A 60-year-old woman with a history of distal gastrectomy for gastric cancer presented with a chief complaint of epigastric pain. Duodenal ileus due to the migration of a gastric bezoar was diagnosed, and she was hospitalized. We performed endoscopic lithotripsy and injection of cola, but the bezoar migrated toward the anus. Her abdominal pain worsened the following day, and she was diagnosed with ileus induced by the gastric bezoar. After decompression with an ileus tube, 1000ml/day of cola was injected via the ileus tube, and the ileus resolved on the 5th day of therapy. Based on this experience, we believe that dissolution therapy with cola via an ileus tube is effective in the treatment of bezoar-induced small bowel ileus.
We report a case of jejunal perforation related to cholesterol crystal embolism (CCE) in a woman in her seventies. The jejunum was partially resected;histological examination of the resected tissue revealed that the perforation was caused by CCE. On postoperative day 12, computed tomography (CT) showed free air in the abdomen. We then performed a second operation to alleviate the anastomotic leakage. Subsequently, 26 days after the second surgery, CT again showed free air in the abdomen. A third operation was performed, and multiple perforations of the jejunum were detected. She died of multiple organ failure 43 days after the first surgery. The prognosis of CCE with gastrointestinal perforation is reported to beextremely poor, and there is a high rate of anastomotic leakage. Partial resection of the intestine and ileostomy might be useful for removing the intestinal perforations caused by a CCE. Steroid administration should be continued, however, because discontinuation may worsen the problem.
A 65-year-old woman presented to a nearby clinic with a painful mass in the right lower abdominal region. She was suspected of having an appendiceal tumor on abdominal computed tomography (CT) and was referred to our hospital for surgery. Blood testing revealed increased inflammatory markers. Contrast-enhanced abdominal CT revealed a mass with poorly defined margins in the ileocecal region, which was adjacent to the external iliac vessels. A barium enema revealed unilateral wall deformities in the cecum through to the terminal ileum, whereas lower gastrointestinal endoscopy showed no clear epithelial tumor component. The patient was clinically diagnosed with ileocecal actinomycosis and treated with high-dose penicillin G. On day 15 of treatment, contrast-enhanced abdominal CT showed a reduction in mass size. On day 26, right hemicolectomy (D3) with combined resection of the external iliac vein (which could not be separated from the mass) was performed. Pathological examination revealed granulation tissue with granules of actinomyces, with filamentous bacteria detected by Grocott staining. With no evidence of malignancy, the final diagnosis of ileocecal actinomycosis was made. This report presents a case of clinically suspected ileocecal actinomycosis treated by preoperative antibiotic treatment to reduce mass size, followed by surgical resection.
A 43-year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray. Blood testing showed elevated levels of C-reactive protein and white blood cells. Computed tomography revealed multilocular masses of the right hepatic lobe, reticulonodular shadowing on both lungs, left kidney masses, and aortic arch aneurysm. Fusobacterium nucleatum was isolated from the hepatic abscess after percutaneous transhepatic drainage. Because of severe dental caries, he was diagnosed with liver abscess caused by dental infection with F. nucleatum. Administration of cefmetazole and meropenem was not effective; however, he showed remarkable improvement after treatment with metronidazole and continuous drainage.
A 51-year-old woman was diagnosed with mixed connective tissue disease (MCTD) in 2011. She underwent treatment with prednisolone. Her hepatobiliary enzyme level increased, and multiple nodules were found in both liver lobes in abdominal imaging studies. Ultrasonography revealed large and small hyperechoic lesions with indistinct or well-defined borders. No findings of classic hepatocellular carcinoma or liver cirrhosis were observed on contrast-enhanced computed tomography, but some nodules showed an enhanced effect of the central lesion that was characteristic of focal nodular hyperplasia (FNH) in an arterial phase. On gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging, slightly high-intensity nodules, 10-40mm in size, were observed on T1- and T2-weighted images. The nodules showed highest intensities in the hepatocyte phase and were enhanced with the uptake of Gd-EOB-DTPA as compared with the background liver. FNH was suspected based on the imaging findings, but we performed a liver tumor biopsy for differential diagnosis of the malignant lesion. Based on the immunohistopathological examination results, the final diagnosis was idiopathic portal hypertension associated with nodular regenerative hyperplasia (NRH)-like nodule of the liver. Benign nodular hepatocellular lesions are caused by abnormal hepatic circulation and were previously known as anomalous portal tract syndrome. Our case of atypical NRH with large nodules may be included in this disease entity. Here, we report a rare case of MCTD with NRH-like nodules and idiopathic portal hypertension with a review of literature.