Abdominal Guarding Research Articles

Peritoneal tuberculosis mimicking carcinomatous ascites in a child living in a low prevalence country: a case report

BackgroundAscites can develop as a consequence of a number of diseases in childhood. Despite chronic liver disease is the most common cause, several conditions can lead to ascites also in the absence of liver dysfunction. As non-cirrhotic ascites shows a high degree of overlapping sign and symptoms it is still a challenge for physicians.Case presentationA 8-year-old Caucasian girl was referred for fever, vomit and diarrhea occurred over the past few weeks. Physical examination showed timpanitic distension of the abdomen with marked tenderness and increased abdominal wall rigidity. Abdominal imaging showed diffuse ascites and thickened omentum and bowel wall. Blood tests showed increased C- reactive protein levels and decreased lymphocyte count. Specific treatment for inflammatory bowel disease was started. Persisting of ascites required additional investigations. Positive tuberculin skin test and Interferon Gamma release assay (IGRA) as well as increased Ca125 serum concentrations were found. Computed tomography scan showed mediastinal and mesenteric adenopathies and diffuse smooth thickening of the omentum with significant enhancement (omental cake-like). Ascitic fluid analysis revealed high leucocytes and protein levels. Presumptive diagnosis of peritoneal tuberculosis (PTB) was made. Antituberculous treatment resulted in the resolution of ascites and normalization of lymphocyte count and Ca125 serum concentrations.ConclusionsPTB is still possible in low-prevalence countries. As it is a great mimicker of other abdominal pathology whose treatment might worsen tuberculosis progression, clinical suspicion and adequate screening are required to avoid unnecessary interventions and delayed treatment. Ca125 is a non-specific marker of peritoneal inflammation but it might be helpful in monitoring the treatment response.

Acute Uterine Torsion Mimicking Tumor Lysis Syndrome

Background: Non-gravid uterine torsion is rare and mostly diagnosed at surgery. This report describes a patient with a large abdominal mass, critical illness, and tumor lysis syndrome. Case: A female presented with acute abdominal pain. Physical exam showed a large abdominal mass and abdominal rigidity. Serial laboratory tests showed a drop in hemoglobin level, progressive renal failure and serum uric acid and phosphate concentrations compatible with tumor lysis syndrome. Computed tomography showed a 30 cm mass filling the pelvis and abdomen. At an emergency exploratory laparotomy, a 360 degrees torsion of the uterus was found. An uneventful total hysterectomy was done. After surgery renal function restored. Conclusion: Uterine torsion is rare and can be potentially life threatening when presenting as tumor lysis syndrome

Clinical, laboratory and ultrasonographic findings in 94 cows with type-1 abomasal ulcer.

This study included 94 cows aged 2.1 to 12.0 years (5.2± 2.05 years) that were examined at a referral clinic because of type-1 abomasal ulcer. The most common clinical findings were poor general health status (94%), partial or complete anorexia (93%), congested scleral vessels (89%), decreased skin surface temperature (76%), decreased or absent faecal output (72%), abdominal guarding (59%), tachypnoea (56%), rumen atony (53%) and positive percussion and simultaneous auscultation and/or ballottement and simultaneous auscultation on the right side (53%). The most common laboratory findings were hypokalaemia (68%), positive base excess (60%) and azotaemia (51%). The chloride concentration of rumen fluid was increased in 48% of the cows. The diagnosis of type-1 ulcer was made during laparotomy and/or postmortem examination. One or more concurrent diseases were diagnosed in 97% of the cows. Seventy-eight (83%) cows were euthanased immediately after the initial examination, during laparotomy or after unsuccessful treatment, and eight (8.5%) cows died, and all were examined postmortem. Eight (8.5%) cows were discharged and six of these made a complete recovery.

Spontaneous Splenic Rupture Case Report: an Approach to Anatomy Importance for Radiological Correlation

Spontaneous splenic rupture (SSR) is a rare entity 1, usually associated with hematologic malignancies, infectious processes or inflammatory diseases. Timely diagnosis by ultrasound and/or computed tomography 1 allows early clinical and/or surgical management 2, reducing the mortality 1.Our aim is to expose, through a clinical case of SSR, the importance of anatomy knowledge and its radiological correlation in medical education.A 26‐year‐old man, diagnosed with chronic myeloid leukemia (CML) without chemotherapy treatment, attends to the emergency department for 10/10 (VAS) colic pain in the right inferior abdominal quadrant, irradiated to the ipsilateral inguinal region, associated with non‐emetic nauseas, abdominal distention and dysuria. At presentation, heart rate was 80 beats/minute, respiratory rate 18 breaths/minute, blood pressure 123/71 mmHg, temperature 36.0 ° C and SatO2 87%.Initial workup positive findings were leukocytosis (270.000/mm3), low hemoglobin (11.2 g/dL) and hematocrit (33.3%), thrombocytosis (925.000 platelets), and Hypokalemia (2,96 mEq/L). Abdominal computed tomography showed hepato‐splenomegaly and a poorly defined lesion with irregular borders, infiltration and vascular tracts on the spleen inferior segment. Considerable accumulation of free liquid in the abdominal cavity was present.After 2 hours the patient reported an increase in pain, associated to abdominal guarding and rebound tenderness. Heart rate of 134 beats/minute, respiratory rate 30 breaths/minute, blood pressure 150/70 mmHg, SatO2 84% and metabolic acidosis (pH 7.0).Based on the suspicion of hypovolemic shock, an emergency xipho‐pubic laparotomy was performed, finding a 1500cc hemoperitoneum, active bleeding, clots and splenic segments. Complete splenectomy was selected obtaining a surgical specimen (spleen) of 2 Kg, 32 cm in cephalo‐caudal length, and a lower pole rupture. Patient’s postoperative evolution was satisfactory, specific treatment for CML was initiated and he was discharged 14 days after the surgical procedure.An early diagnosis is crucial for the reduction of morbidity and mortality in patients suffering a SSR. This is carried out through the proper interpretation of diagnostic images. This clinical approach requires a broad body anatomy knowledge, and the capacity to extrapolate it to a bidimensional representation. Several researchers confirm that the inclusion of diagnostic‐images in the anatomy curriculum leads to an early exposure of medical student to these tools, which improves their imaging interpretation and diagnostical skills 2. Finally, the implementation of these diagnostic tools in the anatomy program could lead to better medical practice and, as seen in this case, to a reduction on mortality.

Type-5 abomasal ulcer and omental bursitis in 14 cows

BackgroundType-5 abomasal ulcer (U5) is a perforated ulcer that causes peritonitis limited to the omental bursa. This retrospective study describes the clinical and laboratory findings in 14 cattle with omental bursitis due to U5. The medical records of 14 cows aged 2.5 to 14.6 years (5.4 ± 3.1 years) with U5 were scrutinised.ResultsThe most common clinical findings were partial or complete anorexia (100%), abdominal guarding (100%), obtunded demeanour (93%), congested scleral vessels (79%), tachypnoea (71%), rumen atony (64%), diminished faecal output (64%), reduced skin surface temperature (64%) and fever (46%). Four (29%) cows had between one and four concomitant diseases. The most common abnormal laboratory findings were hypokalemia (71%), haemoconcentration (57%), metabolic acidosis (57%) and azotaemia (43%). All cows were euthanased; five immediately after the initial examination, one after exploratory laparotomy and eight after unsuccessful treatment. A diagnosis of U5 was made in all cows during postmortem examination.ConclusionsThere is a need for improvement of the antemortem diagnosis of U5 because reliable differentiation of this disease from other conditions with a similar clinical presentation is currently not feasible.

Adult Intussusception at a Tertiary Care Center: A Retrospective Study.

Background:In adults, the majority of cases of intussusception are due to malignancy.Aims:The aim of the study is to describe the pattern of intussusception in the adult population diagnosed and treated at a tertiary care center.Subjects and Methods:Study Design: This is a retrospective cross-sectional study based on chart review, and data collection was made from the computer database and inpatient case records. Study Setting: Adult intussusception cases diagnosed and treated at a tertiary care referral center in South India. All inpatient case sheets including investigations and histopathology information on the computer database of all patients diagnosed with intussusception in the period of August 2012 to July 2016 were retracted based on a pretested and standardized form. Demographic data and other baseline data were summarized with descriptive statistics. SPSS software was used for data analysis.Results:Of the 77 patients, 47 (61%) were male. The common presentations were abdominal pain (95%), vomiting (64%), and rectal bleeding (29%). Common examination findings were abdominal tenderness (45%), guarding (39%), and abdominal mass (38%). On ultrasonography, fifty (65%) patients had intussusception with ileocolic (25) as the most common type. Computed tomography abdomen was taken for 28 (36%) patients, in which 23 (82%) had intussusception with ileocolic (9) as the most common type. Surgery was done for 53 (69%) patients, and the most common procedure was right hemicolectomy (25) followed by resection and anastomosis of the small bowel (23). Intraoperatively, 42 (79%) patients had intussusception with ileocolic (23) as the most common type. Intraoperatively, 14 (26%) patients had a bowel gangrene. Biopsy-proven cause for intussusception was present in 46 patients, with malignancy (21) as the most common cause. The patients were on regular follow-up. Recurrence of intussusception occurred in six patients of the small bowel intussusception who had polyposis.Conclusions:Adult intussusception is often associated with malignancy. Hence, a formal resection without reduction is needed and surgery should be done following oncological principles.

Predictive value of total leucocyte count (TLC), bilirubin and C-reactive protein in the diagnosis of gangrenous and perforated appendicitis.

Acute appendicitis is the most common cause of acute abdomen. Most of the cases are diagnosed on history, clinical examination and raised TLC but gangrenous and perforated appendicitis are difficult to diagnose. The TLC, Serum bilirubin and C‑reactive protein (CRP) have been shown to indicate perforation in appendicitis. Objectives: The purpose of this study was to evaluate the role of TLC, hyperbilirubinemia and CRP in the diagnosis of perforated appendix and surgery should be planned. Study Design: Prospective study. Setting: Department of Surgery in Sheikh Zayed Medical College Rahim Yar Khan. Period: 12 months from November 2017 to October 2018. Material & Methods: This study consisted of patients admitted with the clinical suspicion of acute appendicitis. ALVARADO score was calculated. 120 patients with ALVARADO score more than 6 and histologically diagnosed appendicitis were finally included in the study. A proforma was filled which included patients name, age, sex, duration of pain, TLC count, C-Reactive protein (CRP) level and serum total bilirubin level and diagnosis of appendicitis (acute appendicitis, gangrenous appendicitis and perforated appendicitis. Patients were divided into 3 groups. Group A comprised of patients with features of simple appendicitis (AA), Group B Gangrenous appendicitis (GA) and group C Perforated appendicitis (PA). Results: There were 81 patients of acute appendicitis, 13 patients of gangrenous appendicitis and 26 patients of perforated appendicitis. TLC was raised in 13 patients of AA, 10 patients of gangrenous appendicitis and 24 patients of perforated appendicitis. Hyperbillirubinemia (>1mg/dl) was present in 9 patients of GA and 20 patients of PA. Raised C-Reactive protein level (>5mg) was present in 10 patients of GA and 21 patients of PA. There was significant correlation of raised TLC, hyperbillirubinemia and C-reactive protein in gangrenous and perforated appendicitis and p value was less than 0.05. Predictive value of bilirubin in GA and PA was 56.25 % and 74.04 %respectively. Predictive value of C Reactive Protein in GA and PA was 41.66 and 60 respectively. Predictive value of TLC in GA and PA was 43.47 and 60.86 respectively. Conclusion: All the patients who present with pain in right iliac fossa, lower abdominal tenderness and rigidity, Alvarado score>7, raised TLC, CRP and hybillirubinemia are the suspected case of perforated appendix and should be aggressively resuscitated and operated.

Acute shock caused by Clonorchis sinensis infection: a case report

BackgroundClonorchiasis, caused by Clonorchis sinensis (C. sinensis) infection, is a serious food-borne zoonotic disease that is often asymptomatic or shows only mild symptoms, which leads to delayed treatment and chronic clonorchiasis and results in various complications, such as cholelithiasis, cholangitis, cholecystitis and cholangiocarcinoma. However, acute shock caused by C. sinensis infection has not been reported. Here, for the first time, we describe a fatal case of acute shock caused by C. sinensis infection.Case presentationA patient with a history of eating raw or undercooked freshwater fish was hospitalized with acute shock caused by severe abdominal pain. Physical examination suggested acute abdomen with severe abdominal pain and rigidity. Computed tomography (CT) detection indicated acute cholecystitis and cholelithiasis. After cholecystectomy, several liver flukes were found in the drainage tube. Furthermore, morphological analysis and polymerase chain reaction (PCR) identified the pathogen as C. sinensis. The liver gradually restored normal function after anthelmintic therapy with praziquantel.ConclusionsIn this fatal case, C. sinensis infection was the cause of acute shock, which is rarely found in the clinic environment. This report aims to increase awareness of the hazards and complications related to clonorchiasis. The PCR diagnosis method used in this report might be helpful in reducing the misdiagnosis of clonorchiasis and unnecessary cholecystectomy.

A CASE OF ADULT UNILATERAL LUNG HYPERLUCENCY

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Both Swyer-James McLeod (SJM) syndrome and Congenital Lobar Emphysema (CLE) are rare conditions which may appear radiographically identical, characterized by hyperlucency of one or more lung lobes resulting in hyperexpansion and compression of normal lung tissue. CLE is a developmental anomaly more commonly presenting in the neonatal population within the first few weeks of life as respiratory distress. Those diagnosed beyond the neonatal period are typically still diagnosed within the pediatric time frame due to recurrent pulmonary infections. SJM presents similarly but is more likely an incidental finding developing over time by a childhood viral infection resulting in bronchiolitis obliterans and reduced pulmonary vasculature. CASE PRESENTATION: We present a case of a 30-year-old, non-smoker, El Salvadorean male with no medical history who presented with acute nausea, emesis and mild dyspnea. On exam he had noticeably decreased breath sounds over the right hemithorax and abdominal guarding. While being worked up for esophageal perforation, a CT Chest showed evidence of significant right lung emphysema with mediastinal shift. Consolidation and layered air fluid levels in the right lower lobe were concerning for atelectasis and pneumonia. A mild respiratory acidosis and hypercarbia suggested a chronic process. Esophageal perforation was ruled out with a barium swallow and bronchoscopy showed right bronchial obstruction. Bronchoalveolar lavage did not grow acid fast bacilli or fungal organisms but demonstrated extra-cellular bacteria and CMV. Alpha-1 Anti-Trypsin level was within normal limits. Spirometry showed significant obstruction and reduced lung volumes with an FVC of 1.58 L. Of note, he had presented to clinic two years ago for dyspnea, advised to get a chest x-ray and prescribed an inhaler but was subsequently lost to follow up. Ultimately, this patient’s nausea and vomiting was attributed to impressive over-distension of his right lung and compression of mediastinal structures. He was treated for pneumonia with plans for right lung pneumonectomy once clinically stable. DISCUSSION: We describe an unusual case of unilateral hyperlucency and emphysema. It remains unclear whether it is more consistent with CLE or SJM. Our patient’s somewhat incidental presentation may lead us to think that this is a manifestation of SJM, however the severe emphysematous changes and mediastinal shift suggest that this may be an unusually late presentation of CLE. Given his background from El Salvador, a broad differential for infectious etiology may suggest SJM although this case may be attributed to CLE from congenital CMV as described before[1]. CONCLUSIONS: Consideration of SJM or CLE is necessary especially in the pediatric population as early radiologic findings may be misinterpreted as pneumonia leading to delay in diagnosis. Timely definitive treatment with pneumonectomy may preserve lung volume. Reference #1: Carrol, Enitan D., et al. "Congenital lobar emphysema in congenital cytomegalovirus infection.” Pediatric radiology26.12 (1996): 900-902 DISCLOSURES: No relevant relationships by Nisha Donthi, source=Web Response no disclosure on file for Eric Libre; no disclosure on file for Andrei Minciunescu; No relevant relationships by Shubha Srinivas, source=Web Response

Which One Is More Important For The Diagnosis Of Acute Pancreatitis? Blood Tests Or Imaging?

Introduction:Acute pancreatitis (AP); It is defined as a reversible inflammatory process in which the tissue of the pancreas is affected at various degrees, accompanied by local tissue or organ systems. It is characterized by a sudden onset of upper abdominal pain and associated vomiting, fever, tachycardia, leukocytosis, serum amylase or lipase increase of 3 times normal. Acute pancreatitis has a spectrum of varying severity of disease ranging from self-limiting mild disease that is present with abdominal pain to severe fluid loss, metabolic imbalances, hypotension, sepsis and severe disease that may lead to death. Mortality rate is 6-23% for acute pancreatitis in different article. We report the case with a diagnosis of acute pancreatitis, who have abdominal pain; but no serum amylase and lipase elevation. We diagnosed edematous pancreatitis image in the computed tomography.Case:A 51-year-old male admitted to the emergency department with sever abdominal pain. He had diabetes mellitus in his medical history; but drugs used for DM could not be learned due to communicative reasons.On his presentation to our ED, he was conscious, oriented and cooperative. His vital signs were as follows: his blood pressure was 130/90 mm Hg, his pulse rate was 100 beats per min, his respiratory rate was 20 per min, his body temperature was 36.5°C, and his oxygen saturation was 100% while breathing room air. He has epigastric tenderness and abdominal guarding on palpation; but no rebound tenderness or rigitidy was noted on palpation. No pathological findings were found in the respiratory system, cardiovascular system and neurological examination. The blood test measurements were WBC: 5.50 10³/uL, Hb:13.2 g/dl, Plt:160.000 10³/uL, Glucose: 444 mg/dl, urea:30.0 mg/dl, serum creatinine: 0.74 mg/dL, AST: 13U/L,,ALT: 15 U/L, GGT:33 U/L, ALP: 107 U/L, Amylase: 28: U/L, Lipase: 58.8 U/L, CRP: 104.05 mg/L, cardiac troponine: 0.006 ng/ml. . ECG is normal beat. In abdominal ultrasonography of the patient; pancreas and midline structures could not be evaluated due to gas. No ultrasonographic pathology was detected in other intraabdominal organs and intraabdominal fluid was not seen in the abdominal ultrasonography. Contrast-enhanced computed tomography (CT) of the abdomen was performed because of persistant, severe abdominal pain and it revealed peripancreatic diffuse inflammatory densities (edematous pancreatitis), shown in image 1. The patient was consulted with the internal medicine clinic. Internal Diseases Clinic suggested hydration with intravenous Serum Physiological and then re-consultation with blood tests. We detected that WBC: 5.75 10³/uL, Hb:13 g/dl, Plt:150.000 10³/uL, Glukose: 248 mg/dl, urea:18.0 mg/dl, serum creatinine: 0.6 mg/dL, AST: 12U/L,,ALT: 14 U/L, GGT:31 U/L, ALP: 96 U/L, Amylase: 20: U/L, Lipase: 38.1 U/L, CRP: 120.56 mg/L cardiac troponine: 0.006 ng/ml in blood test after hydration. The patient was re-consulted with the internal medicine clinic. Internal Diseases Clinic suggested hospitalization with the diagnosis of edematous pancreatitis to him.Discussion: Patients with acute pancreatitis are admitted to the emergency department with abdominal pain, nausea and vomiting. Generally, the amylase and lipase elevation are seen in the blood tests and then abdominal computed tomography is performed for further examination and follow-up. When amylase and lipase are detected in normal values, pancreatitis is not thought; but Two of the three criteria for acute pancreatitis must be determined. These criteria are abdominal pain, amylase-lipase elevation and view compatible with pancreatitis in imaging examinations. In this context, a rare diagnosis of pancreatitis can be made without amylase and lipase elevation. In our case, the patient was diagnosed with pancreatitis because of having abdominal pain and imaging consistent with pancreatitis without elevated amylase and lypase.Conclusion: As in this case, blood tests are not sufficient for diagnosis of pancreatitis and if there is clinical necessity, the emergency physician should consider imaging examinations for diagnosis of pancreatitis.

2615 Treating Gas With Gas: A Case of Benign Extensive Pneumatosis Intestinalis

INTRODUCTION: Radiological evidence of extensive gas collections in the bowel wall and, particularly, the portal vein commonly suggests a life-threatening process. We present a patient with massive intramural and portal gas that was adjudged to be of benign origin and managed conservatively with high flow nasal oxygen. CASE DESCRIPTION/METHODS: A 74-year-old male with a history of coronary artery bypass surgery and a 40 pack-year history of smoking was admitted with a two-week history of abdominal discomfort with food ingestion, bloating and belching. History was negative for gastrointestinal bleeding, prior abdominal surgeries or fever. On examination, he was afebrile, hemodynamically stable, and had no abdominal tenderness, rebound or guarding. Initial laboratory measurements were normal and notable for normal white blood cell count of 9180/mm3 and a lactic acid of 1.8 mmol/L. A stool exam for pathogens was obtained. A Computed tomography (CT) scan of the abdomen showed extensive pneumatosis involving the upper small intestine and the stomach, and a relatively massive collection of portal venous gas (see Figure 1). He was admitted to the hospital with the diagnosis of possible ischemia of the small bowel and/or stomach. Despite the ominous abdominal imaging findings, he had a normal physical exam and lack of evidence of sepsis which suggested a benign etiology of the pneumatosis. The patient was essentially asymptomatic throughout his 6-day hospital course. The stool screen for 20 pathogens revealed enteropathogenic E. coli. On the second day of hospitalization, high inhalational oxygen (>50%) via nasal cannula was instituted in addition to an elemental diet. A repeat CT scan on day 5 of hospitalization showed virtually complete resolution of intramural small bowel and gastric gas, and only small residual portal venous gas remained. He was discharged home on antibiotics for 3 weeks and has continued to do well DISCUSSION: Pneumatosis intestinalis should be recognized as a clinical sign and not a diagnosis and should warrant careful review of the clinical context, signs/symptoms and laboratory data. The counter-perfusion supersaturation theory has been proposed as the pathophysiology in most benign cases. It involves increased hydrogen production by intestinal bacteria which supersedes the nitrogen tension in the blood stream. High flow or hyperbaric oxygen may help in the establishment of a nitrogen gradient between intramural gas and blood with improvement of intramural gas

2597 An Unusual Case of an Asymptomatic Intramural Duodenal Abscess

INTRODUCTION: Duodenal abscesses are seldom reported in medical literature. Most recently, a case of an intramural duodenal abscess was reported in 1995 complicated by a perforated peptic ulcer without accompanying peritoneal signs. The lack of signs or symptoms raises for concern for missed intervention and a subsequent high mortality. These abscesses seem to have an association with perforated peptic ulcers. Here we discuss an unusual case of a duodenal abscess in a patient with melena. CASE DESCRIPTION/METHODS: A 83-year-old gentleman with a past medical history atrial fibrillation and cholecystectomy status post stent placement presented to Loma Linda Veterans Affairs Hospital with a new one month onset of generalized abdominal pain and melena following addition of edoxaban. Hemoglobin was noted at 12.9 g/dl down trending from 13.8 g/dl one month prior. The scheduled diagnostic EGD was then performed which showed bleeding gastropathy and two small 2 mm ulcers in the body of the stomach. In the duodenum, we noted mucosal irregularity in the bulb (Figure 1) with purulent drainage consistent with an abscess. This was probed with the biopsy forceps resulting in more purulent drainage continued (Figure 2). A biopsy was taken with mildly edematous duodenal mucosa showing reactive changes and expansion of lamina propria by inflammatory cells consistent with an inflammatory process. DISCUSSION: There is limited literature for the management of duodenal abscesses. The patient did not exhibit any warning signs such as; abdominal tenderness, guarding, fever, or leukocytosis. There is a potential association with chronic inflammation and duodenal abscesses and the previously stated association with peptic ulcers.

1547 Pseudomonas Aeruginosa: A Rare Cause of Community-Acquired Antibiotic-Associated Diarrhea in an Immunocompetent Adult

INTRODUCTION: Pseudomonas aeruginosa (P. aeruginosa) is an opportunistic gram negative pathogen known to cause enterocolitis in children and nosocomial infections, including hospital acquired pneumonia (HAP) and catheter associated urinary tract infections (UTIs). Rarely, P. aeruginosa causes antibiotic-associated diarrhea in immunocompromised hosts, but this has not been reported in immunocompetent ambulatory hosts. CASE DESCRIPTION/METHODS: An 81 year old previously healthy woman presented to the emergency department (ED) with diarrhea for 2 days. A week prior to symptom onset, she completed a 17 day course of ciprofloxacin for a UTI, with resolution of dysuria. She described frequent, watery, nonbloody bowel movements with nausea and emesis. She was treated with intravenous saline and ondansetron, and discharged. The next day, she developed bloody bowel movements associated with weakness and mild lower abdominal pain. With ongoing diarrhea, she returned to the ED. Physical exam showed very mild left lower quadrant abdominal tenderness, without rebound or guarding. Laboratory studies showed white blood cell count 11,800 cells/mcL, potassium 3.3 meq/dL, and lipase 67 units/L. Electrolytes and liver enzymes were otherwise normal. Clostridium difficile (C difficile) stool toxin PCR was negative. CT abdomen and pelvis without contrast showed diverticulosis and mild inflammation surrounding the sigmoid colon (Figures 1 and 2). She was started empirically on ciprofloxacin and metronidazole, and admitted to the medical floor. Over the next 3 days, she gradually improved. Stool culture grew P. aeruginosa, with absence of normal fecal flora. Sensitivities showed resistance to ciprofloxacin and levofloxacin. Given her clinical improvement, antibiotics were discontinued after 7 days. DISCUSSION: We report a case of P. aeruginosa as a cause of bacterial colitis. Our patient's prior antibiotic therapy may have increased her susceptibility to this infection via loss of normal fecal microbiota, leading to a loss of competitive exclusion and diminished colonic barrier protection. To our knowledge, this is the first reported case of post-antibiotic diarrhea caused by P. aeruginosa in an immunocompetent ambulatory host. This may be an important diagnostic consideration in patients presenting with persistent diarrhea following antibiotics, with negative C. difficile stool testing. The role for antibiotic therapy in Pseudomonas associated diarrhea warrants further research.

3035 Pancreatico-Vesical Fistula

INTRODUCTION: Acute pancreatitis is an important cause of acute abdomen. It involves peripancreatic tissues or even remote organs or organ systems due to the enzyme rich fluid of pseudocyst. Here we report a case where acute pancreatitis resulted in a fluid collection that tracked down to the pelvis and spontaneously drained into the urinary bladder via a pancreatico-vesical fistula. CASE DESCRIPTION/METHODS: A 28-year-old male, chronic alcoholic, developed epigastric pain for last 4 days which radiated to the back with raised serum lipase and amylase levels. He was started on conservative therapy for acute pancreatitis and took discharge against medical advice but returned again 3 weeks later with severe pain in epigastrium as well as left flank, which is boring. Abdominal tenderness and muscle guarding were elicited. Diminished bowel sounds. CT abdomen: a bulky pancreas with non-enhancing areas, peripancreatic stranding, and acute fluid collections involving the body and tail of the pancreas extending along the renal fascia toward the pelvis and resting on the left superolateral wall of the urinary bladder. The epigastric pain gradually improved with complaints of burning micturition 2 days after without pyelonephritis signs. The urine had brownish tinge, turbid, foul smelling and microscopy revealed no bacteria/casts. An abdominal sonogram: normal kidneys but thickened UB wall with thick mobile echoes lying on left superolateral UB. Urine lipase and amylase were 499 U/Lit and 350 IU/Lit. CT cystography: contrast leakage from the left superolateral UB wall into the perivesical with fluid-fluid level seen in the UB suggestive of contrast –debris level means pancreatic-vesical fistula. Stenting of the pancreatic duct and percutaneous drainage of the fluid collection are done with regression of urinary symptoms and urinary amylase. 12 days after a repeat cystogram showed spontaneous healing of the fistula. The patient was followed up for 5 months with free of symptoms. DISCUSSION: Inappropriate activation of pancreatic proenzymes causes acute pancreatitis. It digests the pancreatic parenchyma, the peripancreatic tissues, leads to arterial pseudoaneurysms, fat necrosis and bowel perforation. Pseudocyst can communicate with the pleura, peritoneum, and gut or to the skin surface. Pancreatic fistulas to the urinary tract are rare and such fistulas usually communicate with the left kidney. Urinary amylase levels can thus be monitored.

1812 Upper Esophageal Stenosis Secondary to Multiple Foreign Body Ingestions

INTRODUCTION: Multiple episodes of foreign bodies ingestion and subsequent esophagogastroduodenoscopies (EGDs) can lead to an uncommon and disabling complication- esophageal stenosis. We present an interesting case of recurrent foreign body ingestions complicated by upper esophageal stenosis making further foreign body retrieval difficult. CASE DESCRIPTION/METHODS: A 33-year-old female with a past medical history of borderline personality disorder, impulse control disorder and recurrent non-suicidal foreign body ingestions requiring multiple EGDs and surgeries presents to the emergency department after ingesting a battery. On arrival, she complained of trouble swallowing, chest pain and abdominal pain. Physical examination was remarkable for abdominal tenderness and guarding. Laboratory results showed hemoglobin of 8.4 gm/dl and hematocrit of 27.8%. Plain radiography of the chest and abdomen revealed a radiopaque tubular device overlying the stomach (Figure 1a) and a cylindrical radiopaque foreign body overlying the left upper quadrant over the stomach (Figure 1b), respectively. Patient was intubated and scheduled for an EGD. During the procedure, the patient was noted to have scarring and granulation polyp in the mid esophagus. (Figure 2) A battery was found in the gastric body and removed via a snare. During retrieval, the cricopharyngeus muscles were found to be tight and did not enable the passage of the battery. That required the use of Miller blade to open up the pharynx to enable safe passage. Battery was intact on removal. (Figure 3) The patient tolerated the procedure well and was discharged home after a period of observation. DISCUSSION: Foreign body ingestion and subsequent endoscopic procedures are associated with a variety of complications, including perforation, bleeding and infection. Those complications may result from the sedation as well as the diagnostic and therapeutic maneuvers performed. Our patient had a history of multiple foreign body ingestions, including knives and razor blades, requiring multiple EGDs for their removal. These together led to scarring of her esophagus with subsequent healing and contraction, resulting in esophageal stenosis. This warranted additional intervention and multidisciplinary approach for safe removal of the foreign body. Given the risk of esophageal stenosis in patient with recurrent foreign body ingestions, endoscopists should keep this complication in mind and be prepared with the needed equipment.

Clinical and laboratory findings in 60cows with type-3 abomasal ulcer.

This study involved 60 cows aged 1.9 to 13 years (mean 4.8 ± 2.3 years) with type-3 abomasal ulcer. The most common clinical signs were, in decreasing order of frequency, partial or complete anorexia (98%), obtunded demeanour (95%), decreased skin surface temperature (78%), congested scleral vessels (73%), abdominal guarding (61%), tachypnoea (58%), fever (58%) and tachycardia (55%). One or more concomitant disorders were diagnosed in 86% of the cows. The most common abnormal laboratory findings were hypokalaemia (75%), shortened glutaraldehyde test time (46%) and hyperfibrinogenaemia (43%). The diagnosis of type-3 abomasal ulcer was made in all cows during laparotomy and/or at postmortem examination. Forty-eight (80%) cows were euthanased immediately after the initial examination, during laparotomy or after unsuccessful treatment. Twelve (20%) cows were treated with a solution of sodium chloride and glucose administered via an indwelling jugular catheter, antibiotics, metamizole or flunixin, and discharged from the clinic. Ten cows were still in production two years later.

Simplified acute physiological scoring ii ability to accurately predict mortality and morbidity in perforation peritonitis

Background and objective: The purpose of this study was to assess the efficacy of SAPS II scoring in predicting mortality and morbidity in patients with perforated peritonitis. To supply patients with perforation peritonitis with an objective prognostic method. For the purpose of providing a risk classification system for patients with perforation peritonitis. Method: The participants in a prospective observational study included 125 adults over the age of 18 who presented to the surgical ward at Department of General Surgery, Dhanalakshmi Srinivasan Medical College & Hospital, Perambalur, Tamil Nadu, India. with symptoms of perforation peritonitis from June 2018 to May 2019. These symptoms included abdominal tenderness, guarding, rigidity, and rebound tenderness. Additionally, the participants' x-rays showed air under the diaphragm. Result: 125 patients who were admitted to our hospital during the study period all had their SAPS II scores calculated. There were 102 males and 23 females total. Those with a SAPS II score below 20 may be categorized separately from those with a score between 21 and 40, while those with a score over 40 could be categorized separately from those with a score between 21 and 80. The low-risk category included those with a SAPS II score of less than 20, who experienced no deaths and required shorter hospital stays. Patients with a SAPS II score between 21 and 40 were considered to be in the moderate risk group; those with a score of 40 or higher had the highest mortality rate. Conclusion: The severity of a patient's perforation peritonitis can be predicted with high accuracy using the Sequential Organ Failure Assessment (SAPS) II score.

Small-Bowel Volvulus Caused By Mesenteric Lymphangioma

A 6-year-old boy with abdominal pain and vomiting visited the emergency department. He repeated these symptoms once a month from the age of 4 years, which were ameliorated by rest. He had tenderness in the whole abdomen, but no abdominal guarding. Abdominal radiography showed gas in the left upper quadrant. Contrast-enhanced abdominal computed tomography scan showed a snowman-like space-occupying lesion (Figure A, arrow) and a whirlpool sign indicating wrapping of the superior mesenteric vein around the superior mesenteric artery (Figure B, arrow).

Parameters for therapeutic laparotomy in blunt trauma abdomen

Background: The rapid identification of potentially life threatening intra-abdominal injury is critical for patients who sustain blunt abdominal trauma. There has been a shift from operative to non-operative management (NOM) in hemodynamically stable blunt trauma abdomen patients. The aim of present study was to determine the certain clinical and radiological parameters for therapeutic laparotomy (TL) in blunt trauma abdomen in adult patients.Methods: A prospective observational study was conducted on victims of blunt trauma who presented to our level II Emergency Department from May 2012 to June 2014. Their clinical, laboratory and radiological parameters were collected, evaluated and analyzed. A previously developed ultrasound scoring system was applied to FAST findings. Patients were followed to determine if they underwent TL or NOM.Results: A total of 7750 polytrauma patients with suspected blunt trauma abdomen underwent FAST. 338 (4.36%) patients had a positive FAST, out of which 144 were included, 93 (64.58%) patients were selected for NOM, and 51 (35.4%) patients underwent TL. NOM was successful in 76 (81.73%) patients, whereas 17 (18.27%) failed NOM and were operated. Using recursive partitioning analysis, the most important predictor for a TL, was whether the patient has an ED SBP of ≤90mmHg while other parameters include, ED pulse rate >110/min; total fast score >3; large amount of hemoperitoneum; presence of abdominal guarding, pallor and polytrauma.Conclusions: There are certain immediately available clinical, and radiological parameters, which if validated by a prospective, large sample size study could help in deriving a decision rule or even a scoring system that would determine the need for therapeutic laparotomy in blunt trauma abdomen patients.

Seleção de fêmeas de pacu para indução hormonal: efeito da idade e dos métodos de avaliação

Neste estudo, investigamos o ciclo reprodutivo e a época de desova de fêmeas “velhas” (FVs) e fêmeas “jovens” (FJs) de P. mesopotamicus, visando melhorar o processo de seleção de peixes para a indução hormonal. Avaliamos também a acurácia do uso de características corporais externas para a seleção de fêmeas para indução hormonal. Para isso, 60 FVs e 60 FJs (10 e quatro anos, respectivamente) foram submetidas a sete amostragens durante dois ciclos reprodutivos. Em cada amostra, as fêmeas (cinco a 10 por tratamento) foram capturadas para avaliação das concentrações plasmáticas de esteroides gonadais e composição dos ovários (biópsias e estereologia). As fêmeas foram também submetidas à uma avaliação externa relativa à espessura abdominal, o grau de rigidez abdominal e o aspecto da papila urogenital. Exceto pela ocorrência de concentrações reduzidas de 17α-hidroxiprogesterona nas FVs, durante a época de desova, observamos que FVs e FJs , mantidas em cativeiro, apresentam ciclos reprodutivos e épocas de desova similares (em dezembro para ambos os grupos). Não recomendamos o uso exclusivo da avaliação externa para a seleção de reprodutores para indução a desova, devido a uma imprecisão dos dados e falta de associação destes com a histologia e biópsia de ovário, os quais são mais precisos e confiáveis.