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Background. Over several decades, standard management of blunt spleen injury (BSI) has been changed from operative intervention to the selective operative and nonoperative management (NOM). However, some patient needs laparotomy first. This article describes a case of a BSI patient who failed nonoperative management after angioembolization (AE). Case Presentation. A 58-year-old man fell from his motorcycle and was brought to our hospital. His vital sign was stable after extracellular fluid bolus. A contrast-enhanced computed tomography scan of the abdomen showed AAST grade V spleen injury. AE was performed for the splenic artery, but his systolic blood pressure suddenly dropped under 60 mmHg. The resuscitative endovascular balloon occlusion of the aorta was inserted, and immediate laparotomy was performed. A pancreatic tail injury was detected, and the splenic artery and vein were burst at the pancreatic tail and controlled by hemostatic suture. After splenectomy, a drain was placed at the pancreatic tail and the abdomen was temporally closed. The postoperative course was not remarkable except for abdominal abscess treated with antibiotics, and he was discharged on foot. Conclusion. Although NOM is becoming one of the choices for severe BSI, there will still be a patient who requires surgery. Surgeons should be aware of the mechanism of injury and the limitation of AE as an adjunct to NOM. Patient selection for initial NOM and timing to convert to laparotomy are important.

Abstract Background Although gastrointestinal involvement in patients with granulomatosis with polyangiitis is uncommon, it is associated with mild to severe life-threatening complications. We present a case of pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis that was treated successfully with hyperbaric oxygen. Case presentation A 70-year-old Japanese man with a 3-year history of granulomatosis with polyangiitis consulted our hospital with a complaint of severe back pain. Computed tomography showed a large amount of gas located in his bowel wall and mesentery. He underwent urgent exploratory laparotomy, which led to a diagnosis of pneumatosis cystoides intestinalis without intestinal perforation or necrosis. He consequently underwent 13 sessions of hyperbaric oxygen therapy and was discharged from our hospital without complications. Conclusions Several previous reports have supported the efficacy of hyperbaric oxygen for treating pneumatosis cystoides intestinalis. The present case, however, is the first in which pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis was successfully treated with hyperbaric oxygen. We therefore suggest that hyperbaric oxygen therapy could be a candidate treatment for pneumatosis cystoides intestinalis in patients with granulomatosis with polyangiitis.

Introduction. Transarterial chemoembolization (TACE) is the first-line therapy for patient with unresectable hepatocellular carcinoma (HCC). Although TACE is a generally safe procedure, major complications can be occurred. We describe a patient with rupture of HCC after TACE followed by gastric bleeding. Case Presentation. An 81-year-old man presented with worsening epigastric pain. He had been diagnosed with multiple HCC with nonalcoholic steatohepatitis and underwent TACE 19 days previously. A contrast enhanced computed tomography (CT) scan of the abdomen showed rupture of an HCC. He was treated nonoperatively and discharged on hospital day 18. Five weeks after TACE, he was emergently admitted with massive hematochezia and shock. A contrast enhanced CT scan demonstrated extrinsic gastric compression by an HCC lesion with extravasation of contrast into the stomach. Emergent upper gastrointestinal endoscopy showed a bleeding gastric ulcer with extraluminal compression which was successfully controlled by hypertonic saline-epinephrine injection. Due to tumor progression, he was discharged for palliative care and died six weeks after TACE. Conclusion. Rupture of HCC is a life-threatening complication after TACE with mortality rates up to 50%. After treatment of a ruptured HCC, extragastric compression and bleeding can occur due to direct compression by a primary lesion or intraperitoneal dissemination.

Background. Anal stenosis is a rare but serious complication of anorectal surgery. Severe anal stenosis is a challenging condition. Case Presentation. A 70-year-old Japanese man presented with a ten-hour history of continuous anal pain due to incarcerated hemorrhoids. He had a history of reducible internal hemorrhoids and was followed for 10 years. He had a fever and nonreducible internal hemorrhoids surrounding necrotic soft tissues. He was diagnosed as Fournier’s gangrene and treated with debridement and diverting colostomy. He needed temporary continuous renal replacement therapy and was discharged on postoperative day 39. After four months, severe anal stenosis was found on physical examination, and total colonoscopy showed a complete anal stricture. The patient was brought to the operating room and underwent colostomy closure and anoplasty. He recovered without any complications. Conclusion. We present a first patient with a complete anal stricture after diverting colostomy treated with anoplasty and stoma closure. This case reminds us of the assessment of distal bowel conduit and might suggest that anoplasty might be considered in the success of the colostomy closure.

Helicobacter cinaedi is a rare human pathogen which has various clinical manifestations such as cellulitis, bacteremia, arthritis, meningitis, and infectious endocarditis. We report an abdominal aortic aneurysm infected with Helicobacter cinaedi, treated successfully with surgical repair and long-term antimicrobial therapy.

Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated.

Edwardsiella tarda (E. tarda) is a rare human pathogen; however, the overall mortality of bacteremia is reported to be up to 50%. Here, we describe a case of cholangitis with E. tarda bacteremia who had a pancreatoduodenectomy for a locally advanced gastric cancer. He was successfully treated using a cefmetazole, a second generation cephalosporin for 14 days. To the best of our knowledge, this is the first case report about E. tarda bacteremia after biliary reconstruction.