No abstract

We report a case of spontaneous rupture of the urinary bladder (SRUB) due to bacterial cystitis in a 76-year-old woman with chief complaint of abdominal pain a day before presentation. She had fever (38.0°C), and her systolic blood pressure dropped to 70 mmHg; she was referred to our hospital, where she was admitted with a diagnosis of ileus. However, her abdominal pain worsened the following day, and abdominal CT showed free air. Emergency laparotomy was performed for suspicion of digestive tract perforation, which revealed a small hole at the dome of the urinary bladder and another at the peritoneum. Suture repair was performed. We reviewed the abdominal CT on admission and noted that the perforation of the urinary bladder was present during admission, whereas that of the peritoneum occurred the following day. SRUB is rare, and bacterial cystitis rarely causes it; thus, accurate diagnosis and proper treatment are essential.

Introduction: Balloon angioplasty is a common endovascular procedure. The balloon for angioplasty sometimes ruptures (incidence, 3.6%–10%), and it is constructed such that it ruptures in a longitudinal direction and complications related to rupture are rare. However, on rare occasions, retrieval is challenging, especially in the case of ruptures with a circumferential tear. There is no established method for retrieval and careful retrieval is required due to the risk of embolization by the residual balloon fragment. Technique: We describe two cases of balloon rupture in the transverse direction during percutaneous transluminal angioplasty for arteriovenous fistula in hemodialysis patients. In these cases, the balloon ruptured with a circumferential tear and dissected into two parts, and the tip edge remained in the vessel. We inserted an additional introducer at the side of the tip edge, caught the guidewire by a gooseneck snare, and hooked the residual balloon fragment. This also stabilized and increased the stiffness of the guidewire through the “pull-through technique.” Then, we reintroduced the gooseneck snare to catch the residual balloon. We then inserted a cobra-head catheter from the first introducer and pushed the residual balloon. We finally retrieved the ruptured balloon by pulling back the gooseneck snare and pushing using the cobra-head catheter simultaneously. Results: We could retrieve the ruptured balloons successfully using this technique and percutaneous transluminal angioplasty was continued in both cases. Conclusion: Our technique of retrieval may be suitable for cases of balloon rupture with a circumferential tear during percutaneous transluminal angioplasty. The technique enables less invasive retrieval and continuation of the percutaneous transluminal angioplasty thereafter.

A 70-year-old man was referred to our hospital on June 25, 1999 because of recurrent painful tonic spasms in the upper abdomenand lower extremities. The patient used to work as a carpenter and had been retired for several years. He also had worked as a coal miner for a brief period. An appendectomy was performed at the age of 20. He underwent parathyroidectomy because of hyperparathyroidism in 1993. An episode of gout occurred some years before admission. He had been given diagnoses of hyperuricemia, essential hypertension, and supraventricular arrhythmia someyears earlier, and had been treated elsewhere. The treatment had been discontinued for morethan half a year at presentation.On physical examination, a tophus-like nodule was palpated in the right auricle. The patient's liver, spleen, and lymph nodes were not palpated. There was slight tenderness in the epigastrium. Neurological examination was negative. The temperature was 35.7°C, the blood pressure was 154/90 mmHg,and the pulse was 84/min and irregular.AnECGrevealed supraventricular and ventricular premature contractions. An abdominal computed tomographic (CT) scan disclosed a small simple cyst in the left lateral lobe of the liver (Fig. 1A). Upper gastrointestinal endoscopic and total colonoscopic examinations were performed because of positive tests for occult blood of feces. The patient had mild gastritis and colonic adenomatouspolyps. Cranial CT scan disclosed two lacunar infarctions in the bilateral basal ganglia. Since electroencephalogram disclosed abnormalspikes, sodium valpronate was begun under a tentative diagnosis of symptomatic epilepsy with modest improvement of the tonic spasms. Laboratory data on admission disclosed abnormal liver function tests (aspartate aminotransferase 121 IU//, alanine aminotransferase 68 IU//, and alkaline phosphatase 364 IU//), that returned spontaneously to the normal levels. Since the serum uric acid level was high (9.3 mg/dl), benzbromarone was prescribed. The serum uric acid level rapidly returned to the nor- antibiotics developed in a 70-year-old man suffering from intractable recurrent gouty arthritis. 67Ga-scintigraphy disclosed intense focal uptake in the upper abdomen. The lesion in the left lobe of the liver was an ill-defined hypodensity mass on computedtomographic scan and wasenhanced on dynamicmagnetic resonance imaging. The tumor was surgically removed and a diagnosis of IPT was made. Fever and arthritis resolved completely after surgery. Possible interaction between IPT of the liver and gouty arthritis was suggested. (Internal Medicine 40: 493-498, 2001)

Preoperative percutaneous transhepatic portal vein embolization (PTPE) has been used in recent years to decrease the amount of liver resected and to reduce the risk of postoperative liver failure in patients with hepatocellular carcinoma. Various thrombogenic agents have been employed for this purpose..We evaluated the clinical safety and efficacy of absolute ethanol for PTPE and examined the histopathologic changes that follow ethanol embolization of the liver. We studied nine patients with hepatocellular carcinoma who were not originally regarded as surgical candidates because of a high risk of postoperative liver failure. They received preoperative PTPE of the right portal vein, with an average of 22.8ml of absolute ethanol. The right iobe showed complete obstruction of portal venous branches and massive necrosis of the liver parenchyma. Macroscopically, there was atrophy of the embolized lobes and compensatory hypertrophy of the remaining lobes. The mean volume of the nonembolized lobe increased, from 351 to 585 and 633ml, 2 and 4 weeks after embolization, respectively. The mean regeneration rate of this lobe was 16.7cm3/day for the first 2 weeks after embolization and 10.1 cm3/day for the first 4 weeks. Transient dynamic increases in alanine aminotransferase concentrations were seen. All patients subsequently underwent right lobectomy of the liver and survived without severe complications. Portal vein embolization with absolute ethanol makes more extensive hepatectomy possible by reducing the volume necessary to resect, and it preserves the function of the remaining liver.