A 62-year-old male with a smoking history of 30 pack-years presented with a 1-year history of a periumbilical pulsating mass. He had been treated for hypertension for 2 years. Physical examination revealed a huge pulsating mass in the periumbilical abdomen. Femoral and popliteal arterial pulses were palpable. Computed tomography showed arterial dissection in the proximal segment of the superior mesenteric artery, a huge aneurysm (52×50 mm) with mural thrombus and two smaller aneurysms (20×20 mm) in the right ileocolic and ileal branches, along with atherosclerotic changes. Interposition using the great saphenous vein was performed after aneurysmal isolation and ligation of jejunal branches in the sac. Distal flow was reestablished by end-to-end and end-to-side anastomoses of the right ileocolic and ileal branches, respectively. No complications were observed at 1-year follow-up.
Abdomen ; Aneurysm* ; Aortic Aneurysm, Abdominal* ; Follow-Up Studies ; Humans ; Hypertension ; Ligation ; Male ; Mesenteric Artery, Superior* ; Middle Aged ; Physical Examination ; Saphenous Vein ; Smoke ; Smoking ; Thrombosis

Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation. PTLD is the disorder arising from the combined effects of Epstein-Barr virus associated lymphoproliferation with the disruption of the normal immune control of cytotoxic T cells. The only effective treatment of PTLD is often the reduction or elimination of intense immunosuppressive therapy. But we presented here a case of severe acute rejection developed in orthotopic liver transplantation patient after discontinuing the immunosuppression. A 58 year-old male had a liver transplantation for hepatitis B viurs-associated liver cirrhosis and taking cyclosporine postoperatively. He presented two months later with palpable neck mass and abdominal pain. CT scan showed multiple lymphadenopathies in retroperitoneum and more than 3 cm conglomerulated mass in left supraclavicular area. Percutaneous needle biopsy was done in which a this neck mass proved not to be a infectious mononucleosis-like disease or a definite lymphoma. In situ hybridization (ISH) for EBV encoded RNA was positive in a few cell. It suggested a possibility of PTLD, Even though the lymph node is totally necrotic in the given specimen. At that time, the immunosuppression was discontinued, and he was treated with iv gancyclovir. No chemothreapy was administered. Two weeks later, severe acute rejection (RAI=7) followed requiring treatment with steroid pulse. Tacrolimus had replaced cyclosporine and was maintained. Liver function test profile decreased gradually. Serial CT scan showed partial improvement of multiple necrotic lymphadenopathy in the retroperitoneum and supraclavicular area. Two months later, he presented with palpable neck mass and abdominal pain repeatedly. Another incisional biopsy was performed. The results showed B cell lymphoma with CD20 (+), CD3 (-), bcl6 (-), Ki-labelling index 80%, bcl (-), p53 (-). He received 2 courses of cyclophosphamide (600 mg/m2, on day 1 of each course) and prednison (2 mg/kg/day for 5 day). The first 2 courses were given in combination with 4 weekly doses of rituximab (375 mg/m2, i.v). After symptomatic improvement, he was discharged.
Abdominal Pain ; Biopsy ; Biopsy, Needle ; Cyclophosphamide ; Cyclosporine ; Ganciclovir ; Hepatitis B ; Herpesvirus 4, Human ; Humans ; Immunosuppression* ; In Situ Hybridization ; Liver Cirrhosis ; Liver Function Tests ; Liver Transplantation ; Lymph Nodes ; Lymphatic Diseases ; Lymphoma ; Lymphoma, B-Cell ; Lymphoproliferative Disorders* ; Male ; Middle Aged ; Neck ; Organ Transplantation ; RNA ; Rituximab ; T-Lymphocytes ; Tacrolimus ; Tomography, X-Ray Computed ; Transplants

PURPOSE: The aim of this study was to review our experience with splenic abscesses, with respect to the relevant aspects of splenic abscesses and treatment outcomes. MATERIALS AND METHODS: We reviewed the cases of 18 patients who had splenic abscesses and who were treated at our hospital from November 1993 to December 2008. RESULTS: The most common symptom at presentation was abdominal pain in 12 patients (66.7%). The median duration from symptom onset until establishment of a diagnosis was 22 days. Streptococcus viridians was the most common pathogen (27.8%), follow by Klebsiella pneumoniae (22.2%). The mortality rate during the inpatient period and the previous 90 days was 16.6%. Three of four patients with Klebsiella pneumoniae showed a single abscess pocket. Four patients (22.2%) underwent percutaneous drainage, eight (44.5%) recieved antibiotic treatment only and six (33.3%) underwent splenectomy. CONCLUSION: There is no gold standard for treating splenic abscesses. Treatment should be customized for each patient.
Abscess/diagnosis/drug therapy/microbiology/surgery/*therapy ; Adult ; Aged ; Anti-Bacterial Agents/therapeutic use ; Drainage ; Female ; Humans ; Klebsiella Infections/diagnosis/drug therapy/microbiology/surgery ; Klebsiella pneumoniae ; Male ; Middle Aged ; Splenectomy ; Splenic Diseases/diagnosis/drug therapy/*microbiology/surgery ; Streptococcal Infections/diagnosis/drug therapy/microbiology/surgery ; Treatment Outcome ; Viridans Streptococci ; Young Adult

PURPOSE: A splenic abscess is a rare disease, but appears to be increasing in frequency. The key to successful treatment is early diagnosis, effective antibiotics treatment and surgical management when needed. This study was intended to clarify the clinico-pathological and radiological findings of splenic abscesses from their therapeutic aspects. METHODS: Between Jan. 1993 and Dec. 2003, the outcomes of 8 splenic abscess patients were retrospectively analyzed. RESULTS: The male to female ratio was 6: 2, with a mean age of 57 years, ranging from 34 to 70 years. Predisposing conditions were identified in 7, including diabetes mellitus, steroid medication, chronic alcoholism, infective endocarditis and lymphoma. As chief complaints, fever/chills was present in 2, left upper quadrant pain/tenderness in 4, diffuse abdominal pain in 1 and dyspnea in 1, with leukocytosis found in 6 (75%). Ultrasonography or computed tomography detected left pleural effusion, splenomegaly and splenic abscess in 7 (88%). The solitary to multiple ratio was 2: 6. An emergency laparotomy for peritonitis detected a solitary abscess rupture in 1. The original site of infection was detected in 5, including endocarditis, dental abscess, urinary tract infection and pancreatitis in 2. Blood cultures were positive in 3 (43%), with Escherichia coli in 1 and Streptococcus viridans in 2. 3 (75%) of 4 specimens had positive culture results, including Pseudomonas, Streptoccus viridans and Enterococcus. 1 (25%) had pathogens identical to bacteria isolated form the blood culture. 1 was identified as mixed infection, with actinomycosis. A splenectomy was performed in 5, including 2 with a distal pancreatectomy, intraoperative fine needle aspiration in a lymphoma and endoscope-guided aspiration in a gastrosplenic fistula. One lymphoma patient, with multiple abscesses, died of aspiration pneumonia during chemotherapy. CONCLUSION: A splenic abscess is rare, and failure of early diagnose and institution of treatment is fatal. Although patients have various underlying diseases, a splenic abscess can develop arising from a dental abscess in a healthy man. Percutaneous drainage may not be suitable for multiple or hilar locations; therefore, a splenectomy, with appropriate antibiotics, is the definitive treatment. A less-invasive treatment modality can be considered, taking into account the patient's clinical situation from an immunological aspect for preservation of the spleen.
Abdominal Pain ; Abscess* ; Actinomycosis ; Alcoholism ; Anti-Bacterial Agents ; Bacteria ; Biopsy, Fine-Needle ; Coinfection ; Diabetes Mellitus ; Drainage ; Drug Therapy ; Dyspnea ; Early Diagnosis ; Emergencies ; Endocarditis ; Enterococcus ; Escherichia coli ; Female ; Fistula ; Humans ; Laparotomy ; Leukocytosis ; Lymphoma ; Male ; Pancreatectomy ; Pancreatitis ; Peritonitis ; Pleural Effusion ; Pneumonia, Aspiration ; Pseudomonas ; Rare Diseases ; Retrospective Studies ; Rupture ; Schools, Medical* ; Spleen ; Splenectomy ; Splenic Diseases ; Splenomegaly ; Ultrasonography ; Urinary Tract Infections ; Viridans Streptococci

A 34-year-old man was referred to our hospital with gastric polypoid lesions and biopsy-confirmed neuroendocrine tumor (NET). Computed tomography (CT) revealed a 3×3.5×8-cm retroperitoneal mass behind the pancreas, with multiple hepatic metastases. His serum gastrin level was elevated to 1,396 pg/mL. We performed a wedge resection of the stomach, a right hemi-hepatectomy, and a retroperitoneal mass excision. After careful review of the clinical, radiological, histopathological, and immunohistochemical findings, peripancreatic gastrinoma, and synchronous gastric NET were ultimately diagnosed. We reviewed a CT scan that had been performed 6 years previously after surgery for a duodenal perforation. There was no evidence of gastric or hepatic lesions, but the retroperitoneal mass was present at the same site. Had gastrinoma been detected earlier, our patient could have been cured using less invasive treatment. This case demonstrates how important it is to consider Zollinger-Ellison syndrome in patients with a recurrent or aggressive ulcer.
Adult ; Gastrinoma* ; Gastrins ; Humans ; Lymph Nodes* ; Neoplasm Metastasis ; Neuroendocrine Tumors* ; Pancreas ; Stomach ; Tomography, X-Ray Computed ; Ulcer ; Zollinger-Ellison Syndrome

The aim of the present study was to determine whether serotonergic drugs could reverse lipopolysaccharide (LPS) -induced anorexia in rats. LPS (500microgram/kg body weight) and all serotonergic drugs, except for 8-OH-DPAT (subcutaneous), were injected intraperitoneally into Sprague-Dawley rats. Without the LPS injection, 8-OH-DPAT (1A agonist), metergoline (1/2 antagonist), and mianserin (2A/2C antagonist) exerted no effects on food intake at any of the doses tested, but ketanserin (2A antagonist) caused an increase of food intake at 4 mg/kg. RS-102221 (2C antagonist) reduced food intake at 2 and 4 mg/kg. LPS reduced food intake 1 hour after injection, and food intake remained low until the end of measurement period (24 hours) (p< 0.05). Pretreatment of rats with 8-OH-DPAT partially recovered of cumulative food intake at all measured times (2, 4, 6, 8, and 24 hours after LPS injection). Pretreatment with metergoline resulted in a partial recovery of cumulative food intake at 2, 4, 6, and 8 hours, but not at 24 hours. Ketanserin caused partial recovery at 2 and 4 hours only. Mianserin and RS-102221 had no effects on LPS-reduced food intake. A variety of serotonergic drugs ameliorated anorexic symptoms, which suggesting that the serotonin system plays a role in LPS-induced anorexia.
8-Hydroxy-2-(di-n-propylamino)tetralin ; Animals ; Anorexia* ; Diethylpropion ; Eating ; Ketanserin ; Metergoline ; Mianserin ; Rats* ; Rats, Sprague-Dawley ; Serotonin ; Serotonin Agents*

We report a 72-year-old male with known myelodysplastic syndrome who presented to the emergency department with a 7-day history of fever and dyspnea. Echocardiography revealed a round echogenic mass 13×16 mm in size attached to the atrial side of the tricuspid valve. Considering the high risk of infective endocarditis in the patient with a low absolute neutrophil count (130/mm3), emergency surgery was performed. Intraoperatively, a single gelatinous neoplasm was resected, and subsequent reconstruction of the involved leaflet was accomplished using autologous pericardium. The tumor was pathologically confirmed as papillary fibroelastoma with no evidence of infective endocarditis. Papillary fibroelastoma is a rare cardiac neoplasm that occurs in either the mitral or aortic valves. Interestingly, a few cases of tricuspid valve papillary fibroelastoma have been reported so far. Similar echocardiographic findings between vegetation and tricuspid valve neoplasm make it difficult to distinguish these two disease entities.
Aged ; Aortic Valve ; Dyspnea ; Echocardiography ; Emergencies ; Emergency Service, Hospital ; Endocarditis ; Fever ; Gelatin ; Heart Neoplasms ; Humans ; Male ; Myelodysplastic Syndromes ; Neutropenia* ; Neutrophils ; Pericardium ; Tricuspid Valve

BACKGROUND/AIMS: Anti-viral therapy using hepatitis B immune globulin and lamivudine could not prevent HBV recurrence after liver transplantation (LT) completely. Adefovir dipivoxil is a acyclic nucleotide phosphate analogue and known to have potent anti-HBV effect. In this study, we analyzed the therapeutic effect of adefovir for recurrent or de novo HBV infection after LT. METHODS: From December 2002 to October 2004, adefovir was administered in 12 post-LT patients of HBV infection (11 recurrent and 1 de novo infection). In these patients, lamivudine and other combined therapies were used before the introduction of adefovir. Thereafter, adefovir combined with lamivudine was administered to all patients. RESULTS: The duration of adefovir administration was 5.5-18 (median, 15.5) months. The median values of serum AST and ALT levels were significantly reduced from 86+/-80 IU/L and 140+/-103 IU/L, respectively before the adefovir administration to 42+/-19 IU/L and 38+/-33 IU/L after 2 months of administration. This trend of improved liver function persisted throughout the follow-up period. HBeAg seroconversion was achieved in 4 of 10 patients (40%) and HBsAg seroconversion was observed in 1 of 10 patients (10%). HBV DNA levels have decreased to undetectable levels by hybridization assay in 6 of 7 patients within the first 2 months of therapy. Nephrotoxicity and hypophosphatemia were not found in all of these patients. CONCLUSIONS: Based on this preliminary result, adefovir dipivoxil seems to be an effective and safe antiviral agent leading to viral inhibition and clinical improvement in post-LT patients with recurrent or de novo HBV infection.
Adenine/administration & dosage/*analogs & derivatives ; Adult ; Antiviral Agents/*administration & dosage ; Drug Therapy, Combination ; English Abstract ; Female ; Hepatitis B, Chronic/*drug therapy ; Humans ; Lamivudine/administration & dosage ; *Liver Transplantation ; Male ; Middle Aged ; Phosphonic Acids/*administration & dosage ; Recurrence ; Reverse Transcriptase Inhibitors/administration & dosage

No abstract available.
Antineoplastic Agents/*administration & dosage ; Carcinoma, Hepatocellular/pathology/*therapy ; Chemoembolization, Therapeutic ; Doxorubicin/*administration & dosage ; *Drug-Eluting Stents ; Humans ; Liver Neoplasms/pathology/*therapy ; *Liver Transplantation ; Male ; Middle Aged ; Tomography, X-Ray Computed

PURPOSE: Despite refinements in the surgical techniques for adult-to-adult living donor liver transplantation (ALDLT), biliary complications still remain the Achilles' heel of ALDLT. Moreover, there is no consensus for the ideal technique of biliary reconstruction to reduce the rate of complications to an acceptable range. We strove to collate the available data of the current surgical techniques for biliary reconstruction in ALDLT in Korea. METHODS: A questionnaire concerning the surgical techniques for biliary reconstruction was sent to 9 surgeons who performed biliary anastomosis in the major LDLT centers of Korea (the response rate was 100%). RESULTS: MR cholangiography (n=7) and/or intra-operative cholangiography (n=5) were routinely performed to evaluate the donor biliary anatomy. All the participants (n=9) preferred duct-to-duct anastomosis to hepatico-jejunostomy. Anastomosis was usually made on the whole layer (n=7 epithelium, n=2) of recipient's common hepatic duct under loupe magnification (n=8); only one center reconstructed the anastomosis on the 2nd order hepatic duct under view of a surgical microscope. There were various techniques for biliary reconstruction as follows: suture material (absorbable: n=5, non-absorbable: n=4), suture method (continuous: n=4, interrupted: n=3, mixed: n=3) and the use of a biliary stent (routine: n=3, sometimes: n=5, rare: n=1). Ductoplasty was performed on the back table (n=7) for the cases with a very close distance (<5 mm) between the bile ducts' openings, but each duct was separately anastomosed to the recipients' bile duct (n=8) or a roux-en-Y limb (n=1) was done in cases with a distance more than 10 mm. CONCLUSION: In 9 LDLT centers of Koreas, duct-to-duct was preferred; however, there was no unique consensus, among the major centers, for the biliary reconstruction techniques that might reduce complications.
Bile ; Bile Ducts ; Cholangiography ; Consensus ; Epithelium ; Extremities ; Heel ; Hepatic Duct, Common ; Humans ; Korea ; Liver ; Liver Transplantation ; Living Donors ; Stents ; Sutures ; Tissue Donors ; Surveys and Questionnaires