Uncommon and Unusual Gastrointestinal Causes of the Acute Abdomen: Computed Tomographic Diagnosis

Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B

People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.

Bowel Obstruction

Small bowel obstruction and large bowel obstruction account for approximately 20% of cases of acute abdominal surgical conditions. The role of the radiologist is to answer several key questions: Is obstruction present? What is the level of the obstruction? What is the cause of the obstruction? What is the severity of the obstruction? Is the obstruction simple or closed loop? Is strangulation, ischemia, or perforation present? In this presentation, the radiologic approach to and imaging findings of patients with known or suspected bowel obstruction are presented.

Foreign objects encountered in the abdominal cavity at CT

Foreign objects are not infrequently seen at computed tomography (CT) of the abdomen and pelvis and may pose a diagnostic challenge to the radiologist, who must recognize the object, characterize its nature and location, and determine its clinical significance. Most foreign objects are incidentally detected at CT, but they may mimic a wide range of pathologic conditions. Some foreign objects (eg, an object that has been swallowed either intentionally or unintentionally) are the cause of the patient's signs and symptoms and require prompt medical attention. Other objects, such as a sponge or surgical instrument that has been retained postoperatively, may have medicolegal consequences. Furthermore, certain objects, such as intentionally concealed drug packets, may go undetected unless a high degree of suspicion exists and appropriate window settings are used to review the study. The radiologist should be familiar with the wide range of foreign objects that may be encountered at abdominopelvic CT, be able to recognize them promptly, and understand their implications for patient treatment.

An interesting rare case of double volvulus

A 71-year-old female presented with recurrent sigmoid volvulus. In the current admission, her symptoms were not settling on conservative measures and subsequently went on to have laparotomy. During laparotomy, along with the sigmoid volvulus, there was associated gallbladder torsion. About 500 cases of gallbladder volvulus have been published in literature, however, in our literature search, the authors did not find any similar published case presenting with volvulus involving the gallbladder and the sigmoid colon at the same time. This patient went onto have cholecystectomy and sigmoid colectomy and had a good postoperative recovery and was discharged on the tenth postoperative day. At 6-week postoperative follow-up, she was doing well with no specific concerns.

[Mechanical obstruction as a cause of acute abdomen. Radiological differential diagnosis]

Mechanical obstruction is a common cause of acute abdomen. Besides the diagnosis of the obstruction itself it is crucial to recognize the cause of the obstruction for planning of conservative or operative treatment.This article gives a general overview of the methods available for imaging obstructions in the setting of an acute abdomen. In the second part the differential diagnoses of the most common causes of obstruction will be discussed.