Retroperitoneal abscess with concomitant hepatic portal venous gas and rectal perforation: a rare triad of complications of acute appendicitis. A case report

Ultrasound and computed tomography findings of hepatic portal venous gas associated with acute appendicitis in a paediatric patient: A case report

Introduction

Hepatic portal venous gas is a rare and life-threatening condition characterised by the presence of gas in the portal vein. Hepatic portal venous gas is frequently associated with intestinal ischaemia and necrosis. We present the case of a paediatric patient with acute appendicitis with hepatic portal venous gas detected using ultrasonography.

Case report

A 5-year-old boy was admitted to our hospital with a respiratory tract infection. The boy started vomiting on day 2 of hospitalisation. He did not complain of any symptoms due to developmental retardation. We performed bedside point-of-care ultrasound, which detected hepatic portal venous gas, although the appendix could not be detected due to an acoustic shadow associated with bowel gas. Contrast-enhanced computed tomography revealed perforated appendicitis and pneumatosis intestinalis associated with paralytic ileus. An emergency laparoscopic appendectomy was performed. He was discharged on day 25 of hospitalisation after antibiotic therapy.

Discussion

The present case suggests that the mechanism of hepatic portal venous gas was paralytic ileus, which caused gas-forming bacterial proliferation. The gas produced by bacteria and/or the gas-forming bacteria entered the bowel wall, which caused pneumatosis intestinalis. The bubbles in the intestinal wall floated in the portal system and were detected as hepatic portal venous gas. Perforated appendicitis and paralytic ileus seemed to be caused by a delayed diagnosis of appendicitis. The point-of-care ultrasound examination was useful for detecting hepatic portal venous gas and for helping establish the diagnosis of appendicitis.

Conclusion

Hepatic portal venous gas is a rare finding associated with appendicitis in children. In addition, point-of-care ultrasound is useful for detecting hepatic portal venous gas in paediatric patients.

Intestinal necrosis cannot be neglected in a patient with hepatic portal vein gas combined with appendicitis: a rare case report and literature review

BACKGROUND

Hepatic portal vein gas (HPVG) is a rare acute abdomen, which is not an independent disease. Meanwhile, HPVG combined with appendicitis has been rarely reported. We found only a similar report by looking for literature, but no intestinal necrosis occurred. We report a patient with HPVG, appendicitis and intestinal necrosis was reported in the current study. The patient was given frequent monitoring and had been conducted operation in time.

CASE PRESENTATION

An 86-year-old female with appendicitis complicated by HPVG was reported in the present study. Abdominal examination revealed rebound tenderness at the McBurney's point. Moreover, abdominal computed tomography (CT) revealed gas in portal and mesenteric veins in addition to appendicitis. An emergency operation was planned on the appendix. However, the patient refused surgical treatment. Therefore, conservative treatment of antibiotics and frequent imaging observation was conducted for this patient. Although imaging results suggested disappeared gas in intra- and extra-hepatic portal veins, the small intestine was dilated, after conservative treatment of antibiotics. In addition, signs of diffused peritonitis could also be observed and an exploratory laparotomy was performed. Intra-operative findings had confirmed suppurated appendix, mesenteric ischemia and small intestinal necrosis.

CONCLUSIONS

Frequent monitoring benefits us in observing the progress of intestinal diseases. When there exist other possible causes of HPVG such as infection, it is not easy for us to ignore the possibility of intestinal necrosis.

Clinical Evaluation of Hepatic Portal Venous Gas after Abdominal Surgery

Hepatic portal venous gas (HPVG) is induced by various abdominal diseases. Since HPVG is accompanied by bowel ischemia, intestinal infection and hypovolemia, various modes of critical management are needed to treat the underlying conditions. HPVG associated with abdominal complications after surgery has rarely been reported. We present 4 patients with HPVG after abdominal surgery: 2 of the 4 patients died of multiple organ failure, and the other 2 recovered with solely conservative therapy. Although postoperative HPVG is a severe and life-threatening condition, early detection and systemic treatment lead to a better patient outcome.

Thigh abscess as an extension of psoas abscess: the first manifestation of perforated appendiceal adenocarcinoma: case report

A 65-year-old woman presented with a painful, swollen, red right thigh and the mild pain in the right abdomen without nausea, vomiting or diarrhoea that lasted for 1 week. Laboratory findings revealed elevated inflammatory markers. Computed tomography of the right thigh, abdomen and pelvis showed an abscess formation in the adductor muscles draining from the abscess that completely occupied the right retroperitoneum up to the diaphragm, dissecting downward through the inguinal canal. Appendix was enlarged with an appendicolith. Emergent exploratory laparotomy revealed a perforated appendix with psoas abscess. Pathohistological diagnosis revealed adenocarcinoma of the appendix. Thigh abscess is an uncommon condition with insidious clinical presentation. Therefore, early recognition and setting of the correct diagnosis enables adequate treatment avoiding additional complications and in some cases potential life-threatening conditions. When upper leg abscess is suspected or proven abdominal examination is mandatory.

Appendicitis and uterine abscess: presentation of an unusual fistula between the gynaecological and gastrointestinal tracts

The authors present the case of a 65-year-old woman with clinical and radiological evidence of pelvic sepsis and a medical history of endometrial ablation 20 years previously. She underwent laparotomy after failing to settle with a course of intravenous antibiotics and her appendix was found to have perforated into the uterus with abscess formation which had not discharged vaginally presumably due to widespread intrauterine synechia following her endometrial ablation. She underwent appendectomy and hysterectomy and made a full recovery with no complications. Macroscopic and microscopic examination suggested the appearances are those of an abscess of the uterine fundus with part of the appendix incorporating into the abscess mass.

Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESSS): a feasibility study for a new NOTES approach in a swine model

INTRODUCTION

A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model.

MATERIALS AND METHODS

Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the "Holy" plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization.

RESULTS

The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach.

CONCLUSIONS

Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.