Abdominal Guarding Research Articles

An Unusually Long Appendix: A Case Report and Literature Review

BACKGROUND: Acute appendicitis is one of the most common conditions in emergency surgery and appendectomy is the most frequently performed surgical procedure. The complexity of this pathology is reflected in the numerous congenital malformations and anatomical variations of the vermiform appendix. Anatomical variations are mainly related to its length and position. The average length of the appendix was found to be 9.5 cm in the male and 8.7 cm in the female, but different length has been reported, from 1 cm to even a 33 cm on the cadaver. CASE PRESENTATION: A 34-year-old man was admitted to the general surgery department due to symptoms that began the previous day. The patient complained of lumbar pain which later migrated to the periumbilical region and the right lower quadrant (RLQ) of the abdomen followed by fever, nausea, and vomiting. On clinical examination, he had a tenderness in RLQ with abdominal guarding. Laboratory analyzes showed leukocytosis and high markers of inflammation. Urinalysis and abdominal ultrasound were normal. Taking into consideration the clinical presentation and laboratory parameters, a decision was made to proceed for an open appendectomy. Intraoperatively, the appendix was inflamed, very long, partly retrocaecal, and partly paracolic in position, with two coils, extending upward. After dividing the mesoappendix, it measured 20 cm in length. The appendectomy was performed. Post-operative recovery was without complications. The patient was discharged from the hospital on the 3rd post-operative day. CONCLUSION: Although acute appendicitis is very frequent condition in emergency surgery, making the diagnosis could be challenging due to numerous differential diagnostic dilemmas. The position of the appendix and direction of its extension could lead to misdiagnosis. The synthesis of clinical examination, laboratory analyzes, and diagnostic procedures should lead clinicians to the right diagnosis and surgical treatment, avoiding possible complications and additional costs.

Risk factors, clinical indicators, and pathological findings of abomasal ulcers in tropical dairy buffaloes.

The current study aimed at identifying the risk factors and initial diagnostic aids for abomasal ulcers. The risk factor analysis confirmed a significant association (P < 0.05) of abomasal ulcers with concentrate-rich diets (OR, 4.795; CI, 1.212-15.974) and concurrent disorders (OR, 2.978; CI, 0.987-8.980), while the buffaloes in early lactation (OR, 2.777; CI, 0.703-10.972) showed a higher tendency (P = 0.078) for the disorder. The depressed demeanour, dark or black manure (melena), anemia, tachycardia, decreased milk production, anorexia, tachypnea, absence of rumination, abdominal guarding, kyphosis, and tachypnea were the most frequent clinical signs. Subjecting the abomasal fluid for cultural isolation, gram staining, and stormy clot fermentation test identified the presence of clostridium perfringes, while screening through uniplex PCR detected cpa toxin. The buffaloes affected with type-3 and 4 abomasal ulcers exhibited a higher peritoneal fluid to serum ratio of total protein, albumin, and glucose with a low (P < 0.01) serum-ascites albumin gradient (SAAG) concentration compared to reference values of healthy buffaloes. The first two principal components of PCA explained 54.50% of the total variances with lymphocytes, creatine kinase, and rumen chloride levels as the top contributors to dimension I, and albumin, total protein, sodium, and methylene blue reduction time (MBRT) for rumen liquor as the major contributors to dimension II. The vector plot revealed lymphocytopenia, decreased hemoglobin, hypoalbuminemia, hypokalemia, decreased rumen pH, neutrophilia, eosinophilia, leucocytosis, greater MBRT, and higher rumen chloride, serum creatine kinase, and blood urea nitrogen as the major indicators for abomasal ulcers. Histopathological studies revealed infiltration of inflammatory cells in the mucosa along with multifocal areas of necrosis, degeneration, and eroded muscle structure. The study projected a few high-scored clinical signs and extremely variable clinical indicators as initial diagnostic aids of abomasal ulcers, which can be confirmed by ultrasonography and peritoneal fluid examination.

An Assessment of the Etiologies Associated With Acute Abdomen Subjected to Exploratory Laparotomy: A Study From a Rural Area of Himachal Pradesh.

Background The aim of this retrospective study is to establish a correlation between clinical features, surgical diagnosis, and the final diagnosis of laparotomies, as well as to establish the relationship between preoperative delay on the outcomes of surgery in the form of mortality and morbidity. Emergency surgery is high-risk in patients with acute abdomen with uncertain diagnosis. The results of surgery are remarkable and provide quick relief to the suffering and agony of patients with the dreadful condition of acute generalized peritonitis. Methodology Patients presenting with complaints of acute abdomen who needed laparotomy based on clinical judgment and investigations were included in this study. The study data were reviewed from April 2007 to January 2011 and March 2014 to February 2016 in a government hospital. Results A total of 174 patients with acute abdomen in whom there was an indication of laparotomy based on clinical judgment and radiological investigations were selected. Most patients had gastrointestinal perforation (n = 115) and acute intestinal obstruction (n = 23). The most important clinical features analyzed were abdominal tenderness (n = 160), guarding (n = 153), distention (n = 75), and tachycardia (n = 63). Conclusions Among the total patients, 150 underwent surgery within 24 hours of the presentation in the emergency and the remaining after 24 hours. The most common cause of laparotomy was a duodenal perforation in 79 patients and gastric perforation in 24 patients. A total of 114 patients developed no complications postoperatively. Among patients who developedpostoperative complications, wound sepsis and acute respiratory distress syndrome were the most common. Mortality was noted in three patients.

Clinical Presentations and Operative Management of Non Traumatic Acute Pain Abdomen- A Prospective Interventional Study from Jorhat, Assam, India

Introduction: Non traumatic acute abdominal pain is a very common reason for patients’ visit to the Emergency Department and remains a challenging task for general surgeons in terms of appropriate diagnosis as well as management in a timely manner. Aim: To evaluate the clinical presentations, the operative management and the post-operative outcome of patients presented with non-traumatic acute pain abdomen. Materials and Methods: A hospital-based prospective interventional study was done in 250 patients presenting with non-traumatic acute pain abdomen to the Emergency Department of General Surgery, Jorhat Medical College and Hospital, Jorhat, Assam, India, from June 2021 to May 2022. Demographic profile, detailed history physical examination, operative managements and the outcome were noted. Results: Out of 250 patients with non-traumatic acute pain abdomen who underwent operative intervention, most affected age group was 2nd-4th decade of life, comprising 165 (66%) patients. A total of 167 (66.80%) were males. Most common presenting symptom besides pain abdomen was nausea, seen in 172 (68.80%) cases. Most common clinical sign besides tenderness was abdominal muscle guarding, seen in 220 (88%) cases. Acute appendicitis was the most common aetiology with 129 (51.60%) patients and emergency open appendicectomy was the most common surgical procedure performed. Most common post-operative complication was surgical site infection, seen in 57 (22.80%) cases. Mortality rate was 3.60% (9 deaths). Conclusion: As most acute pain abdomen invariably present with surgical emergency and varied aetiology, the complexity for imparting the most appropriate treatment is increased. Hence, surgeons in the emergency department need to be wellversed in assessing the patients right from taking of proper history, clinical correlation of symptoms to elicitation of signs, assisted with most readily available investigations, to arrive at a prompt diagnosis to provide appropriate surgical intervention at the earliest.

CLINICOPATHOLOGICAL STUDY OF SMALL BOWEL PERFORATIONS IN NORTH COASTAL ANDHRA

Ÿ Small bowel perforations are one of the most common abdominal surgical emergency . The aim of the study is to review and study patients who have small bowel perforation. To analyze the clinicopathological relations of small bowel perforation in north coastal andhra to understand various causes in geographic variations. This study is a prospective clinicopathological study. 60 patients presenting with features of small bowel perforation were studied. A detailed history was noted in all the patients. Patients underwent both routine and radiological investigations. For pathological analysis, biopsy was taken from the perforation were sent. Co-relation was made between pathological reports and clinical presentation of patients. Ÿ Most patients were males in the age group of 31-40 years. Perforation of the duodenum was most commonly found in all the cases studied. Abdominal pain and distension was found. Guarding and rigidity were present in 70% of cases . On histopathological examination, duodenal perforation was most commonly due to chronic inammation. Ÿ Small bowel perforation commonly presents in middle-aged male working as laborers. Commonly presents with abdominal pain , vomiting, abdominal distension, fever, and constipation are chief complaints. pallor, dehydration, and features of shock were evident. Tenderness, abdominal guarding and rigidity, absent/sluggish bowel sounds were usually found on examination. Air under the diaphragm on erect x-ray abdomen was diagnostic. The pathological analysis was done Chronic inammation was the most common non-traumatic cause of duodenal perforation and nonspecic inammation in ileal perforation found on HPE. Early resuscitation and exploratory laparotomy is the treatment.

S3689 Unforeseen Postoperative Complication in a Bariatric Patient: The Rare Case of a Large Phytobezoar Causing Gastric Outlet Obstruction

Introduction: Bariatric surgery has become increasingly popular in the treatment of obesity to achieve sustainable weight loss. Despite its numerous benefits, complications can arise due to postoperative gastric hypoacidity and motility disorders. Phytobezoars is an infrequent complication of bariatric surgery that arise from impacted aggregates of indigestible fruit and vegetables. Rarely, bezoars can cause gastric outlet obstruction and/or perforation. The following case highlights the presentation, diagnosis and treatment of phytobezoars and the importance of diet compliance in bariatric patients. Case Description/Methods: A 60-year-old woman with hyperlipidemia was admitted due to progressive epigastric fullness and postprandial emesis of 2 weeks’ duration. Moreover, nausea was constant associated with abdominal bloating and 7-pound weight loss. Pepcid did not alleviate symptoms. She denied fever, chills, chest pain, shortness of breath, diarrhea, constipation, hematochezia nor hematemesis. Her past surgical history was pertinent for sleeve gastrectomy in 2017. She denied toxic habits. Labs were unremarkable except for isolated thrombocytopenia. Physical exam was pertinent for mild epigastric tenderness; no abdominal rigidity nor guarding present. Despite abdominopelvic CT revealing a gastric fundus dilation, an upper GI series was the study that diagnosed a large lobular filling defect compatible with a 7.2 cm phytobezoar.1 Upon questioning, the patient reported that she arrived from a cruise vacation before onset of symptoms. She recalled consuming large amounts of vegetables, nuts and fruits. Initial intervention consisted of papain meat tenderizer to help dissolve bezoar. Nevertheless, symptoms persisted due to oral medication intolerance. Upper endoscopy was performed and phytobezoar was removed with Roth Net retriever. After procedure, patient was able to progressively tolerate diet and was discharge home with resolution of symptoms. Avoidance of excessive high fiber diet was recommended to prevent future bezoar formations (Figure 1). Discussion: The incidence of large phytobezoars has been reported as low as 0.3% in the general population, and therefore, its identification is a diagnostic challenge. Even though most of the patients remain asymptomatic, large bezoars can cause gastric outlet obstruction that could end in perforation if not treated promptly. This case emphasizes the importance of considering phytobezoars as a cause of GI symptoms and the importance of diet education in bariatric patients.Figure 1.: 1. Upper GI series X-ray showing a 7.2 cm phytobezoar causing a large lobular filling defect in the stomach fundus.

S3304 Acute Occlusive Mesenteric Ischemia From Venous and Aortic Thrombosis in a Patient with Hyperhomocysteinemia and Liver Cirrhosis

Introduction: Portal vein thrombosis (PVT) is a severe complication of liver cirrhosis and one of its major consequences include intestinal ischemia. Hyperhomocysteinemia (HHcy) has been suggested to be an independent risk factor for deep venous thrombosis, but limited data are available on the prevalence of HHcy in patients with PVT complicating liver cirrhosis. Several clinical studies have also demonstrated the role of HHcy in arterial and venous thrombosis. Case Description/Methods: We report a case of a 57 year old male with Liver Cirrhosis from Alcoholic Liver Disease, who presented at our ED with a two week history of dull periumbilical pain which worsened on the day of consult. Plain abdominal CT scan showed nonspecific small bowel enteritis. He was placed on general liquid diet and started on Ciprofloxacin and Metronidazole intravenously. However, on the third hospital day, he complained of sudden severe abdominal pain accompanied by abdominal distention, guarding, and direct and rebound tenderness on all quadrants. He had hypotension and on laboratory workup, had decreasing hemoglobin levels with elevated WBC count and lactate. Contrast-enhanced abdominal CT scan revealed portal and superior mesenteric vein thrombosis, bowel wall ischemia along the segment of the jejenum in the left hemiabdomen, and infrarenal abdominal aorta and ascending aorta thrombi. Emergency exploratory laparotomy was done with segmental jejunoileal resection and primary end-to-end anastomosis with intraoperative findings of gangrenous small bowels measuring 100 cm in length, with the rest of the proximal small bowels noted to be dilated and edematous. The patient was transferred to the intensive care unit post-operatively for closer monitoring; Heparin drip was started 24 hours post-surgery. Histopathology results showed extensive transmural infarction, hemorrhage, and necrosis on small bowel segments; organizing thrombi were seen on mesenteric vessels. The patient was worked-up for other causes of hypercoagulable states which showed elevated Homocysteine levels at 20.6 (NV: 5-12). Discussion: It is likely that HHcy may increase the risk of patients with liver cirrhosis to develop arterial and venous thrombosis considering the pivotal role the liver plays in the metabolism of sulphur amino acids and Hcy-related vitamin storage. Therefore, identification of this high-risk group may be important to plan prevention management, such as vitamin supplementation, other Hcy-lowering strategies, or long-term anticoagulation.

Emergency Presentations of Meckel's Diverticulum in Adults.

Meckel's diverticulum is the commonest congenital anomaly of the gastrointestinal tract in humans that is commonly encountered during surgical practice as the cause of the patient's presentation or as an incidental finding during other unrelated procedures. Most clinical symptoms are caused due to its complications. The mean age of the involved patients was 24.79 years with slight male predominance, 62.9% males compared to 37.1% females. The mean length of the diverticulum was 55.21 cm. The most common emergency presentation was right lower quadrant abdominal pain in 31% of the patients, intestinal obstruction in 28.6%, acute lower abdominal pain and guarding and acute abdomen in 18.6% and 15.7% of patients, respectively, bleeding per rectum in 2.9%, acute right upper quadrant abdominal pain in 1.4%, and obstructed paraumbilical hernia containing the diverticulum in one patient. Perforation of the Meckel's diverticulum was reported in 18.6%. Histopathological examination showed acute inflammation in the wall of the diverticulum in 37.1%, lymphoid hyperplasia in 24.3%, hemorrhagic necrosis in 22.9%, and chronic inflammation in 8.6%. Ectopic mucosa was detected in 50% of the cases, gastric mucosa was detected in 42.86%, ectopic pancreatic mucosa was detected in 5.71%, and both gastric and pancreatic types in 1.43%. Long diverticula are more liable to develop complications. At surgery, inspection and palpation of the wall of the diverticulum must be done for any evidence of inflammation, necrosis, perforation, or abnormal thickening of the walls of the diverticulum. Resection of the segment of the bowel that contains the diverticulum with primary anastomosis is preferable to other procedures due to the risk of leaving behind an abnormal heterotopic mucosa.

Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients.

Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality. Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS. Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl. This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.

Abomasal impaction in buffaloes: Risk factors, clinical indicators, necropsy findings, and histology studies.

The present study aims to identify potential risk factors and most possible clinical indicators of abomasal impaction in buffaloes. Among the screened buffaloes (n = 636), the logistic model was fitted for 491 buffaloes because of the non-availability of parity-related data for 145 buffaloes. Third-trimester pregnancy, feeding paddy straw alone, and concurrent disorders were identified as the potential risk factors using multivariate regression analysis. The buffaloes reared by farmers devoid of land tended to have a higher incidence of abomasal impaction. Depressed demeanour, absence of rumination, abdominal guarding, scleral congestion, sunken eyeballs, anorexia, reduced dung output, abacus beads-like faeces, colic signs (straining to defecate, frequent lying down, and kicking at abdomen), tachypnea, and tachycardia were the most repeatedly noticed clinical signs in buffaloes diagnosed with abomasal impaction. Further, the principal component analysis revealed increased rumen fluid sedimentation time and chloride content, serum creatine phosphokinase, and blood neutrophil and eosinophil content along with decreased blood lymphocytes proportion, potassium, and chloride as the greatest indicators for abomasal impaction. Next to them, a higher rumen fluid methylene blue reduction time, serum urea nitrogen, and blood total leucocyte count, along with a lower serum albumin and blood haemoglobin were the best possible indicators for diagnosis. The necropsy findings of the buffaloes that died with abomasal disorders revealed an abomasum with increased dimensions and constant pitting on pressure. Furthermore, the histopathological studies showed degeneration and necrosis of the abomasal wall with infiltrated mononuclear cells. The results of the study help in designing a comprehensive evaluation mechanism for diagnosing abomasal impaction in buffaloes.

Small bowel obstruction after laparoscopic adjustable gastric band: The gastric band is not always the one involved

A 67-year-old woman with a history of laparoscopic adjustable gastric banding 15 years ago was admitted with abdominal pain associated with nausea, vomiting, and respiratory distress. The patient’s comorbidities were psychiatric disease and eventration’s repairs. The patient was hemodynamically unstable with a heart rate of 125 bpm and mean arterial pressure of 80 mm Hg. Physical investigation revealed diffuse abdominal pain associated with an abdominal guarding, a distended abdomen, and absent bowel sounds.

Perforated jejunal diverticulum as an unsual cause of acute abdomen: A case report.

Introduction and importanceJejunal divertica is a rare entity with an often clinically silent course. However, it may be associated to life-threatening complications such as perforation. Therefore it should be considered in every case of acute abdomen.Case presentationA 60-year-old female presented with a generalized abdominal pain associated with vomiting evolving for 24 h. Physical examination found an irreducible and tender hernia in the umbilical region with abdominal guarding. Laboratory test results showed a biological inflammatory syndrome. The primary diagnosis of strangulated umbilical hernia was suspected and the patient underwent an emergency laparotomy. Intra-operative examination revealed mutiple jejunal diverticula, with a perforation in one diverticulum leading to generalized peritonitis. A bowel resection and peritoneal lavage were performed with good outcome.Clinical discussionJejunal diverticula is a challenging condition with various non-specific clinical presentations. Jejunal perforation is its most feared complication. Deceitful abdominal examination among elderly patients and lack of specific signs may lead to diagnostic delay responsible for high mortality rate and poor prognosis. Adjunctive imaging modalities may be needed to help establish a prompt diagnosis and dictate management strategy. Treatment of perforated jejunal diverticulum is based on limited bowel resection associated to primary anastomosis.ConclusionJejunal diverticulitis should be kept in mind as a differential diagnosis in every case of acute abdomen. High index of clinical suspicion and eventual further radiological examinations are required to avoid misdaignosis and save patients' lives.

Acute Acalculous Cholecystitis: Think of Hepatitis A Infection and Do Not Underestimate Pain.

A 14-year-old adolescent girl presented with severe abdominal pain, tenderness, and guarding in the right upper quadrant associated with nonbilious vomiting, scleral icterus, and fever. Laboratory tests were consistent with acute hepatitis A virus-related cholestatic hepatitis. A point-of-care ultrasound showed mild gallbladder wall thickening with increased color Doppler flow and pericholecystic fluid collection, in the absence of gallstones or biliary ducts dilatation, thus suggesting acute acalculous cholecystitis. Both the clinical symptoms and the point-of-care ultrasound findings completely resolved within 1 week after admission with conservative treatment.

Internal herniation of the right colon through the foramen of Winslow: A case report.

Introduction and importanceHerniation through the Foramen of Winslow, also known as the epiploic foramen, is an extremely rare phenomenon with less than 200 cases reported in medical literature. Internal hernias account for less than 1% of all hernias and roughly 8% of all internal hernias occur through the foramen of Winslow. We present a case of a foramen of Winslow hernia that was not detected until direct visualization with laparoscopy.Presentation of caseA 52 year-old healthy female with a surgical history of a Caesarean section presented to the ER with severe epigastric pain radiating to her back. Physical exam was positive for abdominal tenderness and guarding. Vital signs were within normal limits. Murphy’s sign and Rovsing’s sign were negative. Initial imaging studies, including a CT scan of the abdomen, and laboratory findings were unremarkable. A hepatobiliary iminodiacetic acid (HIDA) scan was performed and demonstrated non-visualization of the gallbladder suggestive of acute vs. chronic cholecystitis. Following these results the patient elected to undergo exploratory laparoscopy with potential cholecystectomy. Intra-operatively, the colon was noted to be herniated through the foramen of Winslow. The procedure was converted to an open laparotomy. The hernia was manually reduced, and a right hemicolectomy was performed to prevent recurrence of the hernia.DiscussionReports list an enlarged foramen of Winslow, excessive viscera mobility (i.e., persistent ascending mesocolon or long small bowel mesentery), and an increase in intra-abdominal pressure as potential risk factors for this particular hernia. In our case, the patient was noted to have excessive mobility of the viscera with the presence of persistent ascending mesocolon and an abnormally long right mesentery. Physical exam is usually nonspecific and laboratory findings are typically unremarkable, posing a diagnostic challenge. Additionally, radiological findings indicating presence of an internal hernia were missed in the initial CT scan read by the radiologist. Internal hernias need to be managed surgically as there is a risk of strangulation with bowel ischemia.ConclusionThis rare radiographic phenomenon is difficult to diagnose radiographically and warrants further workup due to the potential risk of bowel strangulation despite negative clinical and laboratory findings.

Gastric Pneumatosis with Portal Venous Gas can be Treated Non-operatively: A Retrospective Multi-institutional Study.

Gastric pneumatosis (GP) is a rare radiologic finding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would benefit most from operative management. Between 2010 and 2020, all CT-scan reports in four tertiary centers were searched for the following terms: "gastric pneumatosis," "intramural gastric air" or "emphysematous gastritis." The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions' medical records. Among 58 patients with GP, portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identified the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2mmol/l, and the absence of gastric dilatation. Multivariable analysis identified the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07-1.79) and the absence of gastric dilatation (OR: 0.07, 95% CI: 0.01-0.79). None of the patients presenting with a baseline lactate rate<2mmol/l died within 30days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%). GP could be managed non-operatively, even in the presence of portal venous gas. However, patients with arterial lactate level>2mmol/l, or the absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.

DIAGNOSTIC CHALLENGE OF LEFT-SIDE APPENDICITIS DUE TO SITUS INVERSUS TOTALIS IN A LIMITED SETTING: A CASE REPORT

Background: Acute appendicitis is an acute abdominal case with a high incidence and often requires emergency surgical intervention. Situs inversus totalis is a rare congenital abnormality in which the thoracic and abdominal organs are totally transposed. Left-sided acute appendicitis (LSAA) is common in patients with congenital abnormalities such as situs inversus totalis. Diagnosis of LSAA is even more challenging, especially in peripheral areas which can lead to misdiagnosis and complications such as perforation or abscess. Imaging modalities are usually required to confirm the diagnosis. Case Presentation: A 21 years old male patient came to the emergency department with chief complaint of severe abdominal pain, starting 3 days earlier, localized to the epigastric area and migrating to the left lower quadrant. The patient also demonstrates fever, nausea and vomiting. Physical examination revealed an increasing abdominal wall rigidity and tenderness in the left lower quadrant as well as rebound tenderness. Laboratory tests revealed leucocytosis and increased neutrophils count. The patient underwent 3-position abdominal radiograph after chest X-ray showed dextrocardia. Exploratory laparotomy was done in this patient, showing a perforated appendix and totally transposed abdominal organs. Conclusion: Imaging modalities such as ultrasonography and abdominal CT Scan can be helpful in determining the diagnosis of LSAA and reduce the likelihood of misdiagnosis and complication. The possibility of LSAA and situs inversus should be suspected in a patient presenting with left lower quadrant abdominal pain with proven dextrocardia from chest X-ray. Keyword: Left-sided acute appendicitis, situs inversus totalis, dextrocardia

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.

The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children. Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted. A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7±3.3years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0±3.3years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported. Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis

Research Article| December 01 2021 Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis AAP Grand Rounds (2021) 46 (6): 64. https://doi.org/10.1542/gr.46-6-64 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Tips to Prevent Delayed Diagnosis of Pediatric Appendicitis. AAP Grand Rounds December 2021; 46 (6): 64. https://doi.org/10.1542/gr.46-6-64 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendicitis, delayed diagnosis Source: Michelson KA, Reeves SD, Grubenhoff JA, et al. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. JAMA Netw Open. 2021;4(8):e2122248. doi: https://doi.org/10.1001/jamanetworkopen.2021.22248Google Scholar Investigators from multiple institutions conducted a case control study to evaluate clinical features associated with a delayed diagnosis of appendicitis in children and to assess how frequently the delay in diagnosis might have been preventable. Study participants were patients <21 years old diagnosed with appendicitis at 1 of 5 pediatric emergency departments (EDs) in the US between 2010 and 2019. Cases were children with 2 ED visits within 7 days leading to a diagnosis of appendicitis and were identified by reviewing diagnostic codes available in the Pediatric Health Information System (PHIS). Controls were patients with a diagnosis of appendicitis made at the time of their initial ED visit who had been previously enrolled in a prospective study at 1 of the participating EDs between 2010 and 2013. Demographic and symptom information were collected systematically on control patients at the time of their ED visit. The medical records of cases were reviewed and demographic and clinical data from the 2 ED visits abstracted. Using a validated scoring system, the Modified Safer DX checklist, the record from the initial ED visit in cases was systematically reviewed and the preventability of the missed diagnosis classified as “likely,” “possibly,” or “unlikely” preventable. Logistic regression was used to compare the presence of specific clinical features of appendicitis observed during the initial ED visit for cases compared to ED visit in controls. In a second model, “care features” such as use of specific medications or imaging were included. Length of stay (LOS) and rates of perforation in cases and controls also were compared. Data were analyzed on 748 children with a mean age of 10.2 ±4.3 years, including 471 cases and 277 controls. Overall, 109 (23.1%) of delayed diagnoses of appendicitis in cases were judged to be unlikely preventable, 247 (52.4%) possibly, and 115 (24.4%) likely. Compared to clinical features in controls, at their initial ED visit case patients were significantly more likely to have abdominal pain present for 48-96 hours (vs <24 hours; odds ratio [OR], 2.84; 95% confidence interval [CI], 1.16, 4.97) and less likely to have pain with walking (OR, 0.16; 95% CI, 0.10, 0.25), maximal pain in right lower quadrant (OR, 0.12; 95% CI, 0.07, 0.19), or abdominal guarding (OR, 0.33; 95% CI, 0.21, 0.51). In the model including care features, cases were more likely to have received non-steroidal anti-inflammatory drugs (OR, 3.78; 95% CI, 2.10, 6.80) and ondansetron (OR, 1.99; 95% CI, 1.10, 3.61), less likely to have received opioids (OR, 0.26; 95% CI, 0.14, 0.49), and less likely to have an ultrasound examination (OR, 0.13; 95% CI, 0.08, 0.24). LOS was longer in cases than controls (mean difference, 2.8 days; 95% CI 2.3, 3.4), and risk of perforation was higher in cases (OR, 7.8; 95% CI, 5.5, 11.3). The authors... You do not currently have access to this content.

Meckel\u2019s diverticulum with intraperitoneal hemorrhage in a child detected with screening laparoscopy: a case report

BackgroundThe most common presentation of symptomatic Meckel’s diverticulum (MD) are intestinal obstruction, gastrointestinal hemorrhage, and inflammation of the MD with or without perforation. Intraperitoneal hemorrhage because of MD is extremely rare. We report a case of MD with intraperitoneal hemorrhage in a child detected with screening laparoscopy.Case presentationAn 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days. Acute appendicitis was suspected, and she was referred to our department. Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis. She was diagnosed with a localized intra-abdominal abscess and the decision was made to treat with antibiotics. However, her abdominal pain worsened, with abdominal distension, tenderness and guarding. She was diagnosed with panperitonitis and the decision was made for surgery 5 h after admission. During surgery, laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity, originating from the mesentery of the ileum. MD was observed with bleeding from the surrounding mesentery. Small bowel resection was performed, and the patient was discharged on the 5th postoperative day. Pathological findings revealed an MD containing ectopic gastric mucosa and small intestinal ulcer perforation at the base of the MD.ConclusionsWe report an extremely rare case of an MD with intraperitoneal hemorrhage in a child. In pediatric cases, it is possible that perforation with ectopic gastric mucosa may cause massive bleeding because of rupture of the surrounding mesenteric blood vessels.

Pneumatosis intestinalis in children beyond the neonatal period: is it always benign?

The significance and management of pediatric pneumatosis intestinalis (PI) remains poorly defined. We sought to add clarity in children beyond the neonatal period. Pediatric patients 3months-18years admitted to a quaternary children's hospital with a diagnosis of PI were included in this retrospective study. Pathologic PI was defined as irreversible, transmural intestinal ischemia. 167 children were identified with PI. Of these children, 155 (92.8%) had benign PI and 12 (7.2%) developed pathologic PI. The most common underlying diagnosis for pathologic PI was global developmental delay (75%), although we identified a spectrum of underlying diagnoses at risk for PI. Physical exam notable for abdominal distension (p = 0.023) or guarding (p = 0.028), and imaging with portal venous gas (p < 0.001) or bowel distension (p = 0.001) were significantly associated with pathologic PI. Only 6.6% of all children underwent an operation. For those undergoing non-surgical management of benign PI, 75% of children received antibiotics and average duration of bowel rest was 6.8days. PI in children is primarily a benign phenomenon and often does not warrant surgical intervention. Bowel rest and antibiotics are therapeutic strategies frequently used in the treatment of this finding.