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Volume 70 - 2007 - Fasc.3 - Letters

Takayasu's arthritis associated with chronic hepatitis B

We report a case with Takayasu's arthritis, which is a unique autoimmune disease of unknown etiology co- existing with chronic hepatitis B. A 26-year old female patient was suffering from dif- fuse myalgia and arthralgia. During her physical exami- nation blood pressures of 100/70 mmHg on her left and 80/40 mmHg on her right arm were measured ; no pal- pable pulses over the brachial, ulnar and radial arteries were present. Bruises were noted over both carotid arter- ies and over the left side of the abdomen. Laboratory tests showed an increased erythrocyte sedimentation rate (ESR) of 120 mm/h and C - reactive protein of 20 mg/L. The diagnosis of Takayasu's arthritis was confirmed by angiography. In the angiography subtotal stenosis of the right carotid artery and a 50% stenosis of the left carotid artery were found. (Corticosteroid therapy of) metyl- prednisolon 8 mg/day was started. After administering the corticosteroid medication, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were ele- vated at levels of 462 IU/l and 324 IU/l respectively. Positive hepatitis B surface antigen (HBsAg), negative hepatitis B early antigen (HBeAg) and hepatitis B core antibody (HBcIgM) were found. 40000 copies/ml HBVDNA was detected. The liver biopsy was graded by Knodell's Histological activity index (HAI) (1) and revealed chronic hepatitis B necroinflammatory activity of 9 and fibroblastic activity of 2. Lamivudine treatment was started with a dosage of 100 mg/day. After six months of treatment HBVDNA was no longer detectable. The patient's vasculitis continued ; she had arthralgia with an increased ESR of 70mm/h and C-reactive protein of 15 mg/L.


Ileoileal intussusception due to an inverted Meckel's diverticulum in a child

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. In the majority of cases, it is an incidental finding but symp- toms can occur due to haemorrhage, bowel obstruction, infection, perforation and umbilical fistula. We report a case of intussusception due to an inverted MD. A 7-year-old patient presented to the emergency department with vomiting and abdominal pain of 12 hour duration. He also reported rectal bleeding. On physical examination a palpable mass in the right lower quadrant was noted. Hemoglobin level was 13,8 g/dl and white blood cells count was 18.000/µl. Abdominal radi- ography revealed air fluid levels consistent with bowel obstruction. For further evaluation an abdominal ultra- sound examination was performed and revealed the characteristic "target sign" in the right lower quadrant, indicating an intussusception, and free intraperitoneal liquid. Due to clinical deterioration, the patient was taken urgently to the operation room. At laparotomy a section of small bowel was found to be intussuscepted secondary to an invaginating MD (Fig. 1). The MD was resected. The patient was discharged on postoperative day five. Histological examination confirmed the pres- ence of pancreatic ectopic tissue.


An unusual complication of percutaneous endoscopic gastrostomy

A 76-year-old male stroke patient was admitted because of the dysfunction of his percutaneous endo- scopic gastrostomy (PEG) feeding tube. It had been placed 13 months previously at another institute and no replacement had been needed during this time. We have decided to replace the PEG tube since the PEG catheter was severely deformed and obstructed with feed. We have performed upper gastrointestinal system (UGIS) endoscopy in order to understand the type of PEG. UGIS endoscopy revealed a peptic esophageal stricture at the 34 cm from the incisors that cannot be passed with an endoscope with a diameter of 9.2 mm. A balloon dilation for this stricture was performed using an esophageal-type controlled radial expansion dilation balloon (Boston Scientific Microvasive Corp., Massachusetts, United States) (Fig. 1a). Thereafter, it was possible to pass the stricture. There was no gastric or duodenal lesion, and it was seen that PEG tube had mushroom-like round tip (Fig. 1b). Then the tube was pulled out and a new balloon-type PEG tube was replaced percutaneously. Histopathological examination of the biopsy samples taken from the stricture revealed no malignancy.


A man with abdominal bloating : Chilaiditi's syndrome

An 85-year-old man with abdominal pain reported a feeling of bloating since several days. He was referred to the Emergency Department by the general practitioner with complaints of nausea with vomiting and epigastric discomfort. His history reports hypertension, chronic obstructive pulmonary disease (COPD) and surgery for an inguinal hernia on the left side.


Heterotopic gastric mucosa in the proximal esophagus (inlet patch) : a clinical entity with increased recognition

Heterotopic gastric mucosa patch can be seen in various parts of the gastrointestinal system from mouth to anus. However, esophageal heterotopic gastric mucosa patch, also known as inlet patch (IP), has been increasingly reported. IP is seen as a flat island or islands of red mucosa in the proximal third of the esophagus in endoscopic examination (1). IP is often missed due to its location in the esophagus, just distal to the upper esophageal sphincter, making endoscopic evaluation difficult. Hence the condition is most likely to be under-reported. Nonspecific oropha- ryngeal symptoms are common and thought to be due to laryngopharyngeal reflux. Symptoms as well as morphologic changes associated with IP are regarded as a result of the damaging effect of acid, produced by parietal cells in the mostly fundic type of IP. In a recently published article, authors reported that dysphagia was related with the size of IP and speculated that this might be associated with larger IP causing more acid secretion (2).


Endoscopic diagnosis and conservative management of an intramural sigmoid haematoma complicating anticoagulant therapy

We describe the case of a 63-year old man with a sigmoid intramural haematoma caused by anticoagulant therapy with acenocoumarol and we review the related literature. He presented to the emergency department complaining of haematochezia and colicky lower abdominal pain. He was on regular acenocoumarol 2 mg daily for a previous acute myocardial infarction two years earlier. He also took 500 mg of aspirin the day before admission. He was apyrexial, the blood pressure was 95/60 mmHg, and the pulse rate 86/min irregular. There was tenderness in the left iliac fossa and the bowel sounds were increased. The digital rectal examination showed blood stained liquid only. After a failed attempt to put an intravenous canula, a large haematoma developed in his right arm. The INR was 6.3. The full blood count showed leucocytosis of 14100/µl (86% neutrophils) and haemoglobin of 14.5 g/dl. Abdominal x-rays after water soluble contrast enema demonstrated partial obstruction of the sigmoid colon. The abdominal CT scan with oral administration of contrast medium showed narrowing of the sigmoid lumen and thickening of the descending and sigmoid colon wall (Fig. 1). The flexible sigmoidoscopy demonstrated an intramural sigmoid colon haematoma partially obstructing the lumen. The acenocoumarol was stopped and the patient was treated with vitamin K, fresh frozen plasma, and intravenous fluids. The next day the INR was 1.47. A new flexible sigmoidoscopy performed four days later showed an oedematous sigmoid colon. However the haematoma had considerably shrunk and the colono- scope could easily reach the splenic flexure. The patient was discharged two days later as the abdominal pain settled and he had a normal bowel movement.