Gastrointestinal perforation: ultrasonographic diagnosis

Medical management of pneumoperitoneum, gastric pneumatosis, and hepatic venous gas secondary to 3% hydrogen peroxide toxicity in a dog

OBJECTIVE

To describe the medical management and outcome of a dog suffering severe hydrogen peroxide toxicity.

CASE SUMMARY

A 3-year-old neutered female Bichon Frise was presented to an emergency and referral practice after ingestion of 10-20 mL/kg 3% hydrogen peroxide. On presentation, the dog was obtunded, was tachypneic, and had severe gastric tympany. Abdominal radiographs revealed pneumoperitoneum, gastric pneumatosis, and hepatic venous gas. The dog was managed conservatively with supportive care and oxygen therapy. Repeat radiographs 6 hours later showed complete resolution of all gas inclusions. While hospitalized, the dog developed severe hematemesis, and abdominal ultrasound revealed severe gastric wall thickening. Subsequent endoscopy confirmed severe gastric mucosal necrosis without evidence of deeper ulceration and relatively mild petechiation of the esophagus. The dog was ultimately discharged after 5 days of hospitalization and continued to do well at home. Recheck ultrasound 5 weeks postdischarge showed normal gastric wall appearance.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first reported case of pneumoperitoneum secondary to hydrogen peroxide toxicity and the first description of the clinical course of severe toxicity in dogs.

Endoscopic Management of Jejunal Perforation During Endoscopic Ultrasonography: A Case Report and Literature Review

Endoscopic ultrasound is a useful diagnostic and interventional device for gastroenterologists. Although extremely useful, endoscopic ultrasound is not a benign tool. Possible complications of endoscopic ultrasound include hemorrhage, infection, and perforation. Although rare, iatrogenic small bowel perforations have been reported largely on the duodenum and rarely on the jejunum or ileum. Traditionally, these iatrogenic small bowel perforations have been managed with open surgery. However, recent emerging clinical data has revealed that immediate endoscopic treatment may be a feasible and safe alternative to surgery in select cases. Here, we describe the endoscopic management of an iatrogenic jejunal perforation during a linear endoscopic ultrasound examination managed successfully using an endoscopic clip.

Misdiagnosis of food-borne foreign bodies outside of the digestive tract on magnetic resonance imaging: Two case reports

BACKGROUND

Patients with foreign bodies in the digestive tract are often encountered, but complete penetration of a foreign body through the gastrointestinal tract is rare, and the choice of imaging method is very important. Improper selection may lead to missed diagnosis or misdiagnosis.

CASE SUMMARY

An 81-year-old man was diagnosed as having a liver malignancy after he took magnetic resonance imaging and positron emission tomography/computed tomography (CT) examinations. The pain improved after the patient accepted gamma knife treatment. However, he was admitted to our hospital 2 mo later due to fever and abdominal pain. This time, he received a contrast-enhanced CT scan, which showed fish-boon-like foreign bodies in the liver with peripheral abscess formation, then he went to the superior hospital for surgery. It lasted for more than 2 mo from the onset of the disease to the surgical treatment. A 43-year-old woman with a 1 mo history of a perianal mass with no obvious pain or discomfort was diagnosed as having an anal fistula with the formation of a local small abscess cavity. Clinical perianal abscess surgery was performed, and fish bone foreign body was found in perianal soft tissue during the operation.

CONCLUSION

For patients with pain symptoms, the possibility of foreign body perforation should be considered. Magnetic resonance imaging is not comprehensive and that a plain computed tomography scan of the pain area is necessary.

Gastrointestinal Ultrasound in Emergency Setting

Acute bowel diseases are responsible for more than one third of subjects who were referred to the emergency department for acute abdominal pain and gastrointestinal evaluation. Gastrointestinal ultrasound (GIUS) is often employed as the first imaging method, with a good diagnostic accuracy in the setting of acute abdomen, and it can be an optimal diagnostic strategy in young females due to the radiation exposure related to X-ray and computed tomography methods. The physician can examine the gastrointestinal system in the area with the greatest tenderness by ultrasound, thus obtaining more information and data on the pathology than the standard physical examination. In this comprehensive review, we have reported the most relevant indications and advantages to using ultrasound in the investigation of abdominal acute pain.

Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study

Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment.  Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

The “Black Pattern”, a Simplified Ultrasound Approach to Non-Traumatic Abdominal Emergencies

Background: A key issue in abdominal US is the assessment of fluid, which is usually anechoic, thus appearing “black”. Our approach focuses on searching for fluid in non-traumatic patients, providing a new, simplified method for point-of-care US (POCUS). Objective: Fluid assessment is based on a three-step analysis that we can thus summarize. 1. Look for black where it should not be. This means searching for effusions or collections. 2. Check if black is too much. This means evaluating anatomical landmarks where fluid should normally be present but may be abnormally abundant. 3. Look for black that is not clearly black. This means evaluating fluid aspects, whether wholly anechoic or not (suggesting heterogeneous or corpusculated fluid). Discussion: Using this simple method focused on US fluid presence and appearance should help clinicians to make a timely diagnosis. Although our simplified, systematic algorithm of POCUS may identify abnormalities; this usually entails a second-level imaging. An accurate knowledge of the physio–pathological and anatomical ultrasound bases remains essential in applying this algorithm. Conclusion: The black pattern approach in non -traumatic emergencies may be applied to a broad spectrum of abnormalities. It may represent a valuable aid for emergency physicians, especially if inexperienced, involved in a variety of non-traumatic scenarios. It may also be a simple and effective teaching aid for US beginners.

The Use of Ceus Software with No Contrast Media Administration in the Diagnosis of Pneumoperitoneum

Background: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. Aim: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. Subjects and Methods: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists (with 5, 5, and 25 years of experience). The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. Results: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity (93% vs. 70%, respectively) and specificity (98% vs. 88%, respectively). Conclusion: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses.

Diagnosis of upper gastrointestinal perforation complicated with fistula formation and subphrenic abscess by contrast-enhanced ultrasound: A case report

BACKGROUND

Gastrointestinal perforation complicated by subphrenic abscess is a surgical emergency. Its diagnosis relies mainly on X-ray or computed tomography (CT), while the value of ultrasound, especially contrast-enhanced ultrasound (CEUS), has been underestimated.

CASE SUMMARY

A 37-year-old man presented with fever and edema of the lower extremities for 10 d. He had a history of laparoscopic repair of gastroduodenal perforation 6 mo prior. His first-time intravenous CEUS indicated a diagnosis of subphrenic abscess. He received antibiotic therapy and ultrasound-guided percutaneous drainage of the abscess. However, second-time intravenous CEUS revealed an unsatisfactory therapeutic effect. Intracavitary CEUS was proposed, and this examination detected communication between the abscess and the stomach. Upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess was diagnosed with the help of CEUS. Abdominal CT and esophagogastroduodenoscopy confirmed the diagnosis. The patient recovered after the perforation was repaired by surgery.

CONCLUSION

Intravenous and intracavitary CEUS provides helpful information for the diagnosis of upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess.

'Diagnosis of Boerhaave's Syndrome With Aid of Bedside Ultrasound

BACKGROUND

Boerhaave's syndrome is characterized by transmural rupture of the distal esophagus in the setting of increased intraluminal pressures combined with negative intrathoracic pressure. It is a rare condition with high mortality (20-50% mortality rate).

CASE REPORT

This is a case of a 47-year-old man who appeared acutely ill, presenting with shortness of breath, chest and abdominal pain, and diagnosed with Boerhaave's syndrome with the assistance of bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: Emergency physicians must have a heightened suspicion of this diagnosis in patients presenting with chest and abdominal pain and can use bedside ultrasound skills to aid with diagnosis.

Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review

Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis.

Bowel ultrasonography in acute abdomen: beyond acute appendicitis

Acute abdomen is a common reason for consultation in the emergency department. A broad spectrum of entities, including diverse diseases of the gastrointestinal tract, can cause acute abdomen. Although computed tomography is the technique most widely used to evaluate acute abdomen in the emergency department, abdominal ultrasound is often performed first and allows bowel disease to be suspected. This article describes the ultrasound features of diverse bowel diseases that can cause acute abdomen, such as acute diverticulitis, bowel obstruction, gastrointestinal perforation, bowel ischemia, intraabdominal fat necrosis, and miscellaneous processes such as endometriosis, foreign bodies, or vasculitis. Radiologists must be familiar with the different features of abnormal bowel that can be detected incidentally in patients without clinical suspicion of bowel disease. This article focuses on ultrasonographic signs of bowel disease; other articles in this series cover the ultrasonographic signs of acute appendicitis, inflammatory bowel disease, and infectious diseases.

Typhoid and Enteric Fevers in Intensive Care Unit

Enteric fever (typhoid and paratyphoid)is caused by Salmonella typhi and Salmonella paratyphi. It is spread by fecal-oral route, largely through contamination of water and foodstuff. Developing countries are the worst affected. It takes 7 – 21 days from ingestion of the organism to manifestation of symptoms which are generally Fever, relative bradycardia, and pain abdomen. Hepatosplenomegaly, intestinal bleeding, and perforation are the features at various stages of the disease. The bacteria invade the submucous layer and proliferate in the Payer's patches. Blood culture is the gold standard for diagnosis but it is only rarely positive. Fluroquinolones, cephalosporins, and azithromycin are antibiotics of choice. There is increasing evidence of the development of resistance to all antibiotics. Salmonella sepsis, though uncommon, can occur. Intestinal perforation, peritonitis, and secondary sepsis are complications that may require intensive care unit management.

How to cite this article: Ray B, Raha A. Typhoid and Enteric Fevers in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S144–S149.

Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper

An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.

Analysis of the use of upright abdominal radiography for evaluating intestinal perforations in handlebar traumas: Three case reports

RATIONALE

Intestinal perforations due to blunt abdominal handlebar trauma are difficult to diagnose. This report presents a retrospective analysis of 3 patients with intestinal perforations due to abdominal bicycle handlebar trauma who were diagnosed via upright abdominal radiography.

PATIENTS CONCERNS

All the patients lost their balance while riding a bicycle for leisure and had fallen on the handlebar tip. The patients were initially misdiagnosed at different-level health centers despite various radiologic investigations performed.

DIAGNOSIS

The patients' intestinal perforations were diagnosed via plain upright abdominal X-ray radiography (UAXR) in our institution.

INTERVENTIONS AND OUTCOMES

The children underwent exploratory laparotomy due to intestinal perforations. All the perforations were repaired either with primary closure or bowel resection and anastomosis with successful outcomes.

LESSONS

Pneumoperitoneum due to intestinal perforation can be diagnosed via UAXR with appropriate patient positioning and timing. This case series shows that to accurately diagnose intestinal perforations, upright plain X-ray should be routinely performed, carefully evaluated, and repeated in patients with enduring abdominal complaints.

Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds.

The value of ultrasound in diagnosis of pneumoperitoneum in emergent or critical conditions: A meta-analysis

Background:

Hollow organs perforation is a life-threatening condition. Early diagnosis and emergent intervention are important. Bedside ultrasound may be an alternative diagnostic tool for this condition.

Objective:

The aim of this study was to explore the diagnostic value of ultrasound of pneumoperitoneum in emergent or critical conditions through meta-analysis.

Methods:

PubMed, EMBASE, and Cochrane Library were systematically searched for potential studies. Then, two reviewers performed the processes of study selection, data extraction, and quality assessment independently. Finally, diagnostic indexes were analyzed with STATA 12.0 software (Serial No. 40120519635).

Results:

A total of five studies with moderate to high quality were eligible for meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio and their 95% confidence interval were 0.91 (95% confidence interval = 0.86–0.94), 0.96 (95% confidence interval = 0.75–0.99), 22.05 (95% confidence interval = 3.10–156.96), and 0.10 (95% confidence interval = 0.07–0.15), respectively. The area under the summary receiver operating characteristic curve was 0.92 (95% confidence interval = 0.90–0.94).

Conclusion:

Abdominal ultrasound is a useful alternative tool in diagnosing of pneumoperitoneum. However, due to limited evidence, it is not yet indicated for routine clinical use.

Sonographic and CT imaging features of intestinal perforation from a pill and packing: A case report

RATIONALE

Sharp foreign bodies such as toothpicks or chicken bones can lead to intestinal perforation. Small intestinal perforation secondary to foreign body ingestion is usually manifested as an acute abdomen without a history of trauma. Here we describe the diagnosis and treatment of a case of small bowel perforation caused by an ingested pill and its outer packing.

PATIENT CONCERNS

An 84 years old male patient complained of right lower abdominal pain for 4 days and the pain was becoming progressively worse.

DIAGNOSES

The patient, who has Alzheimer's disease, mistakenly took the pill (oxiracetam) without removing the outer packaging. This resulted in perforation of the small intestine.

INTERVENTIONS

During the ultrasound examination, the scanning physician discovered that the abnormal sonographic findings present could not be explained by the leading diagnosis of perforation of the small intestine at the time. This led the physician to suspect small bowel perforation secondary to a foreign body. The subsequent computerized tomography (CT) examination further confirmed the ultrasound findings.

OUTCOMES

Emergency laparotomy was performed and the foreign body was removed. After the surgical procedure, the patient resumed anti-inflammatory treatment (Cefoxitin sodium 2000mg tid) and rehydration therapy (Sodium Chloride Solution 100mL tid).

LESSONS

Because ingestion of foreign bodies of this type is relatively rare, when patients cannot provide an accurate history, diagnosis can be quite difficult. In this paper, the imaging features associated with intestinal perforation secondary to foreign body ingestion on ultrasound and CT are described. This series of events demonstrate how imaging findings can guide and alter a clinician's decision-making.

Imaging of Oncologic Emergencies

Oncologic emergencies can be either the result of the primary tumor, its metastasis, a paraneoplastic syndrome or reaction to the chemotherapy. Imaging plays a crucial role in ensuring a prompt diagnosis as well as assisting in the therapeutic management. In this article, we discuss the common thoracic and abdominal oncological emergencies that may be encountered in an emergency department.

Esophageal pneumatosis in the setting of small bowel ileus with acute resolution after nasogastric tube decompression

Esophageal pneumatosis is a rare condition with diverse potential etiologies including traumatic, mechanical, ischemic, obstructive respiratory, autoimmune, immunodeficient, and infectious causes. Here, we present a case of esophageal pneumatosis in the setting of upper gastrointestinal and small bowel ileus, diagnosed on computed tomography (CT), with acute resolution after nasogastric tube decompression. A patient presented to the emergency department with epigastric discomfort. CT of the abdomen/pelvis demonstrated intramural air in the mid-to-distal esophagus, consistent with esophageal pneumatosis, and diffuse dilatation of the visualized esophagus, stomach, and small bowel, consistent with an ileus. Patient was managed with nasogastric tube decompression and bowel rest. Subsequent esophagram did not demonstrate any evidence of perforation and a repeat CT of the abdomen/pelvis, performed 11 hours after initial diagnostic CT, demonstrated interval resolution of patient's esophageal pneumatosis, and improvement of patient's ileus.

A Five-Year Review of Perforated Peptic Ulcer Disease in Irrua, Nigeria

Background

Peptic ulcer perforation is a common cause of emergency admission and surgery. This is the first study that documents the presentation and outcome of management in Irrua, Nigeria.

Patients and Method

This is a prospective study of all patients operated on for perforated peptic ulcer between April 1, 2010, and March 31, 2015. A structured questionnaire containing patients' demographics, operation findings, and outcome was filled upon discharge or death.

Results

There were 104 patients. 81 males and 23 females (M : F = 3.5 : 1). The age range was between 17 years and 95 years. The mean age was 48.99 years ± SD 16.1 years. The ratio of gastric to duodenal perforation was 1.88 : 1. Perforation was the first sign of peptic ulcer disease in 62 (59.6%). Pneumoperitoneum was detectable with plain radiographs in 95 (91%) patients. 72 (69.2%) had Graham's Omentopexy. Death rate was 17.3%.

Conclusion

We note that gastric perforation is a far commoner disease in our environment. Perforation is often the first sign of peptic ulcer disease. We identify fasting amongst Christians as a risk factor for perforation.

A case report of blunt gastric perforation treated with endoscopic clip closure

RATIONALE

Gastroscopymay not only allow identification of gastric injury, but may also facilitate prompt repair.

PATIENT CONCERNS

A 39-year-old male patient was admitted 3 hours after abdominal injury caused by penetration of a screwdriver. Physical examination and computed tomography showed no evidence of gastric injury. However, 3000 mL fresh blood was vomited during the subsequent observation period.

DIAGNOSES

Gastroscopy identified a ruptured artery and gastric perforation.

INTERVENTIONS

Repaired immediately using titanium clips.

OUTCOMES

After operation, the patient recovered well without complications. No more bleeding was observed after the operation.

LESSON SUBSECTIONS ASPER STYLE

Interventional endoscopy has evolved as an effective alternative to primary surgery for treating gastrointestinal perforation.

Abdominal manifestations of fishbone perforation: a pictorial essay

PURPOSE

The present article provides an overview of the spectrum of abdominal presentations of fishbone (FB) ingestion and its complications.

METHODS

In image data from 9 patients, FB perforations were found in different levels of the gastrointestinal tract (GIT), including duodenal, jejunal, and sigmoid perforations; in 4 asymptomatic patients, FBs were observed in the mesentery, falciform ligament, and intestinal bowel.

RESULTS

The main imaging features of FB perforation were focal gastric or intestinal wall thickening, fat stranding, bowel obstruction, ascites, localized pneumoperitoneum, intra-abdominal abscess, liver abscess, and a linear hyperdense structure in the abdominal cavity in the GIT or within a parenchymal organ often surrounded by inflammatory changes. Free pneumoperitoneum was rare.

CONCLUSION

Although in most cases, a FB does not cause any serious complications, an inflammatory process and complications may occur when it perforates the stomach or bowel loops. Radiologists need to be aware of the possibility of FB perforation, especially in high-risk patients, because it is not always considered in the differential diagnosis by referring physicians and can mimic other inflammatory conditions and tumoral lesions.

Ultrasound findings in critical care patients: the "liver sign" and other abnormal abdominal air patterns

In critical care patients, point of care abdominal ultrasound examination, although it has been practiced for over 30 years, is not as widespread as its cardiac or pulmonary counterparts. We report two cases in which detection of air during abdominal ultrasound allowed the early detection of life-threatening pathologies. In the first case, a patient with severe Clostridium difficile was found to have portal venous gas but its significance was confounded by a recent surgery. Serial ultrasonographic exams triggered a surgical intervention. In the second case, we report what we call the "liver sign" a finding in patients with pneumoperitoneum. These findings, all obtained prior to conventional abdominal imaging, had immediate clinical impact and avoided unnecessary delays and radiation. Detection of abdominal air should be part of the routine-focused ultrasonographic exam and for critically ill patients an algorithm is proposed.

Management of gastrointestinal perforation from blunt and penetrating abdominal trauma in children: analysis of 96 patients

AIM

The objective of the present study was to evaluate the diagnostic methods, concomitant organ injuries, factors affecting mortality and morbidity, treatment methods, and outcomes of patients treated for traumatic gastrointestinal (GI) perforation.

MATERIALS AND METHODS

We conducted a retrospective review of the medical records of 96 patients who had been treated for GI perforation between January 2000 and October 2015. Data were collected and organised according to the following categories: general patient information, age, gender, hospitalisation period, trauma mechanisms, concomitant injuries, radiological assessment, diagnosis and treatment methods, treatment forms, and complications. The cases were divided into two groups, blunt and penetrating traumas, and the patients within each group were compared. Colorectal trauma cases were not included in this study. Patients suspected of a GI perforation were assessed by standing plain abdominal radiograph (SPAR) and ultrasound scan (US). Patients who had a normal SPAR, and showed free or viscous fluid in the abdomen on US underwent computed tomography (CT) scanning. Surgery was performed if patients displayed free air in the abdomen on a SPAR or CT scan, showed viscous fluid without any additional injury, provided normal radiological images but displayed signs of peritonitis, or were clinically unstable. The patients were scored according to the Injury Severity Score (ISS) system.

RESULTS

In total, 96 patients, with an average age of 10.3 ± 4 years (1-17 years) and diagnosed with a GI perforation, were reviewed retrospectively. The patients included 88 (91 %) males and 8 (9 %) females. The presence of free air on SPAR was detected in 42 (52 %) patients, whereas no free air was detected in 39 (48 %) patients. Non-specific significant findings were detected in 45 (76 %) out of 59 patients by USS, and in 78 % of patients by CT (viscous fluid, fluid, free air). The most affected organ was the ileum, which was detected in 37 (39 %) patients. Primary repair was performed on 71 (74 %) patients, while resection was performed on 22 (23 %); 3 (3 %) patients underwent an ostomy. Ten (10 %) patients experienced complications and five (5 %) patients died. The ISS scores for blunt and penetrating traumas were 14, 15 and no significant difference was detected between the scores (p > 0.05).

CONCLUSIONS

Although the complication rate for patients with penetrating trauma was higher than for those with blunt trauma, the rate of mortality increased in patients with blunt trauma. Free air may not be detected by SPAR even if a GI perforation exists. Since diagnostic challenges may increase the rate of mortality and morbidity in GI perforations, we believe that a combination of radiological imaging and rapid abdominal examination is important in cases where SPAR cannot detect free air.

Common pitfalls in point-of-care ultrasound: a practical guide for emergency and critical care physicians

BACKGROUND

Point-of-care ultrasonography (POCUS) is a widely used tool in emergency and critical care settings, useful in the decision-making process as well as in interventional guidance. While having an impressive diagnostic accuracy in the hands of highly skilled operators, inexperienced practitioners must be aware of some common misinterpretations that may lead to wrong decisions at the bedside.

OBJECTIVES

This article provides a revision list of common POCUS misdiagnoses usually found in practice and offers useful tips to recognize and avoid them.

DISCUSSION

The following aspects were selected and reviewed: pericardial effusion vs. pleural vs. ascites vs. epicardial fat; right ventricle dilation in acute pulmonary embolism and inferior vena cava for volume status assessment in cardiac ultrasound; lung point and lung pulse misinterpretations and mirror artifacts vs. lung consolidations in lung ultrasound; peritoneal fluid vs. the stomach and a critical appraisal of gallbladder signs of acute cholecystitis in abdominal ultrasound; the rouleaux phenomenon vs. deep vein thrombosis or acute right strain in vascular ultrasound.

CONCLUSIONS

Following some rules in technique and interpretation, and always integrating POCUS findings into the broader clinical context, most POCUS misdiagnosis can be avoided, and thus patients' safety can be enhanced. Being aware of a list of common pitfalls may help to avoid misdiagnoses.

Pneumothorax Causing Pneumoperitoneum: Role of Surgical Intervention

The most common cause of a pneumoperitoneum is a perforation of a hollow viscus and the treatment is an exploratory laparotomy; nevertheless, not all pneumoperitoneums are due to a perforation and not all of them need surgical intervention. We hereby present a case of pneumoperitoneum due to a diaphragmatic defect, which allowed air from a pneumothorax to escape through the diaphragmatic hernia into the abdominal cavity.

Sonography of Gastrointestinal Tract Diseases: Correlation With Computed Tomographic Findings and Endoscopy

Sonographic evaluation of the gastrointestinal (GI) tract may be difficult because of overlying intraluminal bowel gas and gas-related artifacts. However, in the absence of these factors and with the development of high-resolution scanners and the technical experience of radiologists, sonography can become a powerful tool for GI tract assessment. This pictorial essay focuses on sonographic findings of GI tract lesions compared with endoscopic, computed tomographic, and magnetic resonance imaging findings. Neoplastic and non-neoplastic diseases and postoperative complications are illustrated, and the distinctive sonographic characteristics of these entities are highlighted.

Predicting the amount of intraperitoneal fluid accumulation by computed tomography and its clinical use in patients with perforated peptic ulcer

The correlation between the amount of peritoneal fluid and clinical parameters in patients with perforated peptic ulcer (PPU) has not been investigated. The authors' objective was to derive a reliable formula for determining the amount of peritoneal fluid in patients with PPU before surgery, and to evaluate the correlation between the estimated amount of peritoneal fluid and clinical parameters. We investigated 62 consecutive patients who underwent emergency surgery for PPU, and in whom prediction of the amount of accumulated intraperitoneal fluid was possible by computed tomography (CT) using the methods described by Oriuchi et al. We examined the relationship between the predicted amount of accumulated intraperitoneal fluid and that measured during surgery, and the relationship between the amount of fluid predicted preoperatively or measured during surgery and several clinical parameters. There was a significant positive correlation between the amount of fluid predicted by CT scan and that measured during surgery. When patients with gastric ulcer and duodenal ulcer were analyzed collectively, the predicted amount of intraperitoneal fluid and the amount measured during surgery were each associated with the period from onset until CT scan, perforation size, the Mannheim peritoneal index, and the severity of postoperative complications according to the Clavien-Dindo classification. Our present results suggest that the method of Oriuchi et al is useful for predicting the amount of accumulated intraperitoneal fluid in patients with PPU, and that this would be potentially helpful for treatment decision-making and estimating the severity of postoperative complications.

Typhoid intestinal perforation: Point-of-care ultrasound as a diagnostic tool in a rural Ugandan Hospital

Introduction

Point-of-care ultrasound (POCUS) in resource-limited areas has demonstrated utility in the hands of physicians and may be useful for non-physician providers to learn as well.

Case Report

An 11 year old male presented with abdominal pain and diffuse abdominal tenderness to a remote Emergency Centre (EC). An Emergency Care Practitioner, a non-physician emergency care provider with limited ultrasound training, used bedside ultrasonography and alerted the on-call surgeon of complex intraperitoneal fluid representing perforated typhoid, which expedited the patient’s care.

Discussion

There is scant literature involving cases of non-physician use of POCUS, particularly in the emergency care setting. This case demonstrates the potential benefits of training these providers in POCUS.

Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study

BACKGROUND

Pneumoperitoneum is a rare cause of abdominal pain characterized by a high mortality. Ultrasonography (US) can detect free intraperitoneal air; however, its accuracy remains unclear. The aims of this pilot study were to define the diagnostic performance and the reliability of abdominal US for the diagnosis of pneumoperitoneum.

METHODS

This was a prospective observational study. Four senior and two junior physicians were shown, in an unpaired randomized order, abdominal US videos from 11 patients with and 11 patients without pneumoperitoneum. Abdominal US videos were obtained from consecutive patients presenting to ED complaining abdominal pain with the diagnosis of pneumoperitoneum established by CT. Abdominal US was performed according to a standardized protocol that included the following scans: epigastrium, right and left hypochondrium, umbilical area and right hypochondrium with the patient lying on the left flank. We evaluated accuracy, intra- and inter-observer agreement of abdominal US when reviewed by senior physicians. Furthermore, we compared the accuracy of a "2 scan-fast exam" (epigastrium and right hypochondrium) vs the full US examination and the accuracy of physicians expert in US vs nonexpert ones. Finally, accuracy of US was compared with abdominal radiography in patients with available images.

RESULTS

Considering senior revision, accuracy of abdominal US was 88.6 % (95 % CI 79.4-92.4 %) with a sensitivity of 95.5 % (95 % CI 86.3-99.2 %) and a specificity of 81.8 % (95 % CI 72.6-85.5 %). Inter- and intra-observer agreement (k) were 0.64 and 0.95, respectively. Accuracy of a "2 scan-fast exam" (87.5 %, 95 % CI 77.9-92.4 %) was similar to global exam. Sensitivity of abdominal radiography (72.2 %, 95 % CI 54.8-85.7 %) was lower than that of abdominal US, while specificity (92.5 %, 95 % CI 79.5-98.3 %) was higher. Accuracy (68.2 %, 95 % CI 51.4-80.9 %) of junior reviewers evaluating US was lower than senior reviewers.

CONCLUSIONS

Senior physicians can recognize US signs of pneumoperitoneum with a good accuracy and reliability; sensitivity of US could be superior to abdominal radiography and a 2 fast-scan exam seems as accurate as full abdominal examination. US could be a useful bedside screening test for pneumoperitoneum. Trial registry ClinicalTrials.gov; No.: NCT02004925; URL: http://www.clinicaltrials.gov.

Small Bowel Perforations: What the Radiologist Needs to Know

The incidence of small bowel perforation is low but can develop from a variety of causes including Crohn disease, ischemic or bacterial enteritis, diverticulitis, bowel obstruction, volvulus, intussusception, trauma, and ingested foreign bodies. In contrast to gastroduodenal perforation, the amount of extraluminal air in small bowel perforation is small or absent in most cases. This article will illustrate the main aspects of small bowel perforation, focusing on anatomical reasons of radiological findings and in the evaluation of the site of perforation using plain film, ultrasound, and multidetector computed tomography equipments. In particular, the authors highlight the anatomic key notes and the different direct and indirect imaging signs of small bowel perforation.

Imaging Assessment of Gastroduodenal Perforations

Gastroduodenal perforation is an emergency situation that usually requires early recognition and well-timed surgical treatment. It can arise from different natural, iatrogenic, or traumatic causes, and it can present with various symptoms especially in the early phase. This article reviews the role of the different imaging techniques in the diagnosis of gastroduodenal perforation, focusing on the direct and indirect signs that are encountered in conventional radiography and computed tomography; our personal experience is also provided.

[Protection of the unborn child in diagnostic and interventional radiological procedures]

The radiation exposure of an unborn child should be principally avoided, whenever it is medically reasonably possible; therefore, the identification of pregnant patients is the first and the most important step in radiation protection of the unborn child. However, in cases of emergency saving the life of the patient has a higher priority than the radiation protection of the unborn child. In this review article, we present a longitudinal section through the national and international literature and guidelines as a basis for radiological management of a (possibly) pregnant patient. We also list some radiological procedures recommended in the literature for a series of maternal indications considering the contraindications of each method during pregnancy and radiation protection of the unborn child.

Imaging of adrenal incidentaloma: our experience

PURPOSE

To investigate clinical, biochemical and radiological features in 35 patients with adrenal incidentaloma found on CT and/or MRI and to define the management of patients with adrenal masses.

MATHERIAL AND METHODS

From January 2011 and May 2013, 35 patients (19F, 16M) with an adrenal mass incidentally discovered on CT and/or MRI were enrolled in a retrospective study. Thirthy-two patients underwent MDCT and eight 1.5 MRI.

RESULTS

Patients consisted in 16 males and 19 females, aged between 25 and 89 yo. Adrenal lesions were most commonly found in the sixth decade; in relation to the side of the mass, 20 were found on left side, 15 on the right. Of all the mass analyzed, 3 were <1 cm diameter, 29 between 1 and 4 cm, 3 > 4 cm. The most common finding on CT was adenoma-like appearance (19 cases in relation to size, 14 in relation to attenuation values). Hormonal analysis showed 32 cases of nonfunctional masses and 3 cases of hormone activity. Adrenalectomy was performed in ten patients having adenoma (5 cases), malignant lesions (2 cases), pheocromocitoma, cyst and myelolipoma (1 case).

CONCLUSION

Diagnostic approach to adrenal incidentaloma is focused on the definition of malignancy and hormonal activity; the characterization is needs hormonal and radiological (CT and/or MRI) evaluation, even if a fine needle aspiration is needed in selected cases. Benign and/or non-hypersecreting hormone lesion with <4 cm diameter could be sent to follow-up; active adrenal tumors or >4 cm diameter lesions with malignancy suspicious or growth during follow-up could be treated with surgical adrenalectomy.

Abdominal Wall Abscess due to Acute Perforated Sigmoid Diverticulitis: A Case Report with MDCT and US Findings

Perforation of the inflamed diverticula is a common diverticulitis complication. It usually leads to the formation of a local abscess. In some rare cases, the inflammatory process may spread towards extra-abdominal sites like the anterior or posterior abdominal wall or the thigh and form an abscess in these sites. We present the case of a 73-year-old man with a history of pain at the lower left quadrant of the abdomen for 20 days and a visible mass in this site. Ultrasonography and computed tomography revealed this mass to be an abscess of the abdominal wall which had been formed by the spread of ruptured sigmoid diverticulitis by continuity of tissue through the lower left abdominal wall. Local drainage of the abscess was performed and the patient was discharged after alleviation of symptoms and an uneventful course. We also discuss causes of abdominal wall abscesses along with the possible pathways by which an intra-abdominal abscess could spread outside the abdominal cavity.

Early diagnosis of pneumoperitoneum in bowel perforation by capnography: a report of 2 cases

Capnography is commonly used for monitoring purposes. Here, we describe a new application of capnography as a bedside diagnostic modality. In doubtful situations of pneumoperitoneum, intravenous cannula is inserted in abdominal cavity, and capnography wave forms are detected with the help of gas sampling port. Capnography can detect pneumoperitoneum of bowel origin quickly and efficiently when radiology and clinical diagnosis are inconclusive. It can also detect gas in supine position. This technique is useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum.