In Memoríam

In hysterical abdominal distention the symptoms may so closely simulate those of obstruction of the bowel that needless laparotomy is carried out.CLUES THAT INDICATE HYSTERICAL DISTENTION RATHER THAN ORGANIC CAUSE ARE: (1) History of vomiting but without dehydration; (2) complaint of severe pain although temperature, pulse and the number of leukocytes in the blood all are normal; (3) normal tympanic quality of the abdomen; (4) distention out of proportion to the amount of gas observed in x-ray examination; (5) pronounced lordosis caused by thrusting the abdomen forward; and (6) remission of distention when the patient is under general anesthesia. It must be remembered, however, that even when there is strong suspicion of hysterical cause, distention may actually be due to obstruction. In the case herein reported, obstructive adhesion finally did occur after the patient had had numerous exploratory operations in which the viscera were observed to be normal.     

DIAGNOSIS OF INTESTINAL OBSTRUCTION IN THE NEWBORN,A Review of the Literature with a Report of Eight Additional Cases

Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made.In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth—a sign which may be helpful in diagnosis.Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal.The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance.     

The diagnosis of intestinal obstruction in the newborn; a review of the literature with a report of eight additional cases

Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made. In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth-a sign which may be helpful in diagnosis. Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal. The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance.     

EARLY DIAGNOSIS OF STRANGULATION OBSTRUCTION OF THE SMALL INTESTINE

Early recognition of strangulation obstruction of the small intestine is important in order that surgical relief may be undertaken before the bowel has been irreversibly damaged or the condition of the patient has so deteriorated as to make immediate operation unreasonably hazardous.In the presence of other symptoms, an operative scar, particularly on the lower abdomen, should alert the examining physician to the possibility of strangulation obstruction. (In a series of 100 cases, the greatest single cause of strangulation was adhesive bands subsequent to abdominal operation.)Other hallmarks of aid in diagnosis and in distinguishing early from advanced strangulation are discussed.X-ray evidence varies in accord with the rapidity of development and the stage of strangulation.Abdominal puncture may be utilized as a means of diagnosis with little risk.     

SURGICAL DECOMPRESSION OF THE BOWEL IN PERITONITIS

In some circumstances peritoneal infection causes distention and crowding of the bowel to such an extent that the effect is that of intestinal obstruction and it is impossible to introduce a tube far enough by physiologic routes to bring about deflation. The pressure upon the diaphragm then may cause pain in breathing, with the result that the patient does not fully expand the lungs and atelectasis develops in the lower lobes. In such circumstances surgical intervention to relieve the pressure in the bowel may be indicated.An ordinary urethral catheter introduced through an incision in the intestine cannot be extended far enough to relieve pressure in more than a few loops.A method of using a Foley catheter and of advancing it for greater distances inside the bowel was used in five cases with good results and without complications.     

Abdominal distention terminates subsequent host-seeking behaviour of Aedes aegypti following a blood meal

The failure of Aedes aegypti females to engage in host-seeking behaviour following a replete blood meal was investigated. Abdominal distention appears to be responsible for this immediate inhibition after feeding. Large enemas of saline had the same effect as blood in terminating host-seeking; this was not due merely to the presence of large amounts of fluid, but rather to the distention produced by these liquids. Since transection of the ventral nerve cord anterior to the 2nd abdominal ganglion did not release the inhibition in blood-fed females, we restricted the degree of distention of abdominal segments with wax. Distention of the abdomen anteriorly by a blood meal more effectively inhibited host-seeking than did distention posteriorly, suggesting that stretch receptors in the anterior portion of the abdomen regulate the response towards a host.     

Assessment of Upper Airways Obstruction

An indication of obstruction to the upper airways (trachea and larynx) may be obtained by calculating the ratio of the forced expired volume in one second to the peak expiratory flow rate (FEV₁/PEFR). This index was found to be usually less than 10 in normal subjects (mean 7·3), and in patients with asthma (mean 6·9), chronic bronchitis (mean 7·7), or interstitial lung disease (mean 6·3). A study of simulated upper airways obstruction showed that this index rises as the obstruction becomes more severe. All of 18 patients with proved upper airways obstruction had FEV₁/PEFR indices greater than 10 (mean 14·0). This test can be carried out with forced expiratory manoeuvres only, and it does not require the use of complicated equipment. An FEV₁/PEFR ratio greater than 10, when upper airways obstruction is suspected, indicates that significant obstruction may be present. High values suggest that the obstruction may be severe, and that further investigations are indicated.     

Grey-scale ultrasonography and percutaneous transhepatic cholangiography in biliary tract disease.

Fifty-one patients with suspected obstructive jaundice and 14 without jaundice in whom disease of the biliary tract was suspected but infusion cholangiography had been unhelpful were examined by grey-scale ultrasonography and percutaneous transhepatic cholangiography and the findings analysed retrospectively. Grey-scale ultrasonography distinguished between obstructive and hepatocellular jaundice in 35 out of 46 patients (76%) and indicated the site of the obstruction in 27 (58%) and the cause of the obstruction in 13 (28%). Percutaneous transhepatic cholangiography distinguished between obstructive and hepatocellular jaundice in 42 of the patients (91%) and indicated the site of the obstruction in 42 (91%) and the cause in 29 (63%). In the 14 patients without jaundice percutaneous transhepatic cholangiography showed bile-duct stones in one an ampullary stenosis in three. It is concluded that grey-scale ultrasonography and percutaneous transhepatic cholangiography are complementary examinations and that ultrasonography should always be undertaken first as it is a non-invasive procedure that may provide the surgeon with all the diagnostic information he requires. Percutaneous transhepatic cholangiography should be performed when grey-scale ultrasonography has shown dilated bile ducts but failed to provide adequate diagnostic information. Cholangiography is also required when preoperative percutaneous drainage of the bile duct is contemplated. In those patients in whom grey-scale ultrasonography shows non-dilated ducts endoscopic retrograde cholangiopancreatography is probably the contract examination of choice.     

INTESTINAL OBSTRUCTION COMPLICATING ACUTE PERFORATIVE APPENDICITIS

Upon preoperative diagnosis of acute small bowel obstruction, without an obvious cause, acute perforative appendicitis must be considered. Reevaluation of the history and careful reexamination of the physical findings with that diagnosis in mind should be carried out. If appendiceal disease is likely, maximum antibiotic therapy must be begun immediately along with the administration of fluids, electrolytes and other corrective therapy. A mercury-weighted small bowel tube should be inserted and every effort made to advance it into the small bowel before operation. Operative treatment should be restricted to the least possible. A McBurney incision is best unless wider operation is indicated. If an abscess is present, drainage alone may be the procedure of choice. Severely distended and decompensated small bowel must be decompressed, for if not relieved it can be the cause of death in acute perforative appendicitis. Decompression may be accomplished either by small bowel intubation with continuous suction or by enterotomy and aspiration. If not relieved, small bowel distention will be the mechanism responsible for death in a large percentage of patients with acute perforative appendicitis.     

POSTOPERATIVE BILE PERITONITIS

Bile peritonitis may occur after open operations on the biliary tract or following needle biopsy of the liver.Usually it is secondary to rupture of the common duct caused by overlooked common duct stone.Sterile intraperitoneal bile collections may be tolerated fairly well for long periods.Placing drains in the abdomen after biliary tract operations helps prevent dangerous accumulations of bile.Patients with extensive bile peritonitis should be operated upon as soon as possible. Ideally, the operation should include drainage of the abdomen and repair of any underlying pathological cause, but the condition of the patient may be so poor that only drainage can be carried out at the moment.     

The role of internal pressure and muscle activation during locust oviposition

The oviposition of female locusts is a complex behaviour that includes a dramatic extension of the abdomen. The role of internal pressure during oviposition was investigated by monitoring the intra-tracheal pressure and the activity of selected longitudinal muscles, while movements of the abdomen were visualised with a video imaging system. Locust oviposition consists of a sequence of four distinct phases: (i) probing the substrate and digging without elongation of the abdomen, (ii) longitudinal extension of the abdomen up to four times its normal length, (iii) laying packages of eggs while (iv) gradually withdrawing the abdomen. During extension, neurograms and myograms of selected longitudinal muscles revealed a decreased level of activity. When the abdomen retracted to its normal length, muscle activity re-appeared. In phases two and three, rising internal pressure prevented the abdomen from slipping back when the valves released their lateral grip from the substrate. Locking the genital segments in the hole by relative bending kept the abdomen in place when producing foam or laying eggs. Intra-abdominal pressure, therefore, is not the main cause of abdominal extension, but rather maintains extension when no mechanical locking in the hole prevents the abdomen from elastic retraction.     

Complete gallbladder torsion diagnosed with sequential computed tomography scans: a case report

ABSTRACT: INTRODUCTION: Torsion of the gallbladder is an extremely rare cause of acute abdomen, which commonly affects thin elderly women. A prompt surgical approach is necessary to avoid fatal complications associated with gangrene and perforation of the gallbladder. However, it is difficult to make a preoperative diagnosis using ordinary imaging modalities. CASE PRESENTATION: An 84-year-old Japanese woman was admitted to our hospital due to left lower abdominal pain. Her pain shifted suddenly to the right upper abdomen a half day after admission. Although her enlarged and wall-thickened gallbladder had been already seen at admission, it rotated approximately 180 degrees and deviated to the midline of her abdomen on the second computed tomography scan, which helped us to make a correct diagnosis of gallbladder torsion. The patient underwent an emergency operation (detorsion and cholecystectomy) and recovered without any complications. The gallbladder had necrosis due to torsion. CONCLUSION: Sequential diagnostic imaging might be helpful to make a preoperative diagnosis of gallbladder torsion when the gallbladder is enlarged and wall thickened but the patient does not present with typical clinical symptoms.     

UPJ Obstruction in the Adult Population: Are Crossing Vessels Significant?

Ureteropelvic junction (UPJ) obstruction describes various causes of impaired drainage at the UPJ. Regardless of the cause, the end result is the same: impedance in the normal flow of urine from the renal pelvis into the proximal ureter, resulting in caliectasis and hydronephrosis. This may lead to progressive deterioration of renal function and, thus, often requires intervention to relieve the obstruction and restore the normal flow of urine. Defining the pertinent anatomy, the degree of obstruction, and differential renal function is key to determining whether and when intervention is necessary.     

Effects of external irradiation of the neck region on intima media thickness of the common carotid artery

Background

Dynamic intraventricular obstruction has been observed in patients with left ventricular ballooning syndrome (LVBS) and has been hypothesized as a possible mechanism of the syndrome. The aim of this study was to assess the prevalence and significance of dynamic intraventricular obstruction in patients with LVBS.

Methods and Results

Dobutamine stress echocardiography was carried out in 22 patients with LVBS (82% apical), all women, aged 68 ± 9 years. At baseline 1 patient had a > 30 mmHg LV gradient; during stress a LV gradient > 30 mm Hg developed in 6/21 patients (28%) and was caused by systolic anterior motion of the mitral valve in the 3 patients with severe gradient (mean 116 ± 29 mmHg), who developed mitral regurgitation and impaired apical wall motion and by obstruction at mid-ventricular level in the other 3 with a moderate gradient (mean 46 ± 16 mmHg). Compared with patients without obstruction those with obstruction had a greater mean septal thickness (11.6 ±.6 vs 9.8. ± 3, p <.01), a higher prevalence of septal hypertrophy (71% vs 7%, p <.005) and a higher peak wall motion score index (1.62 ±.4 vs 1.08 ±.4, p <.01).

Conclusion

Spontaneous or dobutamine-induced dynamic LV obstruction is documented in 32% of patients with LVBS, is correlated with the presence of septal hypertrophy and may play a role in the development of LVBS in this subset of patients. In those without septal hypertrophy a dynamic obstruction is rarely induced with dobutamine and is unlikely to be a major pathogenetic factor of the syndrome.     

Identification and quantification of prosthetic mitral regurgitation by flow convergence method using transthoracic approach

Ultrasound is the preferred imaging modality in diagnosis of vascular complications following cardiac catheterization and intervention. In some cases, however, bleeding surrounding the femoral vessels, may severely distort the color Doppler images, making detection of venous complications especially difficult. This report refers to such a case where post-catheterization haematoma was suspected to cause an obstruction of the femoral vein. Spectral Doppler recordings of blood flow in the common femoral vein, up-stream, distal to the hemorrhagic area, confirmed the diagnosis of obstruction by demonstrating changes in the venous flow pattern in the common femoral vein, consistent with venous hypertension. Due to the poor quality of the ultrasound images, the exact cause of the obstruction had to be established by another imaging modality, not affected by haemorrhages. CT showed that the common femoral vein was compressed at the puncture site by surrounding haemorrhages. Thus, when bleeding due to cardiac catheterization is associated with possible venous obstruction and findings by color Doppler are equivocal due to degradation of the color-Doppler image, detection of venous hypertension by spectral Doppler, performed distal to the bleeding area, strongly supports the presence of venous obstruction where the exact cause may be established by CT.     

POSTURAL SHOCK IN PREGNANCY

Signs and symptoms of shock may be produced in some patients in late pregnancy by putting them in the dorsal recumbent posture. Change from this position will relieve the condition.The features of the supine hypotensive syndrome can be duplicated by applying pressure to the abdomen with the patient in a lateral position.The postural variations of venous pressure, blood pressure, and pulse appear to be due to obstruction of venous return from the lower portion of the body caused by the large uterus of late pregnancy compressing the vena cava.When shock is observed in a woman in late pregnancy, she should be turned to a lateral position before more active measures of treatment are begun.     

Postural shock in pregnancy

Signs and symptoms of shock may be produced in some patients in late pregnancy by putting them in the dorsal recumbent posture. Change from this position will relieve the condition. The features of the supine hypotensive syndrome can be duplicated by applying pressure to the abdomen with the patient in a lateral position. The postural variations of venous pressure, blood pressure, and pulse appear to be due to obstruction of venous return from the lower portion of the body caused by the large uterus of late pregnancy compressing the vena cava. When shock is observed in a woman in late pregnancy, she should be turned to a lateral position before more active measures of treatment are begun.     

在正常和冠状动脉狭窄犬中扩张胃对冠脉血流动力学的影响

饱餐和扩张胃对心血管的影响早已引起人们的注意,但结论是不一致的。以往的实验都是在正常冠脉的动物上进行。本文在造成冠脉狭窄的情况下进行观察。在22条开胸狗的左旋支上,用微米狭窄器造成临界狭窄和重度狭窄。把一个气球送入胃中并充气600ml连续观察30min。正常冠脉组在扩张胃的最初15min内(前期)冠脉流量增多,主动脉压升高,血管总阻力下降,冠脉扩张;在扩张胃后15分钟(后期)无显著变化。冠脉临界狭窄组,前期冠脉流量增多,血管总阻力下降,冠脉扩张;后期流量减少,壁内血管阻力增加,冠脉收缩。冠脉重度狭窄组,前期冠脉流量无明显增加;后期流量显著减少,血管总阻力及心外膜、壁内血管阻力均增加,提示左旋支血管各段都发生收缩。 我们认为,餐后心绞痛的发作可能主要是在原有冠脉狭窄基础上冠脉流量进一步减少的结果。     

MEDIASTINAL EMPHYSEMA

Mediastinal emphysema may occur due to migration of air from the lungs, from the esophagus or tracheobronchial tree and from the abdomen. Of especial interest is the mechanism starting with the rupture of the perivascular alveoli due to a rapid decrease in intrathoracic pressure from any cause, the development of pulmonary interstitial emphysema and migration of the air into the mediastinum.In one case the patient had severe interstitial emphysema of the left lung, mediastinal emphysema and subcutaneous emphysema without pneumothorax and rapid improvement followed tracheotomy.In another case the patient had interstitial emphysema of the left lung that did not progress to mediastinal emphysema and subcutaneous emphysema. Pneumothorax was not present. Recovery was more rapid than in the first patient.