To evaluate the usefulness of computed tomography (CT) in the diagnosis of acute appendicitis and the decision for an appropriate operative approach, CT was performed in addition to the clinical and laboratory findings in 42 patients suspected of having acute appendicitis. As for CT findings, surgical intervention was considered in principle in patients with enlargement of the appendix over 10mm, enhanced appendiceal wall, appendicolith, abscess, ascites, deficiency of appendiceal wall, or hazy periappendicular densities. The maximal diameter of resected specimen was also measured. Surgery was conducted in 23 patients, and 19 of them had phlegmonous/gangrenous appendicitis. The remaining 19 patients were treated without surgery. Enhanced appendiceal wall and hazy periappendicular densities were detected in all patients with phlegmonous/gangrenous appendicitis, and deficiency of the appendiceal wall, appendicolith, and abscess/ascites were seen in 79%, 42% and 58%, respectively. The maximal diameter of phlegmonous/gangrenous appendix was 11.8mm, and was significantly larger than that of the appendix with normal or catarrhal appendicitis. The correlation coefficient of the maximal diameter of the appendix between resected specimen and the appendix as measured with CT was 0.65. The specificity, sensitivity, and accuracy of the preoperative diagnosis including CT were 75%, 97%, and 90%, respectively. Preoperative diagnosis including CT is useful to identify acute appendicitis, to evaluate the severity of disease, and to decide the surgical indication.

View full abstract

The causes of gastrointestinal bleeding have been changed remarkably during the past four decades. In the 1960s, infectious disease accounted for most of the bleeding in the lower alimentary tract now, however, colorectal carcinoma has become the primary cause of bleeding in this region. On the other hand, gastric ulcers remain the most common cause of upper gastrointestinal bleeding. Recently, endoscopic clipping has been confirmed as the best choice for hemostasis in patients with of gastric ulcer bleeding, especially when the bleeding occurs from naked vessels. Between 2003 and 2004, emergency endoscopic treatment for hemostasis was performed in 517 patients at Fujita Health University Hospital. Successful hemostasis was achieved in 514 (99.4%) patients the remaining three cases (0.6%) required surgery. None of the patients died from gastric ulcer bleeding. Although most cases of gastrointestinal bleeding could be successfully treated using an endoscopic approach, care is needed as a few cases remain difficult to treat using endoscopic hemostasis alone.

View full abstract

Non-surgical treatments, such as endoscopic hemostasis, have become the primary means of treating gastroduodenal ulcer bleeding, though patient quality of life can be compromised if an inappropriate method is selected. To determine the proper treatment and measures to be taken when rebleeding occurs, the outcome of 175 cases treated between 2000 and 2004 was evaluated. Among 110 cases with either spurting bleeding, oozing bleeding, or non-bleeding visible vessels-categorized according to the classification system developed by Forrest, 94 (85.5%) patients were treated using endoscopic hemostasis. No significant difference in the ratio of recurrent bleeding was observed among the hemostatic procedures that were utilized, including clipping and injection. Of the 16 cases with recurrent bleeding, which were mainly treated using additional endoscopic hemostasis, only 4 received emergency interventional radiology, including crucial cases with hemostatic difficulty at the time of initial treatment. As a result, all the cases attained permanent hemostasis, though rebleeding was frequent among the cases with spurting bleeding. Two elderly patients died because of organ failure triggered by the bleeding. The present findings suggest that careful follow-up is necessary for patients with gastroduodenal ulcer bleeding.

View full abstract

This paper addresses the use of endoscopic hemostasis in patients with bleeding from the second portion of the duodenum. Bleeding from the second portion of the duodenum is rare, and the source of bleeding can be difficult to locate in this area. Over the past ten years, we have experienced 12 cases of bleeding from the second portion of the duodenum. The cases consisted of four patients with ulcers, three with diverticula, two with varices, one with invasive pancreatic carcinoma, one with an AV (arterio venous malformation) fistula, and one with SMT (submucous tumor). We mounted a transparent hood at the tip of a forward-viewing endoscope and treated these active bleeding sources. Endoscopic hemostasis was successful in all 12 cases. Our results suggest that endoscopic hemostasis is useful for treating bleeding from the second portion of the duodenum. Endoscopic hemostasis may be adopted as a first line of treatment in cases with bleeding from the second portion of the duodenum.

View full abstract

Endoscopic hemostasis is thought to be the hemostatic procedure of first choice for the treatment of gastrointestinal bleeding. We retrospectively investigated accumulated data on 261 patients who underwent emergency endoscopic hemostatic therapy at our department over a 10-year period. Endoscopic hemostasis was successful in 94.3% (246/261) of the patients. Initial hemostasis was achieved in 158 patients (98.1%) in the haemoclip group and 88 patients (88%) who received an of the injection of 100% ethanol or were in the HSE (Hypertonic Saline-Epinephrine) group. In some patients, however, hemostasis was difficult to achieve with endoscopic therapy. We have recently begun to apply TAE (Transcatheter Arterial Embolization) in such patients. An angiography was performed in 6 patients in whom endoscopic hemostasis had failed, and hemostasis using TAE and microcoils was successfully performed. The ruptured artery was a branch of the left gastric artery in 3 patients and a branch of the pancreaticoduodenal artery in 3 patients. One patient developed an erosion after TAE, but no severe complications were observed. These results indicate that TAE, a nonsurgical and therefore less invasive procedure, is effective for hemostasis in patients with gastroduodenal hemorrhage if endoscopic hemostasis is unsuccessful.

View full abstract

Our medical organization is attempting to increase the efficiency and improve the quality of medical treatment through standardization. Though nonsurgical treatments for bleeding peptic ulcers have been improved, their use has not yet been standardized. Instead, hospitals and doctors continue to treat patients on an individual basis. Here, we show that nonsurgical treatments for bleeding peptic ulcers can be standardized and that patient outcome can be improved with standardization, providing an incentive to adopt standardized protocols. Furthermore, we show that clinical pathways are useful tools for standardization.

View full abstract

We examined the use of nonsurgical treatments for gastrointestinal bleeding in children. Over the past 25 years, 93 children with gastrointestinal bleeding were treated at our hospital nonsurgical treatments were performed in 39 patients (16 cases of intussusception, 9 cases of esophageal varices, 7 cases of colorectal polyp, 2 cases of duodenal ulcer, 1 case of bleeding colitis, and 4 cases of bacterial enterocolitis). Enemal redressment for intussusceptions, endoscopic injection sclerotherapy and endoscopic variceal ligation for the esophageal varices, and endoscopic polypectomy for the colorectal polyps were performed as nonsurgical treatments. Eradication therapy for Helicobacter pylori was performed in a duodenal ulcer patient who was infected with H pylofi. Gastrointestinal bleeding in children frequently exhibits disease characteristics that are specific to children, and nonsurgical treatments may be useful if the patient has been properly diagnosed. On the other hand, diseases like midgut volvulus, ulcerative colitis, Meckel diverticulum, gastroesophageal reflux, Crohn disease, malignant neoplasm, and enteric duplication always require surgery.

View full abstract

Conservative hemostatic therapy using endoscopy and interventional radiology has recently improved the treatment of digestive organ bleeding. However, arterial bleeding control and orientation remains difficult in some cases. We retrospectively investigated 14 patients who required surgery to correct digestive organ bleeding ; all of the patients had been treated at our hospital between 1999 and 2004. Five of the patients had gastric ulcer bleeding, three had duodenal ulcer bleeding, four had hemorrhaging from colonic diverticula, one had hemorrhaging from a jejunal diverticulum, and one had hemorrhaging from an ileal diverticulum. The gastric ulcers were located in the lesser curve, while the colonic diverticula were located on the right side. Emergent operations were performed because of relapses in two cases, invalid conservative therapies in five cases, the need to prevent intestinal necrosis after transcatheter arterial embolization (TAE) in one case, impossible conservative therapies in five cases, and orientation difficulties in one case. Six gastrectomies, two resections of the small intestine, four colectomies, one pancreatoduodenectomy, and one arterial suturing were performed. Three patients died because their bleeding could not be controlled. Patients with active bleeding from gastric ulcers in the upper lesser curve or duodenal ulcers and patients with relapsed right colonic diverticula bleeding may require immediate surgery. For bleeding in the small intestine, intraoperative endoscopy may be necessary for orientation.

View full abstract

A 26-year-old male patient is presented with Marfan syndrome and rupture of an infectious aneurysm on the right hepatic artery 9 months after aortic valve replacement for aortic regurgitation caused by mycotic endocarditis (ME). Nine months postoperatively, the patient was admitted to our hospital for sudden onset of hematemesis and acute upper abdominal pain. Upper gastrointestinal endoscopy revealed biliary hemorrhage; moreover, a right hepatic artery aneurysm was identified with celiac artery angiography. The diagnosis was hemobilia caused by rupture of the intrahepatic arterial anuerysm, the hemostasis of which was achieved with a transcatheter arterial embolization (TAE). The post-TAE course was uneventful with no evidence of recurrence, and the patient was discharged 23 days after TAE. To date, only six cases, including the present one, of an infectious aneurysm of the hepatic artery have been reported in Japan, and this was the third case of Marfan syndrome in which a rupture of an infectious aneurysm has been identified.

View full abstract

A six-year-old girl was admitted to a local hospital with a 5 day history of vomiting and abdominal pain. She had high levels of WBC count and serum CRP. Computed tomography demonstrated moderate fluid collection in the ileocecal region with little pleural effusion. On transfer to our hospital the following day, she had abdominal guarding in the right lower quadrant. Surgery was performed for acute abdomen. A small right lower pararectal laparotomy revealed moderate serosanguinous ascites and an inflammatory change in the terminal ileal wall 20 cm orally. To evaluate the intraabdominal lesion, a laparoscopic operation was performed with the application of a Lap-Disk. Henoch-Schonlein purpura was suspected from the laparoscopic findings of terminal ileitis and hemorrhagic spots in the right abdominal peritoneum. Small hemorrhagic spots appeared on both leg on postoperative day (POD) 2 and her factor XIII level was 28% on POD 1. Acute abdomen due to Henoch-Schonlein purpura was finally confirmed.

View full abstract

A 78-year-old man admitted for recurrent lung cancer was found on chest X ray to have free air in the peritoneal cavity. He had abdominal distension and tenderness around the right upper or lower abdomen. WBC and CRP were 8, 050/mm³ and 10.2mg/dl. Abdominal X ray and abdominal computed tomography (CT) showed continuous bands of air along the intestinal wall. PI was suspected, however gastrointestinal perforation was not denied because of abdominal tenderness, free air, and rising CRP. Emergency laparotomy showed no ascites but gas-filled multiple cysts along the intestinal wall from the jejunum 170 cm toward the anus of the Treitz ligament to the terminal ileum and mesentery. PI confirmed there was no perforation. CT showed free air in the retroperitoneal space, suggesting that this may have developed from alveolar rupture.

View full abstract

A 76-year-old Japanese man with idiopathic abdominal pain and fever was found in Computed tomography (CT) of the abdomen to have pneumoretroperitoneum. Abdominal ultrasonography (US) did not show either stones or stenosis of the biliary tract. Serun biochemical examination demonstrated high amylase, bilirubin, and C reactive protein. Limited to several preoperative diagnoses, we conducted gastrointestinal endoscopy before exploratory laparotomy. Endoscopy showed erosive gastritis and no perforated lesion on the upper gastrointestinal tract, yielding a preoperative diagnosis of pancreatitis or perforation of colon. We then conducted laparotomy. The transverse mesocolon adjacent to the pancreas head was dark, suggesting necrosis of the pancreas head and mesocolon, necessitating segmental transverse colostomy and drainage of the retroperitoneal space next to the pancreas head. After intensive care for severe pancreatitis, respiratory failure, bacterial site infection, and disseminated intravascular coagulation, the patient recovered and was discharged three months after surgery. Different diseases cause pneumoretroperitoneum, and the primary cause may be difficult to find. In some cases of pneumoretroperitoneum, digestive tract endoscopy may aggravate pneumoretroperitonitis. Our case, however, suggests that preoperative gastrointestinal endoscopy contributes to swift, accurate surgical treatment because most cases of pneumoretroperitonitis require surgery.

View full abstract

A 32 year-old woman had crashed off her snowboard severely, and came to our hospital complaining of left epigastralgia. Plain computed tomography revealed ascites around the body of the pancreas and rectouterine pouch. She was admitted for observation as damage to the pancreas was suggested. Twelve hours following admission her the white blood cell count and amylase level increased and the patient's symptoms deteriorated. Contrast-enhanced computed tomography showed an increase in the of fluid collection and enhanced effects indicating defects in the body and tail of the pancreas. A laparoscopic procedure was performed for the diagnosis and the treatment decision. The damage to the pancreas consisted of a subcapsular hematoma. A Drainage and releasing the pancreas were performed. The patient was discharged from the hospital on the 13th postoperative day. Laparoscopic intra abdominal inspection and surgery as a minimally invasive procedure can be an option for the diagnosis and treatment of pancreatic trauma on a case by case basis.

View full abstract

The case of a 64-year-old male patient who underwent a low anterior resection for rectal cancer in February 1999 was followed up. A digital examination indicated postoperative anastomotic stenosis of the rectum. Dilation by ballooning had been performed every few months since the surgery ; however, his local findings gradually deteriorated. A wedge resection of the operative scar at the site of the anastomosis was performed in May 2005. The next day, the patient became confused and hypotensive. CT scans demonstrated perianorectal gas. The patient was diagnosed as having necrotizing fasciitis with septic shock. Drainage of the inflammatory exudates in the retroperitoneum and the pelvic cavity was performed as an emergency procedure under general anesthesia after immediate endotoxin elimination therapy (PMX-DHP). Widespread inflammation had extended to the lower abdomen and the left scrotum. Aggressive postoperative debridement of the musculus rectus abdominis and musculus obliquus externus/internus abdominis was performed, and the open wound was irrigated daily. Intensive treatment under the administration of systemic antibiotics, continuous hemodiafiltration (CHDF), and a ventilator were used during the patient's recovery from multiple organ failure. Ultimately, a skin graft was required. In conclusion, it is important to be aware of the possibility of the recurrence of necrotizing fasciitis during the postoperative surgical dilation of an anastomotic stenosis of the rectum. If a diagnosis of necrotizing fasciitis is made, an emergency surgical debridement should be undertaken with an intensive treatment that would include apheresis therapy (PMX-DHP and CHDF).

View full abstract

A 56-year-old man was brought by ambulance to the emergency department of our hospital with abdominal pain of acute onset. The physical examination showed findings of generalized peritonitis and an abdominal CT scan revealed total situs inversus and generalized peritonitis due to perforation of the colon. An emergency laparotomy was performed, resulting in so-called right hemicolectomy although in this patient the left half of colon was removed. In this clinical setting, the preoperative CT scan was very useful to recognize the anatomical variations in this patient.

View full abstract

Strongyloidiasis is an intestinal parasitic disease caused by Strongyloides stercoralis and often causes upper gastrointestinal bleeding. A 53-year-old man was admitted for repeated melena due to duodenal post-bulbar ulcers despite having been given proton pump inhibitors. As endoscopic hemostasis was not effective, we performed an emergency operation, distal gastrectomy with resection of the duodenal bulbs via the Billroth II method. Five months later, he was once again admitted with melena, and multiple anastomotic ulcers with Helicobacter pylori (HP) infection were detected on gastroscopic examination. We performed HP eradication, anastomotic ulcers continued to deteriorate. Stool cultures and a histological examination then showed positive for Strongyloides infection, so we started thiabendazole therapy with good results. The patient was concomitantly diagnosed as having chronic adult T-cell leukemia and was carefully observed with no treatment. It is our speculation that any therapy involving reduction in the levels of gastric acid can exacerbate gastrointestinal Strongyloides infections. We conclude that refractory upper gastrointestinal bleeding should be carefully treated always bearing in mind the possibility of strongyloidiasis.

View full abstract

Between September 1992 and September 2002, we treated 4 patients with accidental bowel injury during laparoscopic cholecystectomy. Some 820 laparoscopic cholecystectomies we conducted during the same period. All patients had severe adhesion of the gallbladder to the duodenum or colon. Three cases involved duodenal injury and one transverse colon injury. Diagnosis was made during laparoscopic cholecystectomy and injuries were laparoscopically repaired. The three duodenal injuries were treated with single-layer repair. The transverse colon injury was treated with two -layer repair. No major postoperative complications were seen. Mean operative time was 362 minutes (335-415 minutes). Mean postoperative hospitalization was 19 days (15-29 days). These results indicate that when the surgeon is skilled in advanced laparoscopic operative techniques such as intracorporeal suturing and knotting, these bowel injuries during laparoscopic cholecystectomy can be repaired laparoscopically.

View full abstract

The patient was a 19-year-old male. In August 2004, he fell off a motor cycle, and suffered trauma to his upperabdomen. He came to the emergency department of our hospital on the same day, but there were no abnormal findings, and he went home. After 2 days, vomiting and upper abdominal pain developed, and the patient presented at our hospital again 5 days after the injury. Computed tomography (CT) and ultrasonography revealed a phyma lesion measuring 7×4cm in diameter in the area of the duodenal horizontal duct and dilatation of the duodenum at the orifice-side, and the patient was admitted. On admission, his general condition was good. Contrast-enhanced radiography of the upper digestive tract showed compression in the duodenal descending area and passage disorder in the duodenal horizontal area. Upper digestive tract endoscopy revealed extramucosal compression and a protrusion in the duodenal horizontal area. Therefore, conservative therapy was performed under a diagnosis of duodenal intramural hematoma-related complete stenosis of the duodenal horizontal area. On contrast-enhanced radiography of the upper digestive tract 25 days after the injury, contrast medium passed through the small intestine. Abdominal CT confirmed the disappearance of the hematoma 30 days after the injury, and the patient was discharged 34 days after the injury.

View full abstract

A 78-year-old female, without any history of cardiovascular disease, was referred to the department because of left lower abdominal pain. An emergency laparotomy was performed under a diagnosis of torsion of the small bowel. Necrotic intestine, between the 50 cm anal portion of the Treitz ligament and the 45cm oral portion of the end of ileum, was resected, and a jejunoileostomy was performed. Atrial fibrillation occurred on the following day, and on the 2nd postoperative day, computed tomography revealed a hepatic infarction in the left lobe with remarkable elevation of serum transaminase levels. On the 4th postoperative day, the patient suddenly went into shock, and underwent an emergency re-laparotomy. Operative examination revealed infarction of the lateral segment of the liver, and necroses of all residual colon with thrombus of the mesentery. Although all of the necrotic residual colon was removed, the patient died from multiple organ failure on the 9th postoperative day. During the postoperative course, patients who develop atrial fibrillation have to be observed carefully due to in the risk of arterial thromboses.

View full abstract