Abstractfections. In the post-antibiotic era this complication of neck infection is much less Background -Descending necrotising mediastinitis is caused by downward common. Estrera et al 2 reported the largest series since 1960 with 10 cases. We have sucspread of neck infection and has a high fatality rate of 31%. The seriousness of cessfully treated seven adult patients with descending necrotising mediastinitis and also this infection is caused by the absence of barriers in the contiguous fascial planes present a child in whom the infection developed and spread rapidly, leading to death. This paper of neck and mediastinum. Methods -The recent successful treatment reviews these cases and presents a meta-analysis of 24 case reports and 12 series of adult desof seven adult patients with descending necrotising mediastinitis emphasises the cending necrotising mediastinitis since 1970. importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also pre-Methods sented of a child with descending ne- 1 crotising mediastinitis, demonstrating the A 35 year old male engineer with a past history rapidity with which the infection can de-of hepatitis B was admitted following transfer velop and lead to death. Twenty four case from the intensive care unit of a peripheral reports and 12 series of adult patients with hospital. Five days prior to admission he had descending necrotising mediastinitis pub-sought medical attention for odynophagia, lished since 1970 were reviewed with meta-hoarseness, and mild left otalgia for which he analysis. In each case of confirmed des-was given oral penicillin. Forty eight hours later cending necrotising mediastinitis the he was admitted to the intensive care unit There were bilateral pleural effusions and lower 19% when mediastinal drainage was added lobe consolidation. The pericardial space was
Transjugular intrahepatic portosystemic shunts (TIPSs) are used to treat variceal hemorrhage and refractory ascites. We sought to determine factors associated with stenosis and mortality after TIPS placement in patients with end-stage liver disease. This is a retrospective review of 90 TIPSs placed over a 3-year period. Demographic, clinical, and biochemical parameters were analyzed in univariate analyses to determine their association with stenosis and death. Multivariate analyses were conducted using logistic regression and Cox proportional hazard modeling. Thirty-five TIPSs were placed for recurrent variceal bleeding; 14 TIPSs, for uncontrolled variceal bleeding; 34 TIPSs, for refractory ascites; and 7 TIPSs, for other causes. The overall mortality rate was 33%, and 18 patients died within 30 days of TIPS placement. The 1-year stenosis rate was 49%. Fourteen patients underwent liver transplantation a mean of 116 ؎ 143 days after TIPS placement. Prothrombin time greater than 17 seconds, serum creatinine level greater than 1.7 mg/dL, total bilirubin level greater than 3 mg/dL, and uncontrolled variceal bleeding as an indication for TIPS placement were significant predictors of 30-day mortality. Serum creatinine level was a predictor of 30-day mortality in individuals with recurrent variceal hemorrhage or ascites. Multivariate analyses showed that creatinine level greater than 1.7 mg/dL and uncontrolled variceal bleeding as an indication for TIPS placement were independently associated with 30-day mortality. Individuals with both coagulopathy and renal insufficiency had a 30-day mortality rate of 78%. Urgent placement of TIPS was associated with an increased risk for stenosis (hazard ratio ؍ 4.5; 95% confidence interval, 1.9 to 10.1; P < .001), but no other clinical variables were associated with stenosis. Uncontrolled variceal bleeding as an indication for TIPS placement, coagulopathy, hyperbilirubinemia, and renal insufficiency were associated with increased mortality in patients with TIPSs. Individuals with both coagulopathy and renal insufficiency had high mortality. Urgent TIPS placement for uncontrolled variceal bleeding was associated with stenosis. (Liver Transpl 2002;8:271-277.) T ransjugular intrahepatic portosystemic shunts (TIPSs) are used to treat sequelae of portal hypertension that are not responsive to medical and endoscopic therapy. A TIPS is effective in stopping acute variceal bleeding and preventing rebleeding from varices refractory to endoscopic and medical therapy. [1][2][3][4][5] Ascites refractory to diuretic therapy is effectively treated with TIPS placement. 6,7 TIPS placement is effective in reducing variceal rebleeding rates to 10% over 1 year and may be effective in treating ascites in 60% of patients. 6 Although TIPS placement is effective in reducing portal hypertension, it is associated with a high stenosis rate. Stenosis occurs in 50% of TIPSs at 1 year. 8 Stenosis is a result of several factors, one of which is neointimal hyperplasia within the stent. 9 Surveillance for steno...
Hepatopulmonary syndrome (HPS) is defined by the presence of the triad of liver disease, arterial hypoxemia, and intrapulmonary vascular dilatation. The clinical implication of this disorder is impairment of gas exchange. Numerous reports in the literature show that this condition is reversible with orthotopic liver transplantation (OLT). However, patients with HPS often present with PaO 2 levels that are quite low. OLT with a preoperative PaO 2 less than 50 mm Hg is associated with unacceptably high mortality and morbidity. We report a case of severe HPS in which a transjugular intrahepatic portosystemic shunt was successfully used to improve oxygenation, thus allowing a successful elective OLT. (Liver Transpl 2001; 7:147-149.)T here are a variety of pulmonary manifestations of liver disease, including pulmonary hypertension, interstitial fibrosis, pleural effusion, and acute lung injury. One of the most striking manifestations is hepatopulmonary syndrome (HPS), defined as a triad of liver disease, arterial hypoxemia, and intrapulmonary vascular dilatation. 1 HPS may be reversible with orthotopic liver transplantation (OLT). 2 The reported prevalence of HPS ranges from 13% to 47%. 3 The majority of patients with HPS present with complications of their underlying liver disease before showing pulmonary symptoms. Platypnea and orthodeoxia are common findings of HPS. The pathological state of the hypoxemia is not completely understood. The mechanism may be related to an intrapulmonary shunt created by hyperdynamic circulation, with low pulmonary resistance secondary to abnormal dilatation of pulmonary vessels. 3 Increased nitric oxide production resulting from portal hypertension also has been proposed as a mediator of intrapulmonary vascular dilatation. 4 The following case illustrates the use of a transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation in a patient with severe HPS by improving oxygenation. Case ReportA 51-year-old white woman with end-stage liver disease caused by chronic hepatitis C was on the United Network for Organ Sharing list for OLT. In April 1999, she was hospitalized with increasing abdominal girth, as well as worsening jaundice and increasing hepatic encephalopathy. Laboratory data showed the following values: platelets, 43,000/L; bilirubin, 5.8 mg/dL; albumin, 2.5 g/dL; aspartate aminotransferase, 40 IU/L; alanine aminotransferase, 34 IU/L; and prothrombin time, 17.5 seconds (international normalized ratio, 1.8). She also showed progressive shortness of breath, with a pulse oximetry reading of 89% on room air. Blood gas analysis showed a pH of 7.42 with a PaO 2 of 57 mm Hg on 3 L of oxygen by nasal cannula. She had an alveolar-arterial gradient of 109 mm Hg.She continued to have respiratory difficulties and was transferred to the intensive care unit, where she was placed on a ventilator with PaO 2 values in the range of 40 to 50 mm Hg despite a high fraction of inspired oxygen (100%) delivery. Intensive workup of her hypoxia was unrevealing. Chest radiograph...
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