[Ultrasound diagnosis of Meckel diverticulitis in adults]

Meckel's diverticulitis is a rare disease. In addition to physical examination, abdominal ultrasound can help to pinpoint the diagnosis. By presenting a case report we would like to demonstrate the typical ultrasonographic findings in acute Meckel's diverticulitis and differentiate it from acute appendicitis. A 60-year-old patient was admitted to our hospital with the diagnosis of acute appendicitis. Abdominal ultrasound was performed and a blind ending, liquid-filled segment of small bowel in the right lower quadrant of the abdomen found. This segment was not compressible, no peristalsis was evident, nor was there any anatomical association with the cecum. Locally we found free fluid and hints of inflamed mesenteric fatty tissue. A perforated Meckel's diverticulum was diagnosed and confirmed intraoperatively. The major ultrasonographic difference between an inflamed Meckel's diverticulum and acute appendicitis is its anatomical location. In contrast to the appendix there is no association with the cecum. A diameter of up to 40 mm and a well-defined wall of small bowel with 3 definite layers visible by ultrasound may help to distinguish between a Meckel's diverticulum and the appendix.

[Neonatal ascites: meconium ileus with perforation in mucoviscidosis]

Many conditions are known associated with neonatal ascites such as cardiac and vascular malformations, as well as malformations of the brain, kidney, lung and bone, chromosomal abnormalities, infections, fetal anemias, tumors, metabolic and maternal conditions. In 30% no reason can be found. Meconium ileus is a causal gastrointestinal abnormality. We report about a preterm infant 35 weeks of gestation with complicated meconium ileus because of mucoviscidosis.

Prenatal diagnosis of meconium peritonitis in a twin pregnancy after intracytoplasmic sperm injection. A case report

BACKGROUND

Meconium peritonitis occurring in pregnancies following artificial reproductive techniques (ART) is rare. We report the first case of meconium peritonitis following intracytoplasmic sperm injection (ICSI).

CASE

A 37-year-old woman attended our in vitro fertilization (IVF) program because her husband suffered from hypospermatogenetic azoospermia due to cancer surgery and radiotherapy. The patient achieved a twin pregnancy through ICSI from testicular sperm extraction at our IVF center. Meconium peritonitis, fetal ascites, polyhydramnios, bowel dilatation, hydrocele and intraabdominal calcification were noted in one of the twins on ultrasound at 30 weeks' gestation. Cesarean section due to breech presentation in labor was performed at 36 weeks' gestation. A normal female and male infant with a distended abdomen were delivered. Emergency laparotomy was performed on the male twin because of dyspnea. A 0.2-cm perforation was found in the terminal ileum. Ileotomy was performed and closed after 27 days.

CONCLUSION

Prenatal diagnosis of meconium peritonitis is possible through careful ultrasonographic examination, and early surgical intervention and intensive postoperative support are required to improve the prognosis.

Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score

OBJECTIVES

To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis.

DESIGN

A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group).

SETTING

Single tertiary referral centre.

PARTICIPANTS

302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team.

MAIN OUTCOME MEASURES

Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation.

RESULTS

Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45).

CONCLUSION

Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.

Ultrasound examination of gastrointestinal tract diseases

With recent technical advances, increasing use of sonography in the initial evaluation of patients with abdominal disease may allow the detection of unexpected tumor within the abdominal cavity. Easiness of sonographic detection of bowel pathology, purposely or unexpectedly, warrants the inclusion of bowel loops during ultrasound examination when a patient complains of symptoms indicating diseases of the bowel. In patients complaining of acute abdominal symptoms or nonspecific gastrointestinal symptoms and showing signs such as abdominal pain, diarrhea, hematochezia, change of bowel habit, or bowel obstruction, sonography may reveal the primary causes and may play a definitive role in making a diagnosis. On ultrasonography, abnormal lesions may appear as fungating mass with eccentrically located bowel lumen (pseudokidney sign) or symmetrical or asymmetrical, encircling thickening of the colonic wall (target sign). In patients with mass or wall thickening detected on ultrasonography, additional work-up such as barium study, CT or endoscopy would be occasionally necessary for making a specific diagnosis.

Meckel's diverticulum mimicking infantile colic: sonographic detection

We report a case of Meckel's diverticulum in a 6-month-old girl who presented with a 5-month history of chronic screaming but no symptoms or signs of intestinal obstruction. Infantile colic was the presumptive diagnosis. Abdominal sonography at 6 months of age demonstrated an abdominal mass with an anechoic center and a double-layered wall, surrounded by bowel loops. Abdominal CT and barium enema x-ray studies demonstrated nonspecific findings of a cystic mass with compression of adjacent bowel loops. Histologic examination of the resected mass revealed a Meckel's diverticulum with a perforation sealed off by the neighboring bowel and mesentery to form an inflammatory mass.

Perforation of the small bowel as a complication of laparoscopic cholecystectomy: CT findings

Despite the widespread use of laparoscopic cholecystectomy, technical complications unique to the laparoscopic approach may lead to significant postoperative morbidity and mortality. We report a rare case of small bowel perforation due to trocar injury that led to extensive pneumoperitoneum and pneumomediastinum in a patient who underwent laparoscopic cholecystectomy. Small bowel injuries should be suspected when a large or an increasing amount of free air is detected following this procedure.

Perforation of the alimentary tract: evaluation with computed tomography

BACKGROUND

To assess the value of computed tomography (CT) in the diagnosis of perforation of the alimentary tract (AT).

METHODS

During a 4-year period 76 patients with proven AT perforation underwent CT within 1 week before surgery or endoscopy. We retrospectively reviewed these CT scans to determine the signs of AT perforation. There were 41 men and 35 women (28-90 years old). Our goal was to establish the diagnosis of AT perforation and, if this was possible, to identify the site and cause of the AT wall rupture. The CT diagnosis of perforation was based on (a) direct findings of extraluminar air or gastrografin and (b) indirect findings of an abscess or an inflammatory mass surrounding an enterolith in the region of appendix or a bowel wall-related phlegmon or abscess with fluid in the mesentery or surrounding radiopaque foreign body.

RESULTS

There were 65 true-positive and 11 false-negative cases. Levels of perforation were the esophagus (two), stomach (five), duodenum (12), small bowel (15), appendix (six), and colon (36). Causes were peptic ulcer (11), foreign body (five), trauma (seven), iatrogenic (nine), appendicitis (six), diverticulitis (21), Crohn disease (five), AT carcinoma (eight), and ischemia (four). Level and cause were correctly predicted in 55 and 51 instances, respectively. The sensitivity was estimated to 85.5%.

CONCLUSION

CT is a valuable method in the diagnosis of AT perforation. The diagnosis can be established rapidly, without patient preparation and with a high sensitivity.

Complications after laparoscopic gynecologic procedures: CT findings

Laparoscopic gynecologic surgery has gained worldwide popularity in the past few years, but complications of this new technique do occur. We encountered three patients who developed major complications after laparoscopic gynecologic procedures including perforation of the sigmoid colon, urinary bladder, and ureter. We report the computed tomographic findings of these cases and the diagnostic dilemmas they posed.

Retroperitoneal duodenal perforation during endoscopic sphincterotomy: sonographic findings

We present the sonographic findings in 5 cases of retroperitoneal duodenal perforation during endoscopic sphincterotomy. In each case, sonography showed hyperechoic areas associated with shadowing and ring-down artifacts between the liver and the right kidney correlating with the retroperitoneal air seen on plain x-ray films. This brightly echogenic area with shadowing surrounded and obscured the kidney. In 4 patients, resolution was documented on follow-up sonographic examinations in agreement with other radiologic findings; the other patient died.

[Septic shock caused by perforation of sigmoid diverticulum into the Retzius space. A case report]

An uncommon complication of the sigmoid diverticulitis personally observed is described. A woman, 59 years old, presented a septic shock caused by perforated sigmoid diverticulum into the space of Retzius. The diagnosis was carried out by an X-ray of the abdomen that suspected the presence of air in the retroperitoneum and then by barium enema showing a perforation of the sigmoid colon. During laparotomy a perforation of sigmoid diverticulum in to the space of Retzius was observed. So the space of Retzius was opened and then pus and watery exudate containing bubbles of gas were found extended also to the retroperitoneum and the right abdomen wall. The patient was submitted to a sigmoid resection; bowel continuity was restored by circular stapled anastomosis and a temporary colostomy was made. Some drainages were placed into the space of Retzius, into the retroperitoneum and into the peritoneal cavity. Nevertheless the patient died because of the septic shock and the postoperative MOF.

Acute bowel perforation in a fetus with gastroschisis

Gastroschisis is a congenital anomaly with a reported incidence of 1 in 10,000 live births. Although prenatal diagnosis is more common with the widespread use of biochemical markers and obstetric ultrasound, the role of ultrasound in the identification of the fetus that might need early intervention has not been established. Acute bowel perforation was diagnosed by ultrasound at 34 weeks gestation in a fetus with gastroschisis. An immediate Cesarean section was performed, followed by repair with primary closure. The neonatal outcome was favorable. The post-partum findings, including bowel pathology, confirmed the antenatal diagnosis. Acute bowel perforation can be diagnosed antenatally. Immediate intervention, before further bowel injury occurs, might enhance the ability of the surgeon to perform primary closure and obtain a favorable outcome.

A catastrophic complication of systemic lupus erythematosus: massive mesenteric infarction

The AA reports a case of a 64-year-old female patient affected for 3 years by systemic lupus erythematosus who developed a massive perforating mesenteric infarction. An immediate surgical treatment with resection of the small bowel and right colon followed by a side-to-side primary anastomosis between the remaining jejunum and transverse colon were performed. The patient died 15 days after surgery due to recurrence of a mesenteric and pulmonary thromboembolia.

Appendiceal rupture during pelvic ultrasound examination

A case of rupture of the appendix during pelvic ultrasound is presented.

Malignant peritoneal mesothelioma with mimicry of pseudomyxoma peritonei in a patient with a history of perforated sigmadiverticulitis

We describe a 57-year-old man who presented with diffuse abdominal pain, abdominal enlargement, vomitus, dyspnea and a weight loss of 30 kg within 6 months. These acute symptoms were preceded by an episode of ascites and an acute sigmadiverticulitis 7 months ago. Ultrasonography and computed tomography were suggestive of pseudomyxoma peritonei. However, malignant mesothelioma peritonei was diagnosed by open surgery with biopsy for histological examination. Despite R-2-resection of the tumor and following open hyperthermic intraperitoneal chemotherapy with initial remarkable recovery the patient died 5 months after therapeutical intervention. Malignant peritoneal mesothelioma is an extremely rare tumor with great diagnostic and therapeutic difficulties. We report a case including diagnostical work up and the medical surgical therapy of this disease.

Meconium peritonitis

Meconium peritonitis can have a wide range of presentations. This report discusses two cases that have recently appeared in our neonatal intensive care unit. The first report discusses the case of a meconium pseudocyst in a preterm infant. The second case reports on a newborn baby with a healed bowel perforation during the prenatal period. Finally, a brief discussion of meconium peritonitis is also included.

Acute presentation of transverse colon injury following percutaneous endoscopic gastrostomy tube placement: case report and review of current management

We describe a case of a patient who had a percutaneous endoscopic gastrostomy (PEG) tube placed for enteral access. The patient's medical history was remarkable for chronic malnutrition, coronary artery disease, coronary bypass surgery, and severe esophageal dysmotility. We discuss the patient&'s course through treatment and we review the management options for patients that sustain colonic injury related to PEG placement. We conclude that colonic injury can be difficult to diagnose in the acute setting and that diagnosis may be facilitated by abdominal computerized tomographic (CT) scanning.