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Abstract Introduction Small bowel intussusception is rare in adults and accounts for one percent of all bowel obstructions. Malignancy is the etiologic agent in approximately 50 percent of all cases. Case presentation Our first patient was an 80-year-old Caucasian woman with signs and symptoms of intermittent bowel obstruction for the last 12 months. Pre-operative investigation by abdominal computed tomography scanning revealed an obstruction at the ileocecal valve. Exploratory laparotomy revealed an ileocecal intussusception. She underwent an enterectomy. Histological examination showed metastatic breast cancer (lobular carcinoma). Our patient had previously undergone a mastectomy due to carcinoma three years earlier. Our second patient was an 80-year-old Caucasian man with signs and symptoms of acute bowel obstruction. Pre-operative investigation by abdominal computed tomography scanning showed an intussusception in the proximal part of the small bowel. Exploratory laparotomy revealed a jejunojejunal intussusception. He underwent an enterectomy. Histological examination showed metastatic melanoma. Our patient had a prior history of a primary cutaneous melanoma which was excised two years ago. Conclusion Pre-operative determination of the etiologic agent of intussusception in the small bowel in adults is difficult. Although a computed tomography scan is very helpful, the diagnosis of intussusception is made by exploratory laparotomy and histological examination defines the etiologic agent. A prior malignancy in the patient's history must be taken under consideration as a possible cause of intussusception.

Abstract Introduction Blunt duodenal injuries do not occur often. A patient with damage to the duodenal tissue around the pancreatic and common bile duct presents a challenge to surgeons. The choice of procedure must be tailored to the nature of the defect and the amount of tissue lost. Case presentation We describe the case of a 16-year-old Caucasian boy with a blunt duodenal injury after a motor vehicle accident. On admission, the patient had stable vital signs and a normal laboratory workup. Gradually his clinical condition deteriorated and a computed tomography scan showed a retroperitoneal haematoma at the level of his duodenum. A fully circumferential rupture of the second part of his duodenum was found during laparotomy, with the intact Vater's papilla lying adjacent to the defect and a superficial laceration of the head of his pancreas. The retroperitoneal haematoma was thoroughly drained and a pedicled ileal loop was interposed between the duodenal stumps to restore the continuity of the patient's duodenum. Apart from a mild postoperative pancreatitis, the patient's postoperative course evolved with no further problems. The patient was discharged on the 22nd postoperative day in excellent condition and has remained so to date (after five years). Conclusion In our case report, where the second part of the patient's duodenum was completely transected, our choices for reconstruction were limited. Important factors for the successful management of this patient were prompt surgical intervention and the accurate assessment of the nature of the duodenal and associated injuries. We believe that the technique we used was a reasonable choice because the anatomical continuity of the patient's duodenum was restored.

The cause of death of a historical figure with the magnitude of Alexander the Great has at times engaged great interest in scholars from different fields. The many opinions are derived so far from historical evidence as well as interpretation of myth-like clues. Our research focused on examination of the signs and symptoms mentioned and interpreted both by ancient (mainly Arrian and Plutarchus) as well as later scholars. The symptom onset was acute abdominal pain after a lavish meal and wine drinking followed by fever and day-by-day progressive, fatal deterioration over 14 days. Research through medical interpretation and the principles of evidence based medicine led us to conclude, that the world's greatest military leader died from a severe intra-abdominal infection, due to acute pancreatitis progressing to necrotizing pancreatitis and obstruction of the bile duct with possible cholangiitis secondary to an inflamed head of the pancreas and severe sepsis. Through differential diagnosis, other possible and proposed causes; such as malaria, pneumonia or pulmonary abscess, typhoid fever, poisoning, withering after Hephaestion's death, West Nile fever and Guillain-Barré syndrome, were excluded. However, undisputable findings still remain to be uncovered, once and if Alexander's tomb and mummified body are found and undergo forensic examination and autopsy. [ABSTRACT FROM AUTHOR]

Background: Primary aldosteronism (PA) is a syndrome which includes a group of clinical entities in which aldosterone production is inappropriately high and nonsupressible by sodium loading. The most frequent causes of PA are adrenal adenoma and unilateral or bilateral primary hyperplasia. Methods: We report a case of a 55-year-old man with a 10-year history of hypertension in whom functional hormonal studies were indicative of PA. Because adrenal venus sampling was not available at our hospital, the investigation was conducted with a computed tomography (CT) scan and a scan with 131-iodocholesterol (NP-59) which both revealed a left adrenal adenoma. Results: The tumor was excised laparoscopically without any complications and the histological findings confirmed the diagnosis of an aldosterone-producing adenoma. Blood pressure remained normal despite the discontinuation of antihypertensive drugs, further supporting that the adrenal tumor was indeed the cause of high blood pressure. Unfortunately, blood pressure began to rise again 2 months later, and laboratory findings indicated the presence of PA once again. Spironolactone was instituted and blood pressure significantly improved and was finally controlled by the addition of amlodipine. Conclusion: We report this case to underline the difficulties in the discrimination between adenoma and hyperplasia in everyday clinical practice. Although the CT and scintigraphic findings strongly pointed toward an adenoma, the fact that PA re-appeared shortly after the operation, indicated that the underlying cause of the PA was hyperplasia and not adenoma after all. [ABSTRACT FROM AUTHOR]

Low-molecular-weight heparins (LMWHs) have become the corner stone of antithrombotic treatment but their administration protocol needs to be optimized for certain groups of patients. In this paper, we studied the influence of nadroparin treatment on clot formation process assessed by thromboelastography in patients with carotid artery disease undergoing angioplasty and stenting. Standard thromboelastography assays (in-TEM and ex-TEM) and minimal TF-triggered thromboelastography assay in citrated whole blood were performed in normal volunteers (n = 20), in patients with carotid artery disease receiving only antiplatelet treatment (n = 30), and in patients undergoing angioplasty receiving nadroparin 5750 anti-Xa IU s.c. twice daily (n = 60). Blood samples were collected four hours after a second injection of nadroparin. In a subgroup of LMWH-patients (n = 18) blood samples were also obtained prior to first injection of LMWH. Antiplatelet treatment had no effect on any parameter of the thromboelastographic pattern. Nadroparin treatment resulted in significant prolongation of clotting time (CT) and clot formation time (CFT) and significantly reduced a -angle in minimal TF-triggered thromboelastography and 30 - 38% of nadroparin treated patients had thromboelastographic parameters beyond the normal maximum limit. In-TEM test revealed a significant prolongation of clotting time while ex-TEM was not modified, and 20 to 30% of the patients had thromboelastographic parameters beyond the normal maximum limit. Anti factor-Xa activity in platelet-poor plasma (PPP) was also measured, and statistical analysis showed that prolongation of CFT of minimal TF-triggered TEM was significantly correlated to the levels of anti-Xa activity in patients ' plasma (p = 0.04; r (2) = 0.7). There was no statistical correlation for any other parameter in all tests. In conclusion, the present study shows that nadroparin treatment in patients with carotid artery disease undergoing endovascular procedures induces significant modification of the thrombus kinetics assessed by minimal TF-triggered whole blood thromboelastography. The clinical relevance of these findings has to be evaluated in future studies.