Thank you very much Mr M.A Warner for reviewing our article and
sharing your views from the same. We do agree with your suggestion that,
there in no 'strong' correlation between the use of peripheral nerve
blockage and delay in diagnosis of acute compartment syndrome following
surgical procedures on extremities. Among the reported cases of peripheral
nerve blockage use in extremity surgeries and where the compartment
syn...
Thank you very much Mr M.A Warner for reviewing our article and
sharing your views from the same. We do agree with your suggestion that,
there in no 'strong' correlation between the use of peripheral nerve
blockage and delay in diagnosis of acute compartment syndrome following
surgical procedures on extremities. Among the reported cases of peripheral
nerve blockage use in extremity surgeries and where the compartment
syndrome was diagnosed and prompt fasciotomy preformed, all the patients
were within the "hospital or clinical setting". The clinicians were
vigilant with high index of suspension of acute compartment syndrome hence
there were no delays in making the diagnosis nor in performing the
fasciotomy surgery to adequately decompress the compartments, thus avoided
the potential long-term complications and disabilities.
Our patient received 10mls of 0.25% Chirocaine and 13mls of 2%
lignocaine with adrenaline 1:200000 strength, in total for his left
axillary nerve block. The procedure was performed with ultrasound guidance
and confirmed with nerve stimulator of adequate block in Radial, Ulnar,
Median and Musculoskeletal nerve. He was discharged 8 hours following his
surgery as he was quite comfortable with no pain in the operated limb and
unfortunately there was no clear documentation with regards to distal
muscular activity, prior to discharge .
We also agree with you in that, this patient underwent a revision
procedure that would involve more soft tissue dissection and stripping,
which itself contribute to increased post operative swelling compared to
fractures with minimal displacement.
We believe, learning points in addition to aforementioned in the case
report are, clinicians and all health care professional involved in
providing care, should have awareness of compartment syndrome risk in
extremity injuries and caution with clinical vigilance is needed when
treating patients with extremity fractures and regional block is still in
effect.
[Apologies for late edits to letter submitted yesterday, please note
there are 3 new references addressing hepatotoxicity of fluoroquinolones
that were not in orginal letter].
Lugg et al (2015) reported a case study of a 16 year old girl born
who presented with signs of chronic joint pain, dizziness and non-specific
abdominal pains after consuming 3 cups per day of imported herbal green
tea (as tea bags) for a p...
[Apologies for late edits to letter submitted yesterday, please note
there are 3 new references addressing hepatotoxicity of fluoroquinolones
that were not in orginal letter].
Lugg et al (2015) reported a case study of a 16 year old girl born
who presented with signs of chronic joint pain, dizziness and non-specific
abdominal pains after consuming 3 cups per day of imported herbal green
tea (as tea bags) for a period of 3 months [1]. There are a number of
interesting points not addressed in the case study which physicians may
not be aware of that are of clinical significance.
Firstly, the description of the ailments which the subject presented
with strongly suggest chronic fluoride intoxication. Hallanger et al
(2007) reported that the clinical features associated with fluoride
intoxication resulting from habitual tea consumption can include joint
pain and gastrointestinal complaints and that fluoride toxicity is often
overlooked by clinicians [2]. Despite the publication of a large number of
reports addressing fluoride intoxication from habitual tea drinking [3]
many health care professionals remain unaware of the risk of fluoride
intoxication from tea and lack an understanding of the pathophysiology of
fluoride toxicosis. The United States National Academy, National Research
Council (2006) reported that excessive intake of fluoride will manifest
itself in a musculoskeletal disease with associated symptoms including
chronic joint pain and arthritic symptoms [4]. However, perhaps one the
most detailed explanations of the pathophysiology of fluoride toxicosis is
provided by Professor Alexander V. Akleyev [5]. In addition to
musculoskeletal disorders, Akleyev reported that stage 2 fluorosis, the
following symptoms are observed: subatrophic and atrophic rhinitis,
pharyngitis, laryngitis, chronic conjunctivitis, retinal degeneration with
visual impairment, hearing loss, increasing impairment of bronchial
patency, and pulmonary insufficiency; mycrodial dystrophy with reduced
contractility, chronic gastritis mainly with the reduction of secretory
and acid forming function of the stomach, and chronic hepatitis with
persistent liver failure; distinct astheno-vegetative syndrome, toxic
polyneuritis and decrease in glucocorticoid function of adrenal cortex;
and microhematuria and proteinura [4]. Kessabi et al (1986) also reported
that acute hepatitis and degeneration in the liver develop following
chronic fluoride intake [6]. Other studies have also found that fluoride
toxicosis can induce hepatotoxicity and oxidative stress in humans [7-8]
and animals [9].
In the case study described by Lugg and associates [1], the fluoride
concentration in the tea samples ingested by the patient are unknown, as
they were not tested. Chan et al (2013) reported high fluoride levels in
tea infusions in the United Kingdom including green tea leaves which were
found to contained up to 6.67mg/L when made with deionized water [10]. The
European Food Safety Authority (EFSA) have reported that drinking just 2
cups of tea per day (with a fluoride content of 5mg/l), combined with an
average consumption of fluoridated drinking water and use of fluoridated
tap water in the preparation of food, but excluding all other sources
(including solid foods, toothpaste and dental products), would provide a
daily dietary intake of 6 mg per day [11]. The EFSA have established
daily recommended intake levels (AI) and Tolerable Upper Intake Levels
(ULs) for fluoride. For an adult female the AI is 2.9mg per day while the
UL is 7mg per day [11-12]. Birmingham is the largest city in the England
with artificially fluoridated water. Thus, the patient having consumed 3
cups of tea per day, is likely to have exceeded the recommended UL for
fluoride, thereby increasing the risk of chronic fluoride intoxication.
Secondly, Lugg and associates noted that the condition of the subject
worsened following prescribing of amoxicillin [1]. Amoxicillin is a
fluoroquinolone. The name fluoroquinolone comes from the presence of
fluorine which is found in all fluoroquinolones. Hong et al (2005)
reported that amoxicillin was associated with dental fluorosis in children
[13]. Thus, it is likely that administration of amoxicillin resulted in
further contributing to chronic fluoride intoxication of the subject and a
worsening of her condition. Other fluoroquinolones such as ciprofloxacin
have been found to significantly increase plasma fluoride levels in
individuals [14]. Fluoroquinolones have also been found to be associated
with severe hepatotoxicity [15-18]. It is likely that the toxicity of
fluoroquinolones would be more immediate in persons with elevated
background plasma fluoride levels.
Thirdly, on cessation of the herbal tea and treatment with
intravenous fluids and N-acetylcysteine, her condition resolved [1]. N-
acetylcysteine is known to protect against fluoride-induced oxidative
damage [19].
Overall the evidence indicates the symptoms reported may be due
fluoride toxicosis caused by high fluoride intake from tea, combined with
other fluoride sources such as fluoridated drinking water and medications.
There is a need for healthcare workers to be aware of the pathophysiology
of fluoride toxicosis as well as dietary fluoride sources, particularly
among habitual tea drinkers in communities with artificially fluoridated
drinking water. Urinary or blood fluoride levels should be routinely
monitored in patients with muscleoskeletal and gastrointestinal disorders.
Fasting serum fluoride concentrations ranging from 2.5 - 8.0 ?M/L can
result in chronic fluoride intoxication and stage I and stage II skeletal
fluorosis [20].
[1] Lugg ST, Menezes DB, Gompertz S. Chinese green tea and acute
hepatitis: a rare yet recurring theme. BMJ Case Rep 2015, doi:10.1136/ bcr
-2014-208534.
[2] Hallanger-Johnson JE, Kearns AE, Doran PM, Khoo TK., Wermers RA.
Fluoride-related bone disease associated with habitual tea consumption.
Mayo Clinic Proceedings 2007;82(6):719-24.
[3] Yi J, Cao J. Tea and fluorosis. Journal of Fluorine Chemistry,
2008, 129: 76-81.
[4] National Research Council, Review of Fluoride in Drinking Water,
U.S. National Research Council 2006.
[5] Neurological Disorders of Non-Radiation Nature, Fluorosis, In
Chronic Radiation Syndrome, Alexander V. Akleyev, Spriner-Verlag Berlin
Heidelberg 2014. ISBN 978-3-642-45116-4.
[6] Kessabi M, Hamliri A. Experimental fluorosis in sheep:
Alleviating effects of aluminum. Vet. Hum. Toxicol., 1986, 28: 300-304.
[7] Michael M, Barot VV, Chinoy NJ. Investigations of Soft Tissue
Functions In Fluorotic Individuals of North Gujarat. Fluoride 1996, Vol.29
No.2 63-71.
[8] Medvedeva VN. Characteristics of the course of chronic hepatitis
in workers coming in contact with flourine compounds. Gigiena Truda;
Professional'nye Zabolevaniia, Jan 1985. pg 24-6.
[9] AL-Harbia MS, Hamzaa RZ, Dwarya AA. Ameliorative effect of
selenium and curcumin on sodium fluoride induced hepatotoxicity and
oxidative stress in male mice. J Chem Pharma Res, 2014, 6(4):984-998.
[10] Chan L, Mehra A, Saikat S, Lynch P. Human exposure assessment
of fluoride from tea (Camellia sinensis L.) Food Res Internat. 2013; 51:
564-570.
[11] European Food Safety Authority, Scientific Opinion on Dietary
Reference Values for fluoride, EFSA Panel on Dietetic Products, Nutrition,
and Allergies: EFSA Journal. 2013;11(8):3332.
[12] European Food Safety Authority, Scientific Opinion of the Panel
on Dietetic Products, Nutrition, and Allergies (NDA) on the tolerable
upper intake level of fluoride. The EFSA Journal. 2005, 192, 1-65.
[13] Hong L, Levy SM, Warren JJ, Dawson DV, Bergus GR, Wefel JS.
Association of Amoxicillin Use During Early Childhood With Developmental
Tooth Enamel Defects, Arch Pediatr Adolesc Med. 2005;159:943-948, 995-996.
[14] Pradhan KM, Arora NK, Jena A, Susheela AK, Bhan MK. Safety of
ciprofloxacin therapy in children: magnetic resonance images, body fluid
levels of fluoride and linear growth. Acta Paediatr. 1995, 84:555-560.
[15] Hautekeete ML. Hepatotoxicity of antibiotics. Acta
Gastroenterol Belg. 1995 May-Aug;58(3-4):290-6.
[16] Vial T, Biour M, Descotes J, Trepo C. Antibiotic-associated
hepatitis: update from 1990. Ann Pharmacother. 1997 Feb;31(2):204-20.
[17] Thiim M, Friedman LS. Hepatotoxicity of antibiotics and
antifungals. Clin Liver Dis. 2003 May;7(2):381-99, vi-vii.
[18] Robles M, Andrade RJ. Hepatotoxicity by antibiotics: update in
2008. Rev Esp Quimioter. 2008 Dec;21(4):224-33. Article in Spanish.
[19] Paw?owska-G?ral K, Kurzeja E, Stec M. N-acetylcysteine protects
against fluoride-induced oxidative damage in primary rat hepatocytes.
Toxicology in Vitro, December 2013, Volume 27, Issue 8, Pages 2279-2282.
doi:10.1016/j.tiv.2013.09.019.
[20] Xiang QY, Chen LS, Chen XD., Wang CS, et al. Serum Fluoride And
Skeletal Fluorosis In Two Villages In Jiangsu Province, China. 178
Fluoride 2005;38(3):178-184
I have read with surprise the case report which makes rather wide
sweeping claims about green tea being of health concern. After a quick
literature review there have been rare cases after prolonged ingestion of
green tea extract - but none ever analyzed the extract for components
besides green tea.
It is not a secret that there are problems with food safety in china,
especially pesticide use, so making claims about the p...
I have read with surprise the case report which makes rather wide
sweeping claims about green tea being of health concern. After a quick
literature review there have been rare cases after prolonged ingestion of
green tea extract - but none ever analyzed the extract for components
besides green tea.
It is not a secret that there are problems with food safety in china,
especially pesticide use, so making claims about the plant instead of
doing at least a rough test for chemicals in the extract (or in that case
the tea) seem in my opinion very much warranted prior to claims with such
impact.
"Only following specific questioning did she reveal that she had, in
the preceding 3 months, regularly consumed internet ordered Chinese green
tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green
tea, or any other true tea, must come from Camellia sinensis.
"Only following specific questioning did she reveal that she had, in
the preceding 3 months, regularly consumed internet ordered Chinese green
tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green
tea, or any other true tea, must come from Camellia sinensis.
The word "contained" gives the impression that this was added to the
green tea.
Any "tea" from any other plant is considered an herbal tea.
I feel the article is well justified because the dangers of
adulteration are very serious. I also agree with the dangers of
supplements and liver toxicity from high levels of EGCG ingestion.
My concern is that green tea, oolong tea and black tea are all very
healthy drinks and many bloggers will create misinformed conclusions from
the summary which may derogate from the benefits of tea.
This misleading statement in the summary of this article has already
been misinterpreted and published on "Grub Street"
(http://www.grubstreet.com/2015/09/green-tea-hepatitis.html). A reader
pointed out their mistake in the comments section and they have since
retracted and corrected their error.
The real issue here is not the tea. It is the contaminants either
sprayed on, or added to, the tea.
I think the sentence should be revised to prevent any further
confusion.
Should this comment be posted on this or any other website, I ask
that my email not be displayed.
Thank you for your time,
Shawn Weldon
Conflict of Interest:
I run a green tea information website promoting the benefits of green tea consumption. I focus primarily on Japanese green tea.
I don't believe there are any competing interests.
Lugg et al. present a case of acute hepatitis in a 16-year old girl
and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month
exposure to a Chinese green tea ordered via the internet. Other case
reports have associated an idiosyncratic hepatoxicity with green tea
though other factors, including adulterants, can contribute to its
causality (Blumberg et al.). Regrettably, like many of these reports, this
on...
Lugg et al. present a case of acute hepatitis in a 16-year old girl
and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month
exposure to a Chinese green tea ordered via the internet. Other case
reports have associated an idiosyncratic hepatoxicity with green tea
though other factors, including adulterants, can contribute to its
causality (Blumberg et al.). Regrettably, like many of these reports, this
one also fails to test the product and inappropriately presumes the
product label is correct. Green tea adulterated with plant extracts and/or
drugs is not green tea but an illegal product! A relatively simple
analytical test would have revealed adulteration of this product and
helped to remove it from the marketplace and prevent others from suffering
a fate like this patient. Unsurprisingly, the story of this report carried
widely by the media appear to have used only its title and summary to warn
readers about the harm of drinking green tea, despite a strong likelihood
that this product was not simply green tea. Thus, many people may now
choose to forego what Lugg et al. note is "a very safe and healthy drink".
Jeffrey B. Blumberg
Tufts University
Reference
Blumberg, JB, Bolling BW, Xiao H, Chen C-YO. Review and perspective
on the composition and safety of green tea extracts. Eur J Nutr Food
Safety 2015;5:1-31
We are grateful for your comments in our images in medicine article in BMJCR entitled "'Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon"1
We agree that finding bile in what is considered a distal segment of an atretic duodenum does not exclude all possible pathology. We are in agreement with your statement that duodena...
We are grateful for your comments in our images in medicine article in BMJCR entitled "'Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon"1
We agree that finding bile in what is considered a distal segment of an atretic duodenum does not exclude all possible pathology. We are in agreement with your statement that duodenal atresia diagnosed prenatally and presenting at birth with distal bowel gas (on abdominal radiograph) via an anomalous bifurcated bile duct connection is more common than initially thought and occurs more frequently than duodenal stenosis2.
We agree with you that a perforated duodenal windsock web would allow a greater amount of air to pass through (and more gas appearing in the abdomen) particularly when bile passes freely through. We reviewed the abdominal radiograph with our radiology team and indeed there was greater amount of air in the right and transverse colon as seen in figure 1. The gas in the left transverse colon was still visible one week post-operatively as shown in figure 2.
We have considered the pathology of bifid distal bile duct with openings proximal and distal to the web and therefore have performed upper gastrointestinal series and followed it for 24 hours in an attempt to demonstrate this as there is risk for cholestasis, possibly due to duodeno-biliary reflux through the abnormal ampulla2. Upper gastrointestinal contrast studies delineated the windsock deformity and show the site of attachment of the diaphragm. Sometimes there is an indentation externally to mark the site of attachment of the diaphragm as shown with arrows in figure 3.
At operation, there was no duodenal atresia or annular pancreas. WE routinely use flexible neonatal endoscope during the operation to see any visible bile duct opening or the wind shock deformity with or without an opening and provide air distention and transillumination to see shouldering at the attachment of the diaphragm as reported earlier3-4. In this case we could not see any anomalous bile duct opening and a single normal ampulla opening was seen just above the attachment of the diaphragm medially and the eccentric opening in the duodenal wind shock deformity was abutting the medial wall of the duodenum obstructing it completely.
At the first operation, consultant paediatric surgeon was available in the theatre suite and in fact popped in and requested for any help required but the operating senior registrar with special interest in paediatric surgery was confident as has seen dark green bile as confirmation of being distal to the site of obstruction. He did repent his decision not to allow paediatric surgeon to join and learn during first operation when he joined us at second operation and apologized to the parents admitting his ignorance and arrogance.
Patel RV, Govani D, Patel R, Dekiwadia DB
Department of Surgery, PGICHR, KTCGH and PDUMC, Rajkot, India
References:
1. Patel RV, Govani D, Patel R, Dekiwadia DB. Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon. BMJ Case Rep 2014. 15 Jan 2014 doi:10.1136/bcr-2013-202782
2. Komuro H1, Ono K, Hoshino N, Urita Y, Gotoh C, Fujishiro J, Shinkai T, Ikebukuro K. Bile duct duplication as a cause of distal bowel gas in neonatal duodenal obstruction. J Pediatr Surg. 2011; 46(12):2301-4.
3. Patel RV, Kumar H, More B. Preampullary duodenal web simulating gastric outlet obstruction. J Neonat Surg. 2013; 2: 13.
4. Patel RV, Philip I. Distal duodenal stenosis in Down's syndrome-a rare diagnostic and therapeutic challenge. J Pediatr Surg Specialities (in press)
Legends to illustrations
Figure 1. Abdominal radiograph showing greater gas in the right and transverse colon between arrows.
Figure 2. Post-operative chest radiograph demonstrating gas in the left transverse colon
Figure 3. Post-operative upper gastrointestinal contrast at 24 hours depicting indentation at the site of diaphragm attachment (arrows
Indeed, this is a very interesting case illustrating that a positive
intraoperative sign (finding bile in what is considered a distal segment
of an atretic duodenum) does not exclude every possible pathology.
However, I am still not convinced about the underlying pathology in this
case.
In my opinion, a perforated duodenal windsock web would allow a greater
amount of air to pass through (and more gas appearing in the ab...
Indeed, this is a very interesting case illustrating that a positive
intraoperative sign (finding bile in what is considered a distal segment
of an atretic duodenum) does not exclude every possible pathology.
However, I am still not convinced about the underlying pathology in this
case.
In my opinion, a perforated duodenal windsock web would allow a greater
amount of air to pass through (and more gas appearing in the abdomen)
particularly when bile passes freely through. A pathology that could fit
better to the findings is that of a bifid distal portion of the bile duct
with openings proximally and distally to the web. This explains why bile
flows both proximally and distally to the web. Air (in small amounts) can
enter the proximal orifice, bypass the web through the bile duct and empty
to the distal duodenum through the distal orifice. If the authors take
this possibility under consideration, I would like to know if their
findings were consistent with this hypothesis.
Annular pancreaas is a more complex anomaly that might (?), by its protean
pathology, cause similar difficulties, but I believe that it could have
been recognized and described.
Please allow a final question. Do I understand correctly that, at least
in the first operation, no pediatric surgeon was involved?
Thank you for the interesting case and fruitful discussion.
Thank you for your question and kind comments regarding the case
report. The mass seen is the same as in the Computerised Tomography (CT)
and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5
cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the
patient had been incorrectly diagnosed and triaged to the stroke unit. As
a result this time-frame may account for c...
Thank you for your question and kind comments regarding the case
report. The mass seen is the same as in the Computerised Tomography (CT)
and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5
cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the
patient had been incorrectly diagnosed and triaged to the stroke unit. As
a result this time-frame may account for changes in the visualisation of
vasogenic oedema. I'm sure that you'd also agree that vasogenic oedema is
better visualised with the MR imaging modality rather than CT.
We have re-reviewed the images on the dedicated imaging monitors and
the mass is superior to the sylvan fissure, contained in the high right
parietal lobe, this is demonstrated in the coronal image (Figure 4) of the
case report (1). In later images (not shown) 2 months later, it was seen
to extend into the fronto/parietal junction as the mass lesion enlarged.I
hope that this has answered your questions.
Thank you once again for your question and interest in the case.
Kind regards
Hew DT Torrance, MRCS; Kai Lee Tan, FRCR; & Ava Jackson, MRCP.
References:
1. Torrance HD, Tan KL, Jackson A. Metastatic lung cancer, an
interesting stroke mimic. BMJ Case Rep. 2014 Jan 21;2014.
Dear author
Nice case
This case emphasizes the importance in differentiation between vasogenic
edema of white matter due to SOL and edema due to stroke. The vasogenic
edema due to SOL in general doesn't respect the anatomy and in the other
hand edema due to stroke in general yes it respect the anatomy of the
vessels territory and anatomical lobes.
However I have one question:
Is the mass seen in the CT is the same mass...
Dear author
Nice case
This case emphasizes the importance in differentiation between vasogenic
edema of white matter due to SOL and edema due to stroke. The vasogenic
edema due to SOL in general doesn't respect the anatomy and in the other
hand edema due to stroke in general yes it respect the anatomy of the
vessels territory and anatomical lobes.
However I have one question:
Is the mass seen in the CT is the same mass shown in the MRI?
Because the CT shows a mass in pre sylvian fissure And the MRI shows a
mass in the post sylvian fissure (parietal lobe)
Is this the same patient with two different lesions? And in such a case it
is difficult to understand the imaging findings because if so, the
vasogenic edema (the parietal one) that we see in the MRI is not seen in
the CT? Why? How much time occurred between the two modalities (MRI+CT)?
Best regards
Suheil Artul
Thank you very much Mr M.A Warner for reviewing our article and sharing your views from the same. We do agree with your suggestion that, there in no 'strong' correlation between the use of peripheral nerve blockage and delay in diagnosis of acute compartment syndrome following surgical procedures on extremities. Among the reported cases of peripheral nerve blockage use in extremity surgeries and where the compartment syn...
[Apologies for late edits to letter submitted yesterday, please note there are 3 new references addressing hepatotoxicity of fluoroquinolones that were not in orginal letter].
Lugg et al (2015) reported a case study of a 16 year old girl born who presented with signs of chronic joint pain, dizziness and non-specific abdominal pains after consuming 3 cups per day of imported herbal green tea (as tea bags) for a p...
I have read with surprise the case report which makes rather wide sweeping claims about green tea being of health concern. After a quick literature review there have been rare cases after prolonged ingestion of green tea extract - but none ever analyzed the extract for components besides green tea. It is not a secret that there are problems with food safety in china, especially pesticide use, so making claims about the p...
In the summary of this article is the following:
"Only following specific questioning did she reveal that she had, in the preceding 3 months, regularly consumed internet ordered Chinese green tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green tea, or any other true tea, must come from Camellia sinensis.
The word "contained" gives the imp...
Lugg et al. present a case of acute hepatitis in a 16-year old girl and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month exposure to a Chinese green tea ordered via the internet. Other case reports have associated an idiosyncratic hepatoxicity with green tea though other factors, including adulterants, can contribute to its causality (Blumberg et al.). Regrettably, like many of these reports, this on...
Indeed, this is a very interesting case illustrating that a positive intraoperative sign (finding bile in what is considered a distal segment of an atretic duodenum) does not exclude every possible pathology. However, I am still not convinced about the underlying pathology in this case. In my opinion, a perforated duodenal windsock web would allow a greater amount of air to pass through (and more gas appearing in the ab...
Dear Dr Artul,
Thank you for your question and kind comments regarding the case report. The mass seen is the same as in the Computerised Tomography (CT) and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5 cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the patient had been incorrectly diagnosed and triaged to the stroke unit. As a result this time-frame may account for c...
Dear author Nice case This case emphasizes the importance in differentiation between vasogenic edema of white matter due to SOL and edema due to stroke. The vasogenic edema due to SOL in general doesn't respect the anatomy and in the other hand edema due to stroke in general yes it respect the anatomy of the vessels territory and anatomical lobes. However I have one question: Is the mass seen in the CT is the same mass...
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