Abdominal Perforation Research Articles

Protein-Losing Enteropathy Associated with Henoch-Schönlein Purpura

The gastrointestinal manifestations of Henoch-Schönlein purpura include abdominal pain, gastrointestinal bleeding, intussusception, and perforation. Protein-losing enteropathy is rarely associated with Henoch-Schönlein purpura. Two pediatric patients with Henoch-Schönlein purpura who developed protein-losing enteropathy are reported. Tc-99m human serum albumin scintigraphy is useful in the detection of protein-losing enteropathy.

Percutaneous Collagen Induction Therapy as a Novel Therapeutic Option for Striae Distensae

Sir: The occurrence of striae distensae is a well-recognized, common skin condition that rarely causes any significant medical problems but is often a significant source of distress to those affected. Striae are atrophic linear plaques, most often found on the breasts, abdomen, hips, and thighs in the dermal layer. This disruption of collagen-elastic matrix may develop in a variety of circumstances, such as during adolescent growth spurts, and during hormonal changes, such as Cushing syndrome. Striae gravidarum are widely known to occur in pregnancy and, aesthetically, they can be a cause of great concern for many women. Maternal age, body mass index, weight gain, and neonatal birth weight were independently associated with the occurrence of striae gravidarum.1 It appears that the group at highest risk of developing severe striae are teenagers. Treatment is often anecdotical. To date, no therapeutic option offers complete treatment.2 Cocoa butter was recently studied in a randomized controlled trial for prevention of striae gravidarum but failed to be effective.3 Percutaneous collagen induction therapy is capable of dermal rejuvenation by smoothing of the skin by thickening the epidermal layers and expression of genes and proteins relevant for dermal regeneration without the risk of dyspigmentation.4,5 Percutaneous collagen induction works best in combination with a scientific skin care program. In contrast to ablative laser therapy, the epidermis remains intact. Thus, the procedure can be repeated safely if needed, and it is also applicable to regions where laser treatments or deep peelings cannot be performed. Twenty-two female patients with stretch marks underwent single percutaneous collagen induction therapy in an outpatient setting. All patients had conventional tumescence anesthesia. The procedure took a mean time of 30 minutes, without any immediate adverse effects, such as abdominal perforation or infection. Follow-up assessment was performed 6 months after the intervention. Assessment of the result revealed improved skin texture, skin tightening, dermal neovascularization, and no change of pigmentation (Fig. 1). Biopsy specimens obtained 6 months after the intervention revealed an increase of collagen I and elastin (Fig. 2). Collagen III was not affected at all.Fig. 1.: Preoperative (above) and postoperative (6 months after treatment) (below) clinical images.Fig. 2.: Preoperative (above) and postoperative (6 months after treatment) (below) histologic photomicrographs of striae distensae showing a considerable normalization of the collagen/elastin matrix in the reticular dermis and an increase in collagen deposition at 6 months postoperatively. The collagen appears not to have been laid down in parallel bundles but is rather in the normal lattice pattern. Masson's trichrome staining. Scale bar = 50 μm (representative example).Given this preliminary clinical observation of percutaneous collagen induction therapy in striae distensae, we strongly believe that further large-scale and possibly randomized controlled trials are mandatory to elucidate the value of this promising technique. DISCLOSURE Dr. Aust is a medical consultant for Care Concept, distributors for Environ Skin Care Products and Roll-CitR in Germany. Neither of the other authors has any financial information to disclose. Matthias C. Aust, M.D. Karsten Knobloch, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Hannover Medical School Hannover, Germany

Colonoscopic Diagnosis of Trichuris trichiura (Whipworm)

Purpose:Trichuris trichiura is the third most common roundworm worldwide, with more than one fourth of the world's population carrying this parasite. The diagnosis is made primarily by stool examination for eggs. Colonoscopic diagnosis is rare, with less than 20 cases reported in the literature. Case: A 73 year Nepalese male presented to the outpatient endoscopy unit for evaluation of nonspecific generalized abdominal pain and normocytic anemia. He had no associated nausea, vomiting, weight loss or change in bowel pattern. The patient had immigrated to the United States about one year earlier. His laboratory data was significant for normocytic anemia without eosinophilia. Upper endoscopy revealed chronic gastritis but was otherwise unremarkable. Colonoscopy revealed a solitary worm, found in the cecum, with ova characteristic of Trichuris trichiura. The patient was treated with albendazole 400mg daily for three days. Follow-up two months after treatment revealed improvement in symptoms. Discussion:Trichuris trichiura affects more than 800 million people worldwide. The majority of cases in the United States are found within the immigrant population. The mode of transmission is primarily fecal-oral or accidental ingestion of eggs, which are usually found on dry goods such as beans, rice or grains. Upon ingestion of eggs, larvae hatch and develop in the small intestine and then migrate into the right colon. Adult worms live in the cecum and ascending colon. The anterior portion of the adult worm embeds in the mucosa, whilst the posterior portion hangs in the lumen and mates with neighboring worms. It takes approximately 60 days for a gravid female worm to shed eggs. Female worms in the cecum shed between 3,000 and 20,000 eggs per day. The lifespan of adult worms is between 1-3 years. Diagnosis is primarily by stool examination; however it is important to note that stool analysis can be negative if examined within 2-3 months of acquiring infection. Clinical presentations can include non-specific abdominal pain, colonic obstruction, perforation, gastrointestinal hemorrhage or rectal prolapse, with laboratory findings of anemia or eosinophilia. Patients with light infestation can be asymptomatic. Colonoscopic findings of worms in the right colon (cecum and ascending colon) generally reflect a light burden, while worms found in the left colon (descending, sigmoid colon and rectum) reflect heavy burden. Irrespective of infection burden, treatment is recommended. The treatment options are albendazole 400mg once daily for 3 days, or mebendazole 100mg twice daily for 3 days.

Single balloon enteroscopy for diagnosis of small bowel diseases

Objective To evaluate the safety, indications and clinical efficacy of single balloon enteroscopy （SBE） for diagnosis of small bowel diseases. Methods Data of 30 patients （ 21 males and 9 fe- males） with suspected small bowel diseases, who underwent SBE from June to September 2009, were retrospectively studied to analyze the access, procedure time and complications of SBE. Results A total of 35 SBE procedures were performed on 30 patients. Procedures were performed via oral, anal and the combined routes in 15, 10 and 5 cases, respectively, and definite diagnosis was made in 26 cases （86. 7% ）. The av- erage access times via oral and anal routes were 49.7 rain and 48.6 min, respectively. Patietns showed normal vital signs during the procedures. No such procedure-related complications as eadiovascular events, se- vere abdominal pain, bleeding or perforation, were observed. Conclusion SBE is a safe and reliable diag- nostic modality of high clinical value for small bowel diseases. Key words: Diagnosis; Single balloon enteroscopy; Small bowel diseases

Perfil dos pacientes portadores de câncer colorretal operados em um hospital geral: necessitamos de um programa de rastreamento acessível e efetivo

O objetivo do presente trabalho é demonstrar o panorama atual do câncer colorretal em um hospital geral no estado do Rio de Janeiro, enfocando aspectos relacionados à apresentação clínica e ao diagnóstico tardio. Trata-se de um estudo retrospectivo que incluiu os pacientes em acompanhamento no ambulatório de seguimento de câncer colorretal da II Clínica Cirúrgica do Hospital Federal de Bonsucesso nos últimos 5 anos (2004-2009). Os sintomas mais comuns foram dor abdominal (60,1%), obstrução intestinal (41,1%), emagrecimento (36,7%), sangramento (33.5%), anemia (14,5%), perfuração (6,3%) e fístula (1,2%). Em relação aos pacientes com tumores de cólon direito, os sintomas mais prevalentes foram emagrecimento (54,5%), dor (45,4%), obstrução (45,4%) e anemia (27,2%). Nos pacientes com tumores de cólon esquerdo e sigmóide foram dor (60,5%), obstrução (42,9%), emagrecimento (38,5%), sangramento (32,4%) e anemia (16,6%). Enquanto nos pacientes com tumores de reto foram sangramento (70%), obstrução (60%), dor (60%), emagrecimento (20%) e perfuração (10%). No momento da cirurgia, 53 pacientes apresentavam metástases à distância (33,5%), sendo o fígado o órgão mais acometido, em 36 pacientes (67,9%), seguido pelo peritônio com 11 casos (20,7%) e pelos anexos (ovários) com 4 casos (7,5%). Oitenta e oito pacientes (55,6%) apresentavam metástase linfonodal.Quanto ao estadiamento, observamos que os pacientes operados na emergência apresentavam a seguinte distribuição: 0% Estádio I, 28,2% Estádio II, 30,4% Estádio III e 41,3 % Estádio IV. Os pacientes operados eletivamente foram estratificados como Estádio I 2,7%, Estádio II 27,7 %, Estádio III 25% e Estádio IV 44%. Conclusão: O perfil dos pacientes operados na nossa instituição (e que reflete a realidade nacional) é de doença avançada. Com base nos dados apresentados, fica clara a necessidade de implementação de um programa de rastreamento para câncer colorretal.

Colocutaneous Fistula After Suction Lipoplasty

Suction lipoplasty is considered to be a relatively safe procedure but is not without complications, some of which are lethal. Colonic injury after liposuction has not been reported so far, although small intestinal perforations are known to occur. We present a case of colocutaneous fistula after suction lipoplasty that was successfully managed nonoperatively. A 56-year-old man with history of abdominoplasty presented with feculent discharge from the abdominal wall 7 days after liposuction. A computed tomography scan of the abdomen showed free intraperitoneal air, with a suspected transverse colonic fistula to the skin. After drainage of abdominal wall abscess, he recovered and the fistula spontaneously closed. Abdominal wall hernias, abdominal operations, and immunosuppression are risk factors for abdominal and intestinal perforations after lipoplasty. Low output colocutaneous fistulae after lipoplasty may close spontaneously unlike small intestinal perforations.

Evolution of imaging for abdominal perforation

Gastrointestinal (GI) perforation is a common surgical presentation. In recent years, computed tomography (CT) has been shown to be accurate for predicting the site of GI perforation, and has become the investigation of choice. However the signs may be subtle or only indirectly related to the site or aetiology of perforation. A MEDLINE and PubMed search was performed for journals before June 2009 with MeSH major terms 'CT' and 'perforation'. Non-English speaking literature was excluded. Examples of GI perforation of various aetiologies are reviewed (inflammatory, neoplastic, traumatic and iatrogenic) high-lighting characteristic CT appearances as well as pitfalls in diagnosis. Features of perforation include the presence of free gas or fluid within the supra- and/or inframesocolic compartments, segmental bowel wall thickening, bowel wall discontinuity, stranding of the mesenteric fat and abscess formation. These differentiating features facilitate accurate multidisciplinary pre-operative evaluation, necessary to plan patient management and potential surgical approach.

Development of Spontaneous Bacterial Peritonitis after Extended Hepatic Resection in a Patient without Evidence of Liver Cirrhosis

Hilar cholangiocarcinomas are often treated with liver resections. Hepatic dysfunction and infection are common postoperative complications. Although secondary bacterial peritonitis due to abdominal abscess or perforation is common, we report herein the first case of spontaneous bacterial peritonitis after hepatic resection. A 61-year-old male patient without underlying liver disease was diagnosed as having a Klatskin tumor, and a right trisectionectomy with caudate lobectomy was performed. From postoperative days 18-28, the patient gained 4.1 kg as ascites developed, and showed evidence of hepatic insufficiency with prolonged prothrombin time and jaundice. Computed tomography, performed at postoperative day 28 when fever had developed, showed only ascites without bowel perforation or abscess. When paracentesis was performed, the serum-ascites albumin gradient was 2.3 g/dL, indicating portal hypertension, and the ascites' polymorphonuclear cell count was 1,156/mm(3). Since the clinical, laboratory, and image findings were compatible with spontaneous bacterial peritonitis, we started empirical antibiotics without additional intervention. Follow-up analysis of the ascites after 48 hours revealed that the polymorphonuclear cell count had decreased markedly to 108/mm(3); the fever and leukocytosis had also improved. After 2 weeks of antibiotic treatment, the patient recovered well, and was discharged without any problem.

Laparobotic duodenal diverticulectomy and choledochoduodenostomy: a case study and review of the literature.

The duodenum is the second most common site for diverticulae, after the colon. They are common after the fifth decade and usually asymptomatic. Ten percent of patients present with symptoms, which include abdominal pain, hemorrhage, duodenal obstruction, diverticulitis, perforation, pancreatitis, and obstructive jaundice. After a thorough search of medline we present, for the first time, a case of obstructive jaundice secondary to duodenal diverticulum compressing the common bile duct. It was managed by laparobotic duodenal diverticulectomy with choledocho-duodenostomy. The operative technique is discussed. A 78-year-old female was found to have an abnormal cholestatic liver function profile and dilated common bile duct during workup for upper abdominal pain. CT scan showed dilated common bile duct measuring 2.7cm with suspected ampullary mass. Endoscopic ultrasound showed a large diverticulum next to the ampulla. Upper GI endoscopy confirmed duodenal diverticulum, arising from the second part of the duodenum. Laparobotic duodenal diverticulectomy and choledochoduodenostomy were performed. Her post-operative course was complicated by Clostridium difficile diarrhea, treated with metronidazole and she was discharged home on the 6th postoperative day. Follow-up at 18 months demonstrated that she was well. Obstructive jaundice due to compression by a duodenal diverticulum is rare. It poses a diagnostic challenge and requires technically demanding surgical and endoscopic intervention. Robotic surgery has revolutionized the field of minimally invasive surgery by improving vision and motion control. Robotic duodenal diverticulectomy and choledocho-duodenostomy are safe and feasible.

Surgical complications of lipoplasty – management and preventive strategies

Lipoplasty and its associated complications are well researched and documented. In most articles, the focus has been on the major life-threatening complications of liposuction. Most of these major complications are related to conditions other than surgical trauma per se, namely anaesthesia, hypothermia, long duration of surgery and fluid overload. With the exception of pneumothorax and abdominal perforation, surgical trauma does not cause major complications. Although most surgical complications are classified as minor, they present as major events for patients and the treating physician. All efforts to prevent even minor complications to enhance patient satisfaction are needed. This article presents a review of only the surgical-trauma-related complications of lipoplasty and discusses their management and preventive strategy. A review of 200 consecutive cases of lipoplasty, performed between July 2006 and December 2007, including large-volume liposuctions (LVLs) and combined liposuction abdominoplasties, was undertaken. Complications relating only to the surgical trauma of liposuction were analysed. Complications such as hyperpigmentation of access points, postoperative fluid collection, asymmetry, irregularity, external genital swelling and haematoma were noted. Postoperative fluid collection and haematoma required active intervention. Drainage of fluid collection using a liposuction cannula was effective and prevented recurrence and the need for repeated aspirations. Major surgical complications such as pneumothorax and abdominal wall perforations could be avoided by following simple rules. Major complications related to surgery can be avoided by following well-known safety guidelines. To enhance patient satisfaction, minor complications related to surgical trauma need to be addressed aggressively. This article discusses methods to lower the incidence of most surgical complications.

Rapunzel Syndrome: A Comprehensive Review of an Unusual Case of Trichobezoar

An unusual form of bezoar extending from the stomach to the small intestine or beyond has been described as Rapunzel syndrome. Bezoars are concretions in the gastrointestinal tract that increase in size by continuous accumulation of non-absorbable food or fibers. Most bezoars in children are trichobezoars from swallowed hair from the head, dolls, or brushes. Trichobezoars typically cause abdominal pain and nausea, but can also present as an asymptomatic abdominal mass, progressing to abdominal obstruction and perforation. Trichobezoar with Rapunzel syndrome is an uncommon diagnosis in children with less than 40 cases reported. It is predominantly found in emotionally disturbed or mentally retarded youngsters. We present the youngest case of Rapunzel syndrome in the United States, a 5-year-old girl with mental retardation who presented with abdominal pain, vomiting and a non-tender abdominal mass.

Massive lower gastrointestinal haemorrhage, successfully treated with corticosteroids, as main symptom of Schönlein-Henoch purpura

Schönlein-Henoch purpura is a small vessel disease that affects mainly skin and kidney, although several gastrointestinal symptoms may occur including abdominal pain, intussusception, perforation or bleeding. Massive lower gastrointestinal haemorrhage is rare and even more as the main symptom of the disease. We present a case of a 2-year-old boy with Schönlein-Henoch purpura who developed a massive lower gastrointestinal bleeding requiring blood transfusion. In this patient both Schönlein-Henoch purpura and gastrointestinal haemorrhage were successfully treated with intravenous methylprednisolone, avoiding surgical intervention. Physicians need to have a high index of suspicion when evaluating these patients, even more when dermatologic signs are scarce. Glucocorticosteroid therapy may be effective when treating severe gastrointestinal symptoms.

Clinical outcome in patients with small intestinal non-Hodgkin lymphoma

The clinical features and outcome of small intestinal lymphoma remain unclear. We retrospectively analyzed 23 patients who had non-Hodgkin lymphoma with a small intestinal lesion. With a median follow-up of 37 months, the 5-year overall survival and failure-free survival (FFS) were 64% and 60%, respectively. In a univariate analysis, a worse performance status at the start of treatment and the occurrence of abdominal symptoms or perforation during treatment were associated with poor survival. Perforation often resulted in a dismal prognosis in patients with uncontrollable lymphoma, but not in patients with lymphoma in remission. The role of surgery in small intestinal lymphoma remains equivocal. In the current study, surgery before other therapies favorably influenced FFS, and all patients who underwent complete resection of the small intestinal lesion had extremely favorable results. Further studies are warranted to establish optimal therapeutic strategies.

A rare case of multiple myeloma initially presenting with pseudoachalasia

Pseudoachalasia is a rare clinical entity with clinical, radiographic, and manometric features often indistinguishable from achalasia. Primary adenocarcinomas arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes of pseudoachalasia. Rarely, processes other than esophagogastric cancers including chronic idiopathic intestinal pseudo-obstruction, amyloidosis, sarcoidosis, Chagas' disease, vagotomy, antireflux surgery, pancreatic pseudocysts, von Recklinghausen's neuroinomatosis, gastrointestinal stromal tumor, and other malignancies and rare genetic syndromes, may lead to the development of pseudoachalasia. Secondary achalasia is extremely rare, with less than 100 cases reported in the literature so far. Gastrointestinal manifestations in primary or secondary amyloidosis include abdominal pain, diarrhea, constipation, malabsorption, obstruction, motility disturbance, intestinal infarction, perforation, and hemorrhage; however, gastrointestinal tract involvement is asymptomatic in most instances. We present here a rare case of multiple myeloma initially presenting with dysphagia because of esophageal amyloidosis and manometric findings typical of achalasia.

Abdominal perforation after rupture of a diamond-studded wire: a case report

IntroductionThere are numerous cases of abdominal injuries due to bullets. Abdominal injuries due to bullets are a diagnostic and therapeutic challenge. Here, an unusual case of an abdominal perforation caused by a metal projectile, lead to confusion in the interpretation of the preoperative computer tomography.Case presentationWe present an unusual case of a 32-year-old male worker who sustained a "shot" to the left upper abdominal quadrant, as a result of a work-related accident. The projectile derived from a special wire that tore during operation. One chain element happened to accelerate towards the patients belly and perforated the abdominal wall. Computer tomography located the radiopaque projectile to the cortex of the left kidney and showed a lesion of the tail of the pancreas. The presence of intraperitoneal free air suggested a gastrointestinal perforation. Immediate open exploration of the peritoneal cavity and the retroperitoneal space revealed perforating lesions of the anterior and posterior gastric wall, as well as the pancreatic tail. The projectile was finally retrieved in the upper pole of the left kidney. The patient had a good clinical course subsequent to surgery and was discharged in good general condition.ConclusionThis case represents a rare form of a retained bullet injury and corroborates the need of sufficient measures of worker-protection in area of diamond-studded wire cutting devices.

Revisional operations for marginal ulcer after Roux-en- Y gastric bypass

Background Marginal ulcer is a potentially serious complication of Roux-en- Y gastric bypass (RYGB). This study reviewed 1 surgeon's experience with 39 revisional operations for intractable marginal ulcer after primary RYGB. Methods A total of 2282 consecutive patients underwent RYGB by 1 surgeon from 1984 to 2006, of which 1621 were open and 661 laparoscopic. The stomach was transected in laparoscopic RYGB and was left undivided in the open group. All revisions included ulcer excision, revision of the gastrojejunostomy with gastric transection as needed. Six patients underwent vagotomy. Results Of the 2282 patients, 122 (5.3%) developed marginal ulcers (88 and 34 from the open and laparoscopic group, respectively). Of these 122 patients, 39 (32%) underwent revision for intractability (35 open and 4 laparoscopic). Of these 39 patients, 28 (71.7%) had gastrogastric fistulas. Risk factors for ulcer (medication, smoking) were present in 26 patients (66.6%). The primary indications of intractability included abdominal pain (66.6%), gastrointestinal bleeding (20.5%), stomal obstruction (10.2%), and perforation (2.5%). Early postoperative complications included 2 leaks (5.1%) and 2 wound infections (5.1%). Three smokers (7.7%) developed recurrent ulcers postoperatively. One patient died of acute respiratory distress syndrome 5 months postoperatively. Of the 39 patients, 34 (87%) remained asymptomatic after revision. The revision rate was significantly less after laparoscopic RYGB (.6%) than after open RYGB (2.1%; P ≤.0025). Conclusion The results of our study have shown that operations for intractable marginal ulcer after RYGB are highly successful in nonsmokers. Patients who undergo laparoscopic RYGB with gastric transection are less likely to require revision than patients who undergo RYGB with an incontinuity gastric partition. The rate of reoperation for marginal ulcer was greater than anticipated.

Acute Ischemic Colitis in a Patient with Metastatic Breast Cancer Undergoing Bevacizumab Therapy

Purpose: Although combination therapy with bevacizumab (a monoclonal antibody against vascular endothelial growth factor) and paclitaxel has shown improvement in progression-free survival in patients with metastatic breast cancer, bevacizumab has been linked to an increased risk of severe bowel complications. Methods: NA Results: A 71 year old Caucasian female with history of metastatic breast cancer presented to her oncologist's clinic with rectal bleeding. Her medical history began four years ago when she was diagnosed with stage IIB estrogen and progesterone-receptor positive, HER2-negative breast adenocarcinoma, which was treated with mastectomy and hormonal therapy. Three months prior to this presentation, she was found to have liver and bone metastases, and was started on bevacizumab and paclitaxel therapy. Her past medical history was also significant for a history of paroxysmal atrial fibrillation for which she was on warfarin therapy. At her oncologist's office, the patient reported several days of mild left lower quadrant abdominal cramps and then one episode of rectal bleeding that morning. The patient denied any previous episode of rectal bleeding or thrombotic events. On exam, she was found to be hypotensive. Her physical exam was otherwise normal except for tenderness to palpation in the left lower quadrant. The patient was administered IV fluids and admitted to the hospital, where initial laboratory evaluation was notable for a hemoglobin level of 9.5 and INR of 1.9. Colonoscopy revealed focal ischemia within the sigmoid colon spanning approximately 8 cm with surrounding ulceration and edema. Histological examination was consistent with ischemic colitis. Her rectal bleeding was of a self limited nature with no further episodes of bleeding during the hospitalization and stable hemoglobin prior to discharge. Conclusion: This case illustrates a serious complication of bevacizumab therapy. Although ischemic colitis has been reported in treatment for metastatic cancer in patients who have received prior radiation therapy, to our knowledge, this is the first documented case of ischemic colitis in the treatment of metastatic cancer in the absence of radiation. Treatment with bevacizumab increases the risk of ischemic damage to the bowel. This could possibly be due to its anti-angiogenic properties. However, treatment with bevacizumab has also been shown to increase the risk of arterial thromboembolism which could also potentially lead to bowel ischemia. Other known complications of bevacizumab therapy include abdominal pain, vomiting, gastrointestinal hemorrhage, and perforation. New abdominal symptoms must be taken seriously in patients treated with bevacizumab and caution must be used when prescribing this therapy to patients.

Endometriosis of the Ileocecal Valve in a Young Asymptomatic Female

Purpose: The gastrointestinal tract is the most common site of extra-pelvic endometriosis. Most commonly the rectum, sigmoid colon, terminal ileum and appendix are involved. Patients can present with abdominal pain, rectal bleeding, bowel obstruction or perforation. We present a young asymptomatic patient with endometriosis of the Ileocecal valve. Methods: 22 yr old African American female was found to have bilateral complex ovarian cysts on evaluation for an episode of left flank pain. CT Abdomen and Pelvis showed a soft tissue density in the cecum. Patient was lost to follow up and presented 3 years later with right lower quadrant abdominal pain and diarrhea for 1 day. On physical examination there was right lower quadrant abdominal tenderness and thick, foul smelling, vaginal discharge. Laboratory studies showed a normal CBC and Urinalysis with 24 RBC,47 WBC, small leukocyte esterase. Repeat CT Abdomen and Pelvis showed no interval change in the cecal mass, no evidence of appendicitis and reduction in size of the ovarian cysts. Patient was treated for PID with resolution of her abdominal pain. Colonoscopy showed a large, irregular, polypoidal mass in the cecum which seemed to originate from the ileocecal valve. Biopsy showed colonic mucosa with non-specific chronic inflammation. Patient was asymptomatic and delayed her surgery for five months. Results: Because of diagnostic uncertainty and the large mass patient underwent right hemicolectomy. Intraoperatively a firm rubbery mass involving the terminal ileum and cecum was found with enlarged mesenteric lymph nodes. There were dense pelvic adhesions. On pathological examination there was 6.5 cm endometrioma of the ileocecal valve and endometriosis of terminal ileum. The mesenteric lymph nodes were reactive. Conclusion: Our case illustrates the diagnostic challenge of intestinal endometriosis. Our patient had cecal involvement which is uncommon. She also did not have recurrent abdominal symptoms that could be ascribed to the ileocecal endometriosis. Endoscopic biopsies as in our case, usually yield insufficient tissue for a definitive pathologic diagnosis as endometriosis involves the deeper layers of the bowel wall. Laparotomy/Laparoscopy is often required for making a diagnosis and for treatment.Figure: Endometriosis of ileocecal valve

Congential hepatophrenic fusion: septum transversum-liver primordium anomaly

Congenital fusion of the liver and diaphragm has not been reported in the literature. Surgery of the liver, e.g. in the case of trauma or transplantation, could be challenging in this situation. A patient was admitted with blunt abdominal trauma and bowel perforation. Hepatic injury, especially grades III, IV and V, could have posed severe difficulties because mobilisation of the liver could have entailed extensive additional haemorrhage.1-4 A midline thoraco-abdominal incision may be required in this situation for adequate access. South African Journal of Surgery Vol. 45 (1) 2007: pp. 28-29

Esophageal Diversion

Esophageal Diversion