report. We presented a 73-year-old patient with the years-long medical history of hipertension and renal insufficiency, who developed PRES with the symptomatology of the rear cranium. CT and MR verified changes in the white matter involving all lobes on both sides of the brain. After a two-week treatment (antihypertensive, hypolipemic and rehydration therapy) clinical improvement with no complications occurred, with complete resolution of changes in the white matter observed on CT and MR. Conclusion. PRES is a reversible syndrome in which the symptoms withdraw after several days to several weeks if early diagnosis is made and appropriate treatment started without delay

Successful treatment with cladribine of Erdheim-Chester disease with orbital and central nervous system involvement developing after treatment of langerhans cell histiocytosis

Introduction. Erdheim-Chester disease (ECD) is a rare, systemic form of non-Langerhans cell histiocytosis of the juvenile xantho-granuloma family with characteristic bilateral symmetrical long bone osteosclerosis, associated with xanthogranulomatous extras-keletal organ involvement. In ECD, central nervous system (CNS) and orbital lesions are frequent, and more than half of ECD patients carry the V600E mutation of the proto-oncogene BRAF. The synchronous or metachronous development of ECD and Langerhans cell histiocytosis (LCH) in the same patients is rare, and the possible connection between them is still obscure. Cladribine is a purine substrate analogue that is toxic to lymphocytes and monocytes with good hematoencephalic penetration. Case report. We presented a 23-year-old man successfully treated with cladribine due to BRAF V600E-mutation-negative ECD with bilateral orbital and CNS involvement. ECD developed metachronously, 6 years after chemotherapy for multisystem LCH with complete disease remission and remaining central diabetes insipidus. During ECD treatment, the patient received 5 single-agent chemotherapy courses of cladribine (5 mg/m2 for 5 consecutive days every 4 weeks), with a reduction in dose to 4 mg/m2 in a fifth course, delayed due to severe neutropenia and thoracic dermatomal herpes zoster infection following the fourth course. Radiologic signs of systemic and CNS disease started to resolve 3 months after the end of chemotherapy, and CNS lesions completely resolved within 2 years after the treatment. After 12-year follow-up, there was no recurrence or appearance of new systemic or CNS xanthogranu-lomatous lesions or second malignancies. Conclusion. In accordance with our findings and recommendations provided by other authors, cladribine can be considered an effective alternative treatment for ECD, especially with CNS involvement and BRAF V600E-mutation-negative status, when interferon-α as the first-line therapy fails