Abdominal Signs Research Articles

Laparoscopic management of acute presentations of obstructed, congenital, diaphragmatic hernias in adults: case reports

: Congenital diaphragmatic hernia (CDH) occurs in 1/2,500 neonates. Hernia of Bochdalek accounts for 6%; hernia of Morgagni for 3%. Our case reports highlight the unusual, acute presentation of CDH in adults, outline diagnostic process and discuss laparoscopic techniques that can be used by surgeons faced with these rare cases. Early papers suggest presence of less than 100 reported cases of symptomatic Bochdalek and Morgagni type hernias in adults. Due to limited available evidence, the need to share successes and failures of surgical techniques used is greater than ever. Case reports here discuss successful laparoscopic techniques that can be used. Hernia of Morgagni presented in a 62 years old gentleman with acute abdominal pain and signs of obstruction on CT. Hernia of Bochdalek presented in a 50 years old lady with acute abdominal pain and vomiting, with obstruction on CT. Laparoscopically, reduction of Morgagni hernia was followed by partial reversal of hernial sac—step where controversies exist in literature. Mesh repair of defect presented challenges. Primary closure of defect was performed for Bochdalek hernia owing to its smaller size, followed by tension pneumothorax—not an uncommon occurrence. Acute, uncomplicated cases of CDH in adults can be successfully managed with emergency laparoscopic surgery. Although there is lack of standardisation currently on best surgical technique, we found good results with reduction followed by primary closure of diaphragmatic defect and use of mesh repair in case of a larger defect.

Successful Medical Management of a Retroperitoneal Abscess: A Difficult Diagnosis in Pyrexia of Unknown Origin

Retroperitoneal abscesses are uncommon conditions with occult and insidious presentations. There is often a lack of abdominal signs and ultrasound findings, causing a delay in diagnosis and definitive treatment, leading to poor patient outcomes. We report a case of right-sided retroperitoneal abscess of a 28-year-old female patient with diabetes mellitus. Prior to admission, the patient reported a vague 2 weeks history of right-sided back and abdominal pain and dysuria. She presented to our medical ward with suspected pyelonephritis with right-sided renal abscess. A retroperitoneal abscess involving the right renal fossa was revealed on an urgent CT scan. The patient underwent percutaneous ultrasound-guided pigtail catheter drainage. Patient clinically and biochemically improved with medical management gradually over 2 weeks. This case report highlights the importance of investigating for recurrent urinary tract infections of diabetics which are often overlooked in general practice.

Case report of abdominal left upper quadrant collection secondary to fish bone perforation

We present an unusual case of an intra-abdominal collection which evidenced a rare etiology and raises diagnostic particularities.BackgroundFish bones ingestion is frequent, but seldom followed by complications. Those are often reported at specific sites.ObjectivesThis case report emphasizes the unusual presentation and site localization of a colonic perforation by a small fish bone, in the context of limited radiological accuracy at the diagnostic phase.Case presentationA 37 year old male was admitted to the gastroenterology ward with upper and left sided abdominal pain associated with fever and marked fatigue. His medical history was marked by a sleeve gastrectomy in 2010 for obesity. Abdominal signs and elevated acute inflammatory syndrome on blood tests were followed by computer tomography which revealed a pericolic mass near the left splenic flexure. The pain and fever increased in intensity, so a laparotomy was proposed. Intraoperatively, a tumor-like lesion was found and a resection with oncologic limits was performed. Microscopic examination of the specimen revealed a fish bone, but only after surgery did the patient confirm that he had eaten fish meal the week before. The post-operative period was uneventful.ConclusionFish bones remain some of the most frequently ingested alimentary foreign bodies; they may cause atypical clinical presentations, frequently omitted by the patients themselves if symptoms appear delayed. They could also lead to possible high-risk complications which need to be addressed by surgeons.

Abdominal Tuberculosis in Children: Challenges, Uncertainty, and Confusion.

The diagnosis of abdominal tuberculosis (TB) is challenging, and the prevalence of abdominal TB in children is likely underestimated. It may present with nonspecific abdominal symptoms and signs, but children who present with pulmonary TB may have additional abdominal subclinical involvement. Diagnosis is specifically challenging because none of the available diagnostic tools provide adequate sensitivity and specificity. In this review, we summarize the best available evidence on abdominal TB in children, covering the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment. We propose a diagnostic approach that could be followed for symptomatic children. We believe that a combination of investigations could be useful to both aid diagnosis and define the extent of the disease, and we propose that abdominal ultrasound should be used more frequently in children with possible TB and any abdominal symptoms. This neglected disease has received little attention to date, and further research is warranted.

Clinical and Biochemical Characteristics of Dengue Infections in Children From Sri Lanka.

Introduction:Analyzing dengue disease patterns from different parts of the world should help us formulate more evidence based treatment guidelines and appropriately allocate limited healthcare resources. Therefore, we described the disease characteristics of hospitalised pediatric patients with dengue infections from Sri Lanka during the 2017 dengue epidemic.Methods:Clinical and biochemical characteristics of pediatric dengue patients treated at a secondary care hospital in Sri Lanka from 1 June 2017 to 31 August 2017 were analyzed. Our findings were compared with previous pediatric dengue studies in Asia.Results: A total of 305 patients (number of males = 184(60%); mean age = 8.6 years) were analyzed. DF (Dengue Fever)—245 (80.3%), DHF (Dengue Hemorrhagic fever)—I:52 (17%), DHF—II:7 (2.3%), and DHF—III:1 (0.3%). Significant associations were found between DHF and abdominal symptoms/signs and overt bleeding manifestations (P < .001). Time of onset of the critical phase was variable (Day 3: 12%, Day 4-5: 78%, Day 6: 5%, and Day 7: 5%). Platelet and white-cell counts (WBC) were significantly lower in DHF than DF; liver enzyme derangement was mild and was similar in the DHF and DF subgroups. None had cardiac, renal, or neurological manifestations and all recovered uneventfully.Conclusion:In Sri Lankan pediatric dengue patients, we found abdominal symptoms and signs, decreased WBC and platelet counts and bleeding manifestations were to be significantly associated with DHF. Liver enzyme derangement did not predict DHF. The time of onset of the critical phase was difficult to predict due to the considerable variations noted.

Post traumatic hepatic bleeding in hepatocellular carcinoma

Background: Hepatic bleeding tumors are rare. It is important to become familiar with CT images because they can create diagnostic issues. Delayed treatment could cause the death of the patient. Case Presentation: A 42-year-old Chinese man was referred to the Emergency Room because of a trauma. One week later, he was readmitted to the Emergency Department for abdominal pain and signs of hemorrhagic shock. At this occasion, a CT scan is performed. The examination revealed the presence of intraabdominal bleeding with a liver hematoma and a liver bleeding mass. The patient had then surgery and a large bleeding hepatocellular carcinoma was resected. Conclusion: We report an unusual case of a bleeding mass following a trauma. In case of mild trauma, the symptoms may be few and hemoperitoneum may not be present in the early phases. The patient may not have a CT scan or the CT scan can be difficult to interpret because of the presence of bleeding.

Malaria in Pregnancy

Malaria is a potentially life-threatening disease that is transmitted by the bite of an infected Anopheles mosquito. Five known species of genus Plasmodium infect humans: Plasmodium vivax, Plasmodium ovale, Plasmodium Knowlesi, Plasmodium Malariae and Plasmodium falciparum. Malaria infection during pregnancy is a significant public health problem with substantial risks for the pregnant woman, her fetus and the newborn child.. The symptoms and complications vary according to malaria transmission intensity in the given area and the individual’s level of acquired immunity. Presented below is a case of a 26-years old primigravida, who returned to the UK from Nigeria after one week presenting with a 24 hour history of abdominal pain, nausea, vomiting and signs of sepsis. During her hospitalization, despite being treated for sepsis, the patient’s overall condition did not improve, therefore suspicion for malaria became very questionable. In consideration of the patient’s history and clinical presentation; a thorough investigation was to take in effect for this possible infection. Once diagnosis of malaria was confirmed, the appropriate treatment was administered.

Gallbladder Torsion: A Rare Diagnostic Challenge

Gallbladder torsion is a rare cause of acute abdominal pain and can be a diagnostic challenge for the general surgeon. We herein present a case of an 81-year-old man who presented with right-sided abdominal pain and signs of intra-abdominal infection. Transabdominal ultrasound, computed tomography (CT) and magnetic resonance cholangio-pancreatography (MRCP) scans could not identify with certainty the underlying cause of the symptoms and eventually the patient underwent a diagnostic laparoscopy, which revealed the presence of gallbladder torsion. Sequentially, a laparoscopic cholecystectomy was performed in a standard fashion and the patient had an uneventful post-operative recovery. Our case highlights the importance of diagnostic laparoscopy as a diagnostic and treatment tool in unclear cases of acute abdomen. J Curr Surg. 2020;10(3):28-31 doi: https://doi.org/10.14740/jcs405

Multicystic dysplastic kidney with severe abdominal obstruction signs – case reports and management of children

Multicystic dysplastic kidney with severe abdominal obstruction signs – case reports and management of children

Uterine Rupture in Subsequent Pregnancy in a Patient with Previous Uterine Manipulator Associated Uterine Perforation

To report a case who experienced uterine rupture at 38th week of gestation and had a history of manipulator associated uterine rupture. A 25 years old primigravid woman at 38 weeks of gestation was referred to our hospital with the signs of active labor. Heavy lower abdominal cramps and signs of acute abdomen suggested uterine rupture and emergent cesarean section was performed. A 3 cm in size and circular in shape uterin rupture at the fundus that was imitative of enlarged previous manipulator associated rupture was observed. A manipulator associated uterine rupture should be repaired when encountered in reproductive ages in order to prevent a possible uterine perforation during subsequent pregnancy.

2624 A Classic Case of Peutz-Jeghers Syndrome Presenting as Recurrent Intussusception

INTRODUCTION: Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant genetic disorder associated with mucocutaneous hyperpigmentation and hamartomatous gastrointestinal polyps. Here, we present a case of PJS presenting as abdominal pain due to recurrent intussusception in a patient without family history of gastrointestinal conditions. CASE DESCRIPTION/METHODS: A 28-year-old African American female with a remote history of intussusception and small bowel resection presented with 5 days of epigastric pain. An EGD and colonoscopy from years prior reportedly revealed multiple benign polyps. There was no family history of PJS, gastrointestinal, ovarian, or endometrial cancer. On exam, right lower abdomen was tender and oral mucosa revealed hyperpigmentation. Labs were notable for iron deficiency anemia with a hemoglobin of 8.3 g/dL. Abdominal CT revealed a left lower quadrant enteroenteric intussusception with a 2.3 cm small bowel tumor functioning as a lead point and a 3 cm cecal mass. Retrograde enteroscopy to evaluate the small bowel tumor revealed ileal nodules, no intraluminal cecal mass, and 2 ileal polyps that were resected. Pathology showed polypoid fragments of ileal mucosa with marked submucosal lymphoid aggregates. Upright abdominal Xray was obtained for worsening abdominal pain and peritoneal signs, which showed an air fluid level in the small bowel, concerning for obstruction. She underwent a diagnostic laparoscopy revealing a cecal mass and ileal intussusception. She had an ileocecectomy and small bowel resection with a large polypoid mass in the resected ileum. Histology of the cecal mass revealed a cystic nodule of benign small bowel mucosa and the ileal polypoid mass demonstrated a hamartomatous polyp with ectopic extension into the muscularis propria, suggestive of PJS. Subsequent STK11 gene analysis revealed an exonic deletion, confirming the diagnosis. DISCUSSION: Up to 69% of patients with PJS experience intussusception. The risk of intussusception reaches 50% by age 20 in these patients. Although the association of PJS with intussusception is well-known due to polyps functioning as lead points, PJS is rarely diagnosed on recurrence of intussusception. Endoscopic polyp removal is recommended in these patients to avoid complications of surgery but surgical resection remains the definitive treatment in most cases. Recurrent intussusception in adult patients is a finding that should elicit consideration of PJS in patients with a history of polyps and no significant family history.

Ovarian dysgerminoma causing multifocal metastases in young bitch

The ovarian neoplasias are unusual in canine species, mainly originated from germinative cells. Among these, dysgerminoma is a rare neoplasm in bitches, predominantly affecting senile and small and medium breeds. They are large, rounded, smooth surface, painless and firm in consistency. The clinical signs commonly demonstrated by patients with this neoplasia are abdominal distension and secondary signs of hyperestrogenism. The diagnosis should be based on the association of history, clinical signs, radiographic, ultrasonographic, cytological, histopathological and immunohistochemical exams. The treatment is the surgical castration and metastases are uncommon. Due to the rarity in bitches, specifically the young animals, this study aimed to describe a case of left ovarian dysgerminoma, of considerable size and adherence in adjacent organs, in a Brazilian Fila, whose showed considerable increase in abdominal volume and progressive weight loss. The diagnosis was confirmed by means of complementary x-ray, ultrasound, histopathological and immunohistochemical tests. Even with the recommended surgical treatment (castration), the patient demonstrated severe respiratory symptoms and increased abdominal volume after two months, and the complementary exams suggested pulmonary and multifocal metastases and the tutor chose euthanasia. As presented by the results, although rare in bitches, dysgerminoma should be included in the differential of ovarian neoplasias, including the young ones.

Surgical management of 86 patients with duodenal injuries

Objective To study the early diagnosis, surgical treatment options, prevention and management of complications in patients with duodenal trauma. Methods All patients with duodenal trauma treated operatively from January 2009 to December 2018 were studied retrospectively. Factors including sex, age, cause of injury, AAST grading, diagnostic method, operative procedure, therapeutic effectiveness, complications, and factors related to death were analyzed. The technique consisting of duodenal decompression and jejunal feeding as recommend by the authors were used in severe cases. Results Blunt trauma occurred in 66 of 86 patients (76.7%). The diagnosis of duodenal trauma was made preoperatively based on abdominal signs, peritoneocentesis, and imaging in 32 patients (37.2%). The remaining 54 patients (62.8%), with duodenal injury was detected during emergency laparotomy. All the 86 patients underwent surgical intervention which included simple suturing, pedicled jejunal flap, segmental resection and anastomosis, Roux-en-Y duodenojejunostomy, diverticularization, and Whipple's procedure using the principle of Damage Control Surgery (DCS). Postoperative morbidity occurred in 15 patients (17.4%). There was a high incidence of duodenal (or pancreatic, biliary) fistulae. The overall mortality rate was 12.8% (in 11 patients). The causes of deaths were mainly massive bleeding and poly-trauma. Conclusions To decrease morbidity and mortality rates, early diagnosis and surgical intervention were critical. The choice of surgical treatment procedures should be based on the duodenal trauma grading and whether there were associated injuries. For patients with a combined pancreaticoduodenal trauma, DCS is a wise procedure to adopt. The double-tube gastrostomy technique as recommended by the authors is beneficial to severe cases in decreasing the incidences of postoperative duodenal and jejunal obstruction. Key words: Duodenum; Wounds and injuries; Digestive system surgical procedures; Decompression, Surgical; Enteral nutrition; Postoperative complications

Acute colonic pseudo‐obstruction after caesarean section: a review and recommended management algorithm

Key content Acute colonic pseudo‐obstruction (ACPO), also known as Ogilvie's syndrome, is a rare but serious complication that may occur after caesarean section. ACPO typically manifests with progressive abdominal distension and discomfort within 48 hours of caesarean section and may be accompanied by electrolyte disturbances and rising levels of C‐reactive protein. If identified early, ACPO can usually be managed conservatively or with neostigmine; even in cases with significant caecal dilatation without evidence of perforation, colonoscopy‐guided decompression can be successful. Worsening abdominal distension, tenderness, or signs of perforation or sepsis imply that laparotomy is necessary. The incidence of laparotomy in reported cases after caesarean section is high, but overall mortality is low; early recognition and appropriate treatment are vital for a good outcome. Learning objectives To describe the incidence, risk factors and pathophysiology of ACPO following caesarean section. To recognise the clinical presentation of ACPO, including symptoms, signs, results from investigations and potential short‐term and long‐term complications. To understand the indications for conservative, medical, colonoscopic and surgical intervention.

Abdominal Physical Signs and Medical Eponyms: Part II. Percussion and Auscultation, 1924-1980.

Percussion and auscultation are derived from the Latin words to touch and hear, respectively. Covered are abdominal percussion signs and ausculatory signs discovered from 1924 to 1980. Signs ascribed as medical eponyms pay homage to these physicians who provided new and unique insights into disease. PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Many of these signs have been discarded because of modern imaging and diagnostic techniques. When combined with a high clinical suspicion, positive results using percussion combined with palpation is a useful bedside technique in detecting splenic enlargement. Thus, some of these maneuvers remain important bedside techniques that skilled practitioners should master, and along with a meaningful history, provide relevant information to diagnosis. It is through learning about these signs that we gain a sense of humility on the difficulty physicians faced prior to the advent of techniques that now allow us an easier way to visualize and diagnose the underlying disease processes.

Abdominal Physical Signs and Medical Eponyms: Part I. Percussion, 1871-1900.

Percussion is derived from the Latin word to hear and to touch. Percussion of the abdomen is used to detect areas of tenderness, dullness within an area of tenderness suggestive of a mass, shifting dullness representing fluid or blood, splenic, hepatic and bladder enlargement, and free air in the peritoneum. Covered are abdominal signs of percussion attributed as medical eponyms from the time-period beginning in the mid-late nineteenth century. Described is historical information behind the sign, descriptions of the sign, and implication in modern clinical practice. PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Percussion signs defined as medical eponyms were important discoveries adopted by physicians prior to the advent of radiographs and other imaging and diagnostic techniques. The signs perfected during this time-period provided important clinical cues as to the presence of air within the peritoneum or rupture of the spleen.

Abdominal Physical Signs and Medical Eponyms: Part III. Physical Examination of Palpation, 1926-1976.

This paper describes medical eponyms associated with abdominal palpation from the period 1926-1976. Despite opposition by some, eponyms are a long standing tradition and widely used in medicine. The techniques may still be useful in some cases, assisting in the selection of an appropriate and cost-effective approach to patient care. In this piece, we cover signs named in honor of physicians who contributed to medicine by developing new palpatory techniques in an attempt to better diagnose disease of the abdominal wall, umbilicus, gallbladder, pancreas, and appendix. PubMed, Medline, online Internet word searches, textbooks, and references from other source texts. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. We describe brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication into today's medical practice.

Abdominal Physical Signs of Inspection and Medical Eponyms.

An eponym in clinical medicine is an honorific term ascribed to a person(s) who may have initially discovered or described a device, procedure, anatomical part, treatment, disease, symptom, syndrome, or sign found on physical examination. Signs, although often lacking sufficient sensitivity and specificity, assist in some cases to differentiate and diagnose disease. With the advent of advanced technological tools in radiological imaging and diagnostic testing, the importance of inspection, the initial steps taught during the physical examination, is often overlooked or given only cursory attention. Nevertheless, in the era of evidence-based and cost-effective medicine, it becomes compelling, and we contend that a meticulously performed history and physical examination, applying the basic tenets of inspection, remains paramount prior to obtaining appropriate diagnostic tests. PubMed, Medline, online Internet word searches and bibliographies from source text and textbooks. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. We describe the historical aspect, clinical application, and performance of medical eponymous signs of inspection found on physical examination during the 18th to 20th centuries.

Abdominal Pain-An Unusual Case of Anti-Phospholipid Syndrome

Antiphospholipid Syndrome (APS), an autoimmune disease associated with hypercoagulability, commonly presents as arterial and/or venous thrombosis, recurrent spontaneous abortions, and moderate thrombocytopenia. It can manifest as a standalone syndrome or a manifestation of a primary systemic disease. The incidence and prevalence of APS without an acquired cause is not well known, although some estimates show around 5 new cases per 100,000 persons per year. Antiphospholipid antibodies (APLA) include anti-cardiolipin, Lupus anticoagulant (LA), and antibeta-2 glycoproteins which are responsible for the underlying pathophysiology. APS is known to be associated with SLE, connective tissue disorders, various autoimmune diseases, malignancies, HIV, and drugs. Anti-cardiolipin antibody causing thrombosis represents a spectrum of APS which is usually associated with an acquired condition and rarely presents as a primary syndrome. We present the case of an African American female, aged 30, with an atypical presentation of a thrombotic episode and the presence of anti-cardiolipin antibodies without any associated secondary cause. Our case stands out because of the primary nature of APS and the atypical presentation with abdominal signs, both of which are rare and constitute only 1.5% of cases of APS. Sharp clinical suspicion with prompt diagnosis can potentially prevent progression to a catastrophic event.

Hematoma mesentérico espontáneo asociado a warfarina con resolución quirúrgica

Spontaneous mesenteric hematoma isinfrequent. It has been related to prolonged anticoagulation, mainly with warfarin. No definitive treatment has been established; A treatment is suggested in hemodynamically stable patients, while in patients in shock, the surgical treatment is suggested. Our goal is topresent the case of a mesenteric hematoma associated with prolonged conservative anticoagulation with surgical resolution. Female patient with 67 years old, consulted for 24 hours of evolution abdominal pain and signs of peritonism; Computed tomography was performed with a diagnosis of spontaneous mesenteric hematoma. In the context of a clinically stable patient anticoagulated with warfarin, emergency laparotomy with intestinal resection of the segment affected by the hematoma was decided. Pathological anatomy reports massive submucosal hemorrhage. Conclusion: Surgical behavior in patients with hemodynamically stable peritonism can be safe and effective