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The bleeding of peristomal varices due to a portosystemic shunt is rare but potentially life-threatening in cirrhotic patients with portal hypertension. The scarce case reports in the literature recommend transjugular intrahepatic portosystemic shunt (TIPS) to prevent further bleeding. We report on a 72-year-old man who was referred to our hospital because of life-threatening bleeding from peristomal varices, three years after radical cystoprostatectomy for invasive bladder cancer. CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices. TIPS was taken into consideration, but not possible due to hepatic encephalopathy (HE). Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension. In a second step, the portosystemic shunt was percutaneously embolized. Here, we present a multimodal approach to treat intractable bleeding from peristomal varices in a patient with ileal conduit urinary diversion, not suitable for TIPS.

We report on a remarkable diagnostic work up of suspect rectal palpation results in a 54-year-old patient. According to a transrectal ultrasound-guided punch biopsy the patient was suspected of having a carcinoma of the seminal vesicles and an aggressive operational approach was considered. After a median laparotomy a generalized peritoneal carcinomatosis was found. A goblet cell carcinoid of the vermiform appendix was identified as the primary tumor. This case report deals with metastazation of a primary goblet cell carcinoma into the seminal vesicles on both sides as an extremely rare reason for suspicious rectal palpation results. The tumor valency, diagnostic work up, therapy and further differential diagnoses are described.

Objective: Assessment of the long-term morbidity of the upper urinary tract and of the voiding pattern in men with an ileal orthotopic bladder substitute with an afferent tubular segment., Materials and Methods: Men surviving more than 5 years after radical cystectomy and orthotopic bladder substitution were evaluated. The urinary tract was regularly assessed with ultrasound and IVU while functional reservoir capacity and continence status were prospectively assessed by voiding volume diaries and a standardized questionnaire., Results: After 5 years 129, after 10 years 45 and after 15 years 8 patients were evaluable. Median age at surgery was 63 years (range 36-80) and median follow-up was 73 months (range 60-201). Of the 254 renal units assessed between April 1985 and September 1998, 199 (78%) had some degree of dilatation in the 20-minute IVU film but rarely at 60 minutes. In 246 (97%) the parenchyma size was normal. Ureteral obstruction presented in 9 (3.5%) units, 4 of which were complete (3 had obstruction preoperatively and 1 postoperatively). Mean creatinine levels remained unchanged from the preoperative values. Functional reservoir capacity averaged 462 ml after 1 year, remained stable and then decreased slightly after 5 years. The daytime continence rate was 94% and 91% after 5 and 10 years, while the nighttime rate was 72% and 60% respectively. Patient age at the time of surgery was an important determinant for reservoir capacity and continence status., Conclusions: These data suggest that an orthotopic bladder substitution combined with an afferent tubular segment offers a sufficient protection of the upper tract with a low complication rate and has good long-term voiding and continence results. Meticulous lifelong follow-up is an important factor for satisfactory functional long-term outcome.

Objective: To prevent catheter occlusion, intermittently used central venous catheters are frequently sealed with vitamin C solution or heparin solution between use. The present study was designed to test the effectiveness of this approach and to compare the efficiency of sealing solutions., Design and Setting: Prospective randomized study performed on a 9-bed medical ICU and on medical wards of an academic tertiary care center. PARTICIPANTS. Ninety-nine central venous line placements were prospectively included in the study and randomized into three treatment groups: sodium chloride 0.9%, vitamin C (200 mg/ml) and heparin (5000 IU/ml) sealing solutions., Interventions and Measurements: Catheters were filled with the respective sealing solution and patency was tested once every 2 days using a standardized routine. Catheter patency was compared among the three groups using Kaplan-Meier statistics and log-rank testing., Results: There was a significant difference in catheter patency between the three groups (p<0.03, log-rank test). A comparison of catheter survival between the catheters filled with heparin and those filled with sodium chloride, but not between those filled with vitamin C solution and with sodium chloride solution, exhibited significant differences in catheter patency (p<0.04, log-rank test)., Conclusions: Local anticoagulation of intermittently used central venous catheters prolongs catheter patency. High-dose (5000 IU/ml) heparin solution is a useful anticoagulant for this purpose, while vitamin C solution does not prolong catheter patency.