Mesenteric Cystic Lymphangioma, an acute presentation in a 9-year-old child

Mesenteric lymphangioma is a rare malformation of the lymphatic system. Misdiagnosis of mesenteric cystic lymphangioma can occur due to its rarity and resemblance to other cystic lesions and ascites. The authors report an acute presentation of a mesenteric lymphangioma in a 9-year-old child. Clinical, radiological, and surgical findings are illustrated accordingly. As authors, we aim to add to the limited data of acute presentations of mesenteric lymphangiomas.

Influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children

PURPOSE

To clarify the influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children in Japan.

METHODS

We collected data on pediatric patients with gastrointestinal perforation between 2017 and 2019, from the National Clinical Database. The surgical volumes of various institutions were classified into three groups: low (average number of surgeries for gastrointestinal perforation/year < 1), medium (≥ 1, < 6), and high (≥ 6). The observed-to-expected (o/e) ratios of 30-day mortality and morbidity were calculated for each group using an existing risk model.

RESULTS

Among 1641 patients (median age, 0.0 years), the 30-day mortality and morbidity rates were 5.2% and 37.7%, respectively. The 30-day mortality rates in the low-, medium-, and high-volume institutions were 4.9%, 5.3%, and 5.1% (p = 0.94), and the 30-day morbidity rates in the three groups were 26.8%, 39.7%, and 37.7% (p < 0.01), respectively. The o/e ratios of 30-day mortality were 1.05 (95% confidence interval [CI] 0.83-1.26), 1.08 (95% CI 1.01-1.15), and 1.02 (95% CI 0.91-1.13), and those of 30-day morbidity were 1.72 (95% CI 0.93-2.51), 1.03 (95% CI 0.79-1.28), and 0.95 (95% CI 0.56-1.33), respectively.

CONCLUSION

Surgical volume does not have significant impact on the outcomes of pediatric gastrointestinal perforation in Japan.

Stercoral perforation of the cecum: A case report

BACKGROUND

With less than 90 reported cases to date, stercoral perforation of the colon is a rare occurrence. Stercoral ulceration is thought to occur due to ischemic pressure necrosis of the bowel wall, which is caused by the presence of a stercoraceous mass. To underscore this urgent surgical situation concerning clinical presentation, surgical treatment, and results, we present the case of a 66-year-old man with a stercoral perforation.

CASE SUMMARY

A 66-year-old man with a history of hypertension, hyperlipidemia, and gout presented at the emergency department with lower abdominal pain and a low-grade fever lasting for a few hours. Abdominal computed tomography indicated a suspected bezoar (approximately 7.6 cm) in the dilated cecum, accompanied by pericolic fat stranding, mild proximal dilatation of the ileum, pneumoperitoneum, and minimal ascites. Intraoperatively, feculent peritonitis with isolated cecal perforation were observed. Consequently, a right hemicolectomy with peritoneal lavage was performed. A histopathological examination supported the intraoperative findings.

CONCLUSION

In stercoral perforations, a diagnosis should be diligently pursued, especially in older adults, and prompt surgical intervention should be implemented.

A plastic bezoar causing bowel obstruction: A case of table cover ingestion

INTRODUCTION AND IMPORTANCE

A bezoar is an indigestible food or other material within the gastrointestinal tract. It can be ingested intentionally or accidentally. The small bowel bezoar prevalence ranges between 0.4 % and 4 %, and the prevalence is less than 0.5 % for gastric bezoars. There are different types of bezoars, but the mention of a plastic bezoar rarely appears in the literature. To our knowledge, this is the first reported case of a plastic bezoar in the Kingdom of Saudi Arabia.

CASE PRESENTATION

A 58-year-old woman was admitted for acute kidney injury, and while working her up, it was discovered that she had a possible foreign body on computerized tomography scan. As a result, she underwent exploratory laparotomy with the findings of plastic foreign objects identified 90 cm from the ileocecal valve and other objects identified in the stomach.

CLINICAL DISCUSSION

The impaction of these materials often occurs in narrow areas such as the lower esophagus, duodenum, ileocecal valve or even the anus. In this unique case, two points of impaction were noted: the first was in the small bowel and the second point in the stomach. The approach to such cases could be Endoscopic versus surgical or even chemical dissolution as a choice of treatment is dependent on multiple factors.

CONCLUSION

The approach to these cases is multidisciplinary and depends on the availability of services and resources at the treating hospital. Reporting such cases helps in managing challenging situations. Additionally, a psychiatric assessment is a crucial step.

A rare case report of patent vitellointestinal duct presenting as a periumbilical pain in an adult

The vitellointestinal duct (VID) is an embryological remnant of the vitelline duct, a structure that connects the developing fetus to the yolk sac and is responsible for the nutritional support of the fetus during the early embryological days. The VID usually gets obliterated by the fifth to ninth week of gestational age after the establishment of placental nutrition. The patent VIDellointestinal duct is a relatively rare congenital condition that occurs in approximately 2% of the general population, with the most common presentation being Meckel's diverticulum. Complete patency is rarer, occurring in 0.1% of the general population. The complete persistence of the VID results in enterocutaneous fistula, and the presentation may vary, ranging from cutaneous manifestations like skin lesions, granulomas, abscesses, or umbilical discharge to abdominal symptoms including acute abdominal pain and hematochezia. Some patients are even asymptomatic and are detected incidentally. We present a rare case of complete patency of the VID in a 30-year-old adult male presenting with acute periumbilical pain. Imaging findings guided the diagnosis, and surgical resection with histopathological examination further confirmed the condition.

Acute abdomen by red degeneration of a parasitic leiomyoma: A case report and literature review

A 43-year-old woman, with a history of uterine fibroids and multiple myomectomy, presented with acute lower abdominal pain. Computed tomography revealed multiple tumors, including a high-density mass in the left lower abdomen indicative of a parasitic leiomyoma undergoing red degeneration. This uncommon condition is due to acute occlusion, often caused by peripheral venous thrombosis at the fibroid edge. The diagnosis was corroborated by distinctive findings on magnetic resonance imaging and computed tomography. Notably, high signal intensity on T1-weighted images (T1WI) suggested methemoglobin presence due to hemorrhagic infarction, whereas low signal intensity on T2-weighted images (T2WI) indicated deoxyhemoglobin. Symptom improvement followed treatment with analgesics. This case underscores the significance of considering parasitic myomas in the differential diagnosis of intraperitoneal tumors after myomectomy and proposes that vascular torsion from mechanical stress on the mobile mesentery may contribute to red degeneration in such tumors. In this report, we detail the imaging characteristics and clinical progression of red degeneration in a parasitic leiomyoma, emphasizing the importance of this diagnosis in patients with a history of uterine surgery.

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Perforated Ischemic Ulcer at the Jejuno-Jejunal Anastomosis 9 Years Post-laparoscopic Roux-en-Y Gastric Bypass-a Case Report

BACKGROUND

Obesity is a common disease among Kuwaitis. Multiple types of bariatric procedures are offered in Kuwait. R-Y gastric bypass is among the common surgeries performed. Early and late complications must be recognized as early as possible to avoid undesirable consequences.

CASE PRESENTATION

Here, we present a case of a 48-year-old lady presented as acute abdominal pain and diagnosed as Jejuno-Jejunal anastomosis site ulceration / perforation taking place several years from surgery.

DISCUSSION

Etiology of late perforation can be attributed to ischemia. Computerized tomography (C.T.) scan is the gold standard for diagnosis. Management can be laparoscopic or open surgery depending on surgeon expertise. We performed a laparoscopic resection for the extended perforated jejunal recess and that was enough to resolve our patient's problem.

Primary splenic abscess in an adult female patient: a case report

BACKGROUND

Primary splenic abscess is rare and typically presents in patients who are immunocompromised. We present a case of a 47-year-old apparently immunocompetent female patient who was diagnosed with primary splenic abscess from a Salmonella Typhimurium infection following emergency laparotomy.

CASE PRESENTATION

A 47-year-old female patient presented with subjective fever and severe epigastric and left flank pain. She was treated empirically with intravenous piperacillin/tazobactam and gentamicin and was resuscitated with intravenous crystalloid infusion. A radiological diagnosis of splenic infarct secondary to splenic artery aneurysm superimposed with splenic abscess was presumed, however at emergency laparotomy, primary splenic abscess was identified. This abscess had eroded the left hemidiaphragm and had ruptured the splenic capsule leading to intra-abdominal pus in the pelvis which on culture grew Salmonella Typhimurium. A splenectomy and primary repair of the left hemidiaphragm were performed, with postoperative pancreatitis diagnosed following the procedure. After intensive care treatment, this patient made a full recovery.

CONCLUSION

This case of primary splenic abscess was treated successfully with a combination of surgery (i.e.: splenectomy and surgical drainage), prolonged antimicrobial therapy, and intensive care in the perioperative period.

Retroperitoneal necrotizing fasciitis mimicking perforated appendicitis: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare and rapidly progressing soft tissue infection. The commonly involved body parts are the extremities and trunk. Necrotizing fasciitis (NF) involving the retroperitoneum is very uncommon but associated with higher morbidity and mortality. There are only a few patients survived according to the report.

PRESENTATION OF CASE

This is a 19-year-old male patient presented with abdominal pain, high-grade fever, vomiting and abdominal distension for 3 days. On physical examination, he was hypotensive, tachycardic and febrile. He had a distended, tender abdomen, and hypoactive bowel sound. There were no significant pertinent findings on the other systems. Laboratory tests showed leukocytosis, thrombocytopenia, and elevated liver enzymes. After optimizing with resuscitation and initiating antibiotics, a laparotomy was performed. The finding was 300 ml of hemorrhagic fluid, ischemic cecum and ascending colon, and retroperitoneal necrosis. Subsequently, multiple debridement and right hemicolectomy with stoma was performed. Despite the close monitoring in the ICU, the patient died of uncontrolled sepsis.

CLINICAL DISCUSSION

Necrotizing fasciitis (NF) is a rapidly progressing infectious condition that requires urgent intervention. While it is rare for the retroperitoneum to be affected by NF, it is associated with a high mortality rate. The symptoms of retroperitoneal NF are not specific, making it difficult to diagnose. Here, we present a case of retroperitoneal NF with signs and symptoms of generalized peritonitis, resembling perforated appendicitis.

CONCLUSION

When patients are presented with a case of generalized peritonitis, it is important to include retroperitoneal NF as a potential differential diagnosis.

Prevalence of SIRS with primary epiploic appendagitis

PURPOSE

Primary epiploic appendagitis (PEA) is not an uncommon cause of abdominal pain. The systemic inflammatory response syndrome (SIRS) criteria have high sensitivity for early detection of inflammation and infection. To date, there is limited data about the association between SIRS and PEA. The aims of this retrospective study were to evaluate the prevalence of SIRS response and its clinical relevance in patients diagnosed with PEA within a large tertiary hospital network.

METHODS

A retrospective study was performed on all consecutive adult patients who presented to four major emergency departments with CT-confirmed PEA from 01 January 2022 to 27 March 2023. The fulfilment of SIRS criteria, hospital admission rate and treatments provided were analysed for these patients.

RESULTS

Seventy-three patients had CT-confirmed PEA. Seventeen patients (23.2%) with PEA were SIRS positive. The hospital admission rate in the SIRS group trended higher than the non-SIRS group (odds ratio of 2.51, 95% CI (0.75, 8.39)). The odds of having an associated radiological comorbidity unrelated to PEA were 18.7 times higher in the SIRS positive group. Fifty-seven (78%) patients were discharged home, and 16 (22%) patients were admitted into hospital. Nearly all patients were treated conservatively (98.6%).

CONCLUSION

PEA patients with SIRS response trend towards a higher hospital admission rate and are significantly more likely to have other radiological comorbidities than non-SIRS patients. It is important to look for other pathological conditions in a SIRS positive patient with a CT-diagnosis of PEA.

Acute abdomen following COVID-19 vaccination: a systematic review

Purpose

Conduct a systematic review of case reports and case series regarding the development of acute abdomen following coronavirus disease 2019 (COVID-19) vaccination, to describe the possible association and the clinical and demographic characteristics in detail.

Materials and Methods

This study included case report studies and case series that focused on the development of acute abdomen following COVID-19 vaccination. Systematic review studies, literature, letters to the editor, brief comments, and so forth were excluded. PubMed, Scopus, EMBASE, and Web of Science databases were searched until June 15, 2023. The Joanna Briggs Institute tool was used to assess the risk of bias and the quality of the study. Descriptive data were presented as frequency, median, mean, and standard deviation.

Results

Seventeen clinical case studies were identified, evaluating 17 patients with acute abdomen associated with COVID-19 vaccination, which included acute appendicitis (n=3), acute pancreatitis (n=9), diverticulitis (n=1), cholecystitis (n=2), and colitis (n=2). The COVID-19 vaccine most commonly linked to acute abdomen was Pfizer-BioNTech (messenger RNA), accounting for 64.71% of cases. Acute abdomen predominantly occurred after the first vaccine dose (52.94%). All patients responded objectively to medical (88.34%) and surgical (11.76%) treatment and were discharged within a few weeks. No cases of death were reported.

Conclusion

Acute abdomen is a rare complication of great interest in the medical and surgical practice of COVID-19 vaccination. Our study is based on a small sample of patients; therefore, it is recommended to conduct future observational studies to fully elucidate the underlying mechanisms of this association.

Spontaneous gastric hematoma as a rare cause of acute abdomen: A case report

BACKGROUND

Spontaneous gastric hematoma is an exceedingly rare condition characterized by the accumulation of blood within the gastric wall without any apparent iatrogenic or traumatic cause. Coagulopathies are the most frequent cause of gastric hematomas. However, other causes include amyloidosis, pancreatitis, visceral vascular aneurysms, endoscopy complications and others. The pathophysiology of spontaneous gastric hematoma is not completely understood. However, it is postulated that it is caused by disruption of submucosal vessels that leads to dissection of the muscularis layer and formation of false lumen. The rarity of this condition increases the challenge of diagnosis, and there is no standard treatment protocol.

CASE SUMMARY

We present the case of a spontaneous gastric hematoma in a 22-year-old male. He presented to our emergency department complaining of pain in the left flank area lasting for 2 wk. There was no history of trauma, anticoagulant medications or endoscopy procedures. His hemoglobin and hematocrit levels were slightly lower than normal. Multi-slice computed tomography, ultrasound and endoscopy confirmed a gastric intramural hematoma. We recommended conservative treatment because there was no hemodynamic instability nor significant bleeding. The patient responded well, and there were no unexpected events. At the 3-mo follow-up, the ultrasound examination revealed complete regression of the hematoma.

CONCLUSION

After reviewing the literature and our experience, we recommend that more of these cases should be treated conservatively. The tendency to treat these cases with potentially burdensome procedures such as total or subtotal gastrectomy should be significantly reduced.

Evaluation of Abdominal Emergencies

Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.

[Epiploic appendagitis: an uncommon and nonsurgical cause of abdominal pain]

BACKGROUND

Epiploic appendagitis (AE) is a rare cause of acute abdomen and is often misdiagnosed as other common causes of acute abdomen, such as acute appendicitis, cholecystitis or diverticulitis due to its low incidence and its nonspecific clinical picture. This study presents the clinical course of AE and typical radiological features for an early and correct diagnosis in order to emphasize the importance of an early and correct diagnosis of AE.

METHODS

This is a retrospective review of 43 patients diagnosed with AE between June 2010 and September 2022 at the Charité - University Hospital Berlin, Campus Benjamin Franklin. The medical records were reviewed regarding clinical und radiological features, anatomical location of the AE und treatment methods.

RESULTS

A total of 43 patients (29 male, 11 female) were diagnosed with AE and almost all patients presented with abdominal pain, except in 8 cases (18.6%). Specific findings in computer tomography (CT) with a typical picture of AE were found in 33 patients (76.7%). AE was mostly localized in the left colon: 12 were found in the sigmoid colon (27.9%), 16 in the descending colon (37.2%) and 5 at the junction of the descending colon and the sigmoid colon (11.6%). Of the patients 28 (65.1%) were admitted for conservative treatment and the rest of the patients were treated as outpatients. No patient underwent surgery, all were treated with analgesics (NSAID) and 17 patients received antibiotics in addition.

CONCLUSION

AE is a self-limiting disease and a common mimic of other serious causes of abdominal pain. Due to the emergence of the widespread use of imaging modalities, an early diagnosis of AE and a conservative approach as first choice of treatment in patients with AE could be established.

Gastric organoaxial volvulus: A lethal twist and a rare cause of acute abdomen

Organoaxial gastric volvulus is a rare clinical condition. We present a 55 years old man with an acute episode of melena and hematemesis with moderate epigastric pain which was unresponsive to analgesics. Initially, the patient was misdiagnosed and treated symptomatically for other gastrointestinal conditions but later contrast-enhanced abdominal CT scan revealed gastric organo-axial volvulus, which was associated with a right hiatal hernia. The patient underwent surgical treatment, including crural dissection, posterior esophageal window creation, lower esophageal sling, crural defect repair with porcine meshes, and anterior gastropexy, followed by intensive physiotherapy and antibiotics. Diagnosis of gastric volvulus can be challenging, due to its symptom similarity to other gastrointestinal disorders, necessitating a high level of suspicion.

Sclerosing encapsulating peritonitis: A rare cause of small bowel obstruction

INTRODUCTION

Sclerosing encapsulating peritonitis (SEP), also known as abdominal cocoon syndrome, represents a rare cause of small bowel obstruction.

CASE PRESENTATION

Herein we report an uncommon case of small bowel obstruction caused by SEP in a 30-year-old male with no prior surgical history who presented to the emergency department. The patient was diagnosed with SEP on preoperative CT scan and underwent a therapeutic laparotomy with extensive adhesiolysis. His symptoms resolved postoperatively and he was discharged in a good condition.

DISCUSSION

Sclerosing encapsulating peritonitis is more prevalent in men, and has a higher incidence in tropical and subtropical countries. The exact pathophysiology of the disease in not well understood, but subclinical intra-abdominal inflammation is theorized to result in a thick fibrocollagenous membrane encapsulating intra-peritoneal organs which leads to intestinal obstruction. The disease is categorized into primary and secondary SEP depending on identification of a pathologic factor. It is further divided into 3 sub-types according to the extent of the peritoneal membrane encasement observed intra-operatively. Patients often present with recurrent history of small bowel obstruction in the absence of prior abdominal surgery. Computed tomography of the abdomen with experienced radiologist interpretation can aid in preoperative diagnosis. In patients with recurrent obstructions and failure of non-operative management, surgical adhesiolysis remains the gold standard.

CONCLUSION

Sclerosing encapsulating peritonitis, is a rare cause of small bowel obstruction. The exact pathogenesis is not well understood. The main line of treatment is surgical adhesiolysis and excision of the intra-abdominal fibrocollagenous membrane.

Omental torsion - A mimicker of the acute appendicitis - A case report

INTRODUCTION

Omental torsion is due to the twisting of the omentum along its axis and is observed in young male patients. The first description of omental torsion was first made by Eitel in 1899.

CASE PRESENTATION

A 35-year-old male presented with right iliac fossa pain, nausea, occasional vomiting and loss of appetite for four days. His clinical and radiological findings were suggestive of acute appendicitis. However, he was diagnosed with greater omental torsion intraoperatively and successfully managed with laparoscopic omentectomy.

DISCUSSION

Omental torsion is a rare condition with a low incidence. Preoperative diagnosis of omental torsion continues to be a challenge as the symptoms reported in the literature are usually confused with other abdominal pathologies such as appendicitis or cholecystitis etc. Preoperative US or CT scans are mandatory, and these procedures can accurately accomplish the pre-operative diagnosis. In search for the treatment of choice, laparoscopy proved its effectiveness as a diagnostic tool since it allows for confirming the diagnosis, evaluating the severity of the ischemia, and ruling out other surgical pathologies and therapeutic tools. At the same time, the open surgery approach can be described in many cases as being too invasive.

CONCLUSION

Greater omental torsion should be considered a differential diagnosis in all patients with acute abdominal emergencies.

Amyand's hernia in a patient with acute complicated diverticulitis. A case report and review of the literature

INTRODUCTION

Amyand's hernia with an inflamed or perforated appendix is rare with incidence of 0.1 % and 0.01 % of cases respectively. It has been described in conjunction with cecal perforation, cholecystitis and ureterolithiasis. Yet, its association with acute sigmoid diverticulitis has never been reported before.

PRESENTATION OF CASE

A 57-year-old male presented to the emergency department with acute abdomen and an indurated right inguinal mass. A preoperative computed tomography (CT) scan reported a giant inflamed sigmoid diverticulum and an Amyand's hernia with a complicated appendicitis. The patient was taken to the operating room and a midline laparotomy incision was made. A giant sigmoid diverticulum with ischemic patches was encountered. The cecal appendix was found inside the right inguinal canal, with a perforation in its distal third. A Hartmann's procedure, appendicectomy and non-mesh inguinal hernia repair was accomplished.

DISCUSSION

Case reports of Amyand's hernia in patients with simultaneous abdominal conditions are scarce. Symptoms in these patients could be various and may lead to preoperative imaging and diagnosis. In this case acute abdomen in physical examination demanded imaging analysis and a preoperative diagnosis of acute diverticulitis and Amyand's hernia with a perforated appendicitis was made.

CONCLUSIONS

Amyand's hernia with acute perforated appendicitis is a rare entity. CT scan is useful for diagnosis of Amyand's hernia and associated conditions. Preoperative diagnosis of Amyand's hernia and concomitant abdominal disease aids in the therapeutic approach and management. To our knowledge this is the first case report of an Amyand's hernia in a patient with acute diverticulitis.

Splenic torsion, a challenging diagnosis in an adult presenting with acute abdomen

INTRODUCTION

Wandering spleen (WS) is a rare condition, occurring in only 0.2 % of cases, where the spleen becomes hypermobile due to the absence or laxity of its anchoring ligaments. Torsion of the spleen, primarily seen in children but occasionally in adults, is a critical complication that can lead to infarction and is considered a medical emergency.

CLINICAL PRESENTATION

We present a case report of a 50-year-old woman with type 2 diabetes and psychiatric illness presented with 2 days of vomiting, abdominal pain, and dehydration. Physical examination showed a tender mass in the abdomen and imaging confirmed a twisted spleen with a thrombosed splenic vein, leading to a successful emergency splenectomy. The patient had an uncomplicated recovery and was discharged with post-splenectomy protocol.

DISCUSSION

Splenic torsion, a rare occurrence primarily observed in children. Clinical diagnosis is aided by palpable abdominal masses and confirmed by radiological imaging. The gold standard diagnostic tool is contrast-enhanced computed tomography (CT), whereas Ultrasonography (USG) is equally good in early assessment. Early identification is crucial to salvage the spleen. Management options include detorsion, splenopexy, or splenectomy depending on the organ viability. Elective splenopexy has emerged as a proactive measure, particularly in children, to prevent complications.

CONCLUSION

Splenic torsion is a rare but important differential diagnosis in patients presenting with acute abdomen. Early diagnosis and prompt management is necessary to preserve the spleen and to prevent the development of complication. Surgery is often necessary and either splenopexy or splenectomy should be done.

Spontaneous bladder rupture after alcohol binge presenting as a rare cause of acute abdomen: A case report and review of literatures

INTRODUCTION AND IMPORTANCE

Bladder rupture, or perforation, is the rupture of the urinary bladder, which is often clinically classified as intraperitoneal, extraperitoneal, or combined types. Spontaneous bladder perforation is an extremely rare event and constitutes less than 2 % of bladder ruptures. It is often associated with previous bladder manipulation, lower urinary tract obstruction, instrumentation, pelvic radiotherapy or surgery, inflammation, and malignancy. Blood work will demonstrate leukocytosis with left shift, hematuria on urinalysis, and an ascites to serum creatinine ratio of more than one, which is highly suggestive of bladder rupture.

CASE PRESENTATION

A 38-year-old male patient presented with abdominal pain for 8 h and loss of consciousness lasting 4 h. The patient was acutely sick-looking with borderline blood pressure of 90/60 mmHg, pulse rate of 120, and has alcoholic breath. With a diagnosis of viscus perforation, he was operated and there was a 1 × 1 cm bladder dome perforation, which looks fresh. The ruptured edge was refreshed and repaired in two layers. The patient has recovered well, discharged and was fine on subsequent follow-ups.

CLINICAL DISCUSSION

Bladder rupture commonly develops after blunt abdominal trauma, of which more than 60 % is extraperitoneal. Intraperitoneal bladder rupture constitutes only a small fraction of all cases of rupture. There are only a few reports of spontaneous bladder rupture in the scientific literature. The risk of bladder rupture may be increased in the alcohol-impaired patient owing to decreased bladder filling sensation and abnormal behavioral responses.

CONCLUSION

Bladder rupture is a rare diagnosis in surgical patients, and spontaneous rupture is by far a very rare finding. The diagnosis of bladder perforation is often overlooked preoperatively for the obvious reason of its rarity and non-specific presentation. Early identification and timely management decrease mortality.

A rare cause of right-upper quadrant abdominal pain: Epiploic appendagitis of the hepatic flexure

Epiploic appendagitis (EA) is an uncommon cause of acute abdominal pain that may mimic other causes of acute abdomen. Epiploic appendages are outpouching of fat tissue located on the external wall of the colon, being more numerous in the descending and sigmoid colon that account for up to 80% of EA cases. We present the case of a 59-year-old woman with right upper quadrant pain. Abdominal ultrasound and contrast-enhanced computed tomography suggested the diagnosis of epiploic appendagitis of the right colonic flexure. Our case highlights the fact that epiploic appendagitis may occur in unusual locations and must be included in the differential diagnosis of acute abdominal pain, in order to avoid unnecessary medical and surgical treatment.

Spontaneous gallbladder perforation in a man with gallstone disease without known anamnesis of cholecystitis: Case report

INTRODUCTION

Spontaneous gallbladder perforation is a rare complication of gallstone disease. It causes acute peritonitis with potentially fatal outcome.

CASE PRESENTATION

We present a case of spontaneous gallbladder perforation with challenging diagnosis.

DISCUSSION

The diagnosis of gallbladder perforation should be considered in elderly patients presenting to the surgical emergency department with symptoms and signs of peritonitis even in the absence of pre-existing gallbladder disease. Spontaneous gallbladder perforation is a rare and potentially fatal diagnosis. In most reported cases, perforation occurred due to predisposing factors like acute cholecystitis, trauma or obstruction. In spite of rarity, spontaneous gallbladder perforation should be considered as differential diagnosis on examination of patients with sudden abdominal pain especially in cases of known cholecystolithiasis. Our patient had type 1 perforation according to Niemeier classification, the type associated with the highest mortality rate. The type of perforations has been reported as being difficult to recognize preoperatively, as with our patient with two inconclusive CT scans. This was due to the absence of classical symptoms of gallbladder perforation. CT is the modality of choice when gallbladder perforation is suspected.

CONCLUSION

We believe the reason for the spontaneous gallbladder perforation in the presented case was the presence of cholecystolithiasis. We acknowledge the importance of considering this diagnosis also in patients without previous signs of cholecystitis.

Infected intraperitoneal collection mimicking pneumoperitoneum

Acute abdomen is an emergent condition that requires immediate evaluation and prompt treatment. Pneumoperitoneum is defined as the presence of air or gas in the peritoneal cavity. There are various potential causes of pneumoperitoneum, as well as conditions that can mimic or pseudo pneumoperitoneum. We encountered a case of a 26-year-old woman who had a history of postexploratory laparotomy, left ovarian cystectomy, left ovarian reconstruction, right salpingooophorectomy, and infracolic omentectomy for bilateral mucinous cystadenoma and mature cystic teratoma. On the eighth day following her operation, she developed progressive abdominal distension.

Infrarenal inferior vena cava agenesis presenting as acute abdomen and hydronephrosis - case report

The inferior vena cava agenesis (IVCA) is a rare and often asymptomatic malformation due to the abundant development of the collateral circulation. However, it is frequently found in young people and carries a significant risk of deep venous thrombosis (DVT). It is estimated that about 5% of patients under 30 years of age presenting with DVT have this condition. We report a case of a previously healthy 23-year-old patient presenting with signs of acute abdomen and hydronephrosis due to the thrombophlebitis of an unusual iliocaval venous collateral, which developed secondary to IVCA. After treatment, the iliocaval collateral and hydronephrosis completely regressed on a 1-year follow-up. To our knowledge, this is the first such case reported in the literature.

A Rare Case of Premenarchal Ovarian Abscess Presenting as an Acute Abdomen

Ovarian abscesses are usually seen in females of reproductive age group. They may occur secondary to urinary tract infections, pelvic inflammatory diseases, or gastrointestinal infections. They are uncommon in premenarchal females. They can be either managed conservatively with antibiotics and analgesics or may require surgery. In this case report, we present the case of a 6-year-old female who presented to us with an acute abdomen, which was diagnosed as a case of ovarian abscess and improved on exploration and drainage.

Complicated appendiceal diverticulitis a extremely rare cause of acute abdomen: A case report and literature review

INTRODUCTION AND IMPORTANCE

Appendiceal diverticulitis (AD) represents a rare cause of acute abdomen. Diagnosis of AD is a challenge because of its rarity and resemblance to other ileocecal diseases like as cecal diverticulitis (CD) and acute appendicitis (AA). Preoperative imaging can be useful to aid diagnosis. Surgery represents the correct treatment of AD.

CASE PRESENTATION

A 48-year-old Caucasian male presented to the Emergency Department with a two-day history of right lower quadrant (RLQ) abdominal pain and fever. Physical examination revealed RLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal computed tomography(CT) scan showed findings of AA and a thin-walled 5 mm appendiceal diverticulum. The patient underwent laparoscopic appendectomy. The postoperative course was uneventful, the patient was discharged on the 5th postoperative day in a stable condition. Gross anatomy confirmed the presence of appendiceal diverticulum in the distal appendix on the mesenteric border. Histopathological examination revealed an inflamed and perforated appendiceal pseudo-diverticulum with surrounding AA and peri-appendicitis.

CLINICAL DISCUSSION

Appendiceal diverticulosis is an uncommon entity, classified as congenital or acquired based on the number of appendiceal layers herniating through the normal wall. Two thirds of diverticula will develop acute or chronic diverticulitis that can lead to several complications some of which can be life-threatening.

CONCLUSION

AD is a rare surgical emergency and represents often an overlooked diagnosis. Early diagnosis and treatment are crucial for reducing morbidity and mortality Appendectomy represents a safe and appropriate treatment of AD.

Peritoneal tuberculosis pretending an acute abdomen; a case report and literature review

INTRODUCTION AND IMPORTANCE

Peritoneal tuberculosis (PTB) is an infrequent clinical condition that frequently eludes diagnosis. The scarcity of PTB cases underscores the necessity for heightened vigilance within clinical settings to detect its presence. Notably, there has been a noticeable increase in PTB incidence in recent years. Mycobacterium tuberculosis is the causative agent responsible for PTB, affecting multiple gastrointestinal components such as the peritoneum and hepatobiliary system. Peritoneum is a rare site for TB with broad unspecific symptoms. It can be asymptomatic to periodic signs or mimic the positive peritonitis examinations like our case.

CASE PRESENTATION

We have reported a case of 19-year-old male experiencing progressive abdominal pain. The presence of generalized tenderness and guarding on physical examination prompted us to perform an urgent laparotomy due to suspicion of peritonitis. During the surgery, we observed the peritoneum exhibiting widespread nodularity, resembling a disseminated seeding pattern, along with mild ascites, which raised our suspicion of peritoneal tuberculosis. Subsequently, cytological analysis of the ascitic fluid and histopathological examination of the lesions confirmed our diagnosis of peritoneal TB.

CLINICAL DISCUSSION

We have shared our experience in facing PTB and reviewed recent papers to find further relevant information. The common presentations, probable causes, the role of imaging in diagnosis and the management are discussed for better management strategy and the best surgical decision.

CONCLUSION

Peritoneal tuberculosis is a rare condition with challenging diagnosis. Key symptoms include vomiting, abdominal pain, ascites, weight loss, and fever. Prompt recognition and treatment are vital for better outcomes.

Rare cause of fatal acute abdomen-celiac artery aneurysm

INTRODUCTION

Aneurysm of the celiac artery is a rare type of visceral artery aneurysm with an incidence of 0.1 %2%, but it carries a definitive risk of rupture. Neurofibromatosis type 1 (NF-1) has a remarkable association with a spectrum of arterial diseases, including an occlusive or aneurismal disease. Less often it affects celiac arteries.

PRESENTATION OF CASE

Here we present a case of rupture of celiac artery aneurysm in a patient NF-1 who presented with sudden onset of acute severe epigastric pain with tenderness and guarding in the epigastric region. Computed tomography (CT) scan revealed celiac artery aneurysm with evidence of retroperitoneal hematoma. As the patient became unstable, we performed emergency laparotomy in the best interest of the patient in our setting, and we barely controlled the source of bleeding. Unfortunately, we could not save the patient as he developed disseminated intravascular coagulation due to a massive blood transfusion.

DISCUSSION

Visceral artery aneurysm should be considered in patients present with an acute abdomen with anemia. As neurofibromatosis is associated with a spectrum of a vascular disease, vascular screening needs to be considered.

CONCLUSION

Even though celiac artery aneurysm is rare, it should be considered as one of the prompt differential diagnoses when patients present with an acute abdomen with anemia to prevent a fatal outcome.

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis

BACKGROUND

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system.

METHODS

This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index.

RESULTS

A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis.

CONCLUSION

Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

An inflammatory myofibroblastic tumor of the small intestine presenting as jejunojejunal intussusception; A case report

INTRODUCTION AND IMPORTANCE

An inflammatory myofibroblastic tumor (IMT) is an uncommon solid neoplasm of mesenchymal origin. They are usually seen in children and adolescents and commonly affect the lung, but they can nearly arise from every organ. The prevalence of IMT in the small bowel is very rare. The tumors have generally a benign clinical course, with some risk of local recurrence or distant metastasis.

PRESENTATION OF CASE

This is a 55-year-old male patient who presented with intermittent abdominal pain, vomiting of ingested matter and loss of appetite for 2 weeks duration. On physical examination, he had stable vital signs and the abdominal examination was non-revealing. Abdominal CT scan with contrast showed a long segment jejunojejunal intussusception. He underwent en-bloc resection of the mass and end-to-end anastomosis of the jejunum.

CLINICAL DISCUSSION

IMTs have a mesenchymal origin and are grouped into a mixture of fibroinflammatory disorders. They show a variable mix of inflammatory cells with spindle cells. The diagnosis of IMT preoperatively is challenging often mimicking malignant lesions. The diagnosis is often confirmed by histopathology after surgery. Complete excision with a negative margin is the preferred treatment. We report a rare case of jejunal IMT presenting with intussusception.

CONCLUSION

An intestinal IMT is a rare and an underdiagnosed entity, and should be considered in the differential diagnosis of small bowel intussusception. Surgery is still the most favored and effective treatment for intestinal IMT. Complete surgical excision with a negative margin has the least chance of disease recurrence.

Risks of Acute Cholecystitis, Acute Pancreatitis, and Acute Appendicitis in Patients with Dengue Fever: A Population-Based Cohort Study in Taiwan

INTRODUCTION

Although cases of acute cholecystitis, acute pancreatitis, and acute appendicitis following dengue virus infections have been documented, very few large-scale studies have investigated the postdengue risk of these acute abdominal conditions.

METHODS

This retrospective population-based cohort study included all patients with laboratory-confirmed dengue from 2002 to 2015 in Taiwan and 1:4 nondengue individuals matched by age, sex, area of residence, and symptom onset time. Multivariate Cox proportional hazards regression models were used to investigate the short-term (≤ 30 days), medium-term (31-365 days), and long-term (> 1 year) risks of acute cholecystitis, pancreatitis, and appendicitis after dengue infection, adjusted for age, sex, area of residence, urbanization level, monthly income level, and comorbidities. Bonferroni correction was used for multiple testing; E-values were used to assess the robustness of the results to unmeasured confounding.

RESULTS

This study included 65,694 individuals with dengue and 262,776 individuals without dengue. Patients with dengue had a significantly increased risk of acute cholecystitis (adjusted hazard ratio (aHR) 60.21; 95% CI 29.11-124.54; P < 0.0001, E-value = 119.92) and acute pancreatitis (aHR 17.13; 95% CI 7.66-38.29; P < 0.0001, E-value = 33.75) within the first 30 days postinfection compared to those without dengue, but this increased risk was not present after that. The incidence rates of acute cholecystitis and pancreatitis in the first 30 days were 18.79 and 5.27 per 10,000, respectively. No increased risk of acute appendicitis was observed among patients with acute dengue infection.

CONCLUSION

This study was the first large epidemiological study to show a significantly increased risk of acute cholecystitis and pancreatitis among patients with dengue during the acute phase of dengue infection, while no such association was observed for acute appendicitis. Early identification of acute cholecystitis and pancreatitis in patients with dengue is crucial for preventing fatal complications.

A pregnant lady with compound bowel obstruction managed with thoracic epidural as sole anesthesia in a resource-restricted setting: a case report

BACKGROUND

Preserving the mother's safety, sustaining the pregnancy state, and achieving the optimal fetal outcome are the major priorities when managing obstetric patients for non-obstetric surgery. Only necessary and urgent surgeries are carried out during pregnancy due to the effects of anesthesia and surgery on the fetus. Compound bowel obstruction (small and large bowel obstruction) is rare, especially during the third trimester of pregnancy. Besides this, the procedure (laparotomy) was done with awake opioid-based thoracic epidural anesthesia as the sole anesthesia. This case report of awake laparotomy for major abdominal surgery is the first of its kind with an excellent feto-maternal outcome.

CASE PRESENTATION

A 30-year-old African pregnant lady presented to the emergency department with a chief complaint of abdominal pain and vomiting for an 8-hour duration; associated with this, she had a history of blurred vision, lightheadedness, loss of appetite, low-grade fever, and constipation. Later, she was diagnosed with large bowel obstruction and underwent an emergency laparotomy, managed with a thoracic epidural sole anesthesia.

CONCLUSION

A multidisciplinary team approach is greatly recommended to safeguard a sufficient standard of care for both the mother and fetus. The provision of regional anesthesia for patients with high risks in perioperative periods is crucial for a better postoperative outcome. We have confidence that thoracic epidural anesthesia can be used as another anesthetic option for major abdominal surgery in a resource-restricted setting for patients who are expected to have a significant risk of perioperative adverse events under general anesthesia.

Pure testicular choriocarcinoma with gastrointestinal metastasis and paraneoplastic symptoms: a case report

BACKGROUND

Pure testicular choriocarcinoma is a rare type of non-seminomatous germ cell tumor extremely poor prognostic with the tendency to bleed at the metastatic site. At the time of the diagnosis, 70% of patients have metastatic lesions. Depending on the site of the metastasis, symptoms vary. Gastrointestinal involvement is seen in less than 5% of cases, mostly in the duodenum.

CASE PRESENTATION

We present a 47 years old male with testicular choriocarcinoma involving the jejunum, lung, liver, and kidney presenting with acute abdominal pain, melena, and dyspnea with some paraneoplastic symptoms. The patient had increased, severe and constant pain in the right lower quadrant for the previous four days. Additionally, he was complaining of nausea, vomiting, anorexia, and a history of melena for the last 10 days. Dyspnea on exertion, hemoptysis, and dry cough were the symptoms he was suffering from, for almost one year. The patient's general appearance was pale, ill, and thin with 10 kg of weight loss during the last some months. The computed tomography (CT) scan reported multiple metastatic lesions in both liver lobes and the left kidney. Pathologic study of the samples of small bowel lesions showed metastatic choriocarcinoma. Following the patient had been referred to an oncologist to start the chemotherapy regime. Finally, the patient has expired after 40 days of his first admission.

CONCLUSIONS

Testicular choriocarcinoma is a rare but fatal malignancy among young men. Gastrointestinal metastases are infrequent involvement represented by melena and acute abdominal pain, obstruction, and mass. Physicians should consider it as a differential diagnosis for acute abdomen and gastrointestinal bleeding causation.

Cystic lymphangioma presenting as an acute abdomen in an adult male with congenital aortic stenosis

Abdominal cystic lymphangioma rarely presents as an acute abdomen. In this article, we describe a young adult male with congenital aortic stenosis who initially presented with abdominal pain and raised inflammatory markers. The imaging in the form of a computed tomography scan was unfortunately inconclusive. In the evolution of this diagnostic dilemma, we describe the importance of early operative management as well as explore the link between cardiac and lymphatic malformations.

Torsion of the whole ileum and hemorrhagic necrosis because of a giant Meckel's diverticulum in a 9-month-old child

Intestinal ischemia caused by torsion of a freely hanging Meckel's diverticulum (MD) resulting in the need for resection is an uncommon complication. We present an extraordinary case of a 9-month-old male with acute abdominal symptoms because of intestinal ischemia and necrosis that necessitated resection of the entire ileum. This was caused by torsion around a particularly large MD.

Acute abdomen caused by spontaneous rupture of degenerative hysteromyoma during pregnancy: A case report

BACKGROUND

Hysteromyoma is not a rare tumor among pregnant women. During pregnancy, the symptoms caused by hysteromyoma can be improved through conservative treatment in most cases. However, in order to ensure the safety of mothers and children, surgeries are necessary in some special cases.

CASE SUMMARY

We report a case of pregnancy complicated with hysteromyoma red degeneration. The patient had peritonitis after sudden abdominal pain during the 20^th week of pregnancy. Laparoscopic exploration suggested rupture and bleeding of hysteromyoma, which were improved after drainage and an anti-inflammatory treatment. A cesarean section was performed after full term. This case shows the complications of rupture after red degeneration of hysteromyoma during pregnancy.

CONCLUSION

We should be alert to rupture of hysteromyoma during pregnancy, and active laparoscopic exploration is essential to improve the prognosis of such patients.

A rare case report of viable ileo-ileal knotting of acute abdomen in adults

INTRODUCTION

Regardless of the cause, bowel obstruction is described as the absence of abnormal transit of intestinal contents. It may involve only the small intestine, the large intestine, or both. It might be brought on by a bodily impediment or widespread modifications to the metabolism, electrolyte balance, or neuroregulatory systems. In the field of general surgery, there are several well-known causes that can vary between developing and developed nations.

CASE PRESENTATION

In this case report, we describe a case of acute small bowel obstruction secondary to ileo-ileal knotting in 35 years old female patient with a complaint of crampy abdominal pain of 7 hour duration. She had associated frequent vomiting of ingested matter followed by bilious matter. She had also mild abdominal distention. She had history of caesarian section delivery 3 times the last time was 4 months back.

CLINICAL DISCUSSION

Ileoileal knotting is a unique and rare clinical entity in which a loop of proximal ileum wrap around the distal part of ileum. The presentation includes abdominal pain and distension, vomiting, and obstipation. The majority of cases require resection and anastomosis or exteriorization of the affected segment, and management entails a high index of suspicion and emergent investigation.

CONCLUSION

We demonstrate an instance of ileo-ileal knotting to highlight the fact that it is an unusual intraoperative finding and, given the rarity of cases, should be taken into account in the alternative diagnosis of patients exhibiting SBO signs and symptoms.

[Gastrointestinal and hepatic emergencies in acute and emergency care]

Acute gastrointestinal emergencies are one of the most common presentations to the emergency department. If the main symptom is acute abdominal pain, this is referred to as "acute abdomen". An acute abdomen demands urgent attention and treatment and can be caused by different pathologies (e.g., peptic ulcer disease, acute pancreatitis, diverticulitis). Hepatic emergencies include acute liver failure and acute-on-chronic liver failure. Due to the large number of possible differential diagnoses with variable clinical symptoms, rapid diagnosis of the underlying etiology of gastrointestinal and liver emergencies is a major challenge in daily clinical practice. A structured approach and prompt initiation of adequate diagnostic and treatment measures are essential in order to reduce mortality.

Acute abdomen secondary to perforated jejunal gastrointestinal stromal tumor and imatinib-related isolated pericardial effusion in a 50-year-old female patient: A case report and review of literature

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract; occurring most often in the stomach and to a lesser extent in the jejunum. The majority of the tumors express activating mutations in either c-KIT or PDGFRA tyrosine kinases, which respond to tyrosine kinase inhibitors (TKI). Jejunal GIST is considered to be extremely rare and challenging to diagnose due to its non-specific presentation. As a result, patients usually present at an advance stage of the disease, making the prognosis poor and difficult to manage.

CASE PRESENTATION

In the present study, we report a 50-year-old female who was diagnosed with metastatic jejunal GIST. She was commenced on Imatinib (TKI) and shortly after she presented to the emergency department with an acute abdomen. A CT scan of the abdomen revealed ischemic changes in the jejunal loops and pneumoperitoneum. The patient required emergency laparotomy due to perforated GIST, and creation of pericardial window due to hemodynamic instability possibly secondary TKI-related isolated pericardial effusion.

CONCLUSION

Jejunal GIST is rare and usually presents as emergency due to obstruction, hemorrhage or rarely perforation. Although, systemic therapy with TKI is the principal treatment for advance disease, Jejunal GIST should be removed surgically. It is surgically challenging due to the anatomical complexity of the tumor. Surgeons treating such patients must be cautious for TKI side effects.

Tummy pain is not often what we think - Imaging findings in uncommon causes of abdominal pain in children and adolescents - A case series

Acute abdominal pain is a common complaint in children. We came across several unusual causes of acute abdomen including jejunal haematoma, perforation and abdominal abscess following hydrostatic intussusception reduction, twisting of mesenteric cyst, perforation of sigmoid colon and Meckel's diverticulum presenting with intussusception. In this article, we aim to present imaging features of these entities so that paediatric surgeons, radiologists and other health-care providers are aware of these unusual manifestations of acute abdomen.

Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study

INTRODUCTION

The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach.

METHODS

This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared.

RESULTS

An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy.

CONCLUSIONS

AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

Misdiagnosis of food-borne foreign bodies outside of the digestive tract on magnetic resonance imaging: Two case reports

BACKGROUND

Patients with foreign bodies in the digestive tract are often encountered, but complete penetration of a foreign body through the gastrointestinal tract is rare, and the choice of imaging method is very important. Improper selection may lead to missed diagnosis or misdiagnosis.

CASE SUMMARY

An 81-year-old man was diagnosed as having a liver malignancy after he took magnetic resonance imaging and positron emission tomography/computed tomography (CT) examinations. The pain improved after the patient accepted gamma knife treatment. However, he was admitted to our hospital 2 mo later due to fever and abdominal pain. This time, he received a contrast-enhanced CT scan, which showed fish-boon-like foreign bodies in the liver with peripheral abscess formation, then he went to the superior hospital for surgery. It lasted for more than 2 mo from the onset of the disease to the surgical treatment. A 43-year-old woman with a 1 mo history of a perianal mass with no obvious pain or discomfort was diagnosed as having an anal fistula with the formation of a local small abscess cavity. Clinical perianal abscess surgery was performed, and fish bone foreign body was found in perianal soft tissue during the operation.

CONCLUSION

For patients with pain symptoms, the possibility of foreign body perforation should be considered. Magnetic resonance imaging is not comprehensive and that a plain computed tomography scan of the pain area is necessary.

Jejunal diverticulosis: A case report

INTRODUCTION

Jejunal diverticulosis is a rare entity that presents a challenging diagnosis due to its vague and non-specific clinical presentations. 40 % of the patients remain asymptomatic until the development of complications.

CASE PRESENTATION

We report a case of 84 years old female who presented to the hospital with vomiting and abdominal pain, found to have jejunal diverticulosis complicated by perforation in a CT scan. The patient underwent emergency expletory laparotomy with segmental intestinal resection and anastomosis.

DISCUSSION

The incidence of jejunal diverticulosis ranges between 3 and 5 %, with most patients discovered incidentally. Therefore, medical or surgical treatment management depends on clinical presentation and complications that necessitate surgical intervention.

CONCLUSION

Jejunal diverticulosis is a rare entity that commonly affects the elderly with significant morbidity and mortality; it is an important clinical entity to consider when approaching patients with acute abdomen.

Accidentally ingested wooden toothpick, perforation of a sigmoid diverticulum and mimicking acute colonic diverticulitis: A case report and literature review

INTRODUCTION AND IMPORTANCE

Ingested wooden toothpick (WT) represents a rare cause of acute abdomen. Preoperative diagnosis of ingested WT is a challenge because of its unspecific clinical presentation, the low sensitivity rate of radiological investigations and the patient's inability to often recall the event of swallowing a WT. Surgery represents the main treatment in case of ingested WT-induced complications.

CASE PRESENTATION

A 72-year-old Caucasian male presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting and fever. Physical examination revealed LLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography (CECT) showed colonic diverticulosis, wall thickening of the sigmoid colon, pericolic abscess, regional fatty infiltration, a suspicion of sigmoid perforation secondary to a foreign body. The patient underwent diagnostic laparoscopy: a sigmoid diverticular perforation caused by an ingested WT was noticed and a laparoscopic sigmoidectomy with end-to-end Knight-Griffen colorectal anastomosis, partial omentectomy and protective loop ileostomy were performed. The postoperative course was uneventful.

CLINICAL DISCUSSION

The ingestion of a WT represents a rare but potentially fatal condition which may cause GI perforation with peritonitis, abscesses and other rare complications if it migrates out of the GI tract.

CONCLUSION

Ingested WT may cause serious GI injuries with peritonitis, sepsis or death. Early diagnosis and treatment are crucial for reducing morbidity and mortality. Surgery is mandatory in case of ingested WT-induced GI perforation and peritonitis.

Patient with suspected severe acute respiratory syndrome coronavirus 2 infection with successful emergency surgery for ulcerative colitis-associated toxic megacolon

BACKGROUND

In patients with acute severe ulcerative colitis with concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the treatment strategy should consider the presence of pneumonia, respiratory status, and the severity of the ulcerative colitis (UC). We report a case of a 59-year-old man with SARS-CoV-2 infection who was diagnosed with toxic megacolon caused by UC.

CASE PRESENTATION

Preoperative computed tomography scanning of the chest showed ground-glass opacities. The patient was treated conservatively until the pneumonia improved, but developed bleeding and liver dysfunction associated with UC. As the patient's condition worsened, emergency surgery with subtotal colorectal resection, ileostomy, and rectal mucous fistula creation was performed while undertaking adequate infection control measures. Intraoperatively, contaminated ascites was observed, and the intestinal tract was markedly dilated and fragile. Nevertheless, the postoperative outcome was positive, with no pulmonary complications. The patient was discharged on postoperative day 77.

CONCLUSIONS

The COVID-19 pandemic presented challenges in surgical scheduling. Patients with SARS-CoV-2 infection required close monitoring for postoperative pulmonary complications.

Hepatitis A virus-associated acute acalculous cholecystitis in an adult-onset Still’s disease patient: A case report and review of the literature

BACKGROUND

Acute acalculous cholecystitis (AAC) is inflammation of the gallbladder without evidence of calculi. Although rarely reported, its etiologies include hepatitis virus infection (e.g., hepatitis A virus, HAV) and adult-onset Still’s disease (AOSD). There are no reports of HAV-associated AAC in an AOSD patient.

CASE SUMMARY

Here we report a rare case of HAV infection-associated AAC in a 39-year-old woman who had a history of AOSD. The patient presented with an acute abdomen and hypotension. Elevated hepatobiliary enzymes and a thickened and distended gallbladder without gallstones on ultrasonography suggested AAC, but there were no signs of anemia nor thrombocytopenia. Serological screening revealed anti-HAV IgM antibodies. Steroid treatment did not alleviate her symptoms, and she was referred for laparoscopic cholecystectomy. The resected gallbladder was hydropic without perforation, and her clinical signs gradually improved after surgery.

CONCLUSION

AAC can be caused by HAV in AOSD patients. It is crucial to search for the underlying etiology for AAC, especially uncommon viral causes.

Ileoileal knotting as a rare cause of acute abdomen in adolescents: Case report

INTRODUCTION

Knotting of bowel loops is a rare cause of acute abdomen and ileoileal knotting is one of the rarest causes, with only a few cases reported mostly in adult literature.

CASE PRESENTATION

We describe cases of ileoileal knotting in 13 and 12-year-old male and female adolescents who presented with crampy abdominal pain, distension, and episodes of vomiting. Both had tachycardia and features of peritonitis. They were explored and gangrenous ileoileal knotting was found. After the knot was disentangled, the gangrenous portion was resected, and ileoileal and ileo-ascending anastomosis were performed respectively. After a smooth postoperative course, the patients were discharged home in good condition.

CLINICAL DISCUSSION

The etiopathogenesis of ileoileal knotting is unknown, but speculative mechanisms are proposed, such as loaded bowel with longer mesentery, vigorous peristalsis, and a single bulky meal. The presentation includes abdominal pain and distension, vomiting, and obstipation. Management involves a high index of suspicion and emergent exploration with the majority requiring resection and anastomosis or exteriorization of the involved segment.

CONCLUSION

We discuss these cases of Ileoileal knotting to emphasize that it is a usual intraoperative surprise given the paucity of cases. But sudden and severe abdominal pain and distension, and features of peritonitis in short duration may be considered clues for suspicion. Surgery is the mainstay of treatment and hence, the prognosis depends on early diagnosis and intervention as morbidity and mortality are very high because of the rapid progression to gangrene.