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gastroenteric anastomosis was performed, excluding the duodenum. Two drainages were placed near the perforated site to drain any possible biliary fistula. A nasoenteral feeding tube was then positioned. To manage the potential perforation risk of the duodenal and ileal ulcerations caused by acute vasculitis, to preserve the abdominal cavity from intraperitoneal collections and to create a guided biliary fistula, an open abdomen treatment with negative pressure system was placed; we positioned a temporary find more fascial mesh to preserve the fascia and prevent its retraction. Two weeks after the second surgical procedure a percutaneous transhepatic biliary drainage (PTBD) was placed to reduce the flow of the peritoneal biliary fistula. Figure 1 Abdominal computed tomography (CT) scan showed free retroperitoneal air (arrow), suspected for a small leakage from the posterior aspect of the third duodenal portion. We changed the negative pressure dressing every 3–4 days, washing the peritoneal cavity and tightening the fascial mesh. The negative pressure system
was very useful and effective because of the large amount of biliary leakage and bowel contamination caused by multiple ischemic ulcers in the second and third portion of the duodenum, otherwise this condition was not manageable with the use of simple drains. After two months, the open abdomen treatment was suspended, the fascial mesh was removed and the fascia was primarily closed. Afterward, we removed the PTBD and the abdominal drain following the execution of abdominal X-ray with oral contrast, demonstrating VX-765 supplier absence of residual duodenal biliary leakage after four months. During her ICU stay, the patient presented signs of renal vasculitis, therefore she underwent cycles Temsirolimus chemical structure of continuous veno-venous hemodialysis (CCVHD), plasmapheresis and intravenous immunoglobulin (IVIG), showing clear improvement of her renal function and negative immunological test. Low molecular weight heparin (LMWH) treatment was complicated by heparin induced thrombocytopenia
(HIT) with low platelet (PLT) count (99.000/μm3). Argatroban was administered obtaining progressive increase in PLT count (354.000/μm3). Three months after surgery she had seizures with MRI scan positive for vasculitic diffuse encephalic CB-839 research buy lesions, treated with levetiracetam and metilprendisone. During hospitalization we observed nasal regurgitation of fluids, nasal speech and hoarseness probably due to loss of pharyngoesophageal muscle tone and increase and reduction in hepatic stasis values of unknown origin. After 8 months of follow-up, no signs or symptoms of abdominal disease were reported. DM is an autoimmune disease characterized by cutaneous heliotropic rash, Gottron papules and proximal myopathy associated to dysphagia, dysphonia, Raynaud phenomenon, fatigue and non-erosive inflammatory polyarthritis [1].