Diagnostic performance of spectral Doppler in acute appendicitis with an equivocal Alvarado score

PURPOSE

This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes.

METHODS

The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted.

RESULTS

Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%.

CONCLUSION

The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%.

Fatal peritonitis due to gastric perforation in a male heroin addict: A case report and literature review

INTRODUCTION AND IMPORTANCE

Perforation of hollow organs, such as the stomach, within the abdomen can lead to the development of acute abdomen, a critical and potentially life-threatening condition. It is important to note that there is currently insufficient information available regarding the specific effects of heroin, an illegal substance commonly abused, in causing this particular complication.

CASE PRESENTATION

We present the case of a 32-year-old male who is addicted to heroin and was admitted to an addiction rehabilitation center with the aim of overcoming his addiction. After a few days of admission, the patient developed symptoms of abdominal pain, anorexia, and subsequent neurological manifestations, such as drowsiness, confusion, and a decreased level of consciousness. Tragically, the patient suffered a cardiorespiratory arrest upon arrival at the emergency room and despite efforts to resuscitate him, he unfortunately passed away.

CLINICAL DISCUSSION

During the autopsy of the aforementioned case, an observation was made of a perforation in the stomach, which ultimately led to the cause of death being identified as peritonitis. Acute peritonitis is recognized as one of the potential causes of acute abdomen, often resulting from the rupture of hollow organs within the abdominal region. It is characterized by inflammation of the serous membrane that lines the abdominal cavity.

CONCLUSIONS

Indeed, conducting original and coherent studies to investigate the potential effects of heroin on gastric perforation could prove to be highly valuable in facilitating the timely diagnosis and treatment of this fatal complication.

A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis

INTRODUCTION

Inflatable penile prostheses (IPP) consist of 2 cylinders implanted into the corpora cavernosa, a pump placed in the scrotum, and a saline-filled reservoir traditionally placed in the space of Retzius. IPPs are used to treat refractory erectile dysfunction with few rare, but serious, complications. Cases of reservoirs causing erosion into the bladder, small bowel obstructions, vascular compression, and inguinal herniation have been described.

AIM

We highlight the importance of keeping a broad differential diagnosis when assessing patients with bowel obstructions.

METHODS

A 68-year-old man with a previous IPP placement presented with left lower quadrant abdominal pain, constipation and obstipation for 5 days. On exam, he was afebrile, and noted to have a firm, distended, tympanic abdomen. CT scan showed a distended cecum at 11 cm, narrowing of the proximal sigmoid with adjacent inflammatory changes, and minimal peri-colonic air, suggestive of a localized perforation. The IPP reservoir was seen in the left iliac fossa, coinciding with the lead point of the obstruction, suggesting that the reservoir may have itself caused the obstruction. The patient was taken to the operating room for an emergent exploratory laparotomy, which revealed a mass in the colon abutting the IPP reservoir.

MAIN OUTCOME MEASURES

Considerations for IPP component explantation, factors considered for reintervention, and preservation of penile length with avoidance of penile fibrosis.

RESULTS

A left colectomy with transverse colostomy was successfully performed and the IPP reservoir was explanted. Intraoperative frozen section revealed adenocarcinoma. Upon initial review of the imaging, it was thought that the IPP reservoir may have caused the obstruction, but intraoperatively, the colonic tumor was found to be the culprit.

CONCLUSION

Although complications related to IPPs, including bowel obstructions, have been previously described in the literature, treatment for large bowel obstructions must take into account all possible etiologies, including malignancy. Atri E, Mallory C, Perez A, et al. A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis. Sex Med 2021;9:100391.

Intravenous Contrast Agent in Abdominal CT: Is It Really Needed to Identify the Cause of Bowel Obstruction? Proof of Concept

Background

To compare sensitivity of unenhanced computed tomography (CT) and contrast-enhanced CT for the identification of the etiology of bowel obstruction.

Materials and Methods

We retrospectively evaluated abdominal CT scans of patients operated for bowel obstruction from March 2013 to October 2017. Two radiologists evaluated CT scans before and after contrast agent in two reading sessions. Then, we calculated sensitivity of CT in the diagnosis of bowel obstruction and determined in which cases the etiology of bowel obstruction was detected on both unenhanced and enhanced CT or on enhanced CT only. The reference standard was defined as the final diagnosis obtained after surgery.

Results

Eighteen patients (mean age 72 ± 15 years, age range 37-88 years) were included in the study. Sensitivity of unenhanced CT and enhanced CT was not significantly different in either small bowel obstruction (64%, 7/11 patients vs. 73%, 8/11 patients; P = 0.6547) or large bowel obstruction (71%, 5/7 patients vs. 100%, 7/7 patients; P = 0.1410). Adhesions were identified on unenhanced CT as the etiology of small bowel obstruction in 80% (4/5) of patients. Tumors were identified on unenhanced CT as the etiology of large bowel obstruction in 67% (4/6) of patients.

Conclusion

In the diagnosis of small bowel obstruction due to adhesions with normal bowel wall thickening and when a neoplasm is identified as the etiology of large bowel obstruction on unenhanced CT, an intravenous contrast agent may be avoided for the identification of the etiology. In remaining cases, contrast agent is still recommended.