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A 65-year-old woman receiving long-term oral anticoagulant therapy was admitted with signs and symptoms suggesting colonic obstruction. A tender, firm left lower-quadrant mass, colonic and small bowel distention, mild leukocytosis, and a markedly elevated prothrombin time were the prominent presenting abnormalities. Emergency colon x-ray study did not demonstrate colonic obstruction, and ultrasound of the abdomen was initially nondiagnostic. Computed tomography scanning revealed a large mass localized in the left rectus sheath and muscle consistent, in this clinical setting, with a spontaneous rectus sheath hematoma. The purpose of this report is to suggest the usefulness of computed tomography scanning in the evaluation of indeterminate abdominal masses such as the rectus sheath hematoma. The subject of rectus sheath hematoma is reviewed to emphasize its inclusion in the differential diagnosis of the acute abdomen and to suggest an earlier, more accurate, and noninvasive approach to its diagnosis.

Thirteen patients with bile duct cancer (excluding gallbladder) and associated chronic ulcerative colitis (CUC) were seen at the Mayo Clinic from 1935 through 1973. Most patients had initial symptoms of severe diarrhea and bleeding, followed by a pattern of mild-to-moderate disease with exacerbations and remissions. Three patients had especially severe symptoms and underwent total colectomy (1 patient) or proctocolectomy (2 patients) an average of 15.7 years from onset of CUC symptoms. Anorexia, followed rapidly by the development of progressive jaundice (or a sudden deterioration when liver disease was already present), marked the onset of symptoms of bile duct cancer in the 13 patients. The overall mean duration from onset of CUC to development of symptoms of bile duct cancer was 19 years. The patients in whom colitis was managed by proctocolectomy or total abdominal colectomy developed symptoms of bile duct cancer an average of 9.4 years after colectomy. When cancer was diagnosed, the tumor had spread beyond the bile ducts in 10 patients. The tumors were difficult to identify and often infiltrated the hepatic hilus. The present series and review of the literature suggest that the relationship between CUC and bile duct cancer is more than a chance occurrence. The carcinoma has an onset approximately 3 decades earlier than does carcinoma of the bile ducts without CUC. Surgical removal of the diseased colon and mode of medical management of the unresected colon have no relationship to the subsequent development of carcinoma of the bile ducts; neither does the extent or severity of the colonic disease. The prognosis of carcinoma of the bile ducts unfortunately continues to be dismal.

A patient with an uncalcified splenic artery aneurysm with an arteriovenous fistula and aneurysmal dilatation of the splenic vein who underwent splenectomy and resection of the fistula is described. Splenic arteriovenous fistulas are rare and are usually associated with aneurysms of the splenic artery. Patients with these fistulas frequently have signs and symptoms of portal hypertension and may often present with upper gastrointestinal hemorrhage. The patient described in this report was asymptomatic, and the only manifestation of the fistula was a loud, continuous bruit in the left flank noted on routine physical examination. Although an upper abdominal incision can be used to manage most splenic artery aneurysms, a left thoracoabdominal incision is advocated in the presence of an arteriovenous fistula, particularly in anticipation of portal hypertension or aneurysm of the splenic vein.

From 1961 to 1971, 73 central splenorenal and 66 portacaval shunts were done for cirrhotic patients who had bled from esophageal varices. Comparative analysis revealed low (3% and 2%, respectively) operative mortality for elective operations, equal (93%) effectiveness in control of variceal bleeding, but substantial diferences in the incidence of postshunt encephalopathy. For patients who had mimal hepatic dysfunction before operation, disabling disorders in mentation developed in 5% of patients who had splenorenal shunts, in contrast to 50% of patients who had portacaval shunts. Survival rates after the two shunts were nearly identical. Thus, the advantages of splenorenal shunts concern the quality of life but not the length of survival. These observations are considered in relation to available therapeutic alternatives.