Atypical Posterior Nutcracker Syndrome in a 17-Year-Old Male Without Hematuria

Retro-aortic left renal vein (RLRV) is an anatomical variation, where the left renal vein (LRV) courses posterior to the aorta and anterior to the vertebrae before it eventually drains into the inferior vena cava (IVC). RLRV is a rare finding, with a prevalence of around 1%-2%, and only a small minority of RLRVs cause symptoms. RLRV symptoms occur secondary to compression of the LRV between the abdominal aorta and vertebrae, otherwise known as posterior nutcracker syndrome (PNCS). The most common symptoms of PNCS are hematuria and flank pain. We present a 17-year-old male, who came in with recurring left flank pain without hematuria, initially thought to be renal colic secondary to nephrolithiasis. On further investigations, an aberrant posterior renal vein was seen on CT suggestive of PNCS. The patient was treated successfully with RLRV vascular stent placement by interventional radiology. This case report adds to the limited number of PNCS cases observed in children and to the even rarer cases of PNCS without hematuria. This case also acts as a reminder for pediatricians to keep a wide scope of differentials in patients presenting with flank pain and provides an outline of both diagnostic and treatment modalities available for these patients.

Successful Conservative Management of Uncomplicated Gallbladder Ascariasis

Ascariasis is one of the common diseases in human beings worldwide. Most cases are asymptomatic. However, the high parasitic load can present with organ-specific symptoms due to the migration of worms to various regions of the body such as the lungs, nasal cavity, oral cavity, and biliary system, and sometimes with surgical emergencies like intestinal and biliary tree obstruction. Treatment modalities depend on the presentation and the complication associated with it. Uncomplicated cases can be initially managed conservatively and followed up subsequently. However, most cases of biliary ascariasis may require surgical intervention or endoscopic management due to failed management or complications. We report a case of a young male with gallbladder ascariasis diagnosed with ultrasonography and successfully treated with a single dose of albendazole 400 mg. Follow-up ultrasonography was done to evaluate the management.

Acute Omental Infarction Mimicking Acute Appendicitis

Acute abdominal pain is a common cause of visits to the emergency department. Acute appendicitis remains the most common indication for abdominal surgical intervention in the pediatric age group. However, several conditions may present with a clinical picture similar to that of acute appendicitis. We report the case of a 7-year-old girl with a history of right lower quadrant abdominal pain of two days in duration. The pain was associated with vomiting and was exacerbated by movement. Abdominal examination revealed a localized tenderness in the right iliac fossa with guarding, giving the impression of acute appendicitis. After a thorough investigation, the patient was diagnosed as having acute omental infarction given the radiological findings seen in the computed tomography scan. The patient was successfully managed conservatively with analgesics and anti-inflammatory drugs. Physicians should keep a high index of suspicion for this condition when encountering a patient presenting with an acute right lower quadrant abdominal pain. Imaging modalities play a pivotal role in making the diagnosis.

Clinical therapeutic effects of opioid analgesia for acute abdominal pain in children and young adults: A protocol for systematic review and meta-analysis

BACKGROUND

Nearly 10% of all patients who visit the emergency department report severe abdominal pain. Out of these, almost one-third are not diagnosed accurately. The conventional practice to care for such inpatients involves actively managed observation and repetitive clinical assessments at regular intervals. The aim of this study is to assess the clinical therapeutic effects of opioid analgesia in the treatment of severe abdominal pain in kids and adolescents.

METHODS

A comprehensive electronic search will be done on Web of Science, EMBASE, PubMed, WanFang database, Chinese National Knowledge Infrastructure, and the Cochrane Library from their establishment to May 2021. The search will identify and retrieve all randomized controlled trials that describe the clinical therapeutic effects of opioid analgesia to treat severe abdominal pain in adolescents and children. Two independent authors will shortlist studies that meet the inclusion criteria, extract data from selected studies, and evaluate the risk associated with bias in the selected articles. We will use RevMan (v: 5.3) to conduct all the data synthesis.

RESULTS

This meta-analysis will conduct a high-quality synthesis on present evidence related to the usage of opioid analgesia to treat severe abdominal pain in both kids and adolescents.

CONCLUSION

Our findings will summarize the present evidence and help judge whether opioid analgesia is an effective and safe line of treatment for severe abdominal pain.

ETHICS AND DISSEMINATION

This study will use pre-published data, and as such, it does not require ethics approval.

OSF REGISTRATION NUMBER

May 29, 2021.osf.io/fp9ym (https://osf.io/fp9ym/).

Optimization of a GF-AAS method for lead testing in blood and urine: A useful tool in acute abdominal pain management in emergency

Suspicion of lead poisoning is confirmed by its concentration in blood and protoporphyrin red blood cells. At low concentrations, lead influences the synthesis of the heme in the sense of lowering it. Acute and chronic lead intoxication is extremely polymorphic in regards to its clinical manifestations, with digestive, hematological, cardiovascular, renal hepatic and neurological features. The aim of the study was to evaluate the presence of lead in human whole blood and urine harvested before and during chelation treatment in the case of lead poisoning. An atomic absorption spectroscopic method for the analysis of lead was developed using graphite furnace atomic absorption spectrophotometer (GF-AAS), Varian Spectra AA-880 with a hollow cathode lead lamp and a deuterium lamp for background correction, coupled to a GTA-100 atomizer and a programmable sample dispenser. Standard calibration solutions were used for the range 10-100 µg/l. The linearity range was 10.0 to 100.0 µg/l with the correlation coefficient of 0.999. We established that the method can be applied for the determination of lead in whole blood and urine, and the results obtained are useful for monitoring chelation therapy in cases of acute lead poisoning, a neglected cause of abdominal colic pain in an emergency situation.

A Diagnostic Score (DS) Is a Powerful Tool in Diagnosis of Acute Appendicitis in Elderly Patients With Acute Abdominal Pain

BACKGROUND/AIM

Although acute appendicitis (AA) in elderly patients is different from AA in younger patients, the accuracy of diagnostic scores (DSs) in detecting AA is rarely considered.

PATIENTS AND METHODS

A cohort of 470 AAP (acute abdominal pain) patients older than 50 years, including 224 women (53.7%) and 193 men (46.3%), were included in the study. The most significant diagnostic predictors were used to construct DS formulas for AA diagnosis with (Tax+) and without body temperature (Tax-). Meta-analytical techniques were used to calculate the summary Se and Sp estimates for each data sets (history-taking, findings, and DS formulas).

RESULTS

In SROC analysis, the AUC values for i) symptoms ii) signs and tests iii) DS_Tax- and iv) DS_Tax+ were as follows: i) AUC=0.658 (95%CI=0.601-0.709); ii) AUC=0.751 (95%CI=0.701-0.800), iii) AUC=0.977 (95%CI=0.942-1.000), and for iv) AUC=0.980 (95%CI=0.956-1.000). Using roccomp analysis for these AUC values, the differences were significant as follows: between i) and ii) p=0.0358; between i) and iii) p<0.0001; between i) and iv) p<0.0001; between ii) and iii) p<0.0001; between ii) and iv) p<0.0001; and between iii) and iv) p=0.682.

CONCLUSION

Similar to younger AA patients, the DS formula was superior to both the clinical history-taking and findings, and therefore, the use of DS should be an important part of the diagnostic decision tree of AA also in the elderly patients presenting with AAP.

Primary omental torsion in a pediatric patient

Omental infarction although infrequent should be considered as a possible cause of acute abdomen precisely in those with negative appendectomy.

Observation of the Effectiveness of a Diagnostic Model for Acute Abdominal Pain Based on the Etiology Checklist and Process Thinking

Objective

The present study aimed to explore the effectiveness of the etiology checklist and process thinking in the differential diagnosis for acute abdominal pain.

Methods

A retrospective design was used to include 5,403 patients with acute abdominal pain in the Emergency Department of Hebei Provincial People's Hospital. The patients with acute abdominal pain between July and December 2017 in whom the etiology checklist and process thinking were not implemented were selected as the traditional group. Those with acute abdominal pain between July and December 2018 in whom the etiology checklist and process thinking were implemented were selected as the process thinking group. The clinical data, such as the emergency length of stay, hospitalization expenses, hospitalization length of stay, diagnostic accuracy, and outcome, were compared between the two groups.

Results

For patients at emergency level 2 and above, the average emergency length of stay was shorter in the process thinking group than in the traditional group, while the average emergency length of stay was longer for patients at emergency level 3. For hospitalized patients at emergency level 2 and above and patients at emergency level 3, those in the process thinking group had improved diagnostic accuracy, shorter average hospitalization length of stay, reduced average hospital expenses, and improved outcomes. In the comparison among six physicians, the results in the traditional group were inconsistent and statistically different in terms of the average emergency length of stay and diagnostic accuracy, while the results in the process thinking group tended to be consistent. The differences were not statistically different.

Conclusion

The diagnostic model for acute abdominal pain based on the etiology checklist and process thinking could improve the diagnostic accuracy and outcomes for patients with acute abdominal pain.

Epiploic Appendagitis and Omental Infarction as Rare Causes of Acute Abdominal Pain in Children

Omental infarction and epiploic appendagitis are rare causes of acute abdominal pain in the pediatric population. Radiological evaluation is necessary to establish a specific diagnosis and to differentiate appendicitis from these conditions as they can be often managed conservatively without surgical intervention.

Pediatric Acute Appendicitis Score in Children With Acute Abdominal Pain (AAP)

AIM

The aim of the study was to compare the accuracy of common clinical findings, laboratory tests and diagnostic score (DS) in diagnosis of clinically confirmed acute appendicitis (AA) in children.

PATIENTS AND METHODS

A cohort of 188 children under the age of 15 years presenting with acute abdominal pain (AAP) were included in the study. The clinical history (n=21), signs (n=14) and tests (n=3) were recorded in each child.

RESULTS

The significant independent diagnostic predictors (disclosed by multivariate logistic regression model) were used to construct the DS formulas for AA diagnosis. These formulas were tested at six different cut-off levels to establish the most optimal diagnostic performance for clinically confirmed AA. In the receiver operating characteristic curve (ROC) comparison test, there was a statistically significant difference (p=0.0055) in the area under curve (AUC) values between i) clinical history and symptoms (AUC=0.594), and ii) signs and laboratory tests (AUC=0.734), whereas both were significantly inferior (p=0.0001) to the AUC value of the DS (AUC=0.952).

CONCLUSION

In diagnosis of clinically confirmed AA in children, the DS formula is superior to both the clinical history/symptoms and signs/lab tests, justifying the use of DS as an integral part of the diagnostic algorithm of AA in all children presenting with AAP.

Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system's validity

OBJECTIVE

Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain.

METHODS

A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access.

RESULTS

Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days.

CONCLUSIONS

The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage.

RELEVANCE TO CLINICAL PRACTICE

The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients.

Epiploic Appendagitis: A Commonly Overlooked Differential of Acute Abdominal Pain

Epiploic appendagitis is an unusual and very commonly overlooked source of acute abdominal pain. Its incidence is highest in middle-aged obese males. It presents clinically as a focal lower quadrant abdominal pain, usually in the absence of pyrexia, nausea, vomiting or change in bowel habit, and unremarkable laboratory markers. Due to its vague presentation, epiploic appendagitis may be mistaken for other more severe causes of acute abdominal pain like diverticulitis and appendicitis, thereby causing patients to undergo unwarranted management interventions and hospital stay. Epiploic appendagitis is usually diagnosed through imaging, most commonly computed tomography (CT). This condition is largely self-resolving and can be managed conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs). Operative intervention is usually employed when symptoms persist or when complications arise. We present a case of epiploic appendagitis in a patient who presented with right lower quadrant pain initially misdiagnosed as acute appendicitis.

Can Inflammatory Markers Foretell Aetiology and Prolonged Hospitalisation in Acute Pancreatitis?

Introduction

Acute pancreatitis (AP) causes a cascade of complex inflammatory responses following an initial insult. Hence, the scoring systems include white blood cell count (WBC) as a marker of severity of acute pancreatitis. C-reactive protein (CRP) was also shown to be useful in predicting the course of pancreatitis. This study analyses role of inflammatory markers in predicting gallstone aetiology of AP and length of hospital stay (LOS).

Materials and methods

A total of 143 patients with acute pancreatitis between October 2016 and 2017 were included in this study and relevant parameters were collected from the electronic patient database. The parameters were WBC, CRP, and LOS.

Results

Among 143 patients with AP, 50 patients had gallstone pancreatitis (GP) and remaining of 93 patients suffered nongallstone pancreatitis (NGP). The WBC count at admission, 24 hours and 72 hours in GP versus NGP were 11.6± 5 versus 13.7±17; P = 0.24; 12.6±20 versus 10.1±17; P = 0.21; and 13.2±22 versus 9.2±4.7; P = 0.15, respectively. Similarly, the serum CRP levels at admission, 24 hours and 72 hours were 30.4± 73 versus 47.6±79; P = 0.25; 71.9±20 versus 92.2±97; P = 0.35; and 89±106 versus 122.7±107; P = 0.05, respectively. More number of patients with elevated WBC in GP arm compared to NGP (12/50±7/93; P = 0.0008) was noted.

In GP arm, patients with elevated CRP at admission (10.5±8.67 versus 5.4±5.8 days; P = 0.02) and 24 hours (9.8±8.3 versus 4.2±4.7 days; P = 0.001) had long LOS. However, patients with elevated CRP at 72 hours (89±106 versus 122.7±107; P = 0.05) had longer LOS in NGP.

Conclusion

Significantly high CRP level at 72 hours was associated with NGP and longer length of hospital stay. In GP, patients with elevated CRP level at admission and 24 hours predicts long LOS.

Intra-Abdominal Testicular Torsion as a Cause of Acute Abdominal Pain in Patient with Silver-Russell Syndrome: First Case of Robot-Assisted Laparoscopic Surgical Exploration with Orchidectomy

Introduction and Background: Silver-Russell syndrome is a rare genetic disorder, occurring in ∼1/50,000 to 1/100,000 births. Anomalies of the urogenital tract such as hypospadias and cryptorchidism can be present. Testicular torsion is a urologic emergency that is most common in prepubertal boys. In patients with cryptorchidism, it can present with abdominal pain and nonspecific symptoms and can mimic other intra-abdominal emergency conditions. Case presentation: A 21-year-old man presented in emergency room at our hospital with acute right lower abdominal pain. Abdominal ultrasonography excluded acute appendicitis, atypical mass on the right side of the bladder was identified. Later, he reported history of inguinal exploration caused by undescended right testis in infancy where testis was not found, and Silver-Russell syndrome. Contrast-enhanced abdominal CT scan revealed an atypical mass on the right side of the bladder, suspicious for torsion of undescended testis, or tumor. Tumor markers for testicular cancer were negative. The patient underwent robot-assisted laparoscopic orchidectomy for torsion of undescended intra-abdominal testis. Histopathologic examination excluded malignancy. Conclusion: Testicular torsion should be considered as the cause of acute abdominal pain in patients with undescended testis and rare genetic disorders. Robot-assisted laparoscopic surgical exploration has the advantage of better exposure and visibility and should be considered in such cases.

Performance of a Diagnostic Score in Confirming Acute Cholecystitis Among Patients With Acute Abdominal Pain

BACKGROUND/AIM

Although acute cholecystitis (AC) is quite a frequent clinical cause of acute abdominal pain (AAP), the accuracy of a diagnostic score (DS) in confirming AC is rarely considered. The aim of the study was to conduct a detailed analysis comparing the accuracy of common clinical findings, laboratory tests and DS in AC diagnosis.

PATIENTS AND METHODS

A cohort of 1,333 patients presenting with AAP were included in the study. The clinical history and diagnostic symptoms (n= 21), signs (n=14) and laboratory tests (n=3) were recorded in each patient.

RESULTS

The significant independent diagnostic predictors (disclosed by multivariate logistic regression model) were used to construct the DS formulas for AC diagnosis. These formulas were tested at five different cut-off levels to establish the most optimal diagnostic performance for clinically confirmed AC. In the ROC comparison test, there was no statistically significant difference in the AUC values of i) clinical history and symptoms (AUC=0.542), and ii) signs & laboratory tests (AUC=0.580), whereas both were significantly inferior (p=0.0001) to the AUC value of the DS (AUC=0.962).

CONCLUSION

In the diagnosis of clinically confirmed AC, the DS formula is superior to clinical symptoms and signs, justifying the use of DS as an integral part of the diagnostic algorithm of AC in all patients presenting with AAP.

Gender-specific Performance of a Diagnostic Score in Acute Appendicitis

BACKGROUND/AIM

Although a negative appendectomy in female patients with acute abdominal pain (AAP) can be twice as frequent as in male patients, the accuracy of diagnostic scores (DSs) in acute appendicitis (AA) is rarely considered among patients with AAP. The aim was to study the gender-specific performance of a DS in AA.

PATIENTS AND METHODS

As an extension of the World Organisation of Gastro-Enterology Research Committee (OMGE) AAP study, 1,333 patients presenting with AAP were inclu ded in the study. The clinical history and diagnostic symptoms (n=22), signs (n=14) and laboratory tests (n=3) were recorded in each patient.

RESULTS

The most significant diagnostic predictors were used to construct DS formulas for AA diagnosis, separately for both genders. The formulas were tested at 6 different cut-off levels to find the best diagnostic performance for AA in females and males. The highest specificities of the DS_LC- [DS without leucocyte count (LC)] and DS_LC+ (DS with LC) scores in detecting AA were 98% (95% CI=97-99%) and 98% (95% CI=96-99%), respectively. In the ROC comparison test, there was no statistically significant difference in the performance of DS_LC- and DS_LC+ in female and male patients.

CONCLUSION

Our gender-specific DS reached very high AUC values for AA (0.948-0.956) in both genders, and there was no statistically significant difference in the AUC values of DS_LC- and DS_LC+ between women and men with AAP.

Epiploic Appendagitis Masquerading as Acute Appendicitis: A Report of Two Cases

Epiploic appendagitis (EA) is a rare clinical entity caused by an inflammatory/ischemic process involving the serosal outpouchings of the colon. Its clinical presentation of acute, localised, lower abdominal pain often mimics more common conditions like diverticulitis or appendicitis. The diagnosis of EA is challenging due to the lack of pathognomic clinical features. The definitive diagnosis primarily relies on cross-sectional imaging modalities like abdominal ultrasound or computed tomography (CT). Being a benign and self-limiting condition, it can be managed conservatively with analgesic and anti-inflammatory drugs. We present two cases to highlight EA as an important differential diagnosis for cases of acute lower abdominal pain, crucial to prevent unnecessary antibiotic therapy and surgical interventions.

Optimization of pulse sequences in ultrafast magnetic resonance imaging for the diagnosis of acute abdominal pain caused by gastrointestinal disease

Background

Magnetic resonance imaging (MRI) is widely used to diagnose acute abdominal pain; however, it remains unclear which pulse sequence has priority in acute abdominal pain.

Purpose

To investigate the diagnostic accuracy of MRI and to assess the conspicuity of each pulse sequence for the diagnosis of acute abdominal pain due to gastrointestinal diseases

Material and Methods

We retrospectively enrolled 60 patients with acute abdominal pain who underwent MRI for axial and coronal T2-weighted (T2W) imaging, fat-suppressed (FS)-T2W imaging, and true-fast imaging with steady-state precession (True-FISP) and axial T1-weighted (T1W) imaging and investigated the diagnosis with endoscopy, surgery, histopathology, computed tomography, and clinical follow-up as standard references. Two radiologists determined the diagnosis with MRI and rated scores of the respective sequences in assessing intraluminal, intramural, and extramural abnormality using a 5-point scale after one month. Diagnostic accuracy was calculated and scores were compared by Wilcoxon-signed rank test with Bonferroni correction.

Results

Diagnostic accuracy was 90.0% and 93.3% for readers 1 and 2, respectively. Regarding intraluminal abnormality, T2W, FS-T2W, and True-FISP imaging were superior to T1W imaging in both readers. FS-T2W imaging was superior to True-FISP in reader 2 (P < 0.0083). For intramural findings, there was no significant difference in reader 1, whereas T2W, FS-T2W, and True-FISP imaging were superior to T1W imaging in reader 2 (P < 0.0083). For extramural findings, FS-T2W imaging was superior to T2W, T1W, and True-FISP imaging in both readers (P < 0.0083).

Conclusion

T2W and FS-T2W imaging are pivotal pulse sequences and should be obtained before T1W and True-FISP imaging.

Acute abdominal pain in non-pregnant endometriotic patients: not just dysmenorrhoea. A systematic review

Endometriosis, defined as the presence of functional endometrial tissue outside the uterine cavity, presents mainly with pelvic pain and infertility. Acute abdominal pain in non-pregnant patients with endometriosis might be minimised as a typical feature of the disease, while endometriosis is rarely considered in the differential diagnosis of acute abdominal pain. Our objective was to conduct a systematic review of the current literature of cases of acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. We performed a PubMed/MEDLINE search of studies published from January 1990 to December 2018, selecting English language reports and series of non-pregnant patients with acute abdomen and histological confirmation of endometriosis. The studies were revised by two independent authors. Data were abstracted and compiled for analysis. Fifty articles reporting 62 patients were identified. The complications were classified according to anatomical sites in bowel, urinary tract, and genital organs emergencies. Rarely was the first diagnostic hypothesis endometriosis, misdiagnosis was frequent. The time frame from symptoms onset to management was often long. This is the first systematic review evaluating acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. These conditions are rare but possibly life-threating and require prompt diagnosis and emergent medical or surgical treatment.

Foreign rectal body - Systematic review and meta-analysis

BACKGROUND

Self-inserted foreign rectal bodies are an infrequent occurrence, however they present a serious dilemma to the surgeon, due to the variety of objects, and the difficulty of extraction. The purpose of this study is to give a comprehensive review of the literature regarding the epidemiology, diagnostic tools and therapeutic approaches of foreign rectal body insertion.

METHODS

A comprehensive systematic literature review on Pubmed/ Medline and Google for 'foreign bodies' was performed on January 14th 2018. A meta-analysis was carried out to evaluate the epidemiology, diagnostics and therapeutic techniques. 1,551 abstracts were identified, of which 54 articles were included.

RESULTS

The motivation of foreign rectal body insertion is mostly sexual stimulation. Patients are typically young and predominantly male, with a male to female ratio of 6:1. Sexual devices (35.7%, n=108) and glass objects (17.5%, n=53) are the most commonly self-inserted rectal foreign bodies. Patient history should be taken sensitively after diagnostic evaluation and identification of the object. Removal was performed under general anesthesia in 45.2% (n=95) and sedation in 29.0% (n=61). The total complication rate was described to be 30.4%.

CONCLUSIONS

Diagnostics must be performed with caution in order to rule out perforation and establish a treatment algorithm. Manual transanal extraction under sedation or general anesthesia may be performed in conjunction with cautious abdominal compression. Because of the variety of objects, i.e. in form and material, each case must be treated individually. Sometimes creativity and surgeon imagination may be required, although different algorithms have been established.

Left renal artery thrombosis in a 78-year-old patient with atrial fibrillation

Renal artery thrombosis is a rare clinical condition. Often, there is a delay in diagnosis due to non-specific clinical complaints. We presented a woman with an elderly atrial fibrillation who developed thrombosis of the left renal artery. Despite the anticoagulant treatment given, patient did not benefit and the kidney was fully damaged.

Significance of Intra-abdominal Free Fluid Detected in Ultrasonography in the Clinical Assessment and Outcomes of Adult Patients Presenting to the Emergency Department Due to Abdominal Pain

Objective The aim of the study was to evaluate the diagnostic process and clinical course in adult patients who presented to the emergency department (ED) with acute abdominal pain (AAP) and were found to have intra-abdominal free fluid (FF) on ultrasonography (USG). Methods This prospective observational study was conducted in a training and research hospital adult emergency department between March 15, 2013, and April 15, 2013. The study included 252 patients aged above 18 years, who were admitted to the emergency room complaining of non-traumatic acute abdominal pain and provided consent for the study. Results The most common diagnoses were acute, nonspecific abdominal pain (37.3%), acute appendicitis (19%), and urinary tract pathology (15.9%). Intra-abdominal free fluid was detected with ultrasonography in 42.5% of patients. Patients with intra-abdominal free fluid were younger than the other patients. The emergency department length of stay was longer in patients with intra-abdominal free fluid (p=0.011). Of the 252 patients enrolled in the study, 32.9% were admitted to the hospital, 21.4% of whom underwent surgery and 11.5% received medical therapy. Most of the patients (64.5%) who were discharged home had no intra-abdominal free fluid in the ultrasonography (p<0.001). Conclusion The presence of intra-abdominal free fluid alone did not guide the clinical decision regarding the diagnostic evaluation of adult patients that presented to the emergency department complaining of non-traumatic acute abdominal pain.

A Fifteen-Year Analysis of Rare Isolated Fallopian Tube Torsions in Adolescent Children: A Case Series

Isolated tubal torsions presenting to the emergency department are a very rare cause of pediatric acute abdominal pain. Since making the diagnosis early is of importance in terms of affecting tubal damage and fertility, we aimed to evaluate cases of isolated tubal torsions in light of the literature. This study included 10 patients under 18 years of age who presented to the emergency department with abdominal pain between January 2003 and December 2018. The mean age was 14.5 ± 1.43 years (range: 12-17 years). The demographic characteristics, surgical findings and techniques, and concomitant pathology results of these patients were retrospectively evaluated. The reason for presenting to the emergency department for the 10 patients included in the study was abdominal pain. The mean duration of hospital admission with pain was 4.97 days. The onset of pain was less than 24 h in seven patients (70%) and more than 24 h in three patients (30%). Of the patients, nine (90%) had tenderness in the lower abdominal quadrant, five (5%) had defense, and three (30%) had rebound. Nausea, vomiting and leukocytosis were present in 50% of the cases. Right and left tubal involvement of the cases was equal. Seven (70%) of the isolated tubal torsions were accompanied by paraovarian cysts. Eight patients (80%) underwent open surgery and two (20%) underwent laparoscopic intervention. Detorsion was performed on five (50%) patients and salpingectomy was performed on five (50%) patients. Isolated tubal torsion should be considered in children presenting with acute abdominal pain in early adolescence. Early diagnosis is important for the preservation of fertility.

Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital

OBJECTIVES

Our objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures.

SETTING

The study was conducted at Timor Leste's national referral hospital in Dili, the country's capital.

PARTICIPANTS

All patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework.

RESULTS

Fifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05).

CONCLUSIONS

Substantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.

Primary epiploic appendagitis as an unusual cause of acute abdominal pain in a middle-aged male: A case report

RATIONALE

Primary epiploic appendagitis (PEA) is a rare cause of acute abdomen caused by spontaneous torsion or venous thrombosis of epiploic appendices, it commonly manifests with acute lower quadrant pain, thus may mimic acute diverticulitis, appendicitis, or mesenteric infarction.

PATIENT CONCERNS

In this case report, we report a 44 years old man who presented with persistent sharp pain in the left lower quadrant abdomen, Laboratory tests were mostly normal, contrast enhanced computed tomography (CECT) revealed a slightly high density shadow with fat foci in the middle was presented around the local descending colon, accompanied by the adjacent peritoneal thickening.

DIAGNOSES

He was diagnosed with PEA as confirmed by an abdominal contrast enhanced computed tomography (CECT) scan.

INTERVENTIONS

He was followed up in the clinic without any dietary restrictions, antibiotic or analgesic drugs use.

OUTCOMES

The abdominal pain gradually subsided a week later, and there were no recurrence of the symptoms during follow-up.

LESSONS

In our case, the diagnosis of PEA using CECT allows the patient to avoid surgery and other invasive treatment.