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Home , Adhesion (medicine), Blind loop syndrome, Diverticulosis, Lipoma

Self-assessment questions 183

An unusual cause of

A Huang, D L McWhinnie, G P Sadler

A 73-year-old woman presented with a 24-hour history of colicky , abdominal distension and vomiting. Medical history revealed that her bowels were opening normally and there was no history of recent change in bowel habit or weight loss. She was hypertensive and had not undergone previous abdominal . The patient had previously been investigated for rec- tal haemorrhage when a barium enema was performed (figure 1). Examination of her revealed distension with no or external herniae. On auscultation tinkling bowel sounds were heard. No peritonism was present and digital rectal examination was normal. Plain abdominal radiograph was obtained (figure 2). The patient underwent an exploratory laparotomy, following which she made uneventful recovery. A post-operative small bowel enema confirmed the diagno- sis (figure 3).

Figure 1 Barium enema Figure 2 Plain abdominal X-ray Department of , Milton Keynes Hospital, Standing Way, Eaglestone, Milton Keynes MK6 5LD, UK A Huang D L McWhinnie G P Sadler

Correspondence to Questions Mr A Huang, 40 York Terrace East, London 1 What is the diagnosis? NW1 4PT, UK 2 What are the diVerential causes of this Submitted 22 March 1999 condition? Accepted 14 June 1999 Figure 3 Small bowel enema 3 What are the surgical options at laparotomy? 184 Self-assessment questions

Answers Learning points QUESTION 1 Mechanical small bowel obstruction. x causes of small bowel obstruction may be categorised into luminal, intrinsic and extrinsic most jejunal diverticula are asymptomatic (60%). QUESTION 2 x When present, symptoms include abdominal Small bowel obstruction may be divided into discomfort, flatulence, borborygmi, luminal, intrinsic or extrinsic (box 1). Adhe- , pseudo-obstruction, stasis or sions, herniae and intra-abdominal ‘blind loop’ syndrome account for 95% of cases with all other condi- x surgical intervention may be necessary for tions being relatively rare. At laparotomy the intestinal obstruction, perforation, haemorrhage patient was found to have an and neoplastic growth x obstruction may arise from enterolith formation, impacted in the with proximal small , intussusception, and bands bowel distension and distal collapse. Multiple jejunal diverticulae were noted, commencing at Box 2 the ligament of Treitz and extending distally for 45 cm. The enterolith had migrated from a into the small bowel lumen and impacted distally causing a bolus obstruction. Extensive diverticular disease of the large where the bowel is ischaemic or gangrenous, bowel was also noted and the rest of the resection with primary anastomosis should be laparotomy was normal. performed.

Discussion

Jejunal diverticula are usually acquired, multi- Causes of small bowel obstruction ple, and located on the mesenteric border of the small bowel where the vessels penetrate the Luminal 1 x foreign bodies muscle. Incidence at autopsy is 0.7%, but this x faeco- and is probably an underestimate as the radiologi- x cal detection rate is up to 2.3%.2 Aetiology is x bezoars unclear but formation may be from disordered x parasites small bowel function and structure, leading to polypoidal tumours x abnormal intestinal motility.3 Synchronous Intrinsic colonic is present in 30–61% of x atresia patients.4 x tumours Asymptomatic jejunal diverticula discovered x strictures (including tuberculosis, Crohn’s) incidentally should be left alone. About 40% of Extrinsic patients with small bowel diverticula are 5 x adhesions symptomatic. These include abdominal dis- x herniae comfort, flatulence, borborygmi, malabsorp- x volvulus tion, pseudo-obstruction, stasis and ‘blind x intussusception loop’ syndrome. In 10% of patients surgical x bands intervention is necessary. Reasons include x inflammatory masses x neoplastic masses intestinal obstruction, haemorrhage and perfo- ration. Neoplastic growth may also occur and Box 1 include fibroma, lipoma, carcinoma and sar- coma formation.2 Intestinal obstruction may arise from entero- lith formation, intussusception or volvulus.167 QUESTION 3 In the latter situation the diverticulum acts as a Small bowel obstruction due to an enterolith pivot, especially where previous may be relieved either by enterotomy or by results in adhesive band formation. Such adhe- simply crushing the enterolith digitally and sions may also cause obstruction by direct milking the fragments into the caecum (as was kinking of the bowel or by trapping another done in this case). In rare cases of small bowel loop of bowel underneath. diverticular disease, where intussusception, haemorrhage or perforation are present, the Final diagnosis diseased segment should be resected and primary anastomosis performed. It may, how- Mechanical small bowel obstruction secondary ever, be necessary to exteriorise the bowel if to an enterolith arising from jejunal diverticu- gross contamination or infection is present. lum. Obstruction caused by band adhesion or volvulus can frequently be relieved by the divi- Keywords: jejunal diverticulum; enterolith; bowel sion of the band without resection. However, obstruction

1 Geroulakos G. Surgical problems of jejunal diverticulosis. 3 Krishnamurthy S, Kelly MM, Rohrmann CA, SchuZer Ann R Coll Surg Engl 1987;69:266–8. MD. Jejunal diverticulosis. A heterogeneous disorder caused 2 Maglinte DDT, Chernish SM, DeWeese R, Kelvin FM, by a variety of abnormalities of or myenteric Brunelle RL. Acquired jejunoileal diverticular disease: sub- plexus. 1983;85:538–47. ject review. Radiology 1986;158:577–80. DIC and during propylthiouracil therapy 185

4 Palder SB, Frey CB. Jejunal diverticulosis. Arch Surg 1988; 7 Soofi R, Abouchedid C. Intussusception of small bowel sec- 123:889–94. ondary to jejunal diverticulosis. NJ Med 1986;83:309–12. 5 Altemeier WA, Bryant LR, Wulsin JH. The surgical signifi- cance of jejunal diverticulosis. Arch Surg 1963;86:732–45. 6 Clarke PJ, Kettlewell MGW.Small bowel obstruction due to an enterolith originating in a jejunal diverticulum. Postgrad Med J 1985;61:1019–20.

Adverse drug reaction

Disseminated intravascular coagulation and vasculitis during propylthiouracil therapy

Imtiaz Khurshid, Jay Sher

The use of antithyroid drugs in the early 1940s trophil cytoplasmic antibody (ANCA) titres revolutionised the management of hyperthy- were normal. Blood cultures were negative and roidism. Since their introduction, a variety of chest X-ray was normal. Bone marrow aspira- adverse reactions, including haematological, tion showed myelosuppression with no evi- dermatological, and rheumatological eVects, dence of leukaemia. Skin showed acute have been associated with these drugs. The vasculitis involving small and medium-sized incidence of these side-eVects is similar to vessels with fibrin thrombi. No immunohisto- many other commonly used drugs, ie, 1–5%.1 chemical testing was done. The skin of the left The most common side-eVects include skin cheek revealed focal superficial epidermal and , fever, arthralgias/arthritis and neutrope- dermal haemorrhagic with marked nia while -like reaction, vasculitis, hepati- acute inflammation and pustule formation. tis, agranulocytosis and thrombocytopenia are The patient was admitted to the hospital and uncommon.2 Disseminated intravascular co- treated with intravenous methylprednisolone agulation (DIC) is a rare adverse eVect of pro- 125 mg every 8 hours. Propylthiouracil was pylthiouracil therapy.3 Herein we report a case discontinued. She responded to intravenous of DIC and vasculitis following a short course methylprednisolone and the purpuric rash of propylthiouracil therapy. gradually disappeared. Subsequently steroids were tapered over next 2 weeks. The haemato- Case report logical abnormalities returned to normal.

A 42-year-old African-American woman with Discussion Grave’s disease, diagnosed 20 years earlier, had received propylthiouracil (100 mg tid) for the The most frequent adverse eVects related to past 2 weeks because of recent exacerbation of propylthiouracil and methimazole, the two symptoms. She was admitted to the hospital most commonly used thionamides, are haema- because of sudden onset of palpable purpuric tological. Transient leucopenia, perhaps the rash, which started on the face and later spread most common side-eVect, has been reported in to her trunk and extremities. 12% of adults and up to 25% of children,4 Laboratory test results on admission dis- while cutaneous adverse reactions occur in closed the following data: haemoglobin 12.2 3–5% of adults and up to 18% of children.45 g/dl, haematocrit 37.8, white blood cells 15.5 × Generalised maculopapular and papular pur- 109/l, platelets 49 × 109/l, erythrocyte sedimen- puric eruptions are perhaps the most common tation rate 23 mm/h, free thyroxine 3.7 ng/dl thionamide-induced cutaneous reactions, but Jersey Shore Medical (normal 0.71–1.85); and thyroid-stimulating rarely bullous haemorrhagic, generalised ve- Center, Department of hormone <0.03 mIU/ml. Tests for erythrocytes sicular and necrotic ulcerative forms have been Endocrinology,1945 5 State Route 33, were normal. Tests for coagulation studies described. Propylthiouracil induces a clini- Neptune, NJ 07754, revealed prothrombin time 14.3 s (10.6–13.4); cally distinctive cutaneous eruption consisting USA activated partial prothrombin time 28.0 s (18– of symmetrical, tender, palpable purpuric I Khurshid 38); D-dimer test positive; fibrinogen degrada- lesions, often in a livedoid pattern and J Sher tion products positive; fibrinogen level 344 curiously involves the ear lobes and malar 5–9 Correspondence to mg/dl (152–392). Serum complement studies areas. Cutaneous vasculitis is usually seen I Khurshid, MD, showed C3 133 mg/dl (88–200), C4 12 mg/dl early in the course of propylthiouracil therapy, Department of Medicine, (16–47) and CH 126 U/ml (100–300 CH ). but has also been observed after long-term 2N-64, East Carolina 50 50 University School of Serum haptoglobin level was normal. treatment. Its exact incidence is not known. Medicine, Greenville, NC Urinalysis showed trace protein and moder- Vasculitic involvement of skin is far more com- 27858–4354, USA ate blood in the urine. Antinuclear, anti-DNA mon than other organs. Cases of nephritis, Submitted 20 August 1999 single stranded, anti-DNA double stranded, myositis, and cavitary pulmonary infiltrates Accepted 20 August 1999 antihistone, antithyroglobulin and antineu- have been reported.67