br Discussion Obscure gastrointestinal bleeding of

Discussion Obscure gastrointestinal bleeding of intestinal origin remains a diagnostic dilemma and a therapeutic challenge. The small intestine is quite long and folded in the peritoneal cavity, and makes identification of the genuine bleeders in the small intestine particularly difficult by conventional endoscopic or radiological studies. While multiple diagnostic procedures may confirm the source of small intestinal bleeding before operation, the diagnostic yield may vary and preoperative investigation does not guarantee successful intraoperative localization. Precise localization during laparotomy to allow appropriate surgical resection of the intestine may still be problematic, especially for intermittent small intestinal bleeders or for minute vascular lesions confined to the mucosa of the intestine that are neither visible nor palpable from the serosal surface. There are various novel modalities for intraoperative localization of intestinal bleeders, including intraoperative enteroscopy, injection of methylene blue dye via the retained angiographic catheter, and identification of the retained angiographic catheter by palpation. Intraoperative double-balloon enteroscopy is a promising modality for concomitant treatment of bleeders. However, the method is typically time-consuming and the total small-bowel exploration rate may vary considerably. Injection of methylene blue dye during operation through a retained catheter to a branch of the mesentery artery was reported to be helpful, but it stained a long segment of the demarcated intestine and the surgeon found it distracting as the infusion of dye was too rapid and widespread. The development of the angiographic micro-catheter allows for Oxamflatin cost of the catheter into a distal branch of the vascular arcade so that injection of dye during laparotomy may no longer be necessary when the micro-catheter can already be identified by palpation. Therefore, the authors recommend performing intra-operative palpation of an indwelling catheter that has been selectively retained before operation to guide subsequent resection of the intestine in the vicinity of the distal mesentery branch. Reed et al reported successful intraoperative identification of arteriovenous malformation of the intestine by palpation of a catheter preoperatively placed in the feeding artery. Surgeons may found this approach to be practical, straightforward and time-saving during laparotomy for precise localization of the bleeding site, which thus allows for appropriate resection of the intestine.
Introduction Esthesioneuroblastoma, also known as olfactory neuroblastoma, constitutes about 3% of endonasal neoplasms. It is thought that the tumor arises from basal olfactory epithelial stem cells. The tumor is locally aggressive and therefore recurs frequently. However, recurrence usually occurs in the tumor bed. In this case, the patient presented with pure bilateral subdural extension of a recurrent tumor, while the previous tumor bed was free of tumor. Such a pattern of recurrence is rare, with only three similar cases reported in the literature, and all of these carried a poor prognosis. Therefore, we discuss here the possible pathophysiology of such an unusual presentation in the hope of preventing its occurrence in the future.
Case report A 40-year-old female presented to our emergency department in January 2009 because of a rapid deterioration of visual acuity within a week, associated with frontal headache, eye pain, nasal congestion, nasal pain, and anosmia. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed a huge tumor extending from the frontal base into the orbital and nasal cavities with associated destruction of bony structures (Fig. 1). Bilateral encasement of the optic nerves was observed. The intracranial portion of the tumor was evacuated totally via bilateral frontal craniotomy. The arachnoid membrane was preserved carefully during resection of the tumor. Further dissection of the intraorbital and intranasal tumor was achieved through the skull base. A histopathological study of the specimen confirmed the diagnosis of esthesioneuroblastoma, Hyam grade III. The lack of metastasis was deemed consistent with modified Kadish stage C disease (Table 1).