תוצאת חיפוש

אלישבע בר-מאיר

מכון הרנטגן ומכון מ.א.ר. המרכז הרפואי בני-ציון, הפקולטה לרפואה רפפורט, הטכניון, חיפה

סרטן הכרכשת הוא הקטלני ביותר מכלל סוגי הסרטן הידועים. הבדיקות הקיימות היום לגילוי מוקדם של מחלה זו אין יעילות דיין, מאחר ששליש בלבד מהאוכלוסייה מבצעים בדיקות שיגרתיות לגילוי מוקדם של המחלה.

עם פיתוח דור חדש של סורקי טומוגרפיה מחשבית מסוג multi-slice, המאפשר סריקת נפח (scanning) מהירה, ניתן היום לבצע בדיקה מהירה ויעילה לגילוי סרטן הכרכשת ולמניעתו. השיפורים הטכנולוגיים שהושגו מאפשרים ביצוע בדיקה לגילוי פוליפים בקוטר 6 מ"מ ומעלה ברגישות הזהה לזו המתקבלת בקולונוסקופיה אנדוסקופית. הבדיקה אינה כרוכה בסיבוכים כלשהם, היא מהירה, יעילה ומתקבלת ברצון על ידי ציבור הנבדקים.

בעבודה זו מובאות תוצאות יישום הבדיקה המדווחות בספרות הרפואית, חסרונותיה ויתרונותיה, ויובא ניסיון המחברים בביצוע הבדיקה ב- 1,450 נבדקים.

הוריות לביצוע בדיקת קולונוסקופיה וירטואלית כוללות:

1)    מצבים בהם האנדוסקופ אינו מאפשר להשיג דימות מלא של הכרכשת עקב פיתוליות המעי או סיבות טכניות אחרות;

2)    הדגמה של המעי קריבנית לתהליך חסימתי – לעיתים קרובות הדגמה כזו אינה מתאפשרת באמצעות אנדוסקופ או בצילום לאחר חוקן באריום. הוריה זו חשובה במיוחד כהכנה לניתוח לכריתת שאת של הכרכשת.

הוריות יחסיות בעתיד כוללות:

1)    בדיקות סקירה (scanning) לגילוי מוקדם באוכלוסייה מעל גיל 50 (ובאוכלוסיית סיכון מעל גיל 40);

2)    בדיקות מעקב לאחר כריתת פוליפ או תהליך שאתי בכרכשת.

אילן ליבוביץ, איליה פוליצ'וק, טטיאנה רייטבלט, דוד גיאורגיו ודורון זמיר

מובאת בזה פרשת חולה, שאובחנה כלוקה במורסה של הטחול והחלימה לכאורה בעקבות טיפול אנטיביוטי. בשל היעדר סיבה ברורה או גורמי סיכון למורסה, בוצע צילום לאחר חוקן באריום שחשף שאת של הכרכשת באזור כפף הטחול, שלא הודגמה בבדיקת טומוגרפיה מחשבית ובבדיקת על-שמע של הבטן.

בחולים הלוקים במורסה של הטחול מסיבה לא ברורה, מן הצורך לשלול שאת של הכרכשת, ולשם כך נדרשת בדיקת דימות או בדיקה אנדוסקופית של הכרכשת.

ניר מרכוס (1,2), אמנון וזינה (1), בועז תדמור(1)

(1) חיל הרפואה, צה"ל, (2) המח' לרפואת ילדים א', מרכז שניידר לרפואת-ילדים, פתח תקוה

בוטוליזם הינקות הוא מחלה רעלנית-זיהומית, הנגרמת על-ידי נבגים של Clostridium botulism הנובטים בכרכשת, מתרבים ומפרישים רעלן. פרשת החולה הראשונה דווחה בשנת 1931. בדו"ח זה דווח על תינוק בן שלושה חודשים וחצי, שאושפז עם הפרעה בבליעה, חולשת שרירים ועצירות. בבדיקת הצואה של התינוק נמצא החיידק קלוסטרידיום בוטולינום (ק"ב). ההנחה היתה שהגורם הבלעדי למחלת הבוטולינום היה אכילת שימורים מעשה-בית. האפשרות של התפרצות המחלה בתינוק זה, הניזון מחלב אם, נשללה על הסף, והאבחנה של בוטוליזם נדחתה. רק בשנת 1976 הוגדרה מחלת בוטוליזם הינקות על מאפייניה הקליניים, האפידמניולוגיה והפתופיזיולוגיה.

Colonic Pseudo-Obstruction (Ogilvie Syndrome) Following Cesarean Section

Ido Solt, Peter Jakobi

Dept. of Obstetrics and Gynecology, Rambam Medical Center and Technion Faculty of Medicine, Israel Institute of Technology, Haifa

Acute colonic pseudo-obstruction, or Ogilvie syndrome can be a major surgical complication. Ogilvie syndrome, unlike adynamic ileus, is usually not self-limiting and may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Ogilvie syndrome represents a diagnostic and therapeutic challenge that deserves a multidisciplinary approach. We present a case report and a literature review of the syndrome.

Pseudomembranous Colitis: Clinical, Endoscopic and Radiological Correlation - A 2 - Year Experience

Fabiana Benjaminov MD⁽¹⁾, Rivka Zissin MD⁽²⁾, Benjamin Novis MD⁽¹⁾

⁽¹⁾Gastroenterology Institute and ⁽²⁾CT Unit, Meir Hospital, Sapir Medical Center, Kfar-Saba, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Abstract: The incidence rates of pseudomembranous colitis are rising. Early diagnosis and treatment are required for management of this potentially life-threatening disease. This report outlines our 2-year experience (1997-1998) at the gastrointestinal institute with 43 patients diagnosed with pseudomembranous colitis and describes the clinical course and imaging studies.

The group consisted of 25 women and 18 men, aged 34-93 years (mean: 67). Thirty-nine patients were treated with antibiotics. Twelve patients were referred directly to an endoscopic examination with a presumed clinical diagnosis of pseudomembranous colitis (diarrhea, fever and abdominal pain) that was confirmed by colonoscopy. Thirty-one were referred to colonoscopy following abdominal imaging performed to clarify cause of fever and abdominal pain. Twenty-nine patients had an abdominal CT, one had an US and one a barium follow-through. The CT finding suggesting pseudomembranous colitis included colonic mural thickening in 28 patients (71% diffuse versus 29% segmental colitis), with an average wall thickness of 16 mm. Sixteen patients (59%) had pericolonic fat changes and 15 patients (51%) had ascites. All of these patients, except one, had endoscopic findings consistent with pseudomembranous colitis.

Five patients (11.6 %) died due to the severe PMC.

To conclude, as an abdominal CT is often performed in the acutely ill patient, it may arouse the diagnosis of pseudomembranous colitis in the proper clinical setting. Such a suspected diagnosis justifies endoscopic evaluation, which is the most reliable diagnostic examination.

Metallic Stents for Acute Colonic Obstruction

M. Itkin, E. Atar, H. Neuman, D. Kravarosic, Z. Fuko, M. Kaz

Radiology and General Surgery B Depts., Golda Campus; and General Surgery Dept., Beilinson Campus; Rabin Medical Center, Petah Tikva

The traditional treatment of acute colonic obstruction, usually caused by malignant tumor, is a 2-stage surgical procedure. The first operation is emergent and includes primary tumor resection and end colostomy followed by scheduled colostomy closure. These operations are associated with high mortality and morbidity. Recently, insertion of self-expanding metallic stents for temporary colonic decompression has been was introduced. With this new technique colostomy can be avoided in the acute phase.

In advanced colonic cancer stent-insertion is the only palliative treatment. It is done in the radiology department under fluoroscopic guidance. We present 2 cases of malignant colonic obstruction treated successfully by stent insertion.

One-Stage Surgery for Hirschsprung's Disease in Children

Mark Weinberg, Baruch Klin, Itzhak Vinograd

Dept. of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, and Sackler School of Medicine, Tel Aviv University

Traditionally Hirschsprung's disease has been treated by 2-or 3-stage procedures. During the past 6 years a 1-stage Duhamel procedure without stoma has become our treatment of choice for Hirschsprung's disease in neonates and young infants. Over a 6-year period, 15 infants and children with colonic Hirschsprung's disease were treated with the 1-stage Duhamel retro-rectal pull-through procedure without a stoma, with the Lester-Martin modification. All patients had the usual short segment aganglionosis, but 1 had a long segment which included the splenic flexure.

Early complications included wound infection in 1 and minor rectal bleeding in 3. Late complications included constipation in 1 and enterocolitis in 4. Long-term functional results were very good in all those operated except for 1 with rectal achalasia.

We conclude that Hirschsprung's disease can be successfully treated with a 1-stage pull-through operation, the child usually benefitting from the shorter hospital stay and the avoidance of a colostomy.

Adjuvant Therapy of Large Bowel Carcinoma

G. Ezekiel, S. Walfisch, Y. Cohen*

Dept. of Oncology and Colorectal Unit, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C.

From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m²/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines.

16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes.

Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment.

The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p<0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS).

The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

* Jules E. Harris Chair in Oncology.

Muir-Torre Syndrome: Importance of Clinical Diagnosis and Genetic Investigation

Hana Strul, Paul Rozen, Tova Naiman, Ruth Shomrat

Gastroenterology Dept. and Genetics Institute, Tel Aviv Medical Center and Tel Aviv University

Muir-Torre syndrome is a relatively rare cutaneous manifestation of hereditary nonpolypous colorectal cancer (HNPCC). This autosomal dominant syndrome is characterized by a combination of sebaceous gland and malignant visceral tumors. The common sites of internal malignancies are the gastrointestinal tract and urinary system. It appears in early adult life and its clinical course is relatively slow.

In some families genetic diagnosis can identify asymptomatic carriers of the mutation. All first-degree relatives, especially mutation carriers, should be referred from the age of 20 years for routine follow-up and early treatment, as it has been proven to decrease morbidity and mortality.

We present a 51-year-old man with Muir-Torre syndrome diagnosed by the presence of multiple adenomas of sebaceous glands, colonic adenoma and adenocarcinoma of the duodenum. The family history was typical for HNPCC. A mutation in the hMSH2 gene on chromosome 2p was found in the patient and in several asymptomatic family members. The aim of this report is to increase awareness of this syndrome and emphasize the importance of referring patients and their families for clinical and genetic counseling and diagnosis.

Is Ileostomy Necessary In Surgical Treatment of Ulcerative Colitis and Familial Polyposis?

Michael M. Krausz, Simon Daniel Duek

Dept. of Surgery A, Rambam Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Proctolectomy with ileal pouch anal anastomosis (IPAA) has become the procedure of choice for the surgical treatment of ulcerative colitis (UC) and familial polyposis (FP). Ithas traditionally been performed in 2 stages, but recently the necessity for an ileostomy hbeen challenged by several authors who recommend a 1-stage procedure.

5 years ago we started to test this policy for treatment of UC and FP. In 48 patients (Group A), 45 with UC, the 2-step procedure, and in 17 of the 27 in Group B with FP, the 1-stage procedure were performed. The indications for surgery were intractable UC in 37 patients in group A and in 5 patients in Group B (p<0.01).

Postoperative infection due to bowel leakage developed in 2 in Group A and in 6 in Group B (p<0.01). Reoperation was necessary in 4 patients (15%) in Group B and only 1 (0.9%) in Group A (p<0.01). Bowel leakage in Group B occurred in 5 (19%) with UC and in only 1 with FP (p<0.05), which responded to medical treatment. All those with UC who developed this complication were relatively malnourished, with serum albumin levels lower than 3.0 g% and were regulated with corticosteroids.

We therefore conclude that the 2-stage IPAA is feasible and safe for the treatment of UC and FP. The 1-stage IPAA should be limited only to FP or good risk UC patients.

Multiple Angiodysplastic Lesions of the Colon - a Therapeutic Challenge

Nir Hilzenrat, Edit Liberty

Division of Gastroenterology and Dept. of Medicine E, Soroka Medical Center and Ben-Gurion University, Beer Sheba

Colonic angiodysplasia is one of the most frequent causes of recurrent lower gastrointestinal tract bleeding, mainly in the elderly. In 50% of patients multiple angiodysplastic lesions were reported when they were the cause of rectal bleeding. Bleeding from angiodysplasia is more severe and less responsive to treatment in those with coagulation disorders. A 74-year-old woman with an artificial mitral valve who was treated with coumadine is reported. A few years after operation she began to develop severe recurrent rectal bleeding because of multiple angiodysplastic lesions along the right colon, proven by colonoscopy. She was frequently hospitalized for blood transfusions; endoscopic treatment was not feasible and the surgical risk of colectomy was very high. Treatwith estrogen and progesterone significantly decreased recurrent episodes of bleeding.

Incarcerated Diaphragmatic Hernia presenting as Colonic Obstruction

Yoram Moses, Simon Sapoznicov, Yuri Manoskin, Boris Yoffe

Dept. of General and Vascular Surgery, Barzilai Medical Center, Ashkelon (Affiliated with the Faculty of Health Sciences, Ben-Gurion University of the Negev)

Diaphragmatic hernias in adults that are not categorized as hiatal hernias are rare. Hernias of the diaphragm itself appear in the perinatal age group and are defined as congenital hernias, presenting with severe respiratory distress and requiring immediate repair. There are a few asymptomatic postpartum cases in young children or adults.

We present 3 cases of diaphragmatic hernia in men, aged 19, 20 and 74, respectively. 2 were admitted because of colonic incarceration with strangulation in the hernial sac. In the other case there was an incidental finding of incarcerated colon in a diaphragmatic hernia discovered in a patient who initially presented with unrelated thoraco-abdominal trauma. Contrary to the dominant clinical presentation as infant-respiratory distress, the predominant findings in adults are gastrointestinal complications.

We believe successful treatment is more likely when there is a high level of awareness of the possibility of this kind of hernia in the adult, which can be a recurrence after perinatal hernia repair. It is essential to recognize that this is a combined thoraco-abdominal problem since it is often necessary to perform simultaneous laparotomy, thoracotomy and stoma formation.

Acute Gastroenteritis caused by Enterohemorrhagic E. Coli O157:H7

Tuvia Weinberger, Tony Hayek, Shlomo Keidar

Dept. of Medicine E, Rambam Medical Center, and Dept. of Family Care, Haifa and West Galilee, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 48-year-old man admitted for watery diarrhea, high fever, chills and abdominal cramps. Entero-hemorrhagic E. coli O157:H7 was isolated. This new, dangerous pathogen causes dysentery and complications such as hemolytic uremic syndrome and thrombotic thrombo-cytopenic purpura. These complications can cause renal failure, neurological deficit and death. Recognition of E. coli O157:H7 infection is important since it causes a rare and dangerous condition. To the best of our knowledge this is the first case reported in Israel.