Abdominal Examination Research Articles

Biofeedback efficacy for outlet dysfunction constipation: Clinical outcomes and predictors of response by a limited approach.

Functional defecation disorders (FDD) are a common etiology of refractory chronic constipation (CC). FDD diagnosis (dyssynergic defecation [DD] and inadequate defecatory propulsion [IDP]), requires diagnostic tests including anorectal manometry (ARM) and balloon expulsion test (BET). Biofeedback (BF) is the treatment of choice for DD. The aims of our study were to evaluate: the outcome of BF in a group of constipated patients with defecatory disorders of any etiology; the efficacy of two simple diagnostic tools in predicting BF outcome in the short-term. One hundred and thirty-one refractory CC patients failing the BET underwent BF therapy. Before BF, all patients underwent the following: ARM. Straining questionnaire. The answers were: "belly muscles"; "anal muscles"; "both"; "Don't know/No answer." Digital rectal examination augmented by abdominal palpation on straining (augmented-DRE). The BF therapist was blinded to ARM, straining questionnaire, and augmented-DRE results. Eighty-one patients responded to BF. Gender, age, and IBS-C showed no significant impact on BF response. Both DD and IDP responded equally to BF, while the rate of response in patients with isolated structural pelvic floor abnormalities was lower (p < 0.001). The answer "anal muscles" to straining questionnaire showed a strong association with BF response (p < 0.001). A lack in abdominal contraction and in anal relaxation on augmented-DRE were strongly associated with BF response (p < 0.01). Absence of manual maneuvers to facilitate defecation was associated with BF response (p < 0.001). BF is the therapy of choice for refractory constipation due to FDD of any etiology, inducing both clinical and anorectal physiology improvement in the short term. Comorbid IBS-C did not affect outcome while symptomatic isolated pelvic floor abnormalities appeared refractory to behavior treatment. The straining questionnaire and augmented-DRE outcomes showed a strong correlation with BF response and can be implemented in clinical practice to improve the management of constipated patients by prompting early referral to BF.

Uterine Rupture Due to Oxytocin Overdose Leading to Dystocia in a Labrador Bitch

A three-year-old Labrador bitch brought to the TVCC-FVAS-BHU-Mirzapur, with the history of whelped one dead puppy 12 hrs before further no progress of delivery. The bitch administered with a total dose of 30 IU of oxytocin intramuscularly but there was no progress. Abdominal palpation revealed presence of fetal like mass and per-vaginal examination revealed presence of fetal parts in the birth canal. The bitch was treated with oxytocin @ 0.2 IU/kg body weight slow IV with 25% dextrose 0.2ml/kg body weight slow IV, a dead male fetus was removed through mutational operation after 15 minutes, after that no puppies were palpable. Radiographic examination revealed presence of four fetuses in the abdominal cavity. It was then decided to go for cesarean section. The surgical operation was done as per the standard routine procedures. The bitch was treated with antibiotic and analgesic for 3 days. The bitch had uneventful recovery with proper postoperative care. In the present study we concluded that the dystocia was due to uterine rupture and this can be corrected through exploratory laparotomy.

Krukenberg tumour in a 46-year-old black African woman with a background of ovarian fibroma- A case report

BackgroundTumours that metastasize to the ovary can occur in conjunction with other ovarian lesions, including benign sex cord stroma tumours like fibroma or fibrothecoma. This case report presents a unique instance of metastatic signet ring carcinoma involving the ovary in a background of fibroma in a Black African woman.Patient presentationA 46-year-old gravida 3, para 0 (2 alive), patient was referred from the general outpatient clinic to the gynecology clinic due to progressive abdominal swelling over the past eight months. Abdominal examination revealed marked distension with massive ascites. Physical examination of the chest demonstrated dullness to percussion over both lung bases, with increased dullness noted on the right. Auscultation revealed decreased air entry in the right middle and lower lung zones, with normal to increased air entry in the remaining lung fields. Abdominopelvic ultrasound revealed a large irregularly marginated homogeneous solid mass in the right adnexa measuring 16.4 × 11.7 × 12.7 cm. An abdominal CT scan revealed bilateral pleural effusion, which was more pronounced on the right, ascites, and evidence of pulmonary and hepatic metastasis. Serum chemistry revealed abnormal levels of several analytes, including elevated CA 125 at 1,108.8 (normal range 0–35) U/L and CA 19–9 at 63.8 (normal range 0–35) U/L. She subsequently underwent staging laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy, without any postoperative complications. The histologic sections of the right and left ovaries revealed a moderately cellular lesion composed of intersecting bundles of spindle cells in a fascicular and storiform pattern. Additionally, pockets of small round to oval-shaped cells with intracytoplasmic clear vacuoles pushing the nucleus to the periphery (signet ring cells) were identified in a few foci. These cells were initially thought to be ovarian stroma or theca cells. Microscopic examination revealed signet ring cells with cytoplasmic positivity for periodic acid-Schiff (PAS) staining. The histopathological diagnosis was metastatic signet ring cell carcinoma involving the ovary, with an underlying ovarian fibroma.ConclusionsOvarian metastatic signet ring carcinoma in a background of fibroma can pose a significant diagnostic challenge, as signet ring cells can mimic the ovarian stroma or theca cells, especially if they are only observed in a few foci of the sections.

Validation of abdominal ultrasound examination for assessment of abdominal wall thickness and size of left lobe of liver in morbidly obese patients in comparison with CT and operative findings

BackgroundIncreased abdominal wall thickness and size of left lobe of liver affect the ergonomics of bariatric surgery increasing its difficulty and leading to need of special preparations such as extra-long instruments. Computed tomography (CT) abdomen is the gold standard modality in assessment of abdominal wall thickness and size of left lobe of liver, but it has many drawbacks such as radiation and contrast. In this study, we validate ultrasound as an alternative to CT by comparing its results with CT abdomen and operative findings.ResultsAbdominal ultrasound examination gives accurate results in assessment of anterior abdominal wall thickness and size of left lobe of liver in morbidly obese patients compared to CT and intra-operative with slight difference between values which is clinically accepted. Accuracy of ultrasound examination was 78.6%, 74.1%, and 100% for midline measurements, midclavicular line measurements and size of lt lobe of liver measurements, respectively. Ultrasound examination has sensitivity of 75%, 66.7% and 63.2% for midline measurements, midclavicular line measurements and size of lt lobe of liver measurements, respectively. Ultrasound examination specificity was 50%, 77.1% and 75.3% for midline measurements, midclavicular line measurements and size of lt lobe of liver measurements, respectively.ConclusionAbdominal ultrasound examination is a valid method in preoperative assessment of anterior abdominal wall thickness and size of left lobe of liver in morbidly obese patients. It is reliable, easy, and cheap and avoids drawbacks of CT.

A Case of Abdominal Discomfort for Long Duration

In our regular medical practice, we encounter a lot of patients with abdominal discomfort. Commonly every physician suspects this kind of symptoms as gaseous distension of gastro-intestinal tract or acidity. The most valuable thing is the proper physical examination to rule out any underlying pathology. Most common causes of epigastric pain are associated with gastritis, or hepatobiliary system and pancreas related disorders. Here we will describe a 47-year-old male patient who presented with abdominal discomfort for last 6 months. For last 2 months he developed an epigastric lump which was increasing in size and was associated with weight loss. After proper clinical evaluation and necessary relevant investigations, he was diagnosed having Non-Hodgkin’s Lymphoma (NHL). Non-Hodgkins Lymphoma represents monoclonal proliferation of lymphoid cells. The incidence of these tumors increases with age. Clinically the proliferation rate indicates whether it is a high- or low-grade tumor. The patient underwent some investigations like CT guided FNAC from the enlarged abdominal lymph node which confirmed high grade Non-Hodgkins Lymphoma and started with chemotherapy and responded well. As abdominal discomfort is one of the common complaints, we face during our regular medical practice so routine physical examination including abdominal examination is very crucial and informative for clinical diagnosis and Lymphoma is an important differential diagnosis in case of any abdominal lump. Bangladesh Crit Care J September 2024; 12 (2): 175-178

Gastrointestinal ultrasound in the critically ill: A narrative review and a proposal for a protocol.

Critically ill patients are at risk of presenting with gastrointestinal dysfunction at intensive care unit admission or during their stay. However, identifying gastrointestinal dysfunction is difficult because clinical evaluation is frequently nonspecific and validated biomarkers are lacking. In this context, ultrasound of the digestive tract may help to identify gastrointestinaldysfunction. In this narrative review, we summarize available evidence and propose a protocol for assessment of the gastrointestinal tract with ultrasound. First, we report available evidence from use of four available protocols: the gastrointestinal and urinary tract sonography protocol, the acute gastrointestinal injury ultrasound score, the transabdominal gastrointestinal ultrasoundprotocol, and the Lai protocol, each addressing somewhat different aspects. Outputs from these protocols have been associated with clinical scores of gastrointestinal failure, feeding intolerance, and 28-day mortality. Second, we describe the potential pitfalls of using ultrasound in the critically ill, such as obesity, abdominal dressings, or the presence of intraluminal gas. Third, we suggest perspectives of ultrasound in monitoring the response to enteral nutrition and for early identification of nonocclusive mesenteric ischemia. Fourth, we propose a structured protocol for gastrointestinal ultrasound describing all the different structures that should be evaluated and provide detailed guidance for a clockwise abdominal examination. In conclusion, the use of a specific and structured protocol might help to identify patients presenting with gastrointestinal dysfunction, guide nutrition, and allow the proposal of pathophysiological hypotheses (complications of enteral nutrition, intra-abdominal infection, bowel ischemia, etc.). The benefit of using a structured protocol requires further investigation.

Diagnosing acute appendicitis: a case study.

Advanced clinical practitioners (ACPs) are experienced health professionals educated to master's level. They are accountable for the assessment, diagnosis and treatment of individuals, and are responsible for making complex decisions. The case study presented in this article critically analyses the consultation involving a male patient in his sixties with a 2-day history of abdominal pain, who was referred by his GP to a surgical assessment unit. Analysis was carried out using the Calgary-Cambridge Model. The article discusses history-taking, abdominal examination and differential diagnoses, and presents the process of how the trainee ACP arrived at the diagnosis of appendicitis.

Acute abdomen: an atypical presentation of acquired hemophilia

Acquired hemophilia is a rare but potentially life-threatening disorder characterized by the development of acquired hemophilia A, leading to bleeding complications. Spontaneous, mild-to-life-threatening bleeding in typically elderly individuals without a personal or family history of bleeding is the hallmark of acquired hemophilia A (AHA), a rare autoimmune bleeding illness caused by the formation of auto-antibodies against endogenous factor VIII (FVIII). This hallmark represents our present case, with no obvious history related to the bleeding issue. Prompt detection and treatment of bleeding are essential for the best outcomes. We present a case of a 66-year-old male who had acute-onset severe abdominal pain and with constipation for five days, associated with nausea and loss of appetite. On physical examination, the patient appeared pale, and abdominal examination revealed diffuse tenderness with guarding. Initial evaluation revealed tachycardia and hypotension. Initial abdomen X-rays revealed features suggestive of small bowel obstruction. The patient was stabilized with intravenous fluids, referred to a surgical team, and admitted to the acute bed in the general ward for further management. Keywords: Acquired Hemophilia; Auto-Antibodies; Factor VIII; Intraabdominal Bleeding Citation: Hehsan MR. Acute abdomen: an atypical presentation of acquired hemophilia. Anaesth. pain intensive care 2024;28(5):974−976; DOI: 10.35975/apic.v28i5.2556 Received: March 19, 2024; Reviewed &amp; Accepted: September 08, 2024

6698 Rapidly Progressive Type 1 Diabetes Mellitus Complicated By Hyperglycemic Crisis And Bowel Ischemia

Abstract Disclosure: D. Bondarenko: None. D. Deyar: None. R. Nadeem: None. M. Herrera: None. L.E. Arzeno: None. Introduction: Type 1 diabetes mellitus (T1DM) stems from insulin deficiency due to islet-related autoantibodies. Misclassification of T1DM as type 2 diabetes mellitus (T2DM) occurs in 40% of those developing T1DM after age 30. Fulminant T1DM (FT1DM), described in East Asia, exhibits rapid progression and is diagnosed by ketosis, blood glucose ≥288 mg/dL, HgbA1c &amp;lt;8.7%, and fasting C-peptide &amp;lt;0.3 ng/mL. We present a case of rapidly progressing T1DM in a white male presenting as a hyperglycemic crisis (HC) complicated by multiorgan failure and bowel ischemia. CASE:A 52-year-old male, T2DM diagnosed by HgbA1c of 8% (normal &amp;lt;5.7%) 1 month prior, presented to the emergency room obtunded with two days of nausea and vomiting. Vital signs were normal other than tachycardia and tachypnea. Blood work showed pH 7.0 (normal 7.31-7.41), creatinine 4.58 mg/dL (0.7-1.3 mg/dL), glucose &amp;gt;1500 mg/dL (normal 65-139 mg/dL), beta-hydroxybutyrate 114.7 mg/dL (normal 0.2-2.8 mg/dL), lactate 5.7 mmol/L (normal 0.5-2 mmol/L), serum osmolarity 438 mOsmol/kg (normal 275-295 mOsmol/kg), WBC 26.2 B/L (4-11 B/L) and 4% bands (normal 0%), Hgb A1c 17.1% , C-peptide 0.11 ng/mL (0.8 - 3.85 ng/mL), GAD65 1:600 - 1:1200 (normal &amp;lt; 1:600). He was intubated Day 1-5. HC was treated with intravenous (IV) fluids and IV insulin infusion. He transitioned to subcutaneous insulin by Day 2. 10 days hemodialysis achieved renal recovery. He was diagnosed with latent autoimmune diabetes of adult (LADA). No triggers were identified for his HC. From Day 1, his abdominal exam was notable for guarding. Initial abdominal computed tomography (CT) was normal. Abdominal pain and distension persisted despite normalized blood work. Repeat CT showed ileus vs obstruction. Surgery on Day 12 showed multifocal bowel ischemia requiring surgical resection. Conclusion: FT1DM is a subtype of T1DM seen in Asia characterized by rapid β-cell destruction with hyperglycemia and ketoacidosis. LADA subset of T1DM manifests in adults and may take up to three years to progress to insulin dependence. Triggers for both include autoimmunity, infections, and pregnancy. HC has been associated with increased risk of occlusive and nonocclusive bowel ischemia. While this case does not meet all criteria of FT1DM, the rapid progression of the HgbA1c and disease severity is an unusual presentation of LADA. Raising awareness of the complications of this severe metabolic disorder can improve timely interventions and medical outcomes. Presentation: 6/1/2024

6472 Methimazole Induced Agranulocytosis: Uncommon Complication of a Common Medication

Abstract Disclosure: R. Kaur: None. L. Kaur: None. A. Sridhar: None. T. Chaudhary: None. N. Patel: None. Methimazole (MMI) induced agranulocytosis is a rare and life threatening adverse effect that usually occurs within 3 months of drug initiation and can rapidly lead to overwhelming infection. It is reported in 0.1 to 0.5 % of patients on treatment with methimazole. MMI is a standard drug used in graves disease and toxic multinodular goiter. We report a case of MMI induced agranulocytosis in an elderly female with recently diagnosed toxic multinodular goiter. A 66 year old female with past medical history of recently diagnosed toxic multinodular goiter for which she was started on methimazole 80mg/day two months ago presented to the emergency department with chief complaint of severe sore throat associated with rapidly increasing pharyngeal pain and fever over the past 24 hours. She was lethargic, febrile with temperature of 102 F, tachycardic with heart rate of 115/minute and hypotensive with blood pressure of 108/64 mm Hg. Physical examination revealed diffuse pharyngeal and tonsillar erythema with bilateral purulent exudate with tender anterior cervical lymphadenopathy. Thyroid was enlarged, firm, irregular and nontender. Pulmonary, cardiac and abdominal exam was unremarkable. Lab work showed severe leukopenia with WBC count of 1,600/mm3, neutropenia with absolute neutrophil count of 0.0 x 1000/ul (normal range 1.8-7.3 x 1000/ul) and erythrocyte sedimentation rate and C reactive protein were both elevated. Blood cultures and fungal cultures showed no growth. Urinalysis and urine culture were both unremarkable. She had an extensive haematological, rheumatological and infectious disease workup for neutropenia, which was largely unrevealing. Rapid streptococcal testing was negative but throat cultures grew beta haemolytic streptococci. Treatment included suspending methimazole, administering antimicrobial therapy with piperacillin - tazobactam, acyclovir and fluconazole. She was also started on a granulocyte colony stimulating factor. Patient presented satisfactory evolution with progressive increase in leukocyte count and remission of symptoms by day 5 of treatment, rendering further bone marrow testing unnecessary. Antibiotics were changed to oral amoxicillin-clavulanic acid after throat culture results were available and the patient was discharged in stable condition. One month after discharge she underwent total thyroidectomy for definitive cure and is currently followed up as an outpatient by endocrinology. The objective of this case report is to present an uncommon case of agranulocytosis secondary to use of methimazole and to increase awareness among the physicians about the need to consider this diagnosis in patients on this medication. It is also advised that these patients be educated about the drugs side effects, a practice that may avert suffering and unnecessary costs. Presentation: 6/3/2024

Suspected encrusting cystitis in a domestic ferret (Mustela putorius furo)

BackgroundEncrusting cystitis diagnosis and medical management in domestic ferrets (Mustela putorius furo) has never been documented. Case descriptionA client-owned, 6.5-year-old, neutered, male domestic ferret was presented for lethargy, abdominal pain, straining to urinate for 12 days, and red, purulent urine. On physical examination, the ferret was quiet, alert, and responsive, had a distended and inexpressible bladder, large and firm kidneys, and was displaying signs of severe pain including vocalization on abdominal palpation and when attempting to urinate. Sonographic evaluation showed an irregular, layered, hyperechoic mass lesion present in the lumen of the urinary bladder with extensions of the layered luminal material into the urethra, and severely dilated renal pelves and ureters. These severe, urinary bladder changes were consistent with pseudomembranous, encrusting cystitis. Following a discussion with the owner about options for humane euthanasia versus exploratory surgery, euthanasia was elected. The remains were taken home with the owner and a necropsy was not performed. Conclusion and case relevanceTo the author’s knowledge, this paper reports the first known case of suspected encrusting cystitis in a domestic ferret including radiologic and ultrasonographic findings.

Delayed Diagnosis of Volvulus without Complications in Pediatric Patient : A Case Report

Introduction: Volvulus in children is rare occurrence, it’s only about 3-5% cases in worldwide. Without abdominal radiological examination, it is difficult to make diagnosis of volvulus based on history and physical examination alone. The management procedures are also controversial, as some recommend a non-operative approach, while others recommend an operative approach in the form of Ladd's Procedure or laparoscopy. Sigmoidoscopy or a barium enema can be attempted as an initial treatment for sigmoid volvulus. Objective: The purpose of this case report is to discuss why there was a delay in diagnosis of volvulus in this case and how to deal it. It also discusses the approach to diagnosis and management of volvulus in pediatric patients, both at the primary health center and the hospital, and why in this case. Case presentation: In this case, volvulus occurred in a pediatric patient who had sought treatment at a primary health center with a complaint of abdominal pain for nine days without improvement. The complaint was accompanied with constipation and fever. Due to limited facilities in primary health center, the patient was referred to the hospital. Result: At the hospital, after taking the history, performing physical examination, and conducting radiological examination and laboratory tests, the patient was diagnosed with ileus obstruction due to volvulus. Conclusion: Although volvulus is a rare case, volvulus should still be included as a differential diagnosis of abdominal pain in pediatric patients to avoid delayed diagnosis. Delay in diagnosis and management of volvulus can lead to serious complications and even life-threatening conditions

Clinical and diagnostic evidence of benign endometrial pathology in postmenopausal patients

The objective: to study clinical and diagnostic features of the benign endometrial conditions in the postmenopausal women.Materials and method. 64 postmenopausal patients with various severity of postmenopausal vaginal bleeding were examined. All patients underwent clinical, radiological, laboratory and histological examinations, reproductive history data and body mass index indicators were evaluated. Of them 33 persons were diagnosed with complex endometrial hyperplasia without atypia, 16 women – endometrial polyp and 15 women – hyperplasia with atypia. Routine gynecological examination including abdominal and pelvic examination following transvaginal ultrasound examination for the determination of the uterine and ovarian volume as well, as the endometrial thickness were conducted. Patients included in the study underwent computer tomography and magnetic resonance imaging as indicated. All patients with endometrial pathology underwent endometrial biopsy by standard dilatation and curettage or Pipelle-biopsy with histological examination of the obtained material. The concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEA-S), estradiol, estrone, progesterone, prolactin, and testosterone were determined in blood serum.Results. It was confirmed that in 87,5% of cases endometrial hyperplasia manifested with vaginal bleeding. Endometrial thickness in examined persons ranged from 14.1±1.6 mm in patients with atypical endometrial hyperplasia to 21.3±4.8 mm in patients with complex endometrial hyperplasia without atypia. The study of blood levels of hormones found that postmenopausal patients with endometrial hyperplasia have lower FSH concentration, LH/FSH ratio, estradiol, testosterone levels, with significantly high values of prolactin, DHEA-S and estrone. During the postmenopausal period, hyperplasia was developed in 10% of cases by the presence of bleeding, and 86.2% of cases by the presence of blood spotting. Conclusions. The study suggests that high body mass index, numerous artificial abortions, high blood levels of estrone, DHEA-S and prolactin as well as increased thickness of endometrium influence the frequency of endometrial hyperplasia in postmenopausal women.

Obstructive sleep apnoea is independently associated with non-alcoholic fatty pancreatic disease

Purpose This study investigated the prevalence of non-alcoholic fatty pancreatic disease (NAFPD) in patients with obstructive sleep apnoea (OSA) and analysed the correlation between them. Materials and methods Patients who underwent polysomnography and modified abdominal ultrasound examinations were continuously enrolled and divided into OSA and control groups. The OSA group was further divided into NAFPD and non-NAFPD groups. Differences in various indicators were compared. Binary logistic regression analyses were conducted to identify factors influencing NAFPD. Results A total of 210 participants were included in the study, including 178 in the OSA group and 32 in the control group. The prevalence of NAFPD, weight, body mass index (BMI), and other indicators were significantly higher in the OSA group than that in the control group (p < 0.05). The above indices, prevalence of hypertension and metabolic associated steatotic liver disease (MASLD), and severity of sleep apnoea were higher in the NAFPD group than that in the non-NAFPD group (p < 0.05). Binary logistic regression analysis showed a 4.4% increased risk of NAFPD for each unit increase in apnea-hypopnea index (AHI) after adjusting for BMI and hypertension. Conclusion The prevalence of NAFPD was higher in the OSA group than that in the control group, and chronic intermittent hypoxia was strongly associated with pancreatic fat infiltration; AHI, BMI, and hypertension were independent risk factors for NAFPD. The NAFPD group had a higher prevalence of obesity and some other diseases.

An unusual case of Anasarca-Rapunzel syndrome

Rapunzel syndrome is a rare form of gastric trichobezoar extending into the intestine, often associated with malnutrition and protein-losing enteropathy. A 12-year-old female presented with epigastric abdominal pain, facial puffiness, bilateral lower limb swelling, and anorexia. She was a known case of sickle-thalassemia double heterozygous state but had never received a blood transfusion. Family history revealed parental separation and harsh paternal behavior. The patient was undernourished but otherwise developed normally. On examination, she was lethargic, exhibited generalized anasarca, severe anemia, signs of congestive cardiac failure, and patchy hair loss on the scalp. Abdominal examination revealed moderate ascites, hepatosplenomegaly, and a firm, mobile, non-tender epigastric mass (10×8 cm), suggestive of gastric bezoar. Laboratory findings showed microcytic hypochromic anemia with macro-ovalocytes in the context of sickle-thalassemia heterozygosity. The child required multiple blood and serum albumin transfusions for severe anemia and hypoproteinemia with anasarca. Hepatic and renal causes of anasarca were excluded. Cardiovascular and respiratory systems were normal. Contrast enhanced computed tomography (CECT) abdomen confirmed the gastric bezoar. After stabilization, exploratory laparotomy and trichobezoar evacuation were performed. Psychiatric counseling and diversion therapy were provided. The child was discharged in stable condition, with follow-up showing significant improvement in nutritional status, mood, and general well-being. This case highlights the unusual presentation of Rapunzel syndrome with generalized anasarca in a pediatric patient with underlying sickle-thalassemia, emphasizing the importance of multidisciplinary management and follow-up.

Colonoscopy diagnosis of recurrent abdominal pain in a 4-year-old boy with intestinal duplication cyst involving colon, appendix, and ileum: a case report

BackgroundIntestinal duplication cyst is an infrequent congenital malformation that can involve all the segments of the gastrointestinal tract. The cases of intestinal duplication cyst involving the colon, appendix, and ileum in children are particularly uncommon. The symptoms of abdominal pain are similar to other acute abdominal diseases in children, such as appendicitis, intussusception, and intestinal obstruction, so sometimes its diagnosis is challenging and leads to misdiagnosis.Case presentationWe report a 4-year-old Asian boy who presented to the pediatric emergency department with abdominal pain and vomiting but no fever, peritonitis, or mass. No abdominal abnormality was found via radiology and ultrasonography. After 2 days’ anti-inflammatory therapy, the patient was discharged with pain relief. A total of 9 months later, he was readmitted to the pediatric emergency department for the same complaint as the first admission. Abdominal physical examination and ultrasound examination were still negative. Barium examination found a large mass in the colon. Colonoscopy was performed before operation to confirm the rare co-cavity intestinal duplication cyst involving the colon, appendix, and ileum. After resection of intestinal duplication and ileocolonic anastomosis, the patient’s abdominal pain and vomiting has not recurred for 5 years postoperatively.ConclusionsThe diagnosis of intestinal duplication cyst in children is difficult, especially the rare co-cavity and long segmental intestinal duplication, which is easily misdiagnosed. Colonoscopy may be an effective auxiliary diagnostic method, especially for diseases that are difficult to diagnosed clinically, such as recurrent abdominal pain.

Rectus Abdominis Sheath Hematoma Following Cesarean Section: A Case Series

This case series describes two patients who underwent Cesarean section complicated by a rectus abdominis sheath hematoma that did not immediately resolve following exploratory laparotomy. One of the patients required an additional procedure by interventional radiology. Both patients had similar presentations. Both were noted to have symptomatic anemia on postoperative day 1 with an acute drop in hemoglobin. This was accompanied by severe abdominal pain and distension on physical exam. Computerized tomography (CT) abdomen/pelvis demonstrated evidence of active bleeding within the anterior abdominal wall musculature. Due to increasing concern for intrabdominal hemorrhage in the setting of an acute abdominal exam, the decision was made to proceed with an exploratory laparotomy. A substantial amount of blood was evacuated from the abdomen with greater than 1500 cc of estimated blood loss in both cases. A Jackson-Pratt drain was placed and had increased output immediately postoperatively. Both patients received blood products. One developed a consumptive coagulopathy. Interventional Radiology was consulted following exploratory laparotomy to consider intravascular embolization of the inferior epigastric arteries, which was eventually performed in one of the cases. The patients were discharged on hospital day 5 in good condition. Rectus abdominis sheath hematomas are a rare complication that can lead to significant postpartum hemorrhage. Prompt recognition and management is vital to avoid significant morbidity and mortality. Algorithms exist to guide treatment and standardize patient care. Despite using sound clinical judgment in line with existing algorithms, both patients had delayed resolution of their bleeding following initial management, requiring additional intervention.

EP376 - Portal Pyaemia and Fungal Septicaemia Associated with Mesenteric Venous Pneumatosis - Improving Patient Outcomes

Abstract An 82 year old female presented to A&amp;E with a 1 week history of lower abdominal pain, fever, and nausea. She had a known history of sigmoid diverticulosis, however had not had any previous abdominal surgery, and had no other past medical history of note. At presentation she was in septic shock, requiring vasopressor support to maintain her blood pressure. Her abdominal examination revealed left iliac fossa tenderness, however no features of peritonism. Initial investigations revealed a White Cell Count (WCC) 49.3x10^9/L, a C-Reactive Protein (CRP) 191mg/L, and an ALP of 434IU/L. A CT scan of the abdomen and pelvis confirmed acute sigmoid diverticulitis, with radiological features suggesting gas tracking along the inferior mesenteric vein (IMV). An emergency Hartmann’s procedure was performed, and intra-operatively pus was evidence draining directly from the IMV. Pre-operative blood cultures and intra-operative tissue cultures grew Escherichia coli, for which the patient was treated with intravenous meropenem post-operatively. She was transferred to Intensive Care Unit and stepped down to the ward on post-operative day 5. Within the first 48 hours post-operative, the WCC had risen to 64x10^9/L, however within 72 hours of commencing anti-fungals, this dramatically decreased to 16x10^9/L. After this, her recovery was swift, and was discharged shortly after. In the context of acute diverticulitis, any radiological evidence of gas within the portal venous system is likely secondary to portal pyaemia. Urgent operative intervention for source control remains the mainstay of management, with consideration of anti-fungals imperative.

EP112 - An Unusual Case of Seed Bezoars Intestinal Perforation

Abstract Introduction Seed bezoars are a distinct subgroup of phytobezoars, caused by the accumulation of indigestible vegetable or fruit seeds in the intestinal lumen. Intestinal obstruction due to plant seeds is seldom encountered because of their relatively smaller size, and intestinal perforation is even rarer. Case Report We report a case of a 64-year-old hypertensive, diabetic and cardiac patient who came to surgical emergency department with generalized abdominal pain and vomiting for 3 days. She was tachycardiac, tachypneic and hypotensive at the initial presentation. Abdominal examination revealed tense, rigid abdomen with absent bowel sounds. Bilateral air under diaphragm was seen on an erect abdominal radiograph. Laboratory workup showed leukocytosis and metabolic acidosis. Laparotomy was performed after resuscitating the patient. Operative findings revealed gross contamination and gangrenous small bowel starting from about 8 feet distal to DJ flexure till 15 cm proximal to ICJ. There was a 2 x 2 cm perforation about 8.5 feet distal to DJ flexure secondary to obstructed seed bezoar (1 each of apricot, peach, and mango pickle seeds and 4 java plum seeds). Gangrenous small bowel was resected, and loop ileostomy was fashioned. She underwent cardioversion for ventricular tachyarrhythmias during the surgery. Post-operatively, she remained on ventilatory support in ITU but could not survive due to cardiac arrhythmias. Conclusion Although intestinal obstruction and perforation occur rarely due to phytobezoars, this should always be considered in the differential diagnosis, and early therapeutic intervention should be considered in morbid patients.

Amoebic Liver Abscess Multifocal with Bilateral Parapneumonic Effusion: A Case Report

A liver abscess is defined as a pus-filled mass in the liver that can develop from injury to the liver or an intraabdominal infection disseminated from the portal circulation. The majority of these abscesses are categorized into pyogenic or amoebic, although a minority is caused by parasites and fungi. Most amoebic infections are caused by Entamoeba histolytica. Complications of amoebic liver is abscess Pleuropulmonary involvement, which is reported in 20–30% of patients. A male patient, 53 years old, was admitted to Hospital for Upper right abdominal pain, Fever, Cough, Pain in the lower right chest. Chest examination found weakened bronchovesicular breath sounds as high as RIC V, Pleural Friction Rub, wet crackles. Abdominal Examination found supel palpation, liver palpable 2 fingers below the arcus costae and 2 fingers below the process xiphoid, blunt edge, soft consistency, tenderness pain in the dextra hypochondrium. Laboratory report Anti Amoeba : Positive 40,3 unit. The patient was given intravenous metronidazole therapy 3x750 mg for 10 days. Complications of Amoebic Liver Abscess is Pleuropulmonary involvement. Pulmonary and pleural amebiasis is an uncommon disease, usually occurring on the right side of the lung compared to the left side. Pulmonary amoebiasis is a life-threatening, but treatable, condition.