The ileocaecal knot

Variations in intestinal knot syndromes have been described in the past, including ileoileal knots, ileosigmoid knots and appendico-ileal knots. We report a new type of intestinal knot syndrome, an ileocaecal knot, which, to our knowledge, has not been reported before in the world literature. Features on CT that may raise suspicion of an ileal knot syndrome are described.

Gallbladder torsion-induced emphysematous cholecystitis in a 16-year-old boy

The patient was a 16-year-old boy who had turned to the right rapidly as he fielded a baseball that had come to him quickly. Two days after this event, which occurred in July 2004, he was admitted to hospital with repeated vomiting and increasing right hypochondralgia. Laboratory examination on admission showed elevation of the white blood count and of serum C-reactive protein and total bilirubin. Computed tomography on admission demonstrated an enlarged gallbladder and a thickened wall without gallstones, and magnetic resonance imaging performed 1 day later showed air within the gallbladder wall. His symptoms worsened, with a positive Murphy's sign, and emergency laparotomy was performed, with a diagnosis of emphysematous cholecystitis. Intraoperatively, the gallbladder was dark red, necrotic, distended, and enlarged. The cystic duct was attached only to the mesentery, and the gallbladder was floating freely, with the neck of the gallbladder having rotated 180 degrees counterclockwise, leading to a definitive diagnosis of gallbladder torsion with emphysematous cholecystitis. Cholecystectomy was performed, and analysis of bile showed Escherichia coli to be the causative organism. Histopathologic examination revealed necrotized cholecystitis. The patient is doing well 25 months after surgery, with an uneventful postoperative course.

Intense FDG Uptake in the Ovary With Painless Torsion

We report a case demonstrating intense FDG uptake in the ovary, which was diagnosed to be a hemorrhage and congestion due to painless torsion. An asymptomatic retropelvic mass was detected in a 51-year-old female by echography. FDG-PET demonstrated intense uptake in the mass, thus suggesting an ovarian tumor. A resection of the tumor was performed, and histopathological examination revealed hemorrhage and congestion in the ovary due to ovarian torsion. An ovarian hemorrhage due to painless torsion should be considered in the differential diagnosis of intrapelvic masses demonstrating high FDG uptake, even in asymptomatic patients.

Omental torsion without a whirl sign

Omental torsion is a very rare cause of acute abdomen. Its primary diagnostic modality is CT. The whirl sign visible in CT images is pathognomonic. The whirl sign is not present in all cases. When no whirl sign is seen, omental torsion is rather difficult to be differantieted radiologically from omental infarct and epiploic appendicitis. The diagnosis of these three entites is clinically important due to their different treatments. We present in this paper an omental torsion case where whirl sign was not present and diagnosis was made by other suggestive CT image findings.

Primary epiploic appendagitis: the role of computed tomography in diagnosis

Primary epiploic appendagitis is a rare entity that occurs due to torsion and inflammation of the epiploic appendages. Clinically, this entity may be mistaken for acute abdomen with resultant unnecessary surgery. In contrast to acute surgical abdomen, epiploic appendagitis usually does not require surgical treatment; most of the patients resolve with conservative management. Diagnosis can be achieved with imaging modalities of which computed tomography is the gold standard procedure. Herein, a patient who presented with acute abdomen like clinical picture, with the computed tomography demonstration of primary epiploic appendagitis, is presented.

Gall bladder torsion and rupture in a dog

A 6-year-old desexed female German Shepherd dog was referred to the Murdoch University Veterinary Hospital for assessment and management of acute onset vomiting, diarrhoea, polydipsia and lethargy of 2 days duration. Surgical, microbiological and histological findings were consistent with necrotising cholecystitis secondary to gall bladder torsion, resulting in gall bladder rupture and secondary non-septic bile peritonitis. A chronic peritoneopleural perforation resulting from an abdominal cavity foreign body and congenital peritoneopericardial hernia were also present. The dog made a full recovery following cholecystectomy, foreign body removal, repair of the peritoneopleural perforation and peritoneopericardial herniorrhaphy. This is the first recorded case of gall bladder torsion in the dog.

Delayed presentation of malrotation and midgut volvulus: imaging findings

Midgut volvulus presenting outside the neonatal period often manifests with less than classic findings. One must be ever vigilant for any deviation from normal when imaging the gastrointestinal tract in these patients. Plain films often are noncontributory, and gastrointestinal imaging findings frequently are subtle and not exactly the same as those seen in classic cases in the neonatal period. Cases are presented illustrating the following: abnormal but less than classic small bowel location and configuration, malabsorption and fortuitous spiraling of a nasogastric tube, viral gastroenteritis and pseudo intussusception, intractable vomiting and dehydration with abnormal cecal position, and duodenal obstruction: pseudo SMA syndrome. Fortunately, one now can confirm one's suspicions with computed tomography and ultrasound in terms of determining whether the superior mesenteric artery and superior mesenteric vein positions are normal or reversed.

Complication of laparoscopic detorsion of adnexal mass

Detorsion of an ischemic adnexal mass has recently been advocated for most cases of twisted adnexa. Usually, the affected ovary regains some or all of its vitality and function. However, when the ovary is completely necrotic, it may form an abscess if it contains tissue components that cannot be eliminated by the peritoneal immune system. We report a case of pelvic abscess formation in a detorsed ovary that previously contained an unsuspected dermoid cyst. We call for an extensive inspection of the detorsed ovary before ending the laparoscopic operation, and if it remains necrotic and is suspected of containing a dermoid cyst, it should be removed promptly.

Torsion causing interruption of the ampullary portion of the fallopian tube

OBJECTIVE

To present a description of a young girl who presented acutely with symptoms and findings that are consistent with acute adnexal torsion, where resultant outcome would have led to perception of a congenital anomaly.

DESIGN

Case report.

SETTING

Tertiary pediatric hospital.

PATIENT(S)

A young girl who presented acutely with symptoms consistent with adnexal torsion but who was found to have a torsion affecting a paratubal cyst and the midsegment of her fallopian tube.

INTERVENTION(S)

A salpingectomy was performed because of damage involving the ischemic paratubal cyst and tubal segment that left too little residual tube to allow for a future anastomosis of the residual unaffected components.

MAIN OUTCOME MEASURE(S)

Operative findings, which give an explanation for midsegmental tubal absence.

RESULT(S)

This case challenges previous reports that absent midsegment of a tube is a rare congenital anomaly.

CONCLUSION(S)

Absent midsegment of a tube can be explained as an acquired anomaly, rather than proposing an unusual congenital anomaly.

Cecal epiploic appendagitis: a diagnostic and therapeutic dilemma

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self-limiting condition, EA's ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure supero-lateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis.

Massive ovarian edema with torsion: unusual hemorrhage and the recovery of contrast enhancement

We report a case of massive ovarian edema due to left adnexal torsion. On initial magnetic resonance (MR), unusual hemorrhages were demonstrated as several hypointense areas on T2-weighted images. The lack of contrast enhancement was also observed in the left adnexa. Abdominal pain resolved spontaneously, and then follow-up MR demonstrated the recovery of enhancement and hemorrhages as hyperintense signals on T1-weighted images.

An uncommon cause of acute abdomen--epiploic appendagitis: CT findings

Epiploic appendagitis, which is an uncommon cause of acute abdomen, is a benign self-limiting inflammatory process of epiploic appendices. It has primary and secondary types. Computed tomography findings of the primary type are specific but are demonstrated rarely. Herein, we present pre- and post-treatment computed tomography findings of two cases who admitted to the emergency clinic with acute abdominal pain and were diagnosed to have epiploic appendagitis. Follow-up computed tomography features correlated well with clinical improvement.

[Clinical study on operative treatment of acute scrotum]

Between July 1986 and March 2006, 102 patients underwent an operation for acute scrotum. Median age was 12.0 years old (range 0-51). Post-operative diagnosis revealed 50 cases (49%) of spermatic cord torsion, 29 cases (28%) of epididymal appendix torsion, and 13 cases (13%) of acute epididymitis. Spermatic cord torsion was most frequent in the age between 0 and 5, and 11 and 20, while epididymal appendix torsion was most frequent between 6 and 10. Moreover, acute epididymitis was most frequently seen in the age over 20. There were no apparent differences in the clinical symptoms such as scrotal pain, scrotal swelling, and abdominal pain. In the physical examinations, pyuria was the only finding to indicate acute epididymitis. In case of spermatic cord torsion, 'golden time' is defined as the time from onset to operation when testicular function can be expected for preservation. In this study golden time was defined as 8 hours because the testes was preserved in all 23 patients receiving the operation within 8 hours, but in only 10 (37%) out of 27 patients receiving the operation after 8 hours. Moreover, the operation within 24 hours saved the testes in approximately 90% of the patients. In patients with acute scrotum, emergency operation should be performed as speedily as possible for preservation of testicular function.

Progress over 32 years of a survivor of giant exomphalos and outcome of pregnancy

We report the progress of a female survivor of ruptured giant exomphalos over 32 years. Two-stage repair was performed at birth, resulting in a giant ventral hernia, which was repaired at 31 months. She developed gross benign ascites at 24 years, not previously described in association with congenital abdominal wall defects. This was associated with a misleading radiologic finding of a complex ovarian cyst and led to laparotomy. There were dense adhesions. Benign ascites and loculated pelvic fluid were drained, but the ovaries appeared healthy. A further laparotomy was performed for acute abdominal pain 2 years later. She subsequently had a successful pregnancy complicated by urinary retention. The abdomen expanded without difficulty, unlike the only other such case reported in the literature. A healthy baby girl was delivered by cesarean section at 37 weeks' gestation, which was necessary because of a footling breech presentation.

[A case of nonocclusive mesenteric ischemia (NOMI) which occurred in a patient with torsion of gallbladder]

We report a case of nonocclusive mesenteric ischemia (NOMI) which occurred in a patient with torsion of gallbladder. A 91-year-old woman was admitted to the hospital and was diagnosed of acute cholecystitis. The next day, she went into shock. Then, we diagnosed her illness as torsion of gallbladder by computed tomography and ultrasonography, and performed an emergency operation. After cholecystectomy, it was recognized that the wide range of the small intestine had become necrotic sporadically. We diagnosed it as NOMI, and performed the wide resection of the small intestine followed by making double stomas. There is no previous report of NOMI associated with torsion of gallbladder. We guess the cause of NOMI in this case would be dehydration because of gallbladder torsion. NOMI has high mortality. Early diagnosis and early treatment are of great importance in NOMI.

Laparoscopic resection of an axially torted Meckel's diverticulum in a 13-year-old

We report an unusual case of acute abdomen due to axial torsion and infarction of a Meckel's diverticulum in a 13-year-old boy and illustrate the versatility of laparoscopy in the diagnosis and management of acute surgical abdomen in children. We believe that this is only the third case reported in a child of torsion of a Meckel's diverticulum and the first to be managed by laparoscopic resection.

[Omental torsion. An acute abdomen etiology]

INTRODUCTION

Omental torsion is an uncommon cause of acute abdomen, usually mimicking acute appendicitis; almost all described cases are diagnosed with laparotomy. It can be a primary or secondary condition. Primary torsion occurs without evidence of intrabdominal abnormalities.

MATERIAL AND METHODS

Retrospective, observational, longitudinal, descriptive study carried out between January 2001 and December 2005. Patients diagnosed as acute appendicitis were included and we assessed diagnostic accuracy by means of anatomopathology and omental torsion incidence.

RESULTS

2135 patients were included; diagnostic accuracy was 91.71%. Eight omental torsion cases were identified, with an incidence of 0.37% and all diagnosed with laparotomy. Patients in the first and fourth decades of life were mostly affected; 75% of the cases were observed in adults, and 62.5% displayed secondary torsion.

DISCUSSION

Omental torsion is a rare cause of acute abdomen. Acute appendicitis is a frequent differential diagnosis that should be taken into account. In our series, we found a two-fold higher incidence of omental torsion, compared with previously reported incidence data. We also found a difference in age and sex distribution among patients with this diagnosis.

Primary torsion of the greater omentum. An obscure and unusual cause of acute abdomen

A 36-year-old man was admitted with a 3-day history of severe abdominal pain in the right upper abdomen and was initially diagnosed with acute cholecystitis or acute retrocecal appendicitis. The patient was transferred to the department of surgery for close surgical observation. CT of the entire abdomen was performed just before the operation, which demonstrated inflammation in the omental fat. Surgery revealed primary omental torsion and subsequent resection of the infarcted segment offered a rapid recovery. We report a case of primary segmental omental torsion and discuss the diagnostic and therapeutic implications of this unusual entity.

Isolated torsion of the fallopian tube in a 14-year-old adolescent

OBJECTIVE

Torsion of adnexa is relatively common, but isolated torsion of the fallopian tube is rare. It should be considered in all adolescents who present with acute pelvic pain. Laparoscopy or laparotomy is often necessary to establish the diagnosis. This report focuses on a 14-year-old girl with isolated tubal torsion who presented with acute pelvic pain.

CASE REPORT

A 14-year-old adolescent was admitted to our hospital because of acute right-sided abdominal pain without vomiting and diarrhea. Pelvic ultrasound showed an adnexal mass. Conservative treatment was given but did not improve her condition. Emergent laparoscopy was performed due to persistent symptoms, which later confirmed the diagnosis of isolated torsion of the fallopian tube. Pathology showed hemosalpinx with necrosis.

CONCLUSION

Isolated torsion of the fallopian tube is an uncommon event, especially in adolescents. It must be kept in mind whenever a young girl presents with low abdominal pain and pelvic mass on ultrasound. Prompt laparoscopic intervention may allow for early diagnosis, treatment and preservation of the tube if possible.

Torsion d’un appendice épiploïque au sein d’une hernie de Spigel : premier cas rapporté en imagerie

We present the first case illustred in imaging of an epiploic appendage torsion inside a Spigelian hernia.

Effect of aging on twist-displacement loop by 2-dimensional speckle tracking imaging

BACKGROUND

Newly developed 2-dimensional (2D) speckle tracking imaging provides simultaneous information on both cardiac rotation and radial displacement throughout the cardiac cycle, thus, providing the opportunity to noninvasively construct twist-displacement loops. The aim of this study was to examine the effect of aging on twist-displacement loops.

METHODS

Basal and apical 2D left ventricular (LV) short-axis images with high frame rates were acquired in 59 asymptomatic healthy volunteers. Using commercially available software, LV rotation and radial displacement were obtained at each plane by 2D speckle tracking analysis. LV twist was defined as apical LV rotation relative to the base. To adjust intersubject differences in heart rate, the time sequence was normalized to the percentage of systolic and diastolic duration. Volunteers were divided into 3 groups according to age.

RESULTS

Twist-displacement loops were characterized by a figure of 8 configuration. There was a linear relation between twist and displacement during systole (r = 0.97), with its slope being significantly larger in the older group compared with the young group. During early diastole, a substantial degree of untwisting developed despite a relatively small reversal of systolic radial displacement, resulting in a much steeper twist-displacement relationship observed in all groups. Subsequent diastolic expansion occurred with more gradual additional untwisting.

CONCLUSION

We found that 2D speckle tracking imaging successfully provides twist-displacement loop, noninvasively. Aging affects the systolic component of the twist-displacement loop. The assessment of twist-displacement loop may be useful for evaluating LV function.

Adnexal Torsion Involving Hydatids of Morgagni

OBJECTIVE

Hydatids of Morgagni are common embryonal remnants of the müllerian duct and among the infrequent causes of adnexal torsion. The purpose of this study was to investigate the occurrence of adnexal torsion involving hydatids of Morgagni, as well as its possible mechanisms.

METHODS

A database search was conducted for cases of adnexal torsion treated in our institution from January 2002 to July 2005. These cases were analyzed, focusing on a subgroup of adolescents with adnexal torsion involving the hydatids of Morgagni.

RESULTS

There were 76 patients with adnexal torsion. The rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15-0.51) in the adolescent subgroup (10-19 years old), compared with 0% (0 of 61 cases, 95% CI 0-0.048) in the adult subgroup. The difference between the hydatid torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001-0.532). The four patients with hydatid torsion (postmenarchal girls, aged 13-18 years) were managed with laparoscopic adnexal detorsion and cystectomy of the affected hydatid of Morgagni. At surgery, we noted three different mechanisms of hydatid torsion: torsion of the adnexa together with torsion of the hydatid of Morgagni, torsion of the hydatid of Morgagni with intact adnexa (n = 2), and entanglement of the hydatid's pedicle around the distal fallopian tube. The hydatids of Morgagni were observed on the preoperative transabdominal ultrasonogram in only one patient and appeared as a simple cyst.

CONCLUSION

Adnexal torsion involving the hydatids of Morgagni appears to be more common in adolescents than previously thought.

LEVEL OF EVIDENCE

III.

Prise en charge cœlioscopique des masses latéro-utérines pendant la grossesse

OBJECTIVES

To determine the feasibility, safety and limiting factors of laparoscopic management of pelvic mass in pregnancy.

MATERIAL

and methods. During a 10-year period, 21 laparoscopic procedures were performed in patients with pelvic masses in pregnancy after exclusion of appendicitis and ectopic pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 8 cases, the second trimester in 12 cases and the third trimester in one case. All the procedures were performed with general anesthesia and the laparoscopic cystectomies were performed with the intraperitoneal technique.

RESULTS

The indications were: persistent or sonographically abnormal ovarian cyst (12 cases), torsion of ovarian cyst (5 cases), and symptomatic pelvic mass (4 cases: 2 painful cysts and 2 infarction of fibroma). One borderline tumor were discovered. The laparoscopic procedure could not be performed in two cases due to difficulty of access to the lesion. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 4.5 days. The outcome of the pregnancy was normal in all cases.

CONCLUSION

Laparoscopic management of pelvic masses in pregnancy by an experienced team, is a safe and effective procedure.

Primary torsion of the falciform ligament: Computed tomography and ultrasound findings

Torsion of the free end of the falciform ligament is an extremely rare cause of localized peritonitis. A surgically proven case is presented here, with ultrasound and CT findings and a review of the published work.