The splenic artery is the most frequent site of visceral arterial aneurysms. Usually a splenic artery aneurysm occurs as a single event; rupture is frequent, sometimes occurring as the first symptom and is sometimes fatal. This article presents a case of ruptured multiple splenic artery aneurysms-the symptoms and signs, operative and perioperative management, as well as a literature review of this clinically important entity.

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Hepatic fibrosis is a scarring process associated with an increased and altered deposition of extracellular matrix in the liver. It is caused by a variety of stimuli and if fibrosis continues unopposed, it would progress to cirrhosis which poses a significant health problem worldwide. At the cellular and molecular level, this progressive process is characterized by cellular activation of hepatic stellate cells and aberrant activity of transforming growth factor-β with its downstream cellular mediators. Liver biopsy has been the reference test for assessment of hepatic fibrosis, but because of its limitations, noninvasive markers of liver fibrosis were developed. Liver fibrosis or cirrhosis was considered irreversible in the past but progress of research on the molecular pathogenesis of liver fibrosis has shown that hepatic cellular recovery is possible. Currently, no acceptable therapeutic strategies exist, other than removal of the fibrogenic stimulus, to treat this potentially devastating disease.

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Background/Aim: To investigate the possible association between the polymorphism of the CTLA-4 exon 1 +49 A/G and susceptibility to Crohn's disease (CD) and ulcerative colitis (UC) in the Tunisian population. Methods: The +49 A/G dimorphism was analyzed in 119 patients with CD, 65 patients with UC, and 100 controls by the polymerase chain reaction-restriction fragment length polymorphism method. Results: Significantly higher frequencies of the CTLA-4 +49A allele and A/A homozygous individuals were observed in patients with CD when compared with controls (pc = 0.0023 and pc = 0.0003, respectively). Analysis of CTLA-4 A/G polymorphism with respect to sex in CD showed a significant difference in A/A genotypes between female patients and controls (pc = 0.0001 and pc = 0.038, respectively). There were no differences in the subgroups of patients with CD. Conclusions: Forty-nine A alleles and AA genotype are associated with CD susceptibility in Tunisians. Other genes involved in the T-cell regulation remain strong candidates for IBD susceptibility and require further investigation.

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Background/Aims: Gastric and colorectal cancers are the most common gastrointestinal malignancies in Iran. We aim to compare the survival rates and prognostic factors between these two cancers. Methods: We studied 1873 patients with either gastric or colorectal cancer who were registered in one referral cancer registry center in Tehran, Iran. All patients were followed from their time of diagnosis until December 2006 (as failure time). Survival curves were calculated according to the Kaplan-Meier Method and compared by the Log-rank test. Multivariate analysis of prognostic factors was carried out using the Cox proportional hazard model. Results: Of 1873 patients, there were 746 with gastric cancer and 1138 with colorectal cancer. According to the Kaplan-Meier method 1, 3, 5, and 7-year survival rates were 71.2, 37.8, 25.3, and 19.5%, respectively, in gastric cancer patients and 91.1, 73.1, 61, and 54.9%, respectively, in patients with colorectal cancer. Also, univariate analysis showed that age at diagnosis, sex, grade of tumor, and distant metastasis were of prognostic significance in both cancers ( P < 0.0001). However, in multivariate analysis, only distant metastasis in colorectal cancer and age at diagnosis, grade of tumor, and distant metastasis in colorectal cancer were identified as independent prognostic factors influencing survival. Conclusions: According to our findings, survival is significantly related to histological differentiation of tumor and distant metastasis in colorectal cancer patients and only to distant metastasis in gastric cancer patients.

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Background/Aims: Ingested corrosive material is a major pediatric emergency all over the world. The corrosive material can cause damage to the digestive tract, ranging from minor injury to strictures, and sometimes even death. We aimed to review the pattern of corrosive ingestion in children who had been admitted to Aseer Central Hospital in the Southwestern region of Saudi Arabia. Methods: This is a retrospective study of all children who had been admitted with a history of corrosive ingestion to Aseer Central Hospital over a period of five years period from 1990 to 1995. The records of 72 patients (38 males and 34 females) were reviewed. The data included age, sex, time lapse till admission, action taken by parents, presenting symptoms, general management given to the child, barium study, endoscopy, and the postcorrosive ingestion outcome of the child. Results: The mean age of the pediatric patients was 28 ± 20 months. Different types of corrosives were encountered. The most common type was 5.25% hypochlorite in 36 patients (50%), kerosene in 12 patients (16.7%), caustic soda in nine patients (12.5%), hydrogen chloride and N-alkyl dimethyl benzyl ammonium chloride (HC and ADB) in eight patients (11.1%), and other material in seven patients (9.7%). Endoscopy was done in 30 patients (31.7%), 14 of whom were abnormal. Barium swallow was performed in 11 patients; five of them showed strictures that required frequent dilatation whereas one needed interposition surgery. Conclusion: Corrosive injury is still a major pediatric emergency among young children. It carries a major risk of complications (mainly stricture) and requires standardized management based on evidence-based medicine.

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Background/Aim: To examine the liver size in Saudi children and adolescents. Methods: A large sample of children was selected from the general population by multistage random probability sampling for the assessment of physical growth. A random subsample of children-newborns to 18 years old-was taken from this larger sample for this study. Liver size below the costal margin and liver span along the midclavicular line were determined by physicians. Data were analyzed using SPSS software and medians and standard deviations were calculated. Results: Between 2004 and 2005, 18 112 healthy children up to 18 years of age were examined. All were term and appropriate for gestational age. There were 9 130 boys and 8 982 girls, yielding a nearly 1:1 male to female ratio. The maximum palpable liver size below the costal margin was 2.4 cm. The median and + 2 SD liver span at birth were 4 and 6.9 cm, respectively. There was no difference in the liver span between boys and girls of up to 60 months of age. Thereafter, a difference could be seen increasing with age, with girls having smaller liver spans than boys. Conclusion: This manuscript reports the liver size in Saudi children and adolescents. The data should help physicians in the interpretation of liver size determined by physical examination of children and adolescents.

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Barrett's esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.

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Background/Aims: To quantitatively assess steatosis by a morphometric method and to study its relationship with other histological features of chronic hepatitis C (CHC). This was a comparative descriptive study. The study was carried out in the Department of Histopathology, Army Medical College, Rawalpindi, Pakistan, from March 2006 to March 2007. Methods: Patients who had undergone a liver biopsy for the evaluation of hepatitis C virus (HCV) infection were included in the study. Demographic characteristics and laboratory data were collected at the time of biopsy. The first hundred biopsy specimens that met the inclusion criteria were assessed for grades of steatosis (semiquantitatively), diameter of fat globules (by a morphometric method), necroinflammation, and fibrosis (semiquantitatively). Liver biopsies were processed for paraffin embedding, stained with hematoxylin and eosin, whereas Gomori's Reticulin stain was used for the evaluation of fibrosis. Results: Out of 46 cases showing fatty change, pansteatosis was observed in 24 (52%) patients: 12 (26%) cases had a pericentral and mid zonal distribution of fat globules and eight (17.5%) cases revealed a mid zonal pattern only. There were two (4.5%) cases in which fat globules were found in periportal and mid zonal areas. None of the histological parameters (the stage of fibrosis and grades of inflammation) had any significant correlation with these distribution patterns of steatosis. The diameter of fat droplets was quantified by morphometry. A mixed pattern of steatosis was observed more frequently (21 out of 46 cases): 17 cases had microglobules and eight biopsies showed macroglobules. The size of the fat globules exhibited a significant correlation with the stage of fibrosis ( P < 0.0001). The analysis of the grades of necroinflammation did not reveal any significant relationship with the diameter of fat globules. Conclusions: A mixed pattern of fat globules is more frequently observed in CHC, but macrovesicular steatosis is associated with a higher stage of fibrosis. Morphometry is recommended as one of the important tools for the follow-up of HCV-infected patients. Whether an accurate assessment of fat globule size by morphometry is preferred for the evaluation of patients before and after the antiviral therapy needs further research.

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Celiac artery aneurysms are rare and usually asymptomatic. The management of these aneurysms is challenging, especially when they are large and involve the confluence of the trifurcation. We present here a case of a large celiac artery aneurysm involving its branches in a young woman. Preoperative investigations, intraoperative findings, and the operative procedure are also presented and discussed.

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Malignant gastrointestinal stromal tumor (GIST) is a rare type of sarcoma that is found in the digestive system, most often in the wall of the stomach. Multiple GISTs are extremely rare and usually associated with type 1 neurofibromatosis and familial GIST. We report here a case of a 70-year-old woman who reported pain in the abdomen, loss of appetite, and weight loss for six months. Ultrasound examination showed a small bowel mass along with multiple peritoneal deposits and a mass within the liver. Barium studies were suggestive of a neoplastic pathology of the distal ileum. A differential diagnosis of adenocarcinoma/lymphoma with metastases was entertained. Perioperative findings showed two large growths arising from the jejunum and the distal ileum, along with multiple smaller nodules on the serosal surface and adjoining mesentery of the involved bowel segments. Segmental resection of the involved portions of the intestine was performed. Histopathological features were consistent with those of multicentric malignant GIST-not otherwise specified (GIST-NOS). Follow-up examination three months after surgery showed no evidence of recurrence.

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Cholecystocolic fistula is a rare biliary-enteric fistula with a variable clinical presentation. Despite modern diagnostic tools, a high degree of suspicion is required to diagnose it preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10-20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases. These fistulae are treated by open as well as laparoscopic surgery, with no difference in intraoperative and postoperative complications. We report here a case of obstructive jaundice, which was investigated with a plain film of the abdomen, abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography, but none of these gave us any clue to the presence of the fistula was discovered incidentally during an open surgery and was appropriately treated.

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Neurofibromatosis type-1 (NF-1), also known as von Recklinghausen disease, is an autosomal dominant condition with an approximate incidence of one in 3000 births. NF-1 is known to involve multiple systems in the body. Abdominal involvement include neurofibroma and tumor growth in the liver, mesentery, and retroperitoneum in addition to gastric and bowel tumors. Gastrointestinal neoplasms occur in up to one quarter of patients. The author reports a rare case of diffuse submucosal neurofibromatosis resulting in gastric outlet obstruction.

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Background/Aim: Wider adoption of laparoscopic appendicectomy (LA) is limited by problems in securing the appendiceal base as well as the cost and the duration compared with the open procedure. The objective of this study was to assess the feasibility and efficacy of a new method for securing the appendiceal base in LA, so as to make the entire procedure simpler and cheaper, and hence, more popular. Methods: Twenty-five patients who were candidates for appendicectomy (emergency as well as elective) and willing for the laparoscopic procedure were selected for this study. Ports used were 10 mm at the umbilicus, 5 mm at the lower right iliac fossa, and 10 mm at the left iliac fossa. Extremely friable, ruptured, or turgid organs of diameters larger than 8 mm were excluded from the study. The mesoappendix was divided close to the appendix by diathermy. Fallope rings were applied to the appendiceal base using a special ring applicator, and the appendix was divided and extracted through the lumen of the applicator. Results: The procedure was successful in 23 (92%) cases, and the mean duration of the procedure was 20 minutes (15-32 minutes). There were no procedural complications seen during a median follow-up of two weeks. The equipment and rings were cheaper when compared with that of the standard methods of securing the base of the appendix. Conclusion: LA using fallope rings is a safe, simple, easy-to-learn, and economically viable method.

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Many of the abdominal foreign bodies are due to accidental ingestion. Our objective in this case report is to emphasize the importance of the enquiry about the foreign body in the differential diagnosis of acute abdominal pain. According to our knowledge, this is the first report of bowel perforation caused by paper ingestion. A 14-year-old boy with abdominal pain underwent exploratory laparotomy and was found to have abdominal pus and ileal perforation. A crumpled paper was found at the site of perforation. Postoperative enquiry revealed that the patient had ingested 10 crumpled papers. We highlight that recording the history is an important aspect in the management of patients with acute abdominal pain and that foreign bodies should be included in its differential diagnosis.

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Background/Aim: Information about functional outcome and quality of life after esophagectomy and esophageal reconstruction (ER) for the treatment of esophageal cancer, as evaluated by the patients themselves is limited. We aimed to study the post-surgical outcome of such patients to detect for the development of any complications that may arise from the surgery as well as to evaluate their quality of life following the surgery. Methods: From 1993 to 2003, 240 patients with stage I, II, or III esophageal carcinoma underwent esophagectomy at Razi Teaching Hospital located in the north of Iran. Of these, 192 patients filled out a questionnaire during a 2-year period (ranging from 12 to 48 months after surgical reconstruction). Among them, there were 134 men (69%) and 58 women (31%), and the mean age at the time of ER was 48 years (ranging from 22 to 75 years). Transhiatal esophagectomy, extended esophagectomy (three field operation), and Ivor-Lewis resection were done in 142 (73.95%), 30 (15.62%), and 20 patients (10.42%), respectively. Intestinal continuity after esophageal resection was established with stomach in 154 patients (80%), colon in 28 patients (14%), and small bowel in 10 patients (5.2%). Cervical anastomosis was established in 172 patients (89.6%), while intrathoracic anastomosis was performed in 20 patients (10.4%). Results: After ER, 66 patients (34.4%) suffered from dysphagia to solids and 50 patients (26%) required at least one or three postoperative dilatations for alleviation of symptoms. Gastroesophageal reflux was seen in 32 patients (16.66%) and was more common in thoracic anastomosis patients than in cervical anastomosis patients. Heartburn was present in 33 cases (17%), 30 of whom required medication (37%). The number of meals per day was three to four in 116 patients (60%), more than four in 51 patients (29%), and less than three in 19 patients (9.82%). The number of bowel movement per day increased in 52 patients (27%), decreased in 60 cases (31%), and unchanged in 80 patients (41%). Weight gain was reported by 38 patients (19.8%), and weight loss was reported by 50 patients (26%). No change in weight occurred in 100 patients (52%). Overall satisfaction was excellent in 29 patients (15%). Overall quality of life (work, pain-relief, vitality, and emotional status) was lower than in general population. Age, sex, and stage of cancer did not affect the functional outcome but affected the quality of life. Also patients who received cervical anastomosis and ER with colon had significantly fewer reflux symptoms. Most of the patients with colon reconstruction gained weight. Conclusions: Self-assessment of postoperative ER by the patients after esophagectomy for malignant disease demonstrates that undesirable symptoms are frequently present at short- and long-term follow-ups. Short- and long-term functional outcome is affected by the type of reconstruction after esophagectomy. Results of this study suggest that colon graft in ER is significantly advantageous compared with other methods because of the ability of patients to gain weight and avoid developing postoperative reflux.

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