Category Archives: Case Report

Surgical Strategy in Bouveret’s Syndrome. A Case Report

Márton István Dénes, Árpád Török, Etele Éltes, Levente Kucserik, Zsolt András, Bogdan Borz, Cristian Borz*

University of Medicine and Pharmacy Targu Mures, Romania

DOI: 10.1515/amma-2016-0017

Bouveret’s syndrome is a high mechanical obstruction due to impaction of a gallstone into the duodenum, through a cholecystoduodenal fistula. It belongs to a larger group of gallstone ileus, a disease which occurs after developing a fistula between the gallbladder and the gastrointestinal tract. This is a rare complication of gallstones but because it appears in elderly people, it has a high morbidity and mortality. Patients have various symptoms and the treatment is individualized. We present here a case of a 67 years old patient, admitted in emergency, presenting symptoms of high bowel obstruction, with onset 5 days before admission. Abdominal ultrasound reveals a 5 cm stone that seems to be in the gallbladder, gastric stasis and at gastroscopy appears a foreign body impacted in the duodenum. After a short preparation the patient underwent surgery. We found a dilated stomach and a large cholecystoduodenal fistula with an impacted gallstone in the duodenum. We performed one stage surgery: cholecystectomy, extraction of the stone and suturing of the fistula. We reestablished the continuity of the intestinal tract. We performed also an ileostomy for feeding the patient and protecting the anastomoses. The postoperative evolution was favorable.
We consider that one stage surgical treatment in gallstone ileus is an option, if the patient is in good condition and we have an adequate postoperative intensive care management.

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Deep Venous Thrombosis Associated With Inferior Vena Cava Abnormalities And Hypoplastic Kidney In Siblings

Duicu Carmen*, Bucur Gabriela, Simu Iunius, Tripon Florin, Marginean Oana

University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0011

Congenital inferior vena cava anomalies have a reduced frequency in general population, many times being an asymptomatic finding. Patients caring such anomalies are at risk to develop deep vein thrombosis. In this paper, we present 2 siblings with deep venous thrombosis and inferior vena cava abnormalities, with a symptomatic onset at similar age. The inferior vena cava abnormality was documented by an angio-CT in each case. The thrombophilic workup was negative. Patients were treated with conservative therapy: low molecular weight heparin anticoagulants converted later to oral anticoagulant with resolution of symptoms and disappearance of the thrombus. Finally, in the absence of any risk factor in a young patient admitted with deep vein thrombosis investigations to exclude inferior vena cava anomalies are mandatory.

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Endocrine dysfunction in neurofibromatosis type 1 – an update

Pop Raluca-Monica1,2, Radu Mircea Neagoe3, Kolcsar Melinda4*, Paşcanu Ionela5

1 Research Methodology Department, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Endocrinology Outpatient Clinic, Emergency Mureş County Hospital, Tirgu-Mures, Romania
3 Surgery Department, University of Medicine and Pharmacy Tirgu Mures, Tirgu-Mures, Romania
4 Pharmacology and Clinical Pharmacy Department, University of Medicine and Pharmacy Tirgu Mures, Tirgu-Mures, Romania
5 Endocrinology Department, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0003

Background: Neurofibromatosis type 1 is an autosomal dominant disorder associated with multiple neoplasms particularly those of ectodermal origin. Various endocrine pathologies are often present, among them, hyperparathyroidism and follicular thyroid lesion are very rare described and their coincidence in the same patient has not been described in the literature reviewed.
Subject: A 59-years-old woman with clinical manifestation of neurofibromatosis type 1 developed dysphagia, dysphonia, choking sensation. Physical and imagistic examination revealed a multinodular goiter with microfollicular lesion on fine needle aspiration biopsy (FNAB), elevated parathormone levels and severe osteoporosis. The surgically removed thyroid contained a nodule with follicular architecture of uncertain malignant potential; the parathyroid tissue appeared normal.
Discussion and conclusion: This case serves as a reminder to look for non-neurogenic tumors in patients with neurofibromatosis. Clinicians must be aware of the diverse clinical features of this genetic disorder.

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Volemic resuscitation in a patient with multiple traumas and haemorrhagic shock. Anti-oxidative therapy management in critical patients. A Case Report

Bedreag Ovidiu Horea1,2, Rogobete Alexandru Florin1,2*, Sarandan Mirela3, Cradigati Alina Carmen3, Nartita Radu1, Sandesc Dorel1,2, Papurica Marius1,2

1 Clinic of Anaesthesia and Intensive Care, Emergency County Hospital ”Pius Brinzeu”, Timisoara, Romania
2 Faculty of Medicine, ”Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
3 Clinic of Anaesthesia and Intensive Care ”Casa Austria”, Emergency County Hospital ”Pius Brinzeu”, Timisoara, Romania

DOI: 10.1515/amma-2016-0002

A patient with multiple traumas is usually found in severe haemorrhagic shock. In 40% of the cases, the patient with multiple traumas and haemorrhagic shock cannot recover due to secondary injuries and complications associated with the shock. In this paper we present the case of a male patient 30 years old, who suffered a car accident. The patient is admitted in our hospital with haemorrhagic shock due to femur fracture, acute cranial-cerebral trauma and severe thoracic trauma with bleeding scalp wound, associated with lethal triad of trauma. The clinical and biological parameters demand massive transfusion with packed red blood cells (PRBCs), fresh frozen plasma (FFP), cryoprecipitate (CRY) and colloidal solution (CO) sustained with vassopresor for the haemodynamic stabilisation. During his stay in the ICU, the patient benefits from anti-oxidative therapy with Vitamin C, Vitamin E and Vitamin B1. After 14 days the clinical state of the patient improves and he is transferred in Polytrauma Department.

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Particular Aspects of a Pancreatic Insulinoma Case

Motoc R1,2, Albu C2, Munteanu Irina2, Dirtu Oana2, Motoc Crina2, Tilea I3,2

1 Internal Medicine Clinic III, Dept. M3, Faculty of Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Tirgu Mures Emergency Clinical County Hospital, Tirgu Mures, Romania
3 Family Medicine, Dept. M3, Faculty of Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0130

With a very low incidence (1-4 cases per 1 million per year), characterized by insulin hypersecretion, independent of the glycemia control system, insulinoma is a rare endocrine tumor, clinical with accentuated neuropsychological symptoms that hampers clinical diagnosis. We present a case of a 33 years old patient with no notable personal history, active lifestyle, non-smoker, a work environment that doesn’t involve professional toxicity; a remarkable family history of a brother with type 1 diabetes mellitus and grandmother with liver adenocarcinoma was noticed; in this particular case Whipple triad was strongly suggestive, gastrointestinal upper-ultrasonography endoscopy with tissue puncture as a tumor diagnostic tool was used and laparotomy was used successfully for removing the tumor, with favorable follow-up.

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Coronary Artery Dissection in the Left Main Treated with Stenting in a Patient with Multiple Re-infarction – Case Report

Nyulas Tiberiu1, Blendea Ciprian1,2, Barcan Andreea1, Bajka Balazs1,2, Korodi Szilamer1, Rat Nora1

1 University of Medicine and Pharmacy of Tîrgu Mureș, Clinic of Cardiology, Tîrgu Mureș, Romania
2 Cardio Med Medical Center, Department of Advanced Multimodal Imaging, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0129

Introduction: In complex cases of multiple coronary artery stenosis, revascularization strategy could be essential for improving the life expectancy andqualityof life. However, major complications are sometimes encountered during interventions, such as rupture of the atheromatous plaque with consequent dissection of the coronary artery, causing an acute coronary syndrome which requires immediate intervention from the operator. In the absence of an experienced interventional cardiologist a complication like this can be fatal. Case presentation: We present the case of a 67-years old patient, male, with a known history of cardiovascular disease, who presented in our service complaining of chest pain with tightening character, irradiation in the shoulder and left arm, respectively shortness of breath and fatigue. The patient presented a history of multiple infarctions, intervention and stenting on RCA and circumflex artery. Computed Tomographic Coronary Angiography provided detailed information on the location of the target lesions and was followed by a revascularization procedure. However, despite the complex pre-interventional assessment, while trying to engage the guide in the emergence ofthe circumflex artery, atherosclerotic plaque rupture occurred, causing a dissection of the coronary wall which extended retrogradely into the left main, requiring a rapid response from the operator. A coronary stent was implanted into the left coronary artery trunk, treating the dissection. Conclusions: Coronary artery dissection is a very serious complication that can occur during a complex revascularization procedure, requiring immediate intervention in order to save the patient’s life.

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Inferior Vena Cava Hypoplasia Associated with Deep Vein Thrombosis – Case Presentation

Nyulas Tiberiu1, Blendea Ciprian1,2, Rat Nora1, Barcan Andreea1, Korodi Szilamer1, Bajka Balazs1,2

1 University of Medicine and Pharmacy of Tîrgu Mureș, Clinic of Cardiology, Tîrgu Mureș, Romania
2 Cardio Med Medical Center, Department of Advanced Multimodal Imaging, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0128

Introduction: We present the case of a patient suffering from inferior vena cava hypoplasia complicated with Phlegmasia cerulean dolens. Imaging techniques allow precise diagnosis of inferior vena cava hypoplasia, providing essential structural details on the degree of damage of the vena cava and for the other branches. Case presentation: A 58 years old, obese and diabetic male patient presented with intense pain in the lower limbs, with the onset 24h before presentation. The patient presented generalized edema, cyanosis and functional impotence. Angio CT examination revealed hypoplasia of the inferior vena cava, with extensive DVT (deep vein thrombosis). In emergency conditions, with the agreement of the patient, we initiated the thrombolytic therapy (streptokinase for 72h) associated with anticoagulants (heparin). The evolution was favorable: a significant reduction in leg circumference was recorded, together with pain relief and reduction of local inflammation in the lower limbs. Conclusion: Severe cases of inferior vena cava hypoplasia complicated with deep vein thrombosis can present a good prognosis if appropriate treatment with anticoagulants and thrombolytics is initiated in time.

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Intersphincteric Resection for Low Rectal Cancer – Case Report

Russu Cristian1, Molnar Călin1*, Copotoiu Sanda Maria2, Sărăcuț Claudiu1, Gherghinescu Mircea1, Molnar Varlam Claudiu3, Copotoiu Constantin1

1 Surgical Clinic 1 of the Emergency County Hospital and the University of Medicine and Pharmacy of Tîrgu Mureș, Romania
2 Anesthesia and Intensive Care Clinic 1 of the Emergency County Hospital and the University of Medicine and Pharmacy of Tîrgu Mureș, Romania
3 Obstetric-Gynecology Clinic, Clinical Emergency County Hospital Tirgu Mures, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0118

Introduction: Surgical treatment for low rectal cancer represents a challenge: to perform a radical resection and to preserve the sphincter’s function. We report a case of intersphincteric resection in a combined multimodality treatment for low rectal cancer, with good oncologic and functional outcome.
Case presentation: We report a case of a 73 years old woman admitted in April 2014 in surgery, for low rectal cancer. The diagnostic was established by colonoscopy and malignancy confirmed by biopsy. Complete imaging was done using computed tomography and magnetic resonance to establish the exact stage of the disease. The interdisciplinary individualized treatment began with radiotherapy (total dose of 50 Gy, administered in 25 fractions) followed by surgery after eight weeks. We performed intersphincteric rectal resection by a modified Schiessel technique. There were no postoperative complications and the oncologic and functional results were very good at one year follow up.
Conclusions: Intersphincteric resection, in this selected case of low rectal cancer, represented an efficient surgical treatment, with good functional results and quality of life for the patient. A multidisciplinary team is an invaluable means of assessing and further managing the appropriate, tailored to the case, treatment in the aim of achieving best results.

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Multiparasitic Infection (Hydatid Cyst of the Spleen and Ascaris Lumbricoides Infestation) Mimicking an Acute Surgical Abdomen – Case Report

Molnar Călin1, Vizitiu Alexandru1*, Deak Karoly1, Russu Cristian1, Tudor Adrian1, Suciu Bogdan1, Stolnicu Simona2, Hulub Marius3, Molnar Claudiu4

1 Surgical Clinic No. I, Clinical Emergency County Hospital Tirgu Mures, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Anathomo-Pathology Clinic, Clinical Emergency County Hospital Tirgu Mures, University of Medicine and Pharmacy Tirgu Mures, Romania
3 University of Medicine and Pharmacy Tirgu Mures, Romania
4 Obstetric-Gynecology Clinic, Clinical Emergency County Hospital Tirgu Mures, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0117

Hydatid cyst involving the spleen is a rare clinical condition (0.5-4%). We report a case of multi-parasitic infection in a 62 year old female (hydatid cyst and ascaris lumbricoides infestation), confirmed during surgery. The purpose of the paper is to emphasize on the rare association of the two parasitic infections, affecting two different organs (spleen and jejunum). The combined symptomatology of the two parasites could mimic an acute surgical abdomen.

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Percutaneous Revascularization in a Case of Vasospastic Angina Associated with Polymorphic Ventricular Tachycardia

Rudzik Roxana, Şuş Ioana *, Hadadi László, Şerban Răzvan Constantin, Dobreanu Dan

University of Medicine and Pharmacy of Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0106

Introduction: Coronary vasospasm is a possible cause of ventricular tachyarrhythmias and is frequently associated with atherosclerotic lesions. The revascularization of mild to moderate coronary artery stenosis which causes symptoms only due to associated vasospasm is still a matter of debate, as the standard treatment of Prinzmetal angina is represented by the long term administration of calcium-channel blockers.
Case presentation: We present the case of a 46 year old woman with an intermediate severity coronary artery stenosis complicated by vasospastic angina and subsequent polymorphic ventricular tachycardia. Although the functional significance of the fixed coronary artery lesion was equivocal at invasive fractional flow reserve measurement, a combined pharmacologic and interventional treatment strategy was chosen with stent implantation and long acting calcium channel blocker administration with a symptom-free, good clinical outcome.
Conclusion: Patients with vasospastic angina and intermediate severity atherosclerotic coronary artery stenoses are at risk of malignant ventricular arrhythmias, therefore myocardial revascularization should be considered in addition to the standard medical treatment.

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