Lege Artis Medicinae



DECEMBER 20, 2004

Lege Artis Medicinae - 2004;14(12)

[INTRODUCTION - Gallstone ileus is a rare disorder among elderly population. The gallstone coming through a bilioenteral fistula into the gastrointestinal tract is stuck into the duodenal lumen causing ileus in approximately 0,5% of all cases. The syndrome is named after Bouveret, the first describer. CASE REPORT - Author present the case of 72 year old female patient with known cholelithiasis. Investigations proved existing cholelithiasis causing the patient abdominal pain one year before admission but she gave no consent to surgical intervention. An emergency admission to our department occurred after four days of abdominal pain and vomiting. The clinical status of the patient and abdominal X-ray examination suggested stomach evacuation disturbance. Double contrast barium swallow test and gastroscopy proved bowel obstruction caused by a gallstone. During surgery gastrotomy and the removal of gallstone was carried out. There were no postoperative complications and the patient was discharged home. CONCLUSION - Cholelithiasis should be resolved at any chosen time well before complications may occur. The simultaneous appearance of stomach evacuation problems and cholelithiasis should draw attention to this rare disease.]



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[The organization, the budget and the practical delivery of modern healthcare are all based upon the sum of available evidences. However, in the individualized drug therapeutic decisions beside the external evidences the personal experience of the treating physician as well as the preferences and expectations of the patients must be represented with equal emphasis. Without the interaction of these three modern, patient oriented medicine is not conceivable. Evidenced based drug application is primarily based upon the results of prospective, randomized, controlled clinical trials. The individual experiences and the systematic observations represent the lowest level of the evidence hierarchy. The results of the clinical studies are expressed as the absolute difference of the results of the treated and control groups and as relative values relating the outcome of the experimental group to the control, respectively. In practice the easily interpretable term "number needed to treat" is widely used. It shows how many patients have to be treated relative to the control group in order to observe the expected therapeutic outcome in one case. The wealth of evidences cannot be efficiently used without systematization in the daily practice. Therefore, the data collected from the independent publications containing the primary evidences are subjected to a joint statistical evaluation. Thereafter, the results are combined in systematic reviews by independent experts following thorough weighting without prejudice. Then short summaries, more easily and rapidly digested by practicing physicians are made according to the same principle. They are restricted to the presentation of the problem, the tabulation of the summarized data and the conclusion. It is expected that in the future systems combining the electronically stored patient's data with external evidences making possible the patient oriented presentation of the sum and hierarchy of evidences will be extensively used.]

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MOHÁCSI Attila, LIZANECZ Erzsébet, ÉDES István, CZURIGA István

[The pathobiological aim of treatment with angiotensin converting enzyme inhibitor is to restore the balance between nitrogen-monoxide and angiotensin II due to inhibition of blood and tissue angiotensin converting enzyme. The clinical consquences of the inhibition of tissue angiotensin converting enzyme in patients with additionally high (HOPE) and low (EUROPA) cardiovascular risk without left ventricular dysfunction has already been demonstrated. Ramipril and the perindopril reduce the risk of combined end-point of these trials such as cardiovascular mortality, reinfarction and resuscitated sudden cardiac death. However, pharmacological and genetic differences in blocking of tissue angiotensin converting enzyme may influence the cardioprotective effect of various angiotensin converting enzyme inhibitors. Thus new, well-designed, controlled clinical trials are needed to determine the role of angiotensin converting enzyme inhibitor with different tissue angiotensin converting enzyme affinity in cardiovascular disease.]

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BÉLY Miklós, APÁTHY Ágnes

[INTRODUCTION - The lethal septic infection was studied in a randomized (non-selected) autopsy population of 234 in-patients with rheumatoid arthritis. The patients died at the National Institute of Rheumatology between 1970 and 1999. PATIENTS AND METHOD - The aims of this study were to determine the prevalence of lethal septic infection with or without purulent arthritis in rheumatoid arthritis; the relationship between purulent arthritis and lethal septic infection; the clinically missed diagnosis of lethal septic infection and purulent arthritis; the influence of the main complications and associated diseases on lethal septic infection with and without purulent arthritis; the pathogens in lethal septic infection; and the clinico-laboratory parameters associated with lethal septic infection in rheumatoid arthritis. RESULTS - Lethal septic infection was found in 31 (13.24%) of 234 rheumatoid arthritis patients. Purulent arthritis complicated lethal septic infection in 15 (6.4%) of 31 patients. There was a significant association between lethal septic infection and purulent arthritis. Sepsis was detected clinically in 17 of 31 lethal cases and purulent arthritis was detected 9 of 15 septic infection complicated with suppurative articular processes. The coexistent complications (systemic vasculitis, AA amyloidosis), and associated diseases (tuberculosis with or without miliary dissemination, malignant tumors, diabetes mellitus) did not influence the prevalence of septic infection. The most frequent pathogenic agents were: Staphylococcus aureus, Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella species, Streptococcus species. The patients with septic infection had significantly lower levels of beta-globulin, and higher values of Waaler-Rose or latex fixation test in comparison to patients without septic infection or without complications. CONCLUSION - Lethal septic infection may exist in rheumatoid arthritis without the classical clinical symptoms of sepsis, and clinically latent suppurative processes may be found at autopsy. The missed clinical diagnosis of a fatal complication is explained by the weak immune response and atypical clinical symptoms of elderly patients mainly treated with steroids and immunosuppressive drugs.]

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[Hungarian Cannot be Used Indeed? Anglicisms in the Hungarian Medical Language]


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Hungarian Radiology

[The role of ultrasonography and X-ray examinations in the diagnosis of gallstone ileus in preoperative stage]

FARKAS József, KÁNYA László, LUDVIG Zsuzsanna, BENDE Sándor

[INTRODUCTION - Gallstone ileus develops in elderly patients as a result of complication of cholelithiasis and causes 1-3% of mechanical ileus. Due to its variable presentation and in many cases insidious and intermittent symptoms it is difficult to establish the diagnosis which is often delayed. The mortality rate is high and early diagnosis is essential. The role of X-ray, abdominal ultrasound and recently CT has been emphasized. The role of imaging studies was evaluated in the preoperative diagnosis of gallstone ileus based on their surgically proven cases. PATIENTS AND METHODS - From 1st January 1988 to 30th June 2004 nineteen operations were performed on seventeen patients suffering from gallstone ileus. The average age of the patients was 74.2 years, male/female ratio was 4/13. Ultrasound examination was performed in all cases before the operation. Plane X-ray examination also was carried out except in two cases. CT study was not performed preoperatively. The calculi were removed through an enterotomy whole. In four cases gall bladder were also removed and the biliary fistula was closed. The disease was diagnosed on the basis of symptoms described by Rigler. If two signs from the three was present the diagnosis was established. RESULTS - 17 cases out of 19 mechanical ileus were diagnosed, in one case acute cholecystitis and in one incarcerated abdominal wall hernia was suspected before surgery. Small bowel obstruction was found in all cases (jejunum in six cases, ileum in 13). In five cases multiple calculi were seen in the bowels. Two patients had to undergo surgery twice because of gallstone ileus. It is noted that in eight cases (42.1% of total operations) gallstone ileus was diagnosed before the operation. In seven cases ultrasound played a crucial role in establishing diagnosis. In one case gas was detected in the biliary tract and in six, gallstone was directly seen in the small bowel with ultrasound. CONCLUSIONS - In the preoperative diagnosis of gallstone ileus more and more is expected from appropriate radiological examinations. If diagnosis is primarily based on the physical examination, an illusion of clinical improvement can be created, and the delay of surgical treatment can lead to decompensation of elderly patients with increased mortality rate. A thorough radiological examination can show the stone in the bowel lumen, and observation of the indirect signs together with clinical state can considerably improve the results. The rate of correct diagnosis of gallstone ileus before sugery in our patients can be considered an average and similar to the published data in medical literature.]

Clinical Neuroscience

The etiology and age-related properties of patients with delirium in coronary intensive care unit and its effects on inhospital and follow up prognosis

ALTAY Servet, GÜRDOGAN Muhammet, KAYA Caglar, KARDAS Fatih, ZEYBEY Utku, CAKIR Burcu, EBIK Mustafa, DEMIR Melik

Delirium is a syndrome frequently encountered in intensive care and associated with a poor prognosis. Intensive care delirium is mostly based on general and palliative intensive care data in the literature. In this study, we aimed to investigate the incidence of delirium in coronary intensive care unit (CICU), related factors, its relationship with inhospital and follow up prognosis, incidence of age-related delirium and its effect on outcomes. This study was conducted with patients hospitalized in CICU of a tertiary university hospital between 01 August 2017 and 01 August 2018. Files of all patients were examined in details, and demographic, clinic and laboratory parameters were recorded. Patients confirmed with psychiatry consultation were included in the groups of patients who developed delirium. Patients were divided into groups with and without delirium developed, and baseline features, inhospital and follow up prognoses were investigated. In addition, patients were divided into four groups as <65 years old, 65-75 yo, 75-84 yo and> 85 yo, and the incidence of delirium, related factors and prognoses were compared among these groups. A total of 1108 patients (mean age: 64.4 ± 13.9 years; 66% men) who were followed in the intensive care unit with variable indications were included in the study. Of all patients 11.1% developed delirium in the CICU. Patients who developed delirium were older, comorbidities were more frequent, and these patients showed increased inflammation findings, and significant increase in inhospital mortality compared to those who did not develop delirium (p<0.05). At median 9-month follow up period, rehospitalization, reinfarction, cognitive dysfunction, initiation of psychiatric therapy and mortality were significantly higher in the delirium group (p<0.05). When patients who developed delirium were divided into four groups by age and analyzed, incidence of delirium and mortality rate in delirium group were significantly increased by age (p<0.05). Development of delirium in coronary intensive care unit is associated with increased inhospital and follow up morbidity and mortality. Delirium is more commonly seen in geriatric patients and those with comorbidity, and is associated with a poorer prognosis. High-risk patients should be more carefully monitored for the risk of delirium.

Clinical Neuroscience

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery

ONDER Burcu, KELES Yavuz Betul

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.

Clinical Neuroscience

To handle the HaNDL syndrome through a case: The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis


The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL) is a rare entity. This disease has been related to migrainous headaches. It is a benign, self-limited disorder, which is characterized by fluctuating neurological symptoms and cerebrospinal fluid lymphocytosis. We describe a case of a 47 years old man with acute onset of headache and aphasia. Cerebrospinal fluid analysis revealed a lymphocytic pleocytosis (25 cells/μl, 100% lymphocytes). Electroencephalogram showed moderate slow rhythm in the left hemisphere, with temporoparietal predominance, and without epileptiform activity. His blood tests as well as magnetic resonance imaging (MRI) results were normal. With the diagnosis of HaNDL syndrome the patient was accepted in the Department of Neurology and discharged with full recovery.