Two cases are reported of rectal cancer associated with an abscess of Douglas' cavity due to perforation of the cancerous lesion. Case 1: A 73-year-old man was admitted because of abdominal pain and fever. An emergency operation was performed under the diagnosis of an abscess of Douglas' cavity. During surgery, we found the abscess in Douglas' cavity with reddish swelling and edema of the ileum at the location of the abscess cavity. Abscess drainage and partial ileal resection was performed. Colonoscopic examination after surgery showed advanced cancer in the rectum. Twenty-nine days after surgery low anterior resection of the rectum was performed. Case 2: A 49-year-old woman was admitted because of abdominal pain and fever. An emergency operation was conducted under the diagnosis of abscess of Douglas' cavity and rectal carcinoma. We performed abscess drainage. Colonoscopic examination after surgery showed advanced cancer in the rectum. Fourteen days after surgery low anterior resection of the rectum was performed. In both cases, the histological findings disclosed perforation at the center of the advanced cancerous lesion. In our series of 12 cases of perforated rectal carcinoma, two cases were presented with an abscess of Douglas' cavity. Rectal cancer perforations should be considered in cases with findings similar to those reported here.
A 68-year-old man was carried by an ambulance presenting with partial traumatic amputation of both legs as a result of a railway accident. The hypovolemic shocked patient arrived at the hospital, with potential right tension pneumothorax. Immediate decompression by tube thoracotomy was performed, however the shock state did not improve. Repeated focused assessment with sonography for trauma (FAST) and careful physical examination of the patient revealed no abdominal injuries. Pelvic fracture was not identified with the pelvic X-ray. The partially amputated legs were removed in the emergency department. In spite of these procedures, the hypovolemic shock persisted. However, a wound in the region of the right humerus, which was not bleeding during the initial examination, developed hemorrhage upon later investigation. The circulatory status of the patient stabilized after the wound was packed with gauze packing for hemostasis. Polytetrafluoroethylene (PTFE) graft inter-position of the injured artery and fasciotomy of the right forearm were subsequently performed. The postoperative course was uneventful, and rehabilitation was begun on the 15th post-operative day. Thus, even in a patient with blunt trauma, arterial injuries of the extremities should never be underestimated during the initial assessment.
A 62-year-old man suffered poisoning from 30ml of calcium polysulfide‘610-happu®’, which was sold as a common bath agent, agricultural product, and fungicide. Though a fatal dose of calcium polysulfide is reported to be 50-150ml, he developed cardiopulmonary arrest (CPA) 10 minutes after the intake of“610-happu”and survived with aggressive supportive therapy. Calcium polysulfide reacts with stomach acid and generates hydrogen sulfide. Hydrogen sulfide poisoning was thought to have caused the CPA. After resuscitation, disseminated intravascular coagulation was developed. On the 6th day after admission to the ICU, serum amylase elevated. Abdominal CT revealed a small amount of ascites and no signs of pancreatitis. On Day 19, we detected pancreatic pseudocyst formation. It was suspected that gastric mucosal burn had developed a perforation of the posterior wall, followed by pancreatitis. Both respiratory arrest by hydrogen sulfide and corrosive chemical injury of the stomach due to a small amount of calcium polysulfide poisoning were observed.
Recently, a reversible syndrome characterized by occipital dominant cortical and subcortical abnormal lesions seen on magnetic resonance images (MRI) was described as reversible posterior leukoencephalopathy syndrome (RPLS). We report a case of postpartum reversible posterior leukoencephalopathy syndrome without toxemia of pregnancy. A 39-year-old female was admitted 1 week after delivery because of headache, nausea and the sudden onset of generalized convulsion. MRI showed abnormal lesions in both the occipitoparietal cortex and subcortical white matter. A diagnosis of RPLS was established. As antihypertensive therapy did not have a good effect on the patient's clinical course, steroid therapy was added and the patient improved remarkably with the exception of mild memory disturbance. The abnormal occipitoparietal lesions remained in both lobes as visualized on diffusion-weighted images even on the 33rd day after the attack. Because of the persistence of the lesions seen on MRI and the remaining clinical symptoms, the pathophysiological cause of RPLS was considered to be cytotoxic edema due to vasospasm in addition to vasogenic edema.