An Unusual Presentation of Weil's Disease

Leptospirosis is a potentially fatal disease which can cause multi-organ dysfunction. It can have different rare presentations. Acute pancreatitis is one such rare gastrointestinal manifestation which present as an acute abdomen. Simultaneous presence of features of both acute pancreatitis and acute hyponatremia in a case of Weil's disease characterised by combination of jaundice, acute kidney injury, hypotension and hemorrhagic manifestation is very rare.

Acute Abdomen in Diabetic Patients - What Should We Do?

Diabetes mellitus is a well-known metabolic disease, with an increasing incidence around the world. The histological and clinical features of many diseases, including acute abdomen, are significantly modified in diabetic patients and thus the therapeutic approach should be carefully considered. Two main errors are possible, and they may equally cause a poor outcome of the patient: a delayed surgical procedure in peritonitis, due to its atypical clinical and biological expression, or an un-necessary laparotomy in a diabetic patient with acidosis, which transforms an already severe condition into a worse one. Therefore, in order to avoid confusion of diagnosis and treatment, the extended use of advanced imaging techniques (CT, MRI) or even a laparoscopic inspection of the peritoneal cavity may proove justified in many cases.

Acute gastrointestinal manifestation of situs inversus abdominus

PURPOSE

Whilst situs inversus is associated with intestinal malrotation and volvulus particularly in infants, this is the first known report of acute intestinal obstruction in an adult patient with a situs anomaly specifically due to a congenital transmesenteric hernia.

CASE

A 54-year-old woman presented with a 12-h history of progressive abdominal pain. Contrast-enhanced computed tomography scan of the abdomen revealed an incidental finding of situs inversus abdominus, ischemic small bowel obstruction and a potential occlusive thrombus of the superior mesenteric artery. At operation, the cause of intestinal obstruction was found to be secondary to herniation of the intestine through a congenital mesenteric defect. The hernia was reduced and a strong pulse was subsequently felt in the distal superior mesenteric artery. The patient required resection of a segment of compromised small bowel, and was later anastomosed at a planned second laparotomy. Her laparostomy was closed using an absorbable BioA mesh.

CONCLUSION

A high index of suspicion and low threshold for exploratory surgery should be maintained in patients with major congenital abdominal anomalies presenting with an acute abdomen.

[Application of laparoscopy in gastrointestinal abdominal emergency operation for patients over 65 years old]

OBJECTIVE

To explore the clinical application of laparoscopy in gastrointestinal abdominal emergency operation for patients over 65 years old.

METHODS

Clinical data of 138 cases (age>65 years) with acute abdomen undergoing laparoscopic surgery from January 2006 to June 2014 were analyzed retrospectively. Data of 170 cases treated by laparotomy during the same period were enrolled as controls.

RESULTS

The laparoscopy group and the laparotomy group showed statistically significant differences in blood loss [(107.1±47.7) ml vs. (163.6±106.5) ml, P=0.000], postoperative complications rate [2.9%(4/138) vs. 12.9%(22/170), P=0.022], hospital stay [(10.5±7.5) d vs. (16.5±9.9) d, P=0.044], postoperative ambulation time [(25.6±7.7) h vs. (33.2±5.6) h, P=0.020], and recovery time of postoperative gastrointestinal function [(36.9±9.1) h vs. (49.3±10.6) h, P=0.031]. Patients with acute appendicitis, upper digestive tract perforation and bowel obstruction in the laparoscopy group were superior to those in the laparotomy group in hospital stay, postoperative ambulation time, recovery time of postoperative gastrointestinal function and intraoperative blood loss(all P<0.01), while no significant differences in colon perforation and mesentery diseases were found in hospital stay, intraoperative blood loss and recovery time of postoperative gastrointestinal function between the two groups (all P>0.05).

CONCLUSIONS

Compared with laparotomy, the laparoscopy offers the advantages of less trauma, faster recovery, shorter hospital stay, and lower postoperative complications rate for patients over 65 years with acute abdomen.

Wandering Spleen. A Case of Spontaneous Hemoperitoneum in an HIV-positive Patient with Recurrent Tuboovarian Abscess

BACKGROUND

Wandering spleen is a rare and potentially devastating condition that can present in a variety of ways. Here we present a case that led to acute abdomen and hemoperitoneum in a young woman.

CASE

A 27-year-old woman with a history of human immunodeficiency virus (HIV), pelvic inflammatory disease, and tuboovarian abscess was readmitted to the hospital for intravenous antibiotic treatment. When her clinical picture did not improve, she underwent placement of a pelvic drain for abscess drainage. Overnight she developed an acute abdomen and hemorrhagic shock. She was taken to the operating room for an exploratory laparotomy, which revealed a ruptured spleen with a single, elongated vascular pedicle.

CONCLUSION

Wandering spleen is a rare diagnosis, more common in reproductive-aged women, with potentially fatal complications. It is a necessary component of a differential diagnosis for acute abdomen in reproductive-aged women.

Sonographic diagnosis of intestinal anisakiasis presenting as small bowel obstruction

BACKGROUND

To evaluate the accuracy of ultrasonography (US) in the diagnosis of intestinal anisakiasis presenting as small bowel obstruction.

METHODS

We retrospectively reviewed the clinical features, US examinations, and CT scans of seven patients with intestinal anisakiasis presenting as small bowel obstruction. We compared the performances of US and CT in demonstrating peritoneal fluid, small bowel dilatation, and segmental edema of Kerckring's folds.

RESULTS

All patients presented with a history of ingesting raw saltwater fish or squid less than 2 days prior to presentation at the emergency department and had significant levels of Anisakis-specific IgE. Both US and CT revealed small bowel obstruction, with dilated small bowel in all patients and accumulations of free peritoneal fluid in six patients. CT showed segmental wall thickening and luminal narrowing with submucosal edema distal to the distended small bowel; US did so in four patients.

CONCLUSIONS

Although US was inferior to CT in demonstrating the segmental intestinal edema causing small bowel obstruction, it can be applied in suspected cases of intestinal anisakiasis presenting as small bowel obstruction, particularly where CT is unavailable or there are concerns about radiation exposure.

Estimating the burden of acute gastrointestinal illness in Grenada

This is the first study conducted in Grenada, with a population of approximately 108,000, to quantify the magnitude, distribution, and burden of self-reported acute gastroenteritis (AGE). A retrospective population survey was conducted in October 2008 and April 2009 and a laboratory survey from October 2008 to September 2009. The estimated monthly prevalence of AGE was 10.7% (95% CI 9.0-12.6; 1.4 episodes/ person-year), with a median of 3 days of illness. Of those who reported AGE, 31% sought medical care (stool samples were requested from 12.5%); 10% took antibiotics; 45% took non-prescribed medication; and 81% reported restricted activity. Prevalence of AGE was significantly higher among children aged <5 years (23.5%, p < 0.001). Of the AGE stool samples submitted to the laboratory for analysis, 12.1% were positive for a foodborne pathogen. Salmonella enteritidis was the most common foodborne pathogen associated with AGE-related illness. The estimated percentage of underreporting of syndromic AGE to the Ministry of Health was 69%. In addition, for every laboratory-confirmed foodborne/AGE pathogen, it was estimated that there were 316 additional cases occurring in the population. The minimum estimated cost associated with treatment for AGE was US$ 703,950 each year, showing that AGE has a potentially significant economic impact in Grenada.

A young man with a dizzy spell and acute abdominal pain

Isolated adrenocorticotropic hormone (ACTH) deficiency is a rare cause of secondary adrenal insufficiency and its presentation with adrenal crisis is rather rare. Acute adrenal insufficiency (adrenal crisis) can be an elusive diagnosis, particularly in previously undiagnosed patients. As in this patient, the presentation of adrenal crisis with acute abdominal pain was misdiagnosed as an acute surgical abdomen, leading to a delay in the diagnosis and in the initiation of life saving treatment.

Infected mesenteric cyst

Mesenteric cyst is a rare condition. Presentation with non-typhoid spontaneous infection in an unusual area makes it even more a rare situation with mesenteric cyst. Its diagnosis is mainly based on the imaging modalities. However, there are difficulties in diagnosis when it is present in an uncommon area and rare known complications. Mesenteric cyst can present with few uncommon emergency conditions which pose difficulties in diagnosis as well as treatment options as mentioned in this case.

SAH pituitary adrenal dysfunction

Disruption of the hypothalamic-pituitary-adrenal axis may occur after aneurysmal subarachnoid hemorrhage, resulting in hypopituitarism. An electronic literature search was conducted to identify articles with English-language abstracts published between 1980 and March 2011 that addressed hypothalamic-pituitary-adrenal axis insufficiency and hormone replacement. A total of 18 observational and prospective, randomized studies were selected for this review. Limited data are available evaluating pituitary effects during the acute stage after subarachnoid hemorrhage, with inconsistent results reported. Overall, acutely after subarachnoid hemorrhage, cortisol levels may initially be supranormal, decreasing toward normal levels over time. During the months to years after subarachnoid hemorrhage, pituitary deficiency may occur in up to one in three patients. Limited data suggest modest outcome benefits with fludrocortisone and no benefit or harm from corticosteroids.

Fatal neutropenic enterocolitis due to clostridium septicum

We describe a case of Clostridium septicum enterocolitis in a patient with pre-B acute lymphoblastic leukaemia undergoing autologous stem cell transplant. In the setting of neutropenia, Clostridium septicum should be suspected in patients who develop signs and symptoms of acute abdomen.

An unusual cause of small bowel perforation: apricot pit

Ingestion of foreign bodies can be a common problem, especially among children, alcoholics, and psychiatric and senile patients. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved immediately may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract uneventfully, and perforation occurs in less than 1%. In this study, we report a case of small bowel obstruction with perforation in a 73-year-old female due to the accidental swallowing of an apricot pit.

Acute fulminant myocarditis and the 2009 pandemic influenza A virus (H1N1)

The 2009 Pandemic Novel Influenza A [HIN1] resulted in mild disease mostly but severe cases and death were associated with pneumonia, respiratory failure and multi-organ failure. We present a case of severe disease with acute heart failure and arrhythmia due to fulminant myocarditis in a 50- year old obese man with diabetes mellitus.

Ruptured ectopic pregnancy in rudimentary horn of the uterus

Rudimentary horn is one of the rarest congenital uterine anomalies and consists of a relatively normal appearing uterus on one side with a rudimentary horn on the other side. It is difficult to diagnose before surgery and hazardous to maternal life as rupture of pregnant horn result in severe hemoperitoneum. Case of rudimentary horn pregnancy is reported in a lady with history of habitual abortion and signs and symptoms of acute adnexal pathology. Exploratory laparotomy revealed ruptured rudimentary horn pregnancy. Excision of accessory horn was done.

Perioperative care of the patient with hemophilia undergoing urgent appendectomy

We report the presentation of acute appendicitis in a 20-year-old man with hemophilia A. We review the pathophysiology of hemophilia A and the current recommendations regarding factor VIII replacement in the perioperative period to ensure adequate hemostasis.

Systemic Warming as an Adjunct to Resuscitation in Peritonitis: A Pilot, Randomized Controlled Trial

BACKGROUND

Bacterial peritonitis is accompanied by a high risk of sepsis and endotoxin production resulting in physiological derangements and a high mortality rate. Localized and systemic warming improves tissue perfusion, oxygen tension, and outcomes after surgery. The purpose of this study was to examine the effectiveness of systemic warming as an adjunct to standard antibiotic and fluid resuscitation in patients with peritonitis.

METHODS

In this pilot randomized controlled trial, patients presenting with an acute abdomen were randomized into control and warmed groups using sequential envelopes. Local Ethics Committee approval was obtained. Systemic warming was delivered using the Inditherm warming mattress set at 40 degrees C. Standard oxygen, fluid resuscitation, and antibiotics were delivered simultaneously. Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on admission and 24 h later or just prior to surgery, whichever was earlier.

RESULTS

Thirty-three patients were recruited. The APACHE II scores on admission were comparable (median 9.0 [range 2-23] and 9.0 [0-20], respectively, for the control and warmed groups (p = 0.70; Mann-Whitney U test)). No patient showed any adverse effects of warming. There were statistically significant improvements in APACHE II scores (p = 0.028; Wilcoxon signed ranks test) and the magnitude of its change (p = 0.048; Mann-Whitney U test) in the warmed group compared with the control group.

CONCLUSIONS

Systemic warming may reduce physiological derangements and improve the prognosis in patients with intra-abdominal crisis. The technique may be used safely as an adjunct to standard resuscitation in peritonitis.

Pathology of the appendix in children: an institutional experience and review of the literature

BACKGROUND

The appendix can be affected by a variety of congenital and acquired diseases, but acute appendicitis is the most common pathology found in the pediatric population.

OBJECTIVE

This is a retrospective review of all appendectomies performed during a 2-year period at a major children's hospital with a review of the literature regarding the most common pathologic findings.

MATERIALS AND METHODS

The pathology database was reviewed for appendectomy specimens, and patient medical records were evaluated to determine the age, gender, race and operative diagnosis. All slides were reviewed and the histologic findings were recorded.

RESULTS

A total of 392 appendectomies were performed, including 68 incidental appendectomies and 324 performed for clinical suspicion of acute appendicitis. In 247 of the latter, acute appendicitis was confirmed histologically, and of the remainder 14 were interval appendectomies, 2 had findings suspicious for Crohn disease, 1 confirmed diverticulitis and 60 were histologically negative for appendicitis.

CONCLUSION

Acute appendicitis is the most common pathologic cause of appendectomy, but various other pathologic entities are found in children. Examination of the appendix is warranted even when it appears normal on exploration.