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Lee J, Im C. Time-to-surgery paradigms: wait time and surgical outcomes in critically Ill patients who underwent emergency surgery for gastrointestinal perforation. BMC Surg 2024; 24:159. [PMID: 38760752 PMCID: PMC11100233 DOI: 10.1186/s12893-024-02452-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Waiting time for emergency abdominal surgery have been known to be linked to mortality. However, there is no clear consensus on the appropriated timing of surgery for gastrointestinal perforation. We investigated association between wait time and surgical outcomes in emergency abdominal surgery. METHODS This single-center retrospective cohort study evaluated adult patients who underwent emergency surgery for gastrointestinal perforations between January 2003 and September 2021. Risk-adjusted restricted cubic splines modeled the probability of each mortality according to wait time. The inflection point when mortality began to increase was used to define early and late surgery. Outcomes among propensity-score matched early and late surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). RESULTS Mortality rates began to rise after 16 h of waiting. However, early and late surgery groups showed no significant differences in 30-day mortality (11.4% vs. 5.7%), ICU stay duration (4.3 ± 7.5 vs. 4.3 ± 5.2 days), or total hospital stay (17.4 ± 17.0 vs. 24.7 ± 23.4 days). Notably, patients waiting over 16 h had a significantly higher ICU readmission rate (8.6% vs. 31.4%). The APACHE II score was a significant predictor of 30-day mortality. CONCLUSIONS Although we were unable to reveal significant differences in mortality in the subgroup analysis, we were able to find an inflection point of 16 h through the RCS curve technique. TRIAL REGISTRATION Formal consent was waived due to the retrospective nature of the study, and ethical approval was obtained from the institutional research committee of our institution (B-2110-714-107) on 6 October 2021.
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Affiliation(s)
- Junghyun Lee
- Department of Surgery, Yongin Severance Hostpital, Yongin, Korea
- Yonsei University College of Medicine, Seoul, Korea
| | - Chami Im
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.
- Seoul National University College of Medicine, Seoul, Korea.
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2
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Hughes H, Jajodia A, Soyer P, Mellnick V, Patlas MN. Bowel Emergencies in Patients With Cancer. Can Assoc Radiol J 2024:8465371241252035. [PMID: 38721789 DOI: 10.1177/08465371241252035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Cancer is the second most common cause of death worldwide. Bowel emergencies in patients with cancer are becoming increasingly more prevalent due to advances in cancer therapy and longer overall patient survival. When these patients present acutely, they are often frail and may have pre-existing co-morbidities. This article discusses the imaging features of bowel emergencies commonly encountered in oncological patients in clinical practice. These include chemotherapy related colitis, neutropenia enterocolitis and typhlitis, toxic megacolon, bowel perforation, malignant bowel obstruction and gastrointestinal haemorrhage. The radiologist plays a key role in identifying these oncological emergencies and guiding further management.
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Affiliation(s)
- Hannah Hughes
- Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Ankush Jajodia
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Philippe Soyer
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hopitaux de Paris, Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
| | - Vincent Mellnick
- Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, USA
| | - Michael N Patlas
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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3
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Yamani AS, Morris MC, Schrager JJ, Athota KP, Sams VG. A case of acute colonic pseudo-obstruction, sigmoid volvulus, and massive pneumoperitoneum in a young female patient. Int J Surg Case Rep 2024; 117:109558. [PMID: 38518469 PMCID: PMC10972842 DOI: 10.1016/j.ijscr.2024.109558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Acute colonic pseudo-obstruction (ACPO) is an uncommon phenomenon that is especially rare in young patients and can result in bowl ischemia and perforation if left untreated. Furthermore, pneumoperitoneum is almost always a concerning imaging finding and in the context of recent colonic resection may be a sign of anastomotic leakage. CASE PRESENTATION We describe a case of a young female patient with postpartum ACPO who subsequently underwent a hemicolectomy with colorectal anastomosis. The patient's hospital course was complicated by massive postoperative pneumoperitoneum that resulted in resection of the anastomosis and creation of an end colostomy. However, despite this measure, there was recurrent pneumoperitoneum on cross-sectional imaging 36 h later. This was treated non-operatively and the remainder of their hospital course was uneventful. CLINICAL DISCUSSION A potential etiology for ACPO during pregnancy may be due to compression of parasympathetic plexus nerves by the gravid uterus. Idiopathic pneumoperitoneum has been documented on a number of occasions, though this is generally in older patients. It can present with signs of peritonitis or can be asymptomatic. Simultaneous pneumothorax and pneumoperitoneum is rare and may be due to the transmission of air from the peritoneum to the mediastinum and thorax. The pneumoperitoneum itself may be due the air leakage through the significantly distended colon into the peritoneum. CONCLUSION The combination of ACPO following pregnancy and associated pneumothorax, pneumomediastinum, and recurrent pneumoperitoneum suggest a communicating defect between the thoracic, mediastinal, and peritoneal cavities. Furthermore, the possibility of underlying colonic dysmotility should be considered prior to the restoration of large bowel continuity.
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Affiliation(s)
- Ali S Yamani
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Mackenzie C Morris
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason J Schrager
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Krishna P Athota
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Valerie G Sams
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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4
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Ong D, Yogendran R, Fite E. Abdominal pain after a food crawl. J Am Coll Emerg Physicians Open 2024; 5:e13120. [PMID: 38333105 PMCID: PMC10850610 DOI: 10.1002/emp2.13120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Danier Ong
- Division of Emergency Medicine, Department of SurgerySaint Louis University School of MedicineSaint LouisMissouriUSA
| | - Rajiv Yogendran
- Division of Emergency Medicine, Department of SurgerySaint Louis University School of MedicineSaint LouisMissouriUSA
| | - Emily Fite
- Division of Emergency Medicine, Department of SurgerySaint Louis University School of MedicineSaint LouisMissouriUSA
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5
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Songtanin B, Jacob R, Nugent K. Recurrent spontaneous pneumoperitoneum in a patient with systemic sclerosis. BMJ Case Rep 2023; 16:e258041. [PMID: 37996130 PMCID: PMC10668157 DOI: 10.1136/bcr-2023-258041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Affiliation(s)
- Busara Songtanin
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Roy Jacob
- Radiology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Kenneth Nugent
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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6
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Cairl NS, Sharp VL. Pneumoperitoneum Secondary to Necrotic Intra-abdominal Lymph Node. Cureus 2023; 15:e47871. [PMID: 38022375 PMCID: PMC10681116 DOI: 10.7759/cureus.47871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Pneumoperitoneum is often treated as a surgical emergency as the most common etiology is perforated hollow viscus. Here, we present the case of a man in his 70s who presented to the emergency department with fever and abdominal pain. On physical exam, he was diffusely tender in the bilateral lower quadrants with guarding. Imaging demonstrated moderate volume pneumoperitoneum. On review of his imaging, the pneumoperitoneum was centered around a 7 cm necrotic lymph node. Repeat CT scan with positive oral (PO) and rectal contrast demonstrated no extraluminal contrast extravasation, but air bubbles were seen extending from the necrotic lymph node into the lower abdominal cavity. He underwent CT-guided drain placement and was started on antibiotics, and improved without surgical intervention. In stable patients presenting with pneumoperitoneum and known intra-abdominal lymphadenopathy, perforated viscus should be ruled out prior to surgical intervention, and necrotic intra-abdominal lymph node should be considered as a differential diagnosis.
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Affiliation(s)
- Nicholas S Cairl
- General Surgery, Trinity Health Ann Arbor Hospital, Ann Arbor, USA
| | - Victoria L Sharp
- Trauma, Acute, and Critical Care Surgery, Trinity Health Ann Arbor Hospital, Ann Arbor, USA
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7
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Murata Y, Matsuo Y, Hiraoka E. Successful Conservative Management of Emphysematous Cystitis With Pneumoperitoneum: A Case Report and Literature Review. Cureus 2023; 15:e43769. [PMID: 37727168 PMCID: PMC10506864 DOI: 10.7759/cureus.43769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
Emphysematous cystitis is a rare type of urinary tract infection that is characterized by the accumulation of gas within the walls and lumen of the urinary bladder. In rarer instances, pneumoperitoneum may accompany emphysematous cystitis. When pneumoperitoneum is suspected through imaging studies in patients with emphysematous cystitis, surgical abdominal exploration is frequently performed considering the possibility of bladder perforation or coexistence of intestinal perforation. We successfully managed a case of emphysematous cystitis accompanied with pneumoperitoneum conservatively. A 90-year-old woman hospitalized with a gastric ulcer developed abrupt lower abdominal pain and hematuria. Contrast-enhanced CT revealed gas within the bladder wall, which was consistent with emphysematous cystitis, and pneumoperitoneum. No obvious bowel or bladder perforation was observed in the CT scan. Regarding her high surgical risk and clinical stability, surgical abdominal exploration was not performed, and she was managed conservatively with urethral catheter placement and antibiotics. She recovered with the treatment, and CT imaging obtained on day 18 demonstrated resolution of the bladder wall emphysema and no signs of pneumoperitoneum. We performed a literature review using MEDLINE and Japana Centra Revuo Medicina Web and confirmed 13 previously reported cases of emphysematous cystitis and pneumoperitoneum. Based on the review of these 13 cases and our case, it is difficult to predict the presence of bladder perforation solely based on peritoneal signs in physical findings or ascites on CT scans. Therefore, it would be preferable to perform surgical abdominal exploration to make a definite diagnosis and select an appropriate treatment. However, the fact that at least eight out of the 10 cases managed conservatively survived suggests that there is a specific clinical entity among patients who present with emphysematous cystitis and pneumoperitoneum that can be safely managed conservatively. Further accumulation of cases and research is necessary to determine which cases can be treated conservatively.
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Affiliation(s)
- Yurie Murata
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
- Department of Cardiology, Iwakuni Medical Center, Iwakuni, JPN
| | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Tokyo, JPN
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
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Rinebold EA, Zhang CX, Engelbrecht A, Merola M, Velcek F. Idiopathic pneumoperitoneum in a pediatric patient. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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9
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Yin Y, Zhang Y, Tan B, Zhou W, Liu W, Zeng X. Recurrent spontaneous pneumoperitoneum secondary to intestinal dilatation caused by allied disorders of Hirschsprung’s disease: a case report. BMC Gastroenterol 2022; 22:316. [PMID: 35761190 PMCID: PMC9235130 DOI: 10.1186/s12876-022-02376-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Allied disorders of Hirschsprung’s disease (ADHD) mainly present with bowel obstruction, intestinal dilatation, and chronic constipation, while recurrent spontaneous pneumoperitoneum was rarely reported. We aimed to report a case of recurrent spontaneous pneumoperitoneum caused by ADHD. Case presentation A 59-year-old female patient presented with progressive and severe constipation in the past 30 years. She suffered from abdominal discomfort, which was described as ‘gurgling’ during the last three years. Radiography showed free-air and intestinal dilatation, without any other diseases, and she was identified with recurrent spontaneous pneumoperitoneum. Gastrointestinal transit test indicated gastrointestinal motility disorder, and anorectal manometry confirmed the presence of rectal anus-suppressing reflex. Subtotal colectomy was performed to relieve apparent constipation, and the postoperative pathological examination of the colon demonstrated proliferation of nerve fibers and hyperplasia of myenteric plexuses, as well as a relatively scarcity of ganglion cells in the myenteric plexus. Based on the presentations and the postoperative pathology, she was diagnosed with ADHD. The recurrent spontaneous pneumoperitoneum was regarded as the gas escape from dilated intestines, which was in high pressure. All the symptoms and her mental state were improved after the treatment with gastrointestinal decompression and enteral nutrition. However, during follow-up visits, she had intestinal infection, and suffered from severe diarrhea and water-electrolyte imbalance, and the patient eventually died at 17 months after the diagnosis. Conclusion ADHD could be a rare cause of recurrent spontaneous pneumoperitoneum, and are mainly undiagnosed or misdiagnosed. A full-thickness biopsy of the gastrointestinal tract (especially the small intestine and sigmoid colon) and differential diagnosis are recommended for the definitive diagnosis. While the ADHD have shown a poor prognosis, timely and long-term treatment with intestinal decompression and nutritional therapy could help relieve symptoms and provide a better quality of life for such patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02376-w.
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10
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Artificial Intelligence Based Detection of Pneumoperitoneum on CT Scans in Patients Presenting with Acute Abdominal Pain: a Clinical Diagnostic Test Accuracy Study. Eur J Radiol 2022; 150:110216. [DOI: 10.1016/j.ejrad.2022.110216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/30/2022] [Accepted: 02/11/2022] [Indexed: 11/20/2022]
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Raol K, Kuppusamy N, Sanghavi NA, Kaur N, Rajendran K. Detrimental Pneumoperitoneum and Bowel Necrosis Secondary to Dilatation and Curettage: Necessitating the Importance of Healthcare Awareness. Cureus 2021; 13:e18594. [PMID: 34786217 PMCID: PMC8577819 DOI: 10.7759/cureus.18594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/05/2022] Open
Abstract
We have read about numerous cases depicting life-threatening fatalities due to the lack of awareness and accessibility to health care facilities. A 23-year-old pregnant woman in a village in India underwent a dilation and curettage procedure for spontaneous abortion by an uncertified medical practitioner. Eventually, she presented to the emergency room with ER and an initial abdominal X-ray was consistent with the finding of free air under the diaphragm/pneumoperitoneum and air-fluid levels. Here we present a case of bowel perforation secondary to being strangulated within the uterine cavity.
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Affiliation(s)
- Karanrajsinh Raol
- Internal Medicine, Gujarat Medical Education and Research Society Medical College and General Hospital, Gandhinagar, IND
| | - Naveen Kuppusamy
- Internal Medicine, Government Tiruvannamalai Medical College, Tiruvannamalai, IND
| | | | - Navpreet Kaur
- Internal Medicine, Dayanand Medical College & Hospital, Ludhiana, IND
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12
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Hussein MN, Heinemann A, Shokry DA, Elgebely M, Pueschel K, Hassan FM. Postmortem computed tomography differentiation between intraperitoneal decomposition gas and pneumoperitoneum. Int J Legal Med 2021; 136:229-235. [PMID: 34708283 DOI: 10.1007/s00414-021-02732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study is to investigate the ability of postmortem computed tomography (PMCT) to distinguish intraperitoneal decomposition gas from pneumoperitoneum due to intestinal perforation. METHODS This retrospective study investigated the factors affecting intraperitoneal gas in two groups of 14 decedents as detected by postmortem CT performed in the Department of Legal Medicine of Hamburg University. The first group died with a cause of death associated with intestinal perforation, and the second group with other different natural causes of death. These factors include postmortem interval, gas volume, gas distribution, radiology alteration index (RAI), and pneumoperitoneum-associated pathology. RESULTS The findings of this study showed the appearance of specific gas distribution patterns and a significant increase in gas volumes in the cases of intestinal perforation. Moreover, postmortem interval and the pneumoperitoneum-associated pathology could help distinguish postmortem-generated gas from pneumoperitoneum. CONCLUSION Based on the findings of this study, we propose that these findings can improve the proper detection of intestinal perforation cases in the future.
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Affiliation(s)
- Maged Nabil Hussein
- Forensic Medicine Authority, Ministry of Justice, 14 Berium Eltonsy Street, Elsayda Zainb, Cairo, Egypt.
| | - Axel Heinemann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg University, Butenfeld 34, 22529, Hamburg, Germany
| | - Dina Ali Shokry
- Forensic Medicine & Clinical Toxicology Department, Faculty of Medicine, Cairo University, kasr Alainy Street, Cairo, 11562, Egypt
| | - Mohamed Elgebely
- Lecturer of Forensic Medicine & Clinical Toxicology Department, Faculty of Medicine, Suez University, Cairo-suez road, 41522, Al-salam city, Egypt
| | - Klaus Pueschel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg University, Butenfeld 34, 22529, Hamburg, Germany
| | - Fatma Mohamed Hassan
- Forensic Medicine & Clinical Toxicology Department, Faculty of Medicine, Cairo University, kasr Alainy Street, Cairo, 11562, Egypt
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13
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Sivathasan S, Nagrodzki J, McGowan D. Twelve tips for interpreting abdominal CT scans. MEDICAL TEACHER 2021; 43:956-959. [PMID: 33142074 DOI: 10.1080/0142159x.2020.1839033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Abdominal computerised tomography (CT) scans are a crucial tool in the diagnosis and management of the acute abdomen. Currently, medical students are not widely and extensively trained in the interpretation of abdominal scans. AIM We aim to provide advice about interpreting abdominal CT scans. METHODS We used the critical reflection of our experiences, both in clinical practice and in teaching, alongside advice from the literature to develop these tips. RESULTS Twelve tips following the '4As, 3Bs, 2Cs and 1D' approach are presented to assist doctors and medical students with interpreting abdominal CT scans. CONCLUSION The early identification of pathology on CT scans has been demonstrated to improve patient outcomes in certain cases, while a formal radiologist's report is awaited. Following a systematic approach, such as the one we presented here, may aid trainees in looking at abdominal CT scans.
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Affiliation(s)
| | - Jakub Nagrodzki
- Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - David McGowan
- Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
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14
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Islam FA, Muhlmann M. Acute abdomen with pneumoperitoneum without hollow viscus perforation. ANZ J Surg 2021; 92:262-264. [PMID: 34124831 DOI: 10.1111/ans.16996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/21/2021] [Accepted: 05/20/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Fahad Al Islam
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Mark Muhlmann
- Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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15
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Taylor MA, Merritt CH, Riddle PJ, DeGennaro CJ, Barron KR. Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J 2020; 12:52. [PMID: 33284363 PMCID: PMC7721848 DOI: 10.1186/s13089-020-00195-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/17/2020] [Indexed: 11/11/2022] Open
Abstract
Undifferentiated abdominal pain is a common presentation often requiring immediate medical or surgical intervention. Providing an accurate diagnosis involves a detailed patient history and thorough physical exam. Point of care ultrasound is gaining acceptance as a rapid diagnostic tool that can be used to accurately detect life-threatening conditions while potentially avoiding unnecessary radiation exposure and facilitating rapid treatment. Detection of pneumoperitoneum with point-of-care ultrasound is a simple procedure that relies heavily on the experience of the investigating practitioner. Standard technique involves placing a high-frequency linear-array transducer in the right upper quadrant, where abdominal free air is most likely to accumulate. Detection of the ‘gut point’, which is the transition of abdominal wall sliding to lack thereof in a single image, is the pathognomonic finding of pneumoperitoneum. If visualization is difficult, moving the patient to the left lateral decubitus position or using the scissors technique can provide additional image views. This representative case report and review highlights the use of abdominal POCUS for the diagnosis of pneumoperitoneum. Ultrasound should continue to be explored by clinicians to narrow the differential diagnosis of acute abdominal pain.
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Affiliation(s)
- Matthew A Taylor
- University of South Carolina School of Medicine, Columbia, SC, 29209, USA
| | | | - Philip J Riddle
- Department of Internal Medicine, Prisma Health Midlands, University of South Carolina School of Medicine, Columbia, SC, 29209, USA
| | - Carter J DeGennaro
- Department of Emergency Medicine, Prisma Health Midlands, University of South Carolina School of Medicine, Columbia, SC, 29209, USA
| | - Keith R Barron
- Department of Internal Medicine, Prisma Health Midlands, University of South Carolina School of Medicine, Columbia, SC, 29209, USA. .,Ultrasound Institute, University of South Carolina School of Medicine, Columbia, SC, 29209, USA. .,Palmetto Health-USC Medical Group, 5 Medical Park Road, Columbia, SC, 29203, USA.
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16
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Gastric Perforation with Omental Patch Repair: A Rare Complication of Pulmonary Resuscitation in COVID-19 Pneumonia. Case Rep Surg 2020; 2020:8850739. [PMID: 33224549 PMCID: PMC7673953 DOI: 10.1155/2020/8850739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/16/2020] [Accepted: 10/26/2020] [Indexed: 11/17/2022] Open
Abstract
A 71-year-old male, diagnosed with coronavirus disease 2019 (COVID-19), was admitted to the medical-surgical floor for supportive treatment. The patient received bag-mask ventilation (BMV) secondary to severe hypoxia and reendotracheal intubation in the hospital on day eleven. A chest X-ray following reintubation noted concern for intra-abdominal air. Significant abdominal distention and subsequent diagnostic imaging showed pneumoperitoneum and a possible perforation of the stomach. The patient underwent an exploratory laparotomy with omental patching for a gastric perforation. Amidst the height of the COVID-19 pandemic, several important findings have been made through the disease sequelae of this individual patient.
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17
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Schindler P, Krähling H, Schülke C, Riegel A, Heindel W, Wildgruber M, Masthoff M. CT-Guided Percutaneous Drainage of Pneumoperitoneum Presenting as Acute Abdomen. J Vasc Interv Radiol 2020; 32:271-276. [PMID: 33129651 DOI: 10.1016/j.jvir.2020.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous drainage (PD) in patients with iatrogenic pneumoperitoneum presenting as acute abdomen. MATERIALS AND METHODS In this retrospective, single-center cohort study, 16 consecutive patients (9 males, 7 females; median age, 67.5 [51-85] years) undergoing PD for managing acute abdomen caused by iatrogenic pneumoperitoneum between 2013 and 2019 were analyzed. Inclusion criteria were clinical signs of acute abdomen that was unresponsive to conservative management and pneumoperitoneum due to an iatrogenic cause after PD, observed using CT imaging. Volumetry of pneumoperitoneum was performed using computer-aided image segmentation. To evaluate the clinical outcome, the paired t-test was performed to analyze the course of pain intensity on the numerical pain rating scale (NPRS, 0-10). Patient records were reviewed to determine PD-related adverse events and median drain duration. RESULTS The median pneumoperitoneum volume was 891.1 (127.7-3,677.0) mL. All PD procedures were successfully performed, with symptom relief and immediate abdominal decompression (mean segmental volume reduction, 79.8% ± 13.5). Acute abdomen symptoms were resolved, with significant improvement in pain intensity between the day of the PD procedure and the first day after the procdure (mean NPRS scores, 3.3 ± 1.9 vs 0.8 ± 1.0; P < .001). The median drain duration was 2 (1-3) days. No PD-associated adverse events were observed. After PD, 14 patients required only conservative management, whereas 2 patients with anastomotic leakage required additional surgery as they showed signs of persisting sepsis and generalized peritonitis. CONCLUSIONS PD is a safe and suitable procedure for the management of symptoms in patients with iatrogenic pneumoperitoneum presenting as acute abdomen.
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Affiliation(s)
- Philipp Schindler
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany.
| | - Hermann Krähling
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Christoph Schülke
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Arne Riegel
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Walter Heindel
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
| | - Moritz Wildgruber
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany; Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
| | - Max Masthoff
- Institute of Clinical Radiology, University Hospital Muenster, Muenster, Germany
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Synchronous Colon Cancer Presenting as a Different Concomitant Surgical Emergency; Case Report and Literature Review. HELLENIC JOURNAL OF SURGERY 2020. [DOI: 10.1007/s13126-020-0572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chongxi R, Jinggang J, Yan S, Hongqiao W, Yan L, Fengshuo Y. Spontaneous colonic perforation in adults: Evaluation of a pooled case series. Sci Prog 2020; 103:36850420945462. [PMID: 32993458 PMCID: PMC10451056 DOI: 10.1177/0036850420945462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Spontaneous colonic perforation in adults (SCPA) is rare but important. Its clinicopathological features and outcomes remain unclear. Therefore, the aim of the current study was to explore and investigate the clinicopathological characteristics, clinical outcomes and potential risk factors for patients with SCPA. Data of seven patients with SCPA treated in our hospitals from January 2008 to December 2017, and 221 cases from research databases before 2018 were retrospectively analyzed. The description of SCPA included stercoral perforation of the colon (SPC), idiopathic perforation of the colon (IPC) and spontaneous colonic perforation (SCP) in the study. All SCPA patients presented with unexplained abdominal pain and peritonitis. The median age was 62.5 years. The definite diagnosis preoperatively was 20.6%. The commonest lesion location was sigmoid colon and Hartmann's operation accounted for 59.3%. Histopathology of stercoral perforation (HSP) and histopathology of idiopathic perforation (HIP) were two histopathological findings. Postoperative complication was 67.7% and mortality was 31.1%. Univariate and multivariate analyses showed that chronic constipation was an independent risk factor for histopathological features (p ≤ 0.001, p = 0.005). Age of patients was associated with both postoperative complication (p = 0.012, p = 0.044) and mortality (p = 0.013, p = 0.034). Univariate analysis showed that HSP was associated with postoperative complication (p = 0.015). Our findings from the analysis pertaining to SCPA confirm those from previous studies, supporting the SCPA, as a uniform description, is an infrequent and life-threatening disease requiring early surgical intervention. We found that the elderly with chronic constipation was a high-risk category and those with HIP had a more favorable outcome than that of patients with HSP.
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Affiliation(s)
- Ren Chongxi
- Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, China
| | - Ji Jinggang
- Department of General Surgery, Cangzhou People’s Hospital, China
| | - Shi Yan
- Department of General Surgery, Gucheng County People’s Hospital, China
| | - Wang Hongqiao
- Department of General Surgery, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, China
| | - Liu Yan
- Department of Pathology, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, China
| | - Yang Fengshuo
- Department of General Surgery, Cangzhou People’s Hospital, China
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Tau N, Cohen I, Barash Y, Klang E. Free abdominal gas on computed tomography in the emergency department: aetiologies and association between amount of free gas and mortality. Ann R Coll Surg Engl 2020; 102:581-589. [PMID: 32233866 DOI: 10.1308/rcsann.2020.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Free abdominal gas is an important finding with major clinical implications. However, data on the aetiologies and prognosis of patients with free gas are scarce. Our primary aim was to describe the sources of free abdominal gas on emergency department (ED) computed tomography (CT). The secondary aim was to evaluate the association between the amount of free gas and all-cause mortality. METHODS All patients who underwent CT in the ED between February 2012 and February 2019 with free abdominal gas were included in the study. A scoring system was used to assess the amount of free gas: small - gas bubbles; medium - any gas pocket ≤2cm in diameter; large - any gas pocket >2cm. Data were collected from laboratory and clinical assessment regarding the source of free gas and all-cause mortality. RESULTS A total of 372 patients had free abdominal gas. Colonic diverticulitis was the most common aetiology among those with a small or medium amount of free gas (81/250 [32.4%] and 12/71 [16.9%] respectively). For patients with a large amount of gas, peptic disease was the most common aetiology (11/51 [21.6%]). Three-quarters of the patients (280/372, 75.2%) had the source of free gas identified during ED admission. Ninety-day mortality rates were 7.2%, 9.9% and 21.6% for patients with small, medium and large amounts of gas respectively (p=0.007). CONCLUSIONS Colonic diverticulitis was the most common source of free abdominal gas and peptic disease was the most common cause of a large amount of free gas. Mortality rates correlated with the amount of gas and were significantly higher in patients with a large amount.
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Affiliation(s)
- N Tau
- Sheba Medical Center, Ramat Gan, , Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Cohen
- Sheba Medical Center, Ramat Gan, , Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Barash
- Sheba Medical Center, Ramat Gan, , Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Klang
- Sheba Medical Center, Ramat Gan, , Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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