Chronic intermittent abdominal pain in young woman with intestinal malrotation, Fitz-Hugh-Curtis Syndrome and appendiceal neuroendocrine tumor: a rare case report and literature review

An unusual cluster of Waugh syndrome as a cause of intestinal obstruction in children - A case series

INTRODUCTION AND IMPORTANCE

The association of intussusception with intestinal malrotation is a rare phenomenon named Waugh syndrome by Brereton et. It is a rare disease entity with less than 100 cases described so far. A cluster presentation is something unusual for rare diseases.

CASE PRESENTATION

All four patients have presented with features suggestive of bowel obstruction as all of them have had colicky abdominal pain. Three patients have vomiting as an additional complaint, so as the diarrhea. Fever has also been reported in one patient. Patients have presented in 6 months period, non-consecutively. Abdominal pain, diarrhea and vomiting are alarming in the pediatric population. When each case presented, an immediate resuscitation was performed including IV lines, nasogastric suctioning, electrolytes correction, and blood and FFP transfusion as necessary. Abdominal ultrasonography was performed revealing target sign. After optimization for surgery, manual reduction of the intussusception was done followed by a Ladd's procedure for the malrotation was performed for all 4 patients with excellent outcomes.

CLINICAL DISCUSSION

With the surgery, after case optimization, remains the standard of care; the presence of cluster presentation for Waugh syndrome could suggest that some environmental factors might be implicated and further observations can be carried out to look more into such phenomenon.

CONCLUSION

Waugh syndrome, a combined presentation of intestinal malrotation and intussusception, is a rare syndrome that can present in children. Optimization for surgery followed by a 2-step surgical approach is the usual treatment with excellent outcomes described.

Bowel obstruction due to Chlamydia trachomatis: a case report and review of literature

Background

Chlamydial infection is a difficult-to-diagnose type of sexually transmitted disease that occurs mainly in young people. We report a case of bowel obstruction caused by intrapelvic adhesions formed by chlamydial infection.

Case presentation

This patient was a 23-year-old woman who had been suffering from acute abdominal pain. She had been previously treated several times for intrapelvic abscesses and had a history of chlamydial infection. Endometriosis was thought to be the cause of her pelvic abscess based on endoscopic findings. Computed tomography demonstrated a small bowel obstruction caused by a pelvic abscess. However, the diagnosis could not be confirmed. She underwent laparoscopic surgery and was diagnosed with bowel obstruction due to adhesion of chlamydial infection based on the intraoperative findings and Chlamydia trachomatis antibody test. She was discharged 5 days after surgery.

Conclusions

It is necessary to consider the possibility of chlamydial infection as a cause for lower abdominal pain and unexplained bowel obstruction in female patients.

A rare case of Fitz-Hugh-Curtis syndrome caused by Chlamydia trachomatis in an HIV-positive male patient

Fitz-Hugh–Curtis syndrome, a rare complication of pelvic inflammatory disease, is an inflammation of the liver capsule (thus called perihepatitis) and the surrounding peritoneum. It occurs extremely rarely in men and is typically characterized by a sudden onset of severe pain in the right upper abdominal quadrant. Ultrasound examination of the liver does not reveal any morphologic changes, and liver function tests are usually normal. Computerized tomography shows the thickening of the perihepatic fat, but definitive diagnosis is only possible by direct visualization by laparoscopy or laparotomy. We present a 33-year-old HIV-positive man with Chlamydia trachomatis proctitis who developed severe right upper abdominal quadrant pain. Abdominal ultrasound did not show any liver pathology, while computerized tomography revealed hepatic capsular thickening. After 21 days of doxycycline therapy, the patient’s symptoms subsided. Based on the clinical presentation and liver computerized tomography examination, the diagnosis of proctitis and the resulting Fitz-Hugh–Curtis syndrome was made. Although it is rarely seen in male patients, it should be a part of differential diagnosis in patients who present with right upper abdominal quadrant pain, especially in men who have sex with other men.

A 41-Year-Old Patient with a Rare Cause of Severe Abdominal Sepsis Misdiagnosed as PID

Infectious pelvic inflammatory disease is a common condition and a frequent cause of abdominal pain in a young female patient. In a patient who has not completed family planning, the diagnosis is often made with a low threshold and treatment started on a low suspicion of diagnosis to avoid a negative impact on fertility. Here, we present a case of a 41-year-old woman who was misdiagnosed with infectious pelvic inflammatory disease and treated ineffectively with antibiotics when the underlying condition of her persistent abdominal pain was a midgut neuroendocrine tumor that had caused bowel perforation and formation of an abscess in the pouch of Douglas.

A Rare Case of Intestinal Malrotation and Volvulus of Jejunum with Coexisting Carcinoid Tumour of Appendix

Malrotation of the midgut is generally regarded as a paediatric pathology. It is rare in adults. Patients may present with symptoms of acute bowel obstruction or chronic abdominal pain. Barium study, Contrast Enhanced Computed Tomography (CECT), Magnetic Resonance Imaging (MRI), diagnostic laparoscopy and sometimes explorative laparotomy are used for diagnosis. Ladd's procedure through the open approach has been the treatment of choice for complete malrotation of midgut, however there are reports on successful outcome for both complete and incomplete malrotation after laparoscopic approach as well. We report a case of a 25-year-old female who presented with a history of severe pain in abdomen for one week. CECT abdomen showed incomplete malrotation and volvulus in midgut. Laparoscopic detorsion of bowel loops, adhesiolysis, caecopexy and appendectomy was done. Patient's symptoms subsided immediately after surgery. Histological analysis of the appendix specimen showed small appendiceal carcinoid, which was purely incidental. At three months follow up, patient was symptom free.

Prevention and treatment of peritoneal adhesions in patients affected by vascular diseases following surgery: a review of the literature

Intra-abdominal adhesions are the most frequently occurring postoperative complication following abdomino-pelvic surgery. Abdominal and pelvic surgery can lead to peritoneal adhesion formation causing infertility, chronic pelvic pain, and intestinal obstruction. Laparoscopy today is considered the gold standard of care in the treatment of several abdominal pathologies as well as in a wide range of vascular diseases. Laparoscopy has several advantages in comparison to open surgery. These include rapid recovery times, shorter hospitalisation, reduced postoperative pain, as well as cosmetic benefits. The technological improvements in this particular surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its wider utilization in operations with fully intracorporeal anastomoses. Postoperative adhesions are caused by aberrant peritoneal healing and are the leading cause of postoperative bowel obstruction. The use of anti-adherence barriers is currently being advocated for their prevention. The outcome of the investigation showed adhesion formation inhibition without direct detrimental effects on anastomotic healing. Poor anasto-motic healing can provoke adhesions even in the presence of anti-adhesion barriers. This review gives a short overview on the current evidence on the pathophysiology and prevention of peritoneal adhesions.