[Successful conservative treatment of coecal perforation in a patient with Ogilvie's syndrome]

The case report describes a 37-year-old woman who was diagnosed with Ogilvie's syndrome after caesarean section. Conservative treatment was initiated with minimal effect, and the patient was subsequently treated with IV neostigmine. A computed tomography of the abdomen revealed enlarged peritoneal cavity. However the patient was clinically unaffected without fever or signs of peritonitis. The perforation was managed with a conservative approach including antibiotics and close observation of the patient. After nine days the patient was discharged with normal gastrointestinal function and without further reported complications.

Degos' syndrome complicated by bowel perforation: focus on radiological findings

We describe a 50-year-old man who first presented with multiple skin lesions which were characteristic of Degos' syndrome. The patient developed multiple episodes of abdominal pain. Some episodes resolved with conservative management, for others he underwent urgent operations for bowel perforations. The patient subsequently underwent extensive small bowel resection, but further systemic deterioration ensued and he died. The imaging findings of Degos' syndrome and the implications of pneumatosis intestinalis and pneumoperitoneum are discussed.

Less common nontraumatic bowel perforations: diagnosis and management through a retrospective study

Nontraumatic bowel perforation has always been a consideration because of associated morbidity and mortality. The aim of this study is to define etiologies, treatment, and outcomes as well as to highlight difficulties in the diagnosis and management of nontraumatic bowel perforation. We conducted a retrospective study of 35 patients with less common nontraumatic bowel perforations hospitalized during a six-year period. The most common cause was ulcerative colitis (34.3%). Abdominal pain was the constant symptom. Physical examination showed signs of peritoneal irritation in 29 cases. The abdominal radiograph failed to reveal abnormal findings in two patients; the abdominal computed tomography scan confirmed the diagnosis in all cases. Twenty patients (57.1%) were operated on within 24 hours of developing perforation, whereas seven patients (20%) were initially misdiagnosed. Most of the perforations were located only in the large intestine (60%). There was only one perforation in 25 patients (71.5%) and two or more perforations in 10 patients (28.5%). Many less common diseases are responsible for the spontaneous perforation of the bowel. Early diagnosis before the patient's general condition deteriorates decreases mortality and morbidity rates. Adequate resuscitation and emergency laparotomy followed by resection with or without anastomosis remains the treatment of choice.

Delayed presentation of blunt duodenal injuries in children. Case report and review of literature

BACKGROUND

Duodenal injuries are rare in children and classically present following a fall over the handle bar. Retroperitoneal location of the duodenum may lead to delay in diagnosis, and missed injuries are associated with increased morbidity and mortality.

CASE REPORT

A 5-year-old child was admitted to the National Trauma Center, in Tirana (Albania), 28 hours after a Motor Vehicle Crash (MVC), complaining of mild abdominal pain. He was febrile (39°C) and had a white blood cells count of 18,000 mm³. On physical exam he had mild tenderness. Plain abdominal X-rays and Focused Abdominal Sonography for Trauma (FAST) were negative for free air or free fluid. The CT scan of the abdomen demonstrated free air and fluid in the retroperitoneal space. At laparatomy, a perforation of the second portion of the duodenum was found. A single layer suture repair of the duodenum with wide drainage was performed. The patient was discharged from the hospital tolerating oral feeding 8 days later.

CONCLUSION

Duodenal injuries in children are rare. Most duodenal hematomas are managed non-operatively. This is a case of MCV with delayed presentation that was treated surgically for perforation successfully.

Spontaneous transanal protrusion of ventriculoperitoneal catheter: a case report

Ventriculoperitoneal (VP) shunt placement that diverts the cerebrospinal fluid (CSF) into the peritoneal cavity is the most common method of treatment of hydrocephalus. This shunt has a high incidence of malfunction mainly due to catheter obstruction or infection. About 20% of these complications are abdominal that may occur at any time after shunt placement from 1 week to several years. This study reports a case of 2.5-year old child with a history of hydrocephalus who had a VP shunt placed which was protruded from the anus on the day of referral. The patient was treated successfully after extrusion of the shunt through the anus, receiving antibiotics and being carefully observed. He was discharged from the hospital after one week.

The 'Dr Google' phenomenon--missed appendicitis

Self-diagnosis has been around for many years. In today's society with free access to information, particularly through the Internet, it is more prominent than ever. With new information sources available to patients, doctors may have their diagnostic process influenced. This is the case of a gentleman who self-diagnosed, and subsequently influenced his doctor's diagnostic process, with results detrimental to his outcome. It illustrates the importance of awareness of the risks of self diagnosis, and management of patients who present with information and preconceived ideas regarding their condition.

Inferior vena cava clip migration: unusual cause of duodenal foreign body

Before the development of the inferior vena cava (IVC) filter, various techniques of IVC interruption were described for the management of patients at high risk for thromboembolic events, and for whom anticoagulation was either inadequate or contraindicated. In this report, we describe the enteric migration of a Miles IVC clip, occurring 27 years after IVC interruption. This previously undescribed complication and the patient's prolonged follow-up period render this case of significant interest.

Gastrointestinal stromal tumor arising in an ileal duplication: report of a case

This report presents the extremely rare case of an adult patient who presented with peritonitis caused by the perforation of an ileal duplication, associated with a gastrointestinal stromal tumor (GIST) arising within the duplication. A 70-year-old female was admitted to the hospital with lower abdominal pain. Abdominal computed tomography showed free air in the peritoneal cavity. An emergency laparotomy was performed, presuming diffuse peritonitis caused by a perforation of the gastrointestinal tract. The surgical findings showed that the peritonitis was caused by the perforation of an ileal duplication, 90 cm proximal to the ileocecal valve, with an extrinsic tumor protruding from the duplication. A segmental resection of the ileum-including the tumor and ileal duplication-was performed. Histopathology showed that the tumor was composed of spindle-shaped and epithelioid cells. The tumor was immunohistochemically positive for KIT, with a deletion mutation spanning the intron 10-exon 11 boundary. Accordingly, a diagnosis was made of a GIST arising within a duplication of the ileum. Duplications of the alimentary tract are encountered only occasionally in adults. Although quite rare, malignant change should therefore be considered as a possible complication when a solid portion is observed within a duplication of the alimentary tract.

Double Sigmoid colon perforation due to migration of a biliary stent

Migration of pancreatico-biliary stents is a rare event, usually benign, but which can lead to severe complications such as digestive tube perforation. We report the case of a patient with double sigmoid perforation due to distal migration of a biliary stent placed to decompress a pancreatic head carcinoma.

Plastic bag clip discovered in partial colectomy accompanying proposal for phylogenic plastic bag clip classification

A plastic bag clip was incidentally found anchored in the mucosa of a partial colectomy specimen 2.6 cm proximal to a ruptured diverticulum for which the patient, a mentally retarded, diabetic, 58-year-old man, underwent surgery. Over 20 cases of accidental ingestion of plastic bag clips have been published. Known complications include small bowel perforation, obstruction, dysphagia, gastrointestinal bleeding and colonic impaction. Preoperative diagnosis of plastic clips lodged in the gastrointestinal tract is frustrated due to radiographic translucency. This occult threat could likely be prevented by the design of gastrointestinally safe, plastic-bag-sealing devices. Presented here is a morphologically based classification of bag clips as a possible guide for determining the most hazardous varieties and to aid further discussions of their impact on health.

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

Bowel perforation after erlotinib treatment in a patient with non-small cell lung cancer

Erlotinib is accepted as a standard second-line chemotherapeutic agent in patients with non-small cell lung cancer who are refractory or resistant to first-line platinum- based chemotherapy. There has been no previous report of bowel perforation with or without gastrointestinal metastases related to erlotinib in patients with non-small cell lung cancer. The exact mechanism of bowel perforation in patients who received erlotinib remains unclear. In this report, we report the first case of enterocutaneous fistula in a female patient with metastatic non-small cell lung cancer 9 months, following medication with erlotinib as second-line chemotherapy.

The efficacy of nonoperative management of acute complicated diverticulitis

BACKGROUND

The surgical management of acute complicated diverticulitis has evolved to avoid emergency surgery in favor of elective resection. The optimal manner to accomplish this goal remains debatable.

OBJECTIVE

The purpose of this study was to examine the efficacy of nonoperative management of acute diverticulitis with abscess or perforation.

DESIGN

A retrospective review was performed of an institutional review board-approved database of patients admitted with a diagnosis of acute complicated diverticulitis from 1995 to 2008. Patient demographics, disease manifestation, management, and outcomes were collected.

SETTINGS

This study was conducted at a tertiary care hospital/referral center.

PATIENTS

Patients were included who presented with complicated diverticulitis defined as having an associated abscess or free air diagnosed by CT scan.

MAIN OUTCOME MEASURES

Primary end points were the success of nonoperative management and need for surgery during the initial admission.

RESULTS

One hundred thirty-six patients were identified with perforated diverticulitis: 19 had localized free air, 45 had abscess <4 cm or distant free air measuring <2 cm, 66 had abscess >4 cm or distant free air >2 cm, and 6 had distant free air with free fluid. Thirty-eight patients (28%) required percutaneous abscess drains and 37 (27%) required parenteral nutrition. Only 5 patients (3.7%) required urgent surgery at the time of admission, and 7 (5%) required urgent surgery for failed nonoperative management. Thus, the overall success rate of nonoperative management was 91%. One hundred twenty-four of 131 (95%) patients were treated with nonoperative management successfully. Twenty-five of 27 (92.5%) patients with free air remote from the perforation site were successfully treated nonoperatively.

CONCLUSIONS

Nonoperative management of acute complicated diverticulitis is highly effective. For patients with free air remote from the site of perforation, nonoperative management is able to convert an emergent situation into an elective one in 93% of cases. The decision to attempt nonoperative therapy must be made based on the patient's physiologic state and associated comorbidities.

Antiangiogenic tyrosine kinase inhibition related gastrointestinal perforations: a case report and literature review

Anti-VEGF (vascular endothelial growth factor) therapy with the monoclonal antibody bevacizumab can cause gastrointestinal (GI) perforations. In recent years it became apparent that GI perforations also occur during treatment with antiangiogenic tyrosine kinase inhibitors (TKIs). It is of clinical importance to consider (vague) abdominal complaints during antiangiogenic treatment as a sign of a GI perforation. To illustrate this serious complication, we report four cases of antiangiogenic treatment related GI perforations. In three cases this was due to antiangiogenic TKI treatment. Reported risk factors of GI perforations due to bevacizumab include the presence of a primary tumor in situ and recent history of endoscopy or abdominal radiotherapy. Pathology assessments of surgical removal of the perforated intestinal part reveal that perforations are predominantly seen at the tumor or anastomotic site, in case of carcinomatosis or diverticulitis or when GI obstruction or an intra-abdominal abscess is present. Whether the same risk factors may be involved in antiangiogenic TKI related GI perforations is unknown. The underlying mechanisms responsible for GI perforation during antiangiogenic treatment is unknown, but disturbance of host cell homeostasis of immune cells as well as platelet-endothelial cell interactions may play an important role. In conclusion, while clinical awareness that antiangiogenic treatment can cause GI perforations is critical for current medical practice, it is also very important to get more insight in its underlying mechanisms so that this life-threatening complication may be prevented in the near future.

Small intestinal perforation due to metastasis of breast carcinoma: report of a case

A 79-year-old female patient underwent breast-conservation surgery following a diagnosis of right breast cancer in July 2007. In November 2008, the patient presented at our hospital with acute onset of lower abdominal pain. She was diagnosed with panperitonitis due to gastrointestinal perforation, and underwent an emergency operation. At the time of the operation, one site of free perforation was found in the small intestine, and a 2-3-cm nodule was found in the 50-cm anal side from the site of this perforation. Multiple metastases to the para-aortic lymph nodes and mesenteric lymph nodes were also found. The patient recovered without complications and was discharged from the hospital, but 3 months after surgery she succumbed due to multiple liver metastases. It is important to identify metastatic intestinal tumors in patients who have breast cancer.

Imaging manifestations of faecal impaction and stercoral perforation

Stercoral perforation can be defined as perforation of the bowel due to pressure necrosis from a faecal mass. It is an uncommon but life-threatening complication of unresolved faecal impaction. In this review, we highlight the important computed tomography (CT) findings of faecal impaction and stercoral perforation of the colon and subsequent therapeutic options in the adult population.

Veiled right kidney sign in retroperitoneal duodenal perforation after endoscopic retrograde cholangiopancreatography

Retropneumoperitoneum due to duodenal perforation after endoscopic retrograde cholangiopancreatography is rare. Recognizing the presence of free air, which outlines the right kidney, is essential for its early diagnosis and appropriate management.

A case of fulminant amebic colitis with multiple large intestinal perforations

Amebic colitis normally causes mucous and bloody diarrhea stool as predominant symptoms, thus leading to a course of chronic colitis. However, though rare, there exists a fulminating type that causes intestinal perforations due to wide necrosis of the large intestine. We encountered a case of fulminant amebic colitis that lead to death due to multiple large intestinal perforations. The patient was a 72-year-old female. The patient was admitted to our hospital with symptoms of fever, abdominal pain, and diarrhea. She continued to have a fever of over 38 degrees C and increased left abdominal pain. An abdominal computed tomography scan revealed free gas on the abdominal side of the kidney. Therefore, gastrointestinal perforations were diagnosed and surgery was performed. In surgery, many perforated parts were observed from the appendix to the descending colon, and subtotal colectomy was performed. However, sepsis and disseminated intravascular coagulation occurred, and the patient died on the eighth postoperative day.

[Complicated sigmoid tumor: perforated amebiasis]

Amoeboma is an inflammatory mass of the colon. It can be an inaugural symptom and thus pose the problem of differential diagnosis with colon cancer. The purpose of this report is to describe the case of a 43-year-old patient who presented with acute abdomen. Physical examination revealed a perforated circumferential mass in the sigmoid colon. Based on a presumptive diagnosis of colonic cancer complicated by perforation, segmental colectomy was performed. Histological examination of the surgical specimen demonstrated colonic amoeboma. The patient was treated using metronidazole. Although rare, amoeboma must be considered in differential diagnosis of cancer of any colonic mass.

Should PCNL patients have a CT in the prone position preoperatively?

OBJECTIVE

Lower pole percutaneous nephrostomy is performed frequently for percutaneous nephrolithotomy (PCNL), using a variety of imaging modalities such as fluoroscopic, computed tomography (CT) or ultrasound guidance. This study was performed to estimate the potential risk of colonic injury during lower pole percutaneous nephrostomy for PCNL.

METHODS

We observed the position of the colon relative to the kidney in 134 patients who underwent CT kidney, ureter, bladder (KUB) examinations in the prone position.

RESULTS

We found the prevalence of colon lying posterior to the kidney (i.e. retrorenal) in males to be 13.6% on the right, and 11.9% on the left, whilst in females it was 13.4% on the right and 26.2% on the left.

CONCLUSIONS

Patients at higher risk for retrorenal colon should be considered for preoperative imaging to identify those patients in whom the colon may be situated posterior to the kidney, allowing for appropriate alterations in technique to be made, such as the use of ultrasound or CT guidance.

Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome

OBJECTIVE

The purposes of this study were to retrospectively investigate the effectiveness and safety of CT-guided percutaneous drainage in the treatment of patients with acute appendicitis complicated by perforation and to identify CT findings and procedure-related factors predictive of clinical and procedure outcome.

MATERIALS AND METHODS

From March 2005 through December 2008, 41 consecutively registered patients (24 men, 17 women; age range, 18-75 years) underwent CT-guided percutaneous drainage for the management of acute appendicitis complicated by perforation and abscess. Three board-certified radiologists independently reviewed preprocedure CT images. Patients were assigned to one of three risk categories on the basis of the CT findings. Success and failure of percutaneous drainage were defined on a per-patient (i.e., clinical outcome) and per-procedure (i.e., technical outcome) basis. Immediate, periprocedure, and delayed complications were recorded. The association between candidate predictive variables, including demographic characteristics, preprocedure CT findings, and procedure-related factors and clinical or technical outcome was assessed with logistic regression models.

RESULTS

Fifty-two CT-guided procedures were performed on 41 patients. Percutaneous drainage had clinical and technical success rates of 90% (37 of 41 patients, 47 of 52 procedures) with no procedure-related complications. In seven patients (19%) clinical success required repeated drainage procedures. A large, poorly defined periappendiceal abscess and an extraluminal appendicolith on preprocedure CT images were independent predictors of clinical failure of percutaneous drainage.

CONCLUSION

CT-guided percutaneous drainage is both effective and safe in the treatment of patients with acute appendicitis complicated by perforation and abscess. The clinical and technical success rates are high.

[Management of perforations as adverse events of ERCP plus ES. Personal experience]

INTRODUCTION. ERCP has brought real progress in the study and treatment of pancreatic and biliary diseases, because of its ambivalence as diagnostic and therapeutic procedure. Among its complications, perforations occur in fewer than 1% of patients, but are associated with a mortality rate of 16% -18%.

CASE REPORTS

CASE 1- F, 89 years old with obstructive jaundice by choledocholithiasis submitted to ERCP plus ES, during which occurs type II lesion; the partial removing of stones from choledochus during the procedure allow us to opt for a conservative treatment, with resolution on post-ERCP day 12. CASE 2- F, 53 years old with recurring cholangitis and post-cholecystectomy stenosis of choledochus already treated by stenting; for the occurrence of type I lesion during ERCP, the patient undergoes surgery in emergency with healing in postoperative day 23. CASE 3- M, 84 years old with lithiasic cholecystitis, obstructive jaundice, lung emphysema and ischemic heart disease; after percutaneous cholecystostomy in emergency, we attempt to ERCP with evidence of type I lesion. Because of comorbility, we opt for a conservative treatment, not resolving, and then proceed to surgery. Exitus for cardio-respiratory complications. CASE 4- M, 89 years old with obstructive jaundice; ERCP is suspended for respiratory complications and then a PTC is perform; during it we note a type IV lesion, which is treated conservatively with resignation in day 12. CASE 5- F, 68 years old with cholecystitis and choledocholithiasis; during ERCP plus SE a type II lesion occurs with worsening signs of acute abdomen. Because of clinical conditions and the impossibility of carrying out stones from choledochus by endoscopy, we opt for a surgical treatment in emergency. Exitus for respiratory complications.

DISCUSSION

Because of the controversy exists on what should be the management of perforations as adverse events of ERCP plus ES (immediate surgery or conservative therapy), we can only hope an eclectic approach based on the anatomical and clinical peculiarity of each case.

Abdominal pain in a young woman (2009: 8b)

Juxtapapillary duodenal diverticula and their possible complications are not frequent findings. We present the case of a woman with a giant juxtapapillary diverticulum, complicated by diverticulitis and areas of perforation of the wall that required urgent surgical treatment. We present the preoperative findings on computed tomography and magnetic resonance imaging.

Intra-abdominal abscess caused by toothpick injury

We present the case of a 42-year-old female who presented to our emergency department (ED) complaining of epigastric pain for four days. She had been seen in the outpatient department and ED previously for evaluation, but continued to experience epigastric pain with fever. Emergency panendoscopy was performed and a toothpick was discovered impacted in the duodenal bulb. The gastroenterologist was unable to remove the toothpick endoscopically. Computed tomography of the abdomen revealed a long and straight hyperdense foreign body, and intra-abdominal abscess formation. An emergency laparotomy was performed. The patient recovered gradually and was discharged 11 days later. She could not remember when she swallowed the wooden toothpick, but guessed that it was while out drinking. There is an old wives' tale in Taiwan that putting a toothpick in the cup while drinking beer reduces the likelihood of abdominal distention from the carbonation of the beer.

[Oligosymptomatic alimentary tract perforation in course of Crohn's disease in patient treated with anti-TNF alfa antibodies]

Successful Crohn's disease conservative treatment is often associated with use of few, sometimes new drugs. Their clinical use apart from inflammatory process decrease is associated with some risk. In the paper we report a case of 23-year-old woman suffering from Crohn's disease treated successfully with anti-TNF antibodies. Apart from successful anti-inflammatory there were observed not symptomatic perforation of the alimentary tract. Patients treated with strong anti-inflammatory drugs require especially careful monitoring also because of possibility of occurrence of not symptomatic life-threatening conditions.

The appendix on CT

Appendicitis can be a difficult clinical diagnosis to make. A negative appendicectomy rate of 20% has traditionally been accepted as the consequences of appendiceal perforation can be grave. Cross-sectional imaging is increasingly being employed in the investigation of adults with suspected appendicitis. This review will demonstrate the appearance of the normal appendix on computed tomography (CT) and its appearance in a range of inflammatory and neoplastic processes including appendicitis, Crohn's disease, infections, and benign and malignant tumours.

Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management

OBJECTIVE

The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).

METHODS

A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome.

RESULTS

Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality.

CONCLUSIONS

The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.