Clinical aspectsC treatment and outcome of five patients with ulcerative colitis recto- or anovaginal fistula and were studied retrospectively. All patients had total colitis (relapse and remission type) and more than a 5 year history of ulcerative colitis. They all had anorectal complications, such as periproctal abscessC stenosis of fistula. Four patients had total colectomy with an ileal pouch anal canal anastomosis for intractability or dysplasia. One was treated conservatively. Complete closure of fistula was obtained in two patients;in one patient rectum was resected below the fistula and in one patient defect of the vaginal posterior wall was reconstructed by using a gluteal fold flap following colectomy. Recto- or anovaginal fistula complicating ulcerative colitis is rare but may occur in the patients with severe rectal inflammation and they can be managed by restorative proctocolectomy with an ileal pouch anal or anal canal anastomosis.
A 75-year-old man, in whom upper gastrointestinal endoscopy revealed a submucosal tumor in the greater curvature of the gastric angle, was hospitalized for further investigations. Since the tumor was shown to be located in the submucosal layer by endoscopic ultrasonography, we performed endoscopic mucosal resection. Pathological studies of the resected specimen revealed a gastrointestinal stromal tumor of the stomach. It was also formed that the tumor was connected not to muscularis propria, but to the muscularis mucosae. There has been no previous report about a case of gastrointestinal stromal tumor of the stomach arising from the muscularis mucosae in Japan.
A 68-years-old Japanese woman was hospitalized emergently because of hemorrhagic gastric ulcer. For the hospitalization periodC elevated levels of white blood cell countC eosinophilic leucocyte countC serum IgE and positive MPO-ANCA were recognized. With considering clinical course and these laboratory findingsC we diagnosed Churg-Strauss syndrome (CSS). Steroid therapy in combination with cyclophosphamide was effective. CSS is a rare diseaseC but we should discriminate this disease when we encounter gastrointestinal bleeding of unknown etiologyC especially PPI-resistant gastric ulcer.
Two patients with mesenteric panniculitis are presented. In the first patientC a provisional diagnosis of ileus was made, based on the clinical features and imaging data. Laparotomic findings showed that the ileum was bound tightly by a fibrous strip and dilated, with thickened and swollen mesentery. Incision of the fibrous strip was performed, and the clinical symptoms were improved. The second patient was strongly suspected to have mesenteric panniculitisC from characteristic features on abdominal computed tomography and barium enema. Conservative therapy was effective in this case. We emphasize the variety of clinical courses in mesenteric panniculitisC requiring selection of the most suitable treatment.
A 73-year-old man was admitted with fever and abnormal liver function test. After admission, his fever persisted in spite of administrating a variety of antibiotics. He was diagnosed as acute Q fever on the basis of a high titer of IgM antibodies against phase II Coxiella burneti. His fever resolved after starting minocycline, but biliary enzymes continued to be elevated. Transbronchial lung biopsy and percutaneous liver biopsy revealed caseating granulomas and Mycobacterium tuberculosis was detected by culture. Miliary tuberculosis was diagnosed and his biliary enzymes declined after starting therapy with antituberculous drugs. This report of miliary tuberculosis complicating acute Q fever is a valuable and unprecedented case.
A 69-year-old man was referred to our hospital for epigastralgia. He was found to have elevation of serum amylase and CA19-9. Ultrasonography, abdominal CT, MRCP, ERCP and EUS showed the cystic lesion and a possibility of an other tumor. There was a stenosis of the main pancreatic duct (MPD) at the pancreas head and dilatation of the MPD from the body to the tail. Intraductal papillary mucinous neoplasm (IPMN) of the branch pancreatic duct was diagnosed, and there was a likelihood of ductal carcinoma of the pancreas. We therefore performed pancreatoduodenectomy. Pathological finding showed invasive carcinoma from an intraductal papillary mucinous neoplasm with invasive ductal carcinoma of the pancreas.
A 59-year old woman was admitted to our hospital for further examination of a cystic lesion detected in the tail of the pancreas. Imaging studies showed a 35-mm-diameter cystic lesion with septa and mural nodule at the same site. The mural nodule of the cyst was thick and was enhanced. Partial resection of the tail pancreas was performed with a preoperative diagnosis of pancreatic cystic tumor. The resected specimen showed mulitlobular cyst. HistologicallyC the internal surface of the cyst was covered with stratified squamous cells and the mural nodule of the cyst was spleen tissue. The final diagnosis was an epithelial cyst derived from an accessory spleen in the pancreas.
A 55-year-old male heavy drinker was taken to another hospital because of loss of consciousness. Laboratory data showed anemia and endoscopy of the upper gastrointestinal tract disclosed intraduodenal bleeding from the ampulla of Vater. Further examinations were scheduled. However, three days later, he was given emergency admission to our hospital because of massive rectal bleeding and circulatory shock. Abdominal contrast-enhanced CT showed a pseudoaneurysm in a pseudocyst in the head of the pancreas. Emergency angiography revealed a ruptured pseudoaneurysm of the gastroduodenal artery 15 mm in diameter. He was successfully treated with transcatheter arterial embolization. ERCP demonstrated the pseudocyst communicating from the main pancreatic duct in the pancreatic head. The final diagnosis was ruptured pseudoaneurysm of the gastroduodenal artery into a pseudocyst, presenting with hemosuccus pancreaticus, secondary to chronic pancreatitis.