Dear Editor,. Epiploic appendagitis is a relatively rare, often underdiagnosed condition affecting young adults. A 31-year-old male presented with a 12-hour ...
Correspondence
Conservative management of epiploic appendagitis based on CT scan findings Dear Editor, Epiploic appendagitis is a relatively rare, often underdiagnosed condition affecting young adults. A 31-year-old male presented with a 12-hour history of acute left iliac fossa pain of increasing severity, which had become constant and aggravated by movement. There was no history of gastrointestinal disturbance. On examination, there was marked tenderness and guarding in the left iliac fossa. The white cell count was raised (11.2 3 x 10'/l) with a neutrophilia (7.9x 10 9 /l) . Initially, a clinical diagnosis of diverticulitis was made in spite of the patient's age. An abdominal CT showed an abnormality of the descending and sigmoid junction with a peripheral hyperattenuated ring, a central area of hypoattenuation of the anterior peritoneal lining and thickening and stranding of fat surrounding the lesion (see Figures 1 and 2) . These findings confirmed the diagnosis of epiploic appendagitis. The patient was managed conservatively and by day 5 his symptoms had resolved and he was discharged home. Primary epiploic appendagitis (PEA) results from torsion and inflammation of an epiploic appendix, or less commonly following spontaneous venous thrombosis. ` While formerly thought to be relatively rare, recent literature suggests it is being underdiagnosed. Patients present with localised abdominal tenderness which may mimic the acute surgical emergencies of diverticulitis or appendicitis. Gastrointestinal symptoms are uncommon. The patient is typically apyre`cial with a normal leucocyte count. Clinical diagnosis is difficult. Previously diagnosed at laparotomy for presumed diverticulitis or appendicitis, and treated by ligation and excision of the appendage,' it may now be diagnosed reliably on characteristic CT findings.''' PEA should be considered in the differential diagnosis of acute abdominal pain, particularly in young patients presenting with atypical features.
`vB Robb', MC Barry', AP Ireland', D Duke 2 , MJ Lee=, DJ Bouchier-Hayes' Department of Surgery' and Radiology 2 , Beaumont Hospital, Dublin, Ireland References 1.
2.
3.
Fieber SS, Forman J. Appendices epiploicae: clinical and pathological
considerations. Arch Surg 1953; 66: 329-38. van Breda Vreisman AC, Lohle PN, Coerkamp EG, Puvlaert JB. Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. Eur Radio' 1999; 9 (9): 1886-92. Pines B, Rabinovitch J, Biller SB. Primary torsion and infarction of the appendices epiploicae. Arch Sing 1941; 42: 773-87.
Enterocutaneous fistula due to polypropylene mesh migration Dear Editor, Enterocutaneous fistula formation is a recognised late complication of intraperitoneal placement of mesh for incisional hernia repair.
Although well described in the radiological literature, increased awareness among surgeons of the value of CT examination in the diagnosis of PEA may reduce the incidence of unnecessary surgical interventions in this group of patients. 172
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Leber FE, Garb NIS, Alexander AL et al. Long-term complications associated with prosthetic repair of incisional herniae. .Alrcb SitlyT 1998; 133: 375-82.
Systemic effects of intravesical BCG treatment
A 78-year-old mate with a history of five prior abdominal .procedures had undergone three operations to repair recurrent ventral . incisional hernia which was closed with polypropylene mesh on the third occasion I1 years previously. The mesh had been fixed with non-absorbable sutures in the preperitoneal position. He had been asymptomatic until this presentation. He presented with chills and fever and a draining suppurative tract in the lower abdomen adjacent to the incisional hernia. An abscess was incised and a drain left in place. There was no history of feculent discharge. Cultures grew mixed flora. Parenteral antibiotherapy were given. A Gastrografin fistulogram revealed a communication With the ileum. A six-week trial of bowel rest, total parenteral nutrition and somatostatin failed to close the fistula. Operative treatment was by fistulectomy, small bowel segmental resection and resection of the polypropylene mesh ( see Figures I and 2) . The laparotomy incision was closed with ethibond. The patient recovered well postoperatively and at one-year follow-up the herniorrhaphy has remained intact. In 1981, Kaufman first reported enterocutaneous fistula formation as a late complication of intraperitoneal placement of mesh and advised against this technique. The incidence of enterocutaneous fistula due to prosthetic mesh is reported to be higher in the subfascial (5.2%) than the onlay (2.6%) position, and higher yet with large ventral hernias and obesity.''' The mechanism of fistula formation in our patient might include close contact between mesh and bowel resulting in an inflammatory reaction, necrosis and penetration into the lumen. Migration may also be faciliated by the effects of peristalsis. The delayed presentation of this complication suggests that the risk does not disappear with time. -
T Acar, I Gömceli, R Tacyildiz, S Sözen, S Karakayali, R Aydin Department of Surgery, Emergency Aid and Traumatology Hospital, Ankara, Turkey References I. Kaufiman Z, Engelberg M, Zager M. A late complication of Niarlex mesh repair. Dis Colon Rectum 1981; 24: 543-4. 2. Bleichrodt RP, Simmermacher RK, Van der B, Chakenraed IM. Expanded polytetrafluorethvlene patch versus polypropylene mesh for the repair or contaminated defects or the abdominal wall. Sing Gvnecol Obstet 1993; 176: 18-24. 3.
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Hesselink VJ, Luijendijk RSV, Wilt HJ, Heide R, Jeekel J.: i evaluation of risk factors in incisional hernia recurrence. Sung Gynecol Obstet 1993; l'6:
Dear Editor, Systemic side effects can occur from intravesical bacillus Calmette-Guerin (BCG) instillation and may result in serious complications. A 69-year-old male with a history of insulin-dependent diabetes mellitus underwent transurethral resection of a bladder tumour. Histology confirmed a high grade superficial transitional cell carcinoma of the bladder mucosa (pT 1 G3) . Standard treatment of six weekly instillations of intravesical BCG using a Pasteur strain of BCG to reduce the risk of recurrence. He developed rigors after the third treatment which settled spontaneously within 24 hours, and developed dyspnoea following the fourth treatment. He was admitted with anorexia, night sweats, dyspnoea, weakness, haematuria and urinary frequency. Examination revealed pitting oedema and recent weight loss. His blood glucose was 19.0mmol/l, WCC was 13.1x10 / and serum albumin level 24g/1. Chest X-ray showed no cavitating changes or congestive cardiac failure, but interstitial changes initially thought consistent with chronic lung disease. X-rays from four years earlier were normal and clinical features were consistent with interstitial pneumonitis secondary to intravesical BCG therapy. Urine microscopy revealed acid and alcohol fast bacilli, proven on culture to be BCG. He was commenced on the oral anti-TB therapy Rifater (rifampicin 120mg, isoniazid 50mg and pyrazinamide 300mg), five tablets daily for six weeks, followed by Rifinah 300 (rifampicin 300mg and isoniazid 150mg) txvo tablets daily. Pyridoxine was given to prevent isoniazid-induced peripheral neuropathy. His condition improved. After three months, his weight was normal and he was asymptomatic. anti-tuberculous treatment lasted for six months. He remains recurrence free from bladder carcinoma at one year. Systemic effects of BCC treatment can present insidiously and can be life threatening. Side effects are more common after traumatic instillation. Diagnostic difficulties occurred in our patient as he did not have the classical persistent raised temperature on admission. Prompt anti-TB treatment is the therapeutic option of choice. This should be initiated if a patient receiving BCG therapy develops a pyrexia lasting >48 hours which does not respond to oral antipyretics, even in the absence of a definitive mycobacterial culture. Oral prednisolone enhances survival in BCG septic shock. We would advise antituberculous therapy in all cases where acute unexplained ill health develops after intravesical BCG therapy. Systemic BCG results in serious complications in 3% of patients.' They include persisting pyrexia >39°C (2.9%), granulomatous pneumonitis or hepatitis (0.7%), arthralgia (0.5%), BCG septic shock (0.4%) and 0.1% develop cytopenia.` Sepsis is defined by the ACCP/SCCM consensus conference committee as "The systemic response to infection which is characterised by two or more of the following conditions resulting from that infection: temperature greater than 38°C or below 36°C, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute or PaCO2 below 32mmHg, white cell count greater than 12,000/mm' or below 4,000/mm or greater than 10% immature" . Septic shock occurs when the above criteria are met. In addition, the 3
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