636
Journal of the Royal Society of Medicine Volume 85 October 1992
A barium swallow in 1983 reported 'a slight indentation in the distal oesophagus' and this finding may be significant as it has been suggested that these polyps may occur as a response to injury5. To assume that the HPOA in this case was necessarily due to the fibroid polyp may not be correct. It remains possible that the vagotomy, itself unavoidable during oesophagogastrectomy, led to the resolution of the patient's HPOA6. Rather we feel that this IFP occurred at a critical site in relation to as yet unknown pleural or subpleural receptors. In this way it may share'a mechanism with other unusual causes of HPOA such'as pleural fibromas. Since his operation Mr PM has eaten a normal diet, gained weight and is back to living life to the full.
References 1 Shneerson JM. Digital clubbing and hypertrophic osteoarthropathy: the underlying mechanisms. Br J Dis Chest 1981;75: 113-25 2 Yong IK, Woo HK. Inflammatory fibroid polyps ofgastrointestinal tract. Am J Clin Pathol 1988;89:721-7 3 Stolte M, Finkenzeller G. Inflammatory fibroid polyp of the stomach. Endoscopy 1990;22:203-7 4 Ishikura H, Sato F, Naka A, Kodama T, Aizawa M. Inflammatory fibroid polyp of the stomach. Acta Pathol Jpn 1986;36:327-35 5 Lin S, Tsay 8, Chiang H, Lui W, Lin H. Inflammatory fibroid polyp of stomach. Report of two cases and review of the literature. Chin Med J 1988;42:147-50 6 Flavell G. Reversal of pulmonary hypertrophic osteoarthropathy by vagotomy. Lancet 1956i:260-2
Acknowledgments. We thank Dr Goddard of the Histopathology Department of The Norfolk and Norwich Hospital for his excellent help.
(Accepted 16 March 1992)
Lienocolonic fistula following splenic abscess
M R Cowie MRCP B I Hoffbrand FRCP D S Grant MUCP FRCR Department of Medicine, Whittington Hospital; -London N19 5NF hy; computerized tomography
Keyword splenic abscess;
Splenic abscess is a rare cl'minical problem. Rupture of such an abscess into the colon has -been reported on only two I
previous occasions to our knowledge"2. A further case is now described.
Case report A 55-year-old man withAhonic renal impairment and noninsulin dependent diabetes mellitus presented with a 7-day history of malaise, vomitiig, rigors and vague left-sided abdominal pain. The patient had been born with ectopia vesicae and had had bilateral ureterosigmoidostomy performed at age 5 years.
He was afebrile on admission, with minimal left-sided abdominal tenderness on deep palpation. Investigations revealed a Klebsiella aeruginosa bacteraemia, and a decline in renal function with plasma urea 38.4 mmol/A and creatinine 338 AmolR. The infection was presumed to arise from the urinary tract and treatment with intravenous cefuroxime commenced (to which the organism proved sensitive),iThe pain resolved and intermittent fever settled, but just before discharge the pain and fever recurred. No organisnM was initially cultured from the blood. Two abdomiiial ultrasound examinations revealed no obvious source o is, but a computerized tomogram of the ebdomeraled a 10cm hypodense lesion within the spleen,, 1ith2ao enhancement after -contrast (Figure 1). A percutaneous drain was inserted into the lesion and pus aspiratd-; This subsequently grew Klebsiella aeruginosa sensitive to:amoxycillin and clavulanic acid (with which the patientws treated). Lsrgi6iuunts of pus continued to drain from the abscess cavity a1urther 40 days. A sinogram was performed
~~...
^
...
.... ...
^Er
......
.-
Case presented to Clinical Section, 13 December 1991
..
.:
.. .. ...}..
.
.,,, .. ... . .l .
, ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..............................:._ll
to descendn olon Figure 1. Computerized tomogram abscess cavity within spleen
of the abdom'en showing large
Correspondence to: Dr B I Hoffbrand, Whittington Hospital, Highgate Hill, London N19 5NF
0141-0768/92
'100636-02/$&2.0Qwa Figure 2. sinogram showing fistula connecting splenic abscess cavitzy to descending colon
© 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 October 1992 and this showed an irregular abscess cavity within the spleen, with no communication between it and sr dg structures. Three weeks-later dainage stoppednd a peat sinogram (Figure 2) reyealedafistul.between th,sple'iic, abscess cavity, now muhirld isixe, and thed ding t e it colon. The percutaneous dran v a. continued orally for a furter 6 w -and th pati remained completely well to-fllow.up of 5 mpnths. Discussion Splenic abscess is rare - beint found in 4.7% of autopsies3 and in 0.2% of surgical em;ergencies4. Males are more frequently affected thafemales, with a rativof 2: 1.In the older age groups the paients tend to be diRbe s is prominent and the abece !AIlcUo .Smy' ed in -this follow infection elsewhere,eg6uzary tact( case), trauma, surgery-orreautol o The presenting featur 4.plenic ac -yi ot there is fever, abdominal pain and tenderness, but clinical splenomegaly occurs in less than 60%4. The responsible bacteriological organisms are isolated from blood cultures in almost three-quarters of cases. Gram positive cocci (either streptococci or staphylococci) are found in 30% of cases, and Gram negative organisms, as in this case, in 29%4. Ultrasonography is usefil in identifying splenic abscess, but as in this case, there is an appreciable false negative rate7. Computerized tomography (CT) of the abdomen is the investigation of choice at the present time. It characteristically
Central lumbar disc prolapse following chiropractic manipulation: a call for audit of 'alternative practice'
R N S Slater MA ERCS J D Spencer MRCP PROs Department of Orthopaedic Surgery, United Medical and Dental Schools, Guy's Hospital, London SEl 9RT Keywords: lumbar spine; manipulation; disc prolapse
Manipulation of the lumbar spine for low back pain by 'alternative practitioners' is a treatment that enjoys increasing popularity but awareness of its complications, some of them serious and irreversible, may be poor. By reporting this case of central disc prolapse following a manipulation we seek not to devalue 'alternative' therapy but to improve awareness of the potential hazards and perhaps hasten referral for any definitive treatment that may become necessary. Case report A 28-year-old woman with long-term low back pain attended a chiropractor who obtained plain X-rays of her lumbar spine before performing a manipulation she described as 'vigorous'. Within hours the pain was much worse with-the addition of sciatica in the distribution of the 5th lumbar'dermatome bilaterally. She had never previously suffered from sciatica. Her bladder sensation was described as 'altered'; sphincter control was not lost but she could not say if her bladder was full or empty. On examination, movements of the lumbar spine were grossly restricted and straight leg raising was limited by
637
reveals a non-enhancing hypodense lesion within the spleen
The,treatment of splenic abscess is either b,y splenectomy (with lthe -subsequent increasd 'risk of overwhelming sepsis fiom capsulated organims such as Streptococcus eii or with CT-guidbd percutaneous drainage as wnipneum in this as The occurrence of fisttila formation between the colon and'a spenic abscess has bein reported previously on only twoan many years agoPj few details are given. In this case it appeared to aid resohition of the abscess by allowing spontaneous drainage. T7e-patient remained well at follow-up 5 months later; it would appear-that such an occurrence is not clinically harmful.. References 1 Elting AW. Abscess of spleen-. Ann Sueg. 1915;62:182-92 2 Billings AE. Abscess of the spleen. Ann &rg 1928;88:416-28 8 Faught WE, Gilbertson JJ, Nelson EW. Spisnic abscess: presentation, treatment options, and iesuts. Am J Surg 1989;158: 612-15 4 Lawhorne TW, Zuideman GD.-Splepnic absce. Surgery 1976; 79:686-9 5 Gadacz T, Way LW, Dunphy JE. Changing clinical spectrum of
splenic abscess. Am J Surg 1974;128:182 6 Sarr MG, Zuideman GD. Splenic ahbe - -presentation, diagnos
and treatment. Surgery 1982;2:480-5 7 Linos DA, Nagorney DM, McIrqh--DC. Splenic abscess - the importance of early diagnosis. Mayo Clin Proc 1983;58:261-4
(Accepted 7 April 1992)
extreme nerve root tension to less than 50 on both sides. Pinprick sensation was blunted in the 5th lumbar dermatome. Motor weakness, graded 3/5, was found testing the 5th lumbar myotome. Reflexes were brisk at the knees but absent at the ankles. Anal tone and sensation was preserved and the bladder was found by percussion to be moderately full. An emergency radiculogram (Figure 1) showed complete cessation of contrast flow beyond a block at the level of the 4th/5th lumbar disc space and a diagnosis of central disc prolapse at this level was made. The disc space was explored promptly through a small fenestration between the laminae of L4 and L5 on the right side where symptoms were marginally worse. The findings were an empty disc space, a rent in the annulus fibrosus and a large disc fragment sequestered behind the posterior longitudinal ligament which was compressing the neural elements adjacent to it. The patient made an uneventful recovery with complete resolution of leg symptoms and signs. She continues to suffer from low back pain and stiffness although these symptoms are waning.
Discussion In this country there is increasing enthusiasm for 'alternative' medical therapy in general; enthusiasm for 'alternative' treatments for back pain in particular has been fuelled by a study that suggests superior results of chiiropractic manipulation over hospital outpatient treatment' available through the National Health Service. This study reached a wide audience by repetition in the popular press. We are worried that the complications of lumbar spine manipulation are less familiar and the need for prompt referral in the circumstances reported here may not be recognized. Regrettably others have reported cases of paraparesis2 and complete cauda equina -syndrome3 where there has been delay in definitive management.
Case presented to Section of Orthopaedics, 23 November 1991
0141-0768/92 100637-02/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 October 1992
A barium swallow in 1983 reported 'a slight indentation in the distal oesophagus' and this finding may be significant as it has been suggested that these polyps may occur as a response to injury5. To assume that the HPOA in this case was necessarily due to the fibroid polyp may not be correct. It remains possible that the vagotomy, itself unavoidable during oesophagogastrectomy, led to the resolution of the patient's HPOA6. Rather we feel that this IFP occurred at a critical site in relation to as yet unknown pleural or subpleural receptors. In this way it may share'a mechanism with other unusual causes of HPOA such'as pleural fibromas. Since his operation Mr PM has eaten a normal diet, gained weight and is back to living life to the full.
References 1 Shneerson JM. Digital clubbing and hypertrophic osteoarthropathy: the underlying mechanisms. Br J Dis Chest 1981;75: 113-25 2 Yong IK, Woo HK. Inflammatory fibroid polyps ofgastrointestinal tract. Am J Clin Pathol 1988;89:721-7 3 Stolte M, Finkenzeller G. Inflammatory fibroid polyp of the stomach. Endoscopy 1990;22:203-7 4 Ishikura H, Sato F, Naka A, Kodama T, Aizawa M. Inflammatory fibroid polyp of the stomach. Acta Pathol Jpn 1986;36:327-35 5 Lin S, Tsay 8, Chiang H, Lui W, Lin H. Inflammatory fibroid polyp of stomach. Report of two cases and review of the literature. Chin Med J 1988;42:147-50 6 Flavell G. Reversal of pulmonary hypertrophic osteoarthropathy by vagotomy. Lancet 1956i:260-2
Acknowledgments. We thank Dr Goddard of the Histopathology Department of The Norfolk and Norwich Hospital for his excellent help.
(Accepted 16 March 1992)
Lienocolonic fistula following splenic abscess
M R Cowie MRCP B I Hoffbrand FRCP D S Grant MUCP FRCR Department of Medicine, Whittington Hospital; -London N19 5NF hy; computerized tomography
Keyword splenic abscess;
Splenic abscess is a rare cl'minical problem. Rupture of such an abscess into the colon has -been reported on only two I
previous occasions to our knowledge"2. A further case is now described.
Case report A 55-year-old man withAhonic renal impairment and noninsulin dependent diabetes mellitus presented with a 7-day history of malaise, vomitiig, rigors and vague left-sided abdominal pain. The patient had been born with ectopia vesicae and had had bilateral ureterosigmoidostomy performed at age 5 years.
He was afebrile on admission, with minimal left-sided abdominal tenderness on deep palpation. Investigations revealed a Klebsiella aeruginosa bacteraemia, and a decline in renal function with plasma urea 38.4 mmol/A and creatinine 338 AmolR. The infection was presumed to arise from the urinary tract and treatment with intravenous cefuroxime commenced (to which the organism proved sensitive),iThe pain resolved and intermittent fever settled, but just before discharge the pain and fever recurred. No organisnM was initially cultured from the blood. Two abdomiiial ultrasound examinations revealed no obvious source o is, but a computerized tomogram of the ebdomeraled a 10cm hypodense lesion within the spleen,, 1ith2ao enhancement after -contrast (Figure 1). A percutaneous drain was inserted into the lesion and pus aspiratd-; This subsequently grew Klebsiella aeruginosa sensitive to:amoxycillin and clavulanic acid (with which the patientws treated). Lsrgi6iuunts of pus continued to drain from the abscess cavity a1urther 40 days. A sinogram was performed
~~...
^
...
.... ...
^Er
......
.-
Case presented to Clinical Section, 13 December 1991
..
.:
.. .. ...}..
.
.,,, .. ... . .l .
, ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..............................:._ll
to descendn olon Figure 1. Computerized tomogram abscess cavity within spleen
of the abdom'en showing large
Correspondence to: Dr B I Hoffbrand, Whittington Hospital, Highgate Hill, London N19 5NF
0141-0768/92
'100636-02/$&2.0Qwa Figure 2. sinogram showing fistula connecting splenic abscess cavitzy to descending colon
© 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 October 1992 and this showed an irregular abscess cavity within the spleen, with no communication between it and sr dg structures. Three weeks-later dainage stoppednd a peat sinogram (Figure 2) reyealedafistul.between th,sple'iic, abscess cavity, now muhirld isixe, and thed ding t e it colon. The percutaneous dran v a. continued orally for a furter 6 w -and th pati remained completely well to-fllow.up of 5 mpnths. Discussion Splenic abscess is rare - beint found in 4.7% of autopsies3 and in 0.2% of surgical em;ergencies4. Males are more frequently affected thafemales, with a rativof 2: 1.In the older age groups the paients tend to be diRbe s is prominent and the abece !AIlcUo .Smy' ed in -this follow infection elsewhere,eg6uzary tact( case), trauma, surgery-orreautol o The presenting featur 4.plenic ac -yi ot there is fever, abdominal pain and tenderness, but clinical splenomegaly occurs in less than 60%4. The responsible bacteriological organisms are isolated from blood cultures in almost three-quarters of cases. Gram positive cocci (either streptococci or staphylococci) are found in 30% of cases, and Gram negative organisms, as in this case, in 29%4. Ultrasonography is usefil in identifying splenic abscess, but as in this case, there is an appreciable false negative rate7. Computerized tomography (CT) of the abdomen is the investigation of choice at the present time. It characteristically
Central lumbar disc prolapse following chiropractic manipulation: a call for audit of 'alternative practice'
R N S Slater MA ERCS J D Spencer MRCP PROs Department of Orthopaedic Surgery, United Medical and Dental Schools, Guy's Hospital, London SEl 9RT Keywords: lumbar spine; manipulation; disc prolapse
Manipulation of the lumbar spine for low back pain by 'alternative practitioners' is a treatment that enjoys increasing popularity but awareness of its complications, some of them serious and irreversible, may be poor. By reporting this case of central disc prolapse following a manipulation we seek not to devalue 'alternative' therapy but to improve awareness of the potential hazards and perhaps hasten referral for any definitive treatment that may become necessary. Case report A 28-year-old woman with long-term low back pain attended a chiropractor who obtained plain X-rays of her lumbar spine before performing a manipulation she described as 'vigorous'. Within hours the pain was much worse with-the addition of sciatica in the distribution of the 5th lumbar'dermatome bilaterally. She had never previously suffered from sciatica. Her bladder sensation was described as 'altered'; sphincter control was not lost but she could not say if her bladder was full or empty. On examination, movements of the lumbar spine were grossly restricted and straight leg raising was limited by
637
reveals a non-enhancing hypodense lesion within the spleen
The,treatment of splenic abscess is either b,y splenectomy (with lthe -subsequent increasd 'risk of overwhelming sepsis fiom capsulated organims such as Streptococcus eii or with CT-guidbd percutaneous drainage as wnipneum in this as The occurrence of fisttila formation between the colon and'a spenic abscess has bein reported previously on only twoan many years agoPj few details are given. In this case it appeared to aid resohition of the abscess by allowing spontaneous drainage. T7e-patient remained well at follow-up 5 months later; it would appear-that such an occurrence is not clinically harmful.. References 1 Elting AW. Abscess of spleen-. Ann Sueg. 1915;62:182-92 2 Billings AE. Abscess of the spleen. Ann &rg 1928;88:416-28 8 Faught WE, Gilbertson JJ, Nelson EW. Spisnic abscess: presentation, treatment options, and iesuts. Am J Surg 1989;158: 612-15 4 Lawhorne TW, Zuideman GD.-Splepnic absce. Surgery 1976; 79:686-9 5 Gadacz T, Way LW, Dunphy JE. Changing clinical spectrum of
splenic abscess. Am J Surg 1974;128:182 6 Sarr MG, Zuideman GD. Splenic ahbe - -presentation, diagnos
and treatment. Surgery 1982;2:480-5 7 Linos DA, Nagorney DM, McIrqh--DC. Splenic abscess - the importance of early diagnosis. Mayo Clin Proc 1983;58:261-4
(Accepted 7 April 1992)
extreme nerve root tension to less than 50 on both sides. Pinprick sensation was blunted in the 5th lumbar dermatome. Motor weakness, graded 3/5, was found testing the 5th lumbar myotome. Reflexes were brisk at the knees but absent at the ankles. Anal tone and sensation was preserved and the bladder was found by percussion to be moderately full. An emergency radiculogram (Figure 1) showed complete cessation of contrast flow beyond a block at the level of the 4th/5th lumbar disc space and a diagnosis of central disc prolapse at this level was made. The disc space was explored promptly through a small fenestration between the laminae of L4 and L5 on the right side where symptoms were marginally worse. The findings were an empty disc space, a rent in the annulus fibrosus and a large disc fragment sequestered behind the posterior longitudinal ligament which was compressing the neural elements adjacent to it. The patient made an uneventful recovery with complete resolution of leg symptoms and signs. She continues to suffer from low back pain and stiffness although these symptoms are waning.
Discussion In this country there is increasing enthusiasm for 'alternative' medical therapy in general; enthusiasm for 'alternative' treatments for back pain in particular has been fuelled by a study that suggests superior results of chiiropractic manipulation over hospital outpatient treatment' available through the National Health Service. This study reached a wide audience by repetition in the popular press. We are worried that the complications of lumbar spine manipulation are less familiar and the need for prompt referral in the circumstances reported here may not be recognized. Regrettably others have reported cases of paraparesis2 and complete cauda equina -syndrome3 where there has been delay in definitive management.
Case presented to Section of Orthopaedics, 23 November 1991
0141-0768/92 100637-02/$02.00/0 © 1992 The Royal Society of Medicine
