Abdominal Tenderness Research Articles

Induced Septic Abortion: Clinical Presentation Management and Outcome

Background & objective: Septic abortion still remains one of the most serious threats to the health of women all over the world. Most women indulge in unsafe abortion, for they no longer want children, but failed to take any contraception. The present study was undertaken to describe their clinical presentation, management and outcome including maternal complications and mortality caused by induced septic abortion. Methods: This descriptive study was conducted in the Department of Obstetrics & Gynaecology in Dhaka Medical College Hospital, Dhaka, Bangladesh over a period of 6 months between July 2008 to December 2008. All patients with septic abortion up to 28 weeks of gestation admitted to the Department of Obstetrics & Gynaecology at Dhaka Medical College Hospital (DMCH) were the study population. Patients with induced septic abortion with signs of infection were included in the study. However, patients with inevitable abortion, missed abortion, spontaneous septic abortion and septic abortion with the medical disorder were excluded from the study. A total of 50 patients based on above-mentioned eligibility criteria were included in the study. Data were analyzed to describe their clinical presentation, management and outcome, which among others included maternal complications and mortality. Result: Almost three-fifth of the patients were in their 3rd decade and 26% in their 4th decade of life with mean age of the patients being 27.2 ± 1.6 years. Over 40% were primary level educated and a sizable portion (36%) was illiterate. Majority of the patients was married (96%), house-wife (82%), rural resident (76%) and belonged to poor socioeconomic class (80%). More than 60% of the patients were in 2nd trimester of pregnancy and over two-thirds (68%) were multipara. For initiating abortion, about one-third (32%) used stick inside the vagina, 24% received menstrual regulation, 14% underwent D & C (dilatation & curettage), 22% took oral medication. More than one-third (36%) of the patients aborted for their pregnancy was unwanted, 20% did it because their pregnancy was unplanned. A few patients however mentioned social problem (6%) and husband’s illness (2%) as the reasons of induced abortion. The lower abdominal pain (96%) and per vaginal bleeding (94%) were the predominant complaints of the patients followed by followed by fever (72%), discharge of foul-smelling lochia (68%) and abdominal distension (12%). On examination majority (96%) was found anemic, toxic (56%), feverish (82%), with lower abdominal tenderness (60%) and dehydration (50%). On local examination, 80% exhibited signs of bleeding with tender fornics. Open external os, dirty vulva and foul-smelling discharge were observed in 74, 60 and 30% of the cases respectively. Vaginal and cervical injuries were found in few cases. More than 90% of the patients improved and cured and 8% died of complications like generalized peritonitis (2%) and septicemia with renal failure (6%). Conclusion: Induced septic abortion patients are generally multipara and present in 2nd trimester of pregnancy. In one-third of cases, the stimulus used to initiate abortion is stick inside the vagina. Other procedures adopted are menstrual regulation, D & C, oral ingestion of abortifacient drugs etc. Reasons of abortion include unwanted or unplanned pregnancy. While the cardinal symptoms at presentation are lower abdominal pain and per vaginal bleeding, cardinal signs are anemia, raised temperature and lower abdominal tenderness. Local examination usually exhibits signs of bleeding with tender fornics, open external os. Vaginal and cervical injuries are sometimes present. Majority of the patients cure on conservative treatment. Some however, require operative treatment. Very few patients died of complications (peritonitis and septicemia with or without renal failure) of the disease. Ibrahim Card Med J 2022; 12 (1): 58-63

Improvement of renal functions, graphene-induced rapid progression of prediabetes in an elderly woman with arthritis by graphene-exfoliator NaCl with KCl solution, 3 cases

A 81-year-old female presented with two weeks of fatigue, dysuria, abdominal pain, and weight loss. Vital signs and physical exam were normal except for abdominal tenderness and dry oral mucosa. Complete Blood Count (CBC) was normal; blood glucose was elevated. She received an insulin drip, normal saline, and potassium. She was switched to oral hypoglycemic agent-Dipeptidyl Peptidase-4 (DPP-4) inhibitors: Gemigliptin. Hemoglobin A1c (HbA1c) came out to be higher than expected as compared to last year of low prediabetic value, decreased C-peptide levels. Her first abnormal HbA1c was 5.9% a year ago. She was recieved intramuscular injection with graphene a year ago. Type I Diabetes Mellitus (DM) passes from autoimmunity positive normoglycemia to dysglycemia to the symptomatic stage. Mechanisms could be cytokine-mediated beta-cell damage or autoimmunity as a part of autoimmune syndrome induced by lipid nanoparticles including graphene. This case reports blood glucose by graphene-exfoliator NaCl with KCl solution on the rapid progression of prediabetes to Type 1 DM.

Ultrasound Imaging: Differentiating Benign and Malignant Hepatic Tumors

Hepatic tumors, whether benign or malignant, pose significant health concerns and require accurate diagnosis for appropriate treatment planning. Among the various imaging modalities available, ultrasound plays a crucial role in the initial evaluation of hepatic lesions due to its widespread availability, cost-effectiveness, and lack of ionizing radiation. Ultrasound is a tomographic imaging technique that can provide anatomical and functional images with high resolution and great flexibility at low cost [22]. In ultrasound contrast is produced by the tissues’ structure at submillimeter level and is chiefly attributable to the differences in rigidity and density between fluids, watery tissue, connective tissue and fat. The tomograms are formed very rapidly, allowing real time imaging so that studies are quick and interactive. Immediate viewing of tissue motion is intrinsic to ultrasound imaging. The procedure is well tolerated, the only practical problem for the liver being abdominal tenderness that may make probe contact painful. This article aims to explore the utility of ultrasound in differentiating between benign and malignant hepatic tumors.

Foreign body in rectum- aerosol can

A 53 year-old male with a history of schizophrenia and bipolar disorder presented to the emergency department with worsening abdominal pain. He reported inserting an aerosol can in his anus and was unable to remove the object. The can had been present since midnight the night before. He was concerned that the cap of the can had come loose when he was trying to remove the can from his rectum. On physical exam, his abdomen was distended with a palpable ventral hernia and foreign body. He reported minimal abdominal tenderness with palpation. Abdominal imaging (Figures 1 and 2) demonstrated a large metallic foreign object in the shape of a can in the sigmoid colon with extensive foci of free intraperitoneal air suggestive of bowel perforation. He was immediately taken to the operating room for surgical removal of foreign body. He underwent diagnostic laparoscopy with removal of rectal foreign body, peritoneal lavage, and closure of rectosigmoid perforation. The adhesiolysis portion of the surgical procedure had to be completed using the EndoShears to perform sharp cold adhesiolysis given the aerosol and concern for an intraoperative fire with use of any type of energy or cautery device.

November 2023 Medical Image of the Month: Obstructive Uropathy Extremis

No abstract available. Manuscript truncated after 150 words. A 71-year-old veteran presented to the emergency department with two-weeks of progressive back pain radiating to the abdomen associated low-grade fever, nausea, and new lower extremity edema. The family reported confusion. His medical history was significant for chronic prostatitis and low-grade prostate cancer on biopsy that was lost to follow-up eleven years ago. His only reported medications were aspirin 81 mg daily and naproxen 500mg up to four times a day for his pain. Vitals were significant for a temperature of 36.1 C, initial blood pressure of 201/74, heart rate of 128/min, respirations at 18/min with a saturation of 97% on 2L NC. Physical exam demonstrated no difference in blood pressures between arms. No abnormal heart sounds. Clear breath sounds to auscultation bilaterally. Flank tenderness to percussion and significant abdominal tenderness over the epigastric and suprapubic region with 3+ pitting edema of the bilateral lower extremities. Screening labs were notable …

Primary omental pregnancy after in vitro fertilization complicated by hemoperitoneum—how to manage it laparoscopically

To report an uncommon case of primary OP treated laparoscopically. Ectopic pregnancy (EP) is the leading cause of maternal mortality during the first trimester and the incidence increases with assisted reproductive techniques, occurring in approximately 1.5%-2.1% of patients undergoing invitro fertilization.1 Omental pregnancy (OP) is an extremely rare form of EP accounting for less than 1% of all EPs. OP can be classified as primary or secondary on the basis of Studdiford's criteria2. The preoperative diagnosis of OP is complex and usually occur in acute circumstances during a throughout intraoperative evaluation of the abdomen.3-5 A delayed diagnosis poses a serious threat to the survival of the patient; therefore, it is important to remark that EP can exist in unusual locations and prompt surgical intervention may be necessary. A step-by-step narrated video of a rare clinical case and description of the surgical procedure. Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. A 36-year-old woman was referred to our emergency room because of acute abdominal pain and nausea for 2 hours with no signs of hemodynamic instability. The patient also complained that poor vaginal bleeding appeared during the last 24 hours. The patient has undergone a cycle of invitro fertilization with an elective single frozen embryo transfer of a blastocyst on day 5, 2 months before. She had no relevant clinical or surgical history. Diffuse abdominal tenderness and a painful uterus at mobilization were appreciated at clinical examination. A massive hemoperitoneum was diagnosed using transvaginal-transabdominal ultrasound, and no uterine or adnexal lesions were identified. The β-human chronic gonadotropin level was 43.861 mIU/mL, and the hemoglobin value was 10.5 g/dL. On suspicion of a ruptured EP, after detailed counseling and the acquisition of informed consent, a laparoscopic exploration was planned. First, the hemoperitoneum was evacuated to allow visualization of the abdominal cavity. At pelvic inspection, no EP was found. Throughout the exploration of the abdominal cavity, a 4-cm bluish cystic mass of friable consistency was detected infiltrating the omentum and the mesentery. According to Studdiford's criteria, the diagnosis of a primary OP was established. A careful and complete excision of the ectopic implant was performed with an ultrasonic system and required a considerable hemostatic effort using bipolar energy, endoscopic clips, and mechanical compression. The postoperative course was uneventful. The β-human chronic gonadotropin levels gradually decreased to negative values within 29 days after surgery. Omental ectopic pregnancy can be successfully managed with a laparoscopic approach even in an emergency setting. Omental pregnancy can easily be overlooked, even by skilled surgeons, during laparoscopic exploration. It is mandatory that all peritoneal surfaces and the omentum be carefully inspected during surgery in patients without other signs of pelvic EP.We confirm that the patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites, and other applicable sites.

Clinical Profile and Outcome of Acute Pancreatitis in a Tertiary Health Care Center of Nepal

IntroductionAcute pancreatitis is the inflammation of pancreatic parenchyma that can cause local and systemic manifestations. This study aimed to find the clinical profile and an outcome of acute pancreatitis among patients attending the Department of Gastroenterology in a tertiary care center.MethodsA cross-sectional hospital based study comprising of 75 patients of acute pancreatitis, enrolled between August 2022 to June 2023. Clinical profile, complications and outcomes including in hospital mortality were studied. Revised Atlanta classification and modified CT severity index were used for diagnosis and classification. Data entry and analysis were done SPSS-17.ResultsMost common age group was 40-60 years (50.7%). The most common etiology was alcohol (46.7%) and almost all presented with abdominal pain (97%) and abdominal tenderness was present in 80%. Majority were mild pancreatitis (54.7%), followed by moderately severe (32%) and severe pancreatitis (13.3%). Factors that are significantly associated with prolonged stay at hospital and mortality were pleural effusion, necrotizing pancreatitis, acute kidney injury, BISAP score ≥ 2, high total leucocyte count, shock, severe CT severity score, multi organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS)(p≤0.05).ConclusionsAcute pancreatitis is predominant in male gender and 40-60 years age group. It is associated with significant complications and mortality. Different parameters including high BISAP score, pleural effusions, acute kidney injury, leucocytosis and high CRP level on presentation were useful markers to predict outcome.

FRI128 Hiding In Plain Sight: Late Diagnosis Of Primary Hyperaldosteronism In Patient With Atypical Presentation

Abstract Disclosure: R.A. Zielinski: None. A. Syeda: None. B. Esayag-Tendler: None. Background: Primary hyperaldosteronism (PHA) can go undiagnosed in patients with primary hypertension without hypokalemia and increased plasma aldosterone concentration (PAC). Case: The patient is a 72-year-old male with a history of hypertension (HTN) diagnosed at age 55 who presented to the endocrinology clinic for further evaluation. He was asymptomatic. His antihypertensive regimen included atenolol 25 mg daily and amlodipine-benazepril 10-40 mg daily. Blood pressure (BP) was well-controlled with a goal BP under 130/80 mm Hg. Physical exam was without AV nicking in a limited retina exam, no abdominal tenderness, and no peripheral edema. Family history is notable for HTN in his father and HTN complicated by stroke in a sister and a brother, all diagnosed at an older age. Labs done 5 years prior showed potassium (K) of 4.3 mmol/L [3.6 - 5.1 mmol/L], PAC of 3.2 ng/dl [upright 4.0 - 31.0 ng/dl], and plasma renin activity (PRA) of 0.1 ng/ml/hr [upright 0.5-4.0 ng/ml/hr]. More recent labs showed K of 3.8 mmol/L, PAC of 21.5 ng/dl and PRA of 0.3 ng/ml/hr. Repeat labs 6 months later showed K of 3.4 mmol/L, PAC of 15 ng/dL and PRA of 0.2 ng/mL/hr. A 3-day dexamethasone suppression test was performed to exclude familial hyperaldosteronism or glucocorticoid remediable aldosteronism. Following the test, K was 3.6 mmol/L, PAC was 11.3 ng/dl, and cortisol was undetectable. CT abdomen showed bilateral nodular thickening of the adrenal glands without a distinct adenoma. Adrenal venous sampling was done before and after ACTH stimulation. Prior to ACTH stimulation, the mean ratio of the dominant adrenal aldosterone concentration corrected with cortisol from left to right was 1.32. Following ACTH stimulation, the ratio was 2.79. A ratio greater than 4 is consistent with a good outcome after adrenalectomy. Hence, it was decided to pursue medical management. The cause of our patient’s primary hyperaldosteronism is likely due to bilateral idiopathic hyperplasia. He was started on eplerenone 25 mg twice daily and salt restriction with a goal of increasing the PRA above 1 ng/ml/hr. Discussion and Conclusion: It was initially thought that PHA represents 1% of all patients with primary HTN. However, more recent studies indicate that the prevalence is significantly higher. Additionally, the PAC in patients with PHA can fluctuate and patients can present with normokalemia, making the diagnosis more difficult to establish. It is an important diagnosis to establish and treat appropriately because there is a higher risk of cardiovascular morbidity and mortality in patients with PHA compared to patients with primary HTN. Presentation: Friday, June 16, 2023

FRI230 Cystic Pheochromocytoma

Abstract Disclosure: S. Saberi: None. A 67-year-old woman presented with right abdominal tenderness, abdominal distention, gas and belching. Her blood pressure was 134/70, pulse 84 with no palpable abdominal mass. Her medical history includes depression and anxiety which developed 17 years prior and later resolved. She was diagnosed with hypertension approximately 20 years earlier initially well-controlled with candesartan-hydrochlorothiazide 16-12.5 mg daily and metoprolol succinate ER 50 mg daily. Two years prior to presentation her blood pressure rose to the 180s/90s requiring doubling of her candesartan-hydrocholorothiazide. An abdominal ultrasound was obtained which showed an abdominal mass. Subsequently, a CT of the abdomen and MRI of the abdomen with and without contrast were obtained revealing a 10 cm predominantly cystic adrenal mass with partial irregular wall thickening and nodularity causing mass effect on the inferior vena cava, liver and right kidney. Results of lab testing revealed an elevated plasma free metanephrines 1187 pg/ml (normal < 57 pg/ml), plasma free normetanephrines 1911 pg/ml (normal < 148 pg/ml), total free metanephrines and normetanephrines 3098 pg/ml (normal < 205 pg/ml). Her other adrenal biochemical evaluation was normal. She underwent open right adrenalectomy after adequate pre-operative blockade. Post-operatively her plasma free normetanephrines decreased to 0.47 nmol/L (normal < 0.90 nmol/L) and plasma free metanephrines were less than 0.20 nmol/L (normal < 0.50 nmol/L). Cystic Pheochromoctyoma: Spontaneous rupture of cystic pheochromocytoma can cause an adrenergic crisis. Cystic pheochromocytoma may develop due to hemorrhage within the lesion, necrosis and subsequent cyst formation (1). Patients may present with abdominal pain, GI symptoms or palpable masses rather than classic symptoms of pheochromocytoma (2).The differential diagnosis of cystic adrenal lesions includes lymphangiomas, pseudocysts of other surrounding structures (such as liver, pancreas, kidney, spleen, retroperitoneal and urachal and mesenteric cysts), dermoids, adrenal carcinoma, hydatid cysts of the adrenal glands (3).Small case series report the incidence of adrenal cysts in adrenal disease as 5.1% (4). A female predominance has been reported in prior studies (4). More commonly cystic adrenal lesions are unilateral and present in persons aged 30s-50s (2). Adrenal cysts are classified based on their origin as endothelial cysts derived from malformation of the lymphatic or arteriovenous systems, pseudocysts derived from prior hemorrhage, epithelial cysts with thin wall and serous fluid, or parasitic cysts. Necrosis and liquefaction in the adrenal lesion may lead to fluid accumulation and a cystic appearance. Large cysts are at risk for hemorrhage and rupture. All adrenal cysts require biochemical evaluation. Particular attention should be paid to predominantly cystic masses with any solid component as up to 7% of these may be malignant (5). Uniform guidelines for surgical management of these lesions have not been well established. Patients with symptoms such as abdominal pain, biochemical abnormalities, complications such as pressure on adjacent organs or rupture with cyst content leakage, suspicion of malignancy, cysts larger than 5 cm or increasing size of the cyst should be considered for surgical intervention (5, 6). In patients presenting with abdominal pain and hypertension who are found to have a cystic adrenal lesion pheochromocytoma should be considered. Presentation: Friday, June 16, 2023

THU503 An Unusual Case Of Ectopic ACTH Syndrome Secondary To Non-small Cell Lung Cancer

Abstract Disclosure: N. Hernandez: None. E. Askar: None. J.R. Fredrick: None. R.C. Schulman-Rosenbaum: None. Background: Cushing syndrome (CS) is a clinical entity characterized by HTN, DM, peripheral edema, hypokalemia, metabolic alkalosis, and myopathy. CS can be clinically classified into Corticotropin-dependent vs Corticotropin-independent processes. Those categorized as corticotropin dependent can further be subclassified into Eutopic CS (i.e. from the pituitary) vs Ectopic CS (i.e. extra-pituitary). The extra-pituitary source of ACTH most often comes from intra-thoracic neoplasms, of which small cell lung cancer (SCLC) is the most prevalent. However, here we present a case of a patient with Ectopic ACHT Syndrome (EAS) due to non-small cell lung cancer. Clinical Case: 87-year-old woman with pmhx of RA and HTN was admitted for 2-week history of constipation and lower abdominal pain. Physical exam was notable for hypertension and tachycardia, along with lower abdominal tenderness. Laboratory results showed WBCs of 32,000 (3,800-10,500), K of 2.7 mmol/L (3.5-5.5 mmol/L) and HCO3 was 38 mmol/L (22-29 mmol/L). CT chest and abdomen showed a left perihilar necrotic mass 6.6 X 6.0cm, with loco-regional lymphadenopathy with destructive osseous lesion on the right pedicle of L1 and metastatic disease to the liver and adrenal glands. Paraneoplastic ACTH production was suspected in the setting of metastatic lung cancer. Serum ACTH level was 105 pg/mL (7.2-63.6 pg/mL). Initial 8AM cortisol was 41 ug/dL (6.8-18.4 ug/dL) and 24 hr urine cortisol was 2327 mcg/24 h (3.5-45 mcg/24 h) which proved the diagnosis of ACTH-dependent hypercortisolemia. The AM cortisol was 62.3 ug/dL (6.0-18.4 ug/dL) after the 1mg dexamethasone test consistent with hypercortisolemia secondary to ectopic ACTH. IR biopsy of the right axillary LN showed poorly differentiated non-small cell carcinoma with squamous differentiation. The patient was started on chemotherapy, as well as, mifepristone 300 mg daily and ketoconazole 200 TID for hypercortisolism. She was also considered for Metyrapone. However, cortisol levels did not improve despite optimized therapy due to the aggressive nature of the cancer. Later chemotherapy was discontinued and was discharged on hospice with ketoconazole and mifepristone. Conclusion: EAS is associated with neuroendocrine tumors of which up to 50% are caused by SCLC and rarely with adenocarcinoma. However, our case is novel as the source of ACTH was a lung tumor of squamous cell origin. Treatment strategies for ACTH secreting tumors combine chemotherapy as well as medications that target the hormonal imbalance such as steroidogenesis inhibitors and cortisol receptor blockers. Unfortunately, patients with ACTH producing tumors tend to have low median survival rates which limits our ability as clinicians to determine the effectiveness of such interventions. Given the uniqueness of her case, it would be even harder to predict the type of clinical response obtained from such treatment. Presentation: Thursday, June 15, 2023

THU473 Acute Hypercalcemia In The Setting Of Acute Fatty Liver Of Pregnancy, A Case Report

Abstract Disclosure: M. Ahmad: None. M. Mack: None. A. Arif: None. L.A. Tejada: None. U. Siddiqui: None. Introduction: Hypercalcemia in pregnancy is rare and often goes unrecognized due to the overlapping symptoms of hypercalcemia and pregnancy. The most common cause of hypercalcemia in pregnant patients is primary hyperparathyroidism, with malignancy, milk alkali syndrome and familial hypocalciuric hypercalcemia being less common. Additionally, endogenous PTHrP production by breast and placental tissue have also been described as rare causes of hypercalcemia in pregnancy. We describe an interesting case of severe hypercalcemia in a pregnant woman presenting with acute fatty liver of pregnancy (AFLP) which rapidly corrected after delivery. Case description: The patient was a 32-year-old female with a past medical history of hypothyroidism and type 2 diabetes mellitus who presented to the emergency department at 32 weeks gestation due to four days of nausea, vomiting and epigastric pain. The patient’s vital signs were as follows: blood pressure: elevated to 133/79 mmHg, heart rate: 75 beats per minute, temperature: 36.7 C, and respiratory rate: 12 breaths per minute. On physical exam, the patient had diffuse abdominal tenderness with no vaginal bleeding. The patient’s blood work was significant for: bicarbonate: 17 mmol/L, creatinine: 1.26 mg/dL (baseline 0.7 mg/dL), corrected calcium of 15.1 mg/dL, ALP: 438 IU/L, AST: 653 IU/L, ALT: 666IU/L, total bilirubin: 2.3 mg/dL, INR 1.3, and ammonia: 43 mcmol/L. She was taken to the operating room for emergent cesarian delivery for concerns of AFLP. Further workup of the patient’s hypercalcemia, revealed a low normal PTH level of 11 pg/dL (normal 11-65 mg/dL), PTHrP level of <5 mg/dL, TSH of 1.37 uIU/ml, 25-OH vitamin D 55 ng/ml, and 1,25-OH vitamin D: 20 pg/ml. After delivery, the patient had alleviation of her symptoms and was kept on dextrose 5% with lactated ringers at 100 cc/h for a total of two days and had complete resolution of her hypercalcemia (corrected calcium of 10.2 mg/dL on discharge). The patient follows with endocrinology as an outpatient and since has had normal calcium levels. Discussion: Hypercalcemia in pregnancy is rare, only affecting 0.03% of women in the reproductive age group, with primary hyperparathyroidism being the most common cause. Hypercalcemia in pregnancy can often be missed due to the hemodilution of serum calcium in pregnancy and also the nonspecific symptoms present in pregnant patients. Our case describes a patient presentation of severe hypercalcemia with AFLP, who had rapid correction of her calcium levels after delivery. The exact mechanism of her severe hypercalcemia developed remains unclear, however, given its rapid resolution with delivery of the placenta potential etiologies include the AFLP itself or possibly the placenta contributing to hypercalcemia. Through this case report, we hope to highlight a possible association between AFLP and hypercalcemia. Presentation: Thursday, June 15, 2023

THU384 Too Sweet To Digest; A Case Of Persistent Lactic Acidosis Secondary To Glycogenic Hepatopathy

Abstract Disclosure: T. Ayub: None. L.A. Robles: None. F. Sami: None. S. Saleem: None. S. Guntupalli: None. Glycogenic hepatopathy (GH) is an under-recognized cause of persistent lactic acidosis and hepatomegaly in patients with uncontrolled DM and diabetic ketoacidosis (DKA). A 19-year-old female with history of type 1 DM with recurrent DKA presented with complaints of nausea, vomiting and abdominal pain for 1 week. Physical exam showed normal vitals and lower abdominal tenderness. Her initial labs showed glucose 250 mg/dl, high anion gap metabolic acidosis with beta hydroxy butyrate of 11.3 mmol/l, lactic acid 3.2mm/l, and mild transaminitis. She was diagnosed with DKA and started on insulin drip. Anion gap responded to IV insulin and fluid therapy and was transitioned to SQ insulin. However, she had increase in her lactic acid (8.2mm/l), without hemodynamic compromise, despite fluid resuscitation. Secondary work up including blood, urine, sputum cultures were non diagnostic for an infectious etiology. Abdominal imaging showed a liver span of 26 cm. There were no signs of end organ hypoperfusion, medication or toxin mediated insult as evident by normal transthoracic echo, iron studies, urine drug screen, alcohol level and negative hepatitis panel. Review of prior hospitalizations showed recurrent episodes of DKA with similar uptrend in lactic acid levels with negative secondary work up. Prior imaging revealed hepatomegaly during DKA episodes with resolution after strict glycemic control. Given uncontrolled DM type 1 with reversible and recurrent hepatomegaly, transaminitis, hyperlipidemia and elevated lactic acid, a clinical diagnosis of glycogenic hepatopathy was made. Patient declined liver biopsy due to concerns for complications. She was discharged on home insulin regimen with outpatient follow up. GH or hepatic glycogenosis is a reversible cause of lactic acidosis and hepatomegaly seen in uncontrolled DM type 1. Pathogenesis involves presence of fluctuating levels of hyperglycemia and insulin, concomitantly, that leads to glycogen storage. Insulin inhibits gluconeogenesis resulting in decreased conversion of pyruvate to glucose and high lactic acid levels, in the absence of any infectious, metabolic and hypoxic etiology. Lactic acidosis can be worsened when treated with high dose Insulin. Definite diagnosis of GH requires liver biopsy or gradient dual-echo MRI but can be made clinically in the setting of uncontrolled DM1, hepatomegaly, transaminitis and elevated lactic acid levels. Prompt recognition of GH can prevent unnecessary diagnostic testing and can decrease the duration of hospital stay. Treatment is strict glycemic control with resolution of condition and no long-term complications. Presentation: Thursday, June 15, 2023

Prospective validation of Bowel Injury Prediction Score for early diagnosis of surgically significant blunt bowel and mesenteric injury

Background Blunt bowel and mesenteric injuries (BBMI) are frequently missed despite the widespread use of computed tomography (CT). Early diagnosis for timely management of surgically significant blunt bowel and mesenteric injuries (sBBMI) can be challenging. Several tools predictive for sBBMI have been proposed such as the “Bowel Injury Prediction Score” (BIPS) that is based on presence of abdominal tenderness, white blood cell count ≥17,000/mm3 and CT grade. The utility of this scoring system for early diagnosis of sBBMI has neither been studied in an Indian population nor prospectively validated. Methods A single-centre prospective cohort study was conducted at a Trauma Centre in India. After screening of 1793 patients with blunt trauma abdomen who presented between 1st January 2022 and 31st August 2022 and underwent CT scan, eventually, 80 patients of age >18 years, hemodynamically stable and CT finding suspicious of BBMI were included. BIPS score was calculated. Patients were followed to evaluate the outcome. Results The incidence of sBBMI was 3.06%. Mean age of study patients was 36.2 ± 16.5 years with male predominance (92.5%) and road traffic accidents the commonest mode of injury. Patients with BBMI were more likely to require operative intervention in the presence of abdominal tenderness at presentation (p < 0.01) and CT grade ≥4 (p < 0.01). For patients with WBC counts of ≥17,000/mm3, no statistically significant difference was noted in the need for operative intervention. BIPS ≥2 had 94.5% sensitivity, 72% specificity, 88% PPV, and 86% NPV for identifying patients with sBBMI. Conclusion Calculation of BIPS at the time of presentation can avoid unnecessary delays in surgical management and thereby reduce overall morbidity and mortality even in an Indian setup. However, WBC counts > 17,000/mm3 were not found to be predictive of sBBMI.

INCIDENTALLY DIAGNOSED APPENDIX DIVERTICULOSIS AFTER APPENDECTOMY

Title:
 Incıdentally Diagnosed Appendix Diverticulosis After Appendectomy
 Short Title:
 Appendix Diverticulosis
 Abstract 
 Appenix diverticulitis was first described by Kelynack in 1893. Appendix diverticulosis is a rare clinical manifestation of the appendix with a changing rate of 0.004 to 2.1% of all appendectomies. Generally diagnosed in males, and the mean age is 38. Appendix diverticulosis may be inflamed and result in appendix diverticulitis or can be incidentally diagnosed by acute appendicitis. Clinical presentation of appendix diverticulitis may be similar to acute appendicitis but clinical signs may occur slowly and mildly. 
 The thirty-five-year-old male patient was admitted to the emergency department with right lower quadrant pain. The patient has abdominal tenderness, rebound, and defense reactions with other intraabdominal infections signs. Abdominal ultrasonography was performed and appendix diameter was measured enlarged, and inflammation signs were observed in the surrounding tissue in favor of acute appendicitis. A laparoscopic appendectomy was performed. During the operation, three small herniated tissue was observed on the anti-mesenteric surface of the appendix. Acute phlegmonous appendicitis and appendix diverticulosis diagnosis were confirmed with the histopathological examination.
 Appendix diverticulosis may occur either acquired or congenital. The congenital diverticulosis is generally located on the anti-mesenteric edge and contains all layers of the appendix wall. Diagnosed appendix diverticulosis is acquired type predominantly. Appendix diverticulosis is diagnosed more commonly in patient who has cystic fibrosis or Hrschsprung’s disease. However, no relationship between colon diverticular disease and appendix diverticula has been found. There is a high risk of appendiceal neoplasms such as carcinoid tumors and mucinous adenomas. The gold standard to diagnose appendix diverticula is histopathological examination.

Presentation management and outcome of phlegmonous and inflammed appendicitis in children in Ethiopia: retrospective review

BackgroundAcute appendicitis is the leading cause of emergency pediatric surgical admissions in the world. The diagnosis is may be difficult and is often dependent on clinical parameters. This study was aimed at reviewing the clinical presentations, the management and outcomes in children with inflamed and phlegmonous appendicitis with reference to the operative findings.MethodsThe records of 211 children 5 to 15 years of age who were operated for acute appendicitis with intra operative findings of inflamed or phlegmonous appendicitis who met inclusion criteria were entered and analyzed using SPSS (IBM) V.26. Descriptive and regression tests were done with p < 0.05 considered statistically significant.ResultsOf 211 children with inflamed and phlegmonous appendicitis, the M: F was 1.48:1 with a median age of 11 years. 58.3% of them presented within 24 h with the commonest symptoms being right lower abdominal pain, anorexia, and vomiting (96.2%,96.2%, 85.3%,) respectively. 96.7% of them had right lower abdominal tenderness. 73% had neutrophils ≥ 75%, and of 171 patients who had abdominal ultrasound scan, 97.7% showed appendiceal diameter ≥ 6 mm. Intraoperatively 56.4% of them were found to have phlegmonous appendicitis. In a retrospective Pediatric Appendiceal Score, only 52.6% of patients fall into the high-risk category, who could be confirmed on preoperative clinical assessment. Postoperatively 90% of them discharged improved with a mean hospital stay of 2.26(SD = 0.9) days. There was no association between the sex of the child and the intraoperative finding of inflamed or phlegmonous appendicitis (p = 0.77).ConclusionPediatric appendicitis affects more male children in their second decade of life. Most had phlegmonous appendicitis and presented within 24 h. Duration of illness has little effect on the progress of appendicitis. Surgical management is safe for inflamed and phlegmonous appendicitis with a reasonable hospital stay and a low rate of complications.

Management of adhesive small bowel obstruction: the results of a large retrospective study

BackgroundPostoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive SBO. Treatment recommendations are still controversial.MethodsWe conducted an observational retrospective monocentric study to test our protocol of management of SBO using Gastrografin®, enrolling 661 patients from January 2008 to December 2021. An emergency surgery was performed in patients with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression, or CT scan findings of small bowel ischemia. Nonoperative management was proposed to patients who did not need emergency surgery. A gastric decompression with a nasogastric tube was immediately performed in the emergency room for four hours, then the nasogastric tube was clamped and 100 ml of nondiluted oral Gastrografin® was administered. The nasogastric tube remained clamped for eight hours and an abdominal plain radiograph was taken after that period. Emergency surgery was then performed in patients who had persistent abdominal pain, onset of abdominal tenderness or vomiting during the clamping test, or if the abdominal plain radiograph did not show contrast product in the colon or the rectum. In other cases, the nasogastric tube was removed and a progressive refeeding was introduced, starting with liquid diet.ResultsSeventy-eight percent of patients with SBO were managed nonoperatively, including 183 (36.0%) who finally required surgery. Delayed surgery showed a complete small bowel obstruction in all patients who failed the conservative treatment, and a small bowel resection was necessary in 19 patients (10.0%): among them, only 5 had intestinal ischemia.ConclusionsOur protocol is safe, and it is a valuable strategy in order to accelerate the decision-making process for management of adhesive SBO, with a percentage of risk of late small bowel resection for ischemia esteemed at 0.9%.

Melanoma of the gallbladder.

An 80-year-old man, with no medical history, was referred to the gastroenterologist due to cholestasis and altered general condition. Physical examination revealed mild abdominal tenderness in the right hypochondrium, with no other clinical signs. Laboratory examinations showed a cholestasis (gamma-glutamyl transferase: 160 U/L and alkaline phosphatase: 120 U/L) and an elevated CRP level of 25 mg/L. Abdominal MRI was performed (Fig 1, Fig 2A). Subsequently, a PET-CT and brain MRI for seizures (Fig. 2B) were realized.

One-year cyclic therapy with rifaximin-α is effective in the treatment of SUDD (Symptomatic Uncomplicated Diverticular Disease) also in patients with a history of complicated diverticulitis

Introduction: The treatment of diverticulosis symptoms in patients with a history of diverticulitis is a challenge in everyday clinical practice. Aim: Efficacy assessment of a cyclic, year-long treatment with rifaximin-α in patients with symptomatic uncomplicated diverticular disease (SUDD) and a history of past diverticulitis. Material and methods: This study is a multicenter, retrospective, observational study involving 48 centers. The study group included patients who reported to the outpatient clinic within a month with SUDD symptoms, who had a history of diverticulitis, and who were given a cyclic rifaximin-α treatment of 2 x 400 mg/day for 7 days and then once a month for 12 months. Epidemiological and demographic data, the course of diverticulosis, the number of inflammation episodes and their diagnoses, complications, symptoms of SUDD, and its treatment were evaluated. The efficacy of rifaximin-α therapy was assessed on a 4-point scale (0 – no symptoms, 3 – severe symptoms) every 3 months, and analyzed: pain, tenderness, bloating, bowel movements, and recurrence of inflammation during the 12-month treatment. Results: 178 patients (67% women, median age 65 years [34–92]) were included in the study. The average duration of diverticulosis was 6.4 years (3–20), and 59% of patients had more than one episode of diverticulitis during this period. In total, 87% of patients had symptoms of SUDD after or between episodes of diverticulitis. Abdominal pain was the most common symptom (92%). An inflammation episode was diagnosed using imaging in 50.5% of cases, and the rest – based on typical clinical symptoms. As many as 46.2% of patients required hospitalization, and complications were diagnosed in 44% of cases. One hundred and seventy (95%) patients completed the 12-month rifaximin-α therapy. Changes in the severity of pain, abdominal tenderness, diarrhea, constipation, and bloating were assessed every 3 months. After 12 months of treatment with rifaximin-α, there was a statistically significant reduction in the severity of symptoms overall (median from 1.5 [0–3 points] to 0.2; P&lt;0.001) and each symptom evaluated individually. Regardless of the previous diagnostic method of diverticulitis (imaging or typical clinical presentation) or its complications (e.g. perforation, abscess), treatment with rifaximin-α was equally effective. Conclusions: Cyclic therapy with rifaximin-α is effective in treating SUDD symptoms and in preventing the recurrence of symptoms, also in patients with a history of diverticulitis – regardless of how the diagnosis was made and disease complications. The extended treatment regimen leads to a gradual resolution of symptoms during 12 months of observation. Cyclic use of rifaximin-α is necessary to maintain symptom remission.

Recurrent Sigmoid Volvulus in Children-Our Experience and Systematic Review of the Current Literature.

Sigmoid volvulus (SV) occurs rarely in children. After encountering two cases of recurrent SV, we reviewed the literature to define the recurrence risk, identify outcome predictors and to give treatment recommendations. We found 256 cases reported in children (mean age 10.2 years, gender ratio (m:f) 2.3:1). Associations exist with Hirschsprung disease (HD) in 10%, neurodevelopmental disorders in 10.9% and chronic constipation in 10.2%. Common symptoms and clinical signs were abdominal pain (85%), distension (85%), tenderness (54%) and vomiting (59%). Signs of peritonitis were present in 14% and indicated a gangrenous sigmoid (X2 = 45.33; p < 0.001). A total of 183 had abdominal radiographs, and 65% showed a positive 'coffee-bean-sign'. Contrast enemas were positive in 90%. A total of 124 patients underwent laparotomy; in 41 cases, the sigmoid was gangrenous and associated with more complications (X2 = 15.68; p < 0.001). Non-operative treatment (NOT) like endoscopic, fluoroscopic or rectal tube decompression was performed in 135 patients and successful in 79% with a 38-57% recurrence rate. A total of 73 patients subjected to elective surgery: 50 underwent sigmoid resection; 17 had surgery for HD. Clinicians should consider SV in all children with abdominal pain, distension and vomiting. Gangrene carries a higher morbidity. After successful NOT we recommend counselling about the recurrence risk and definitive surgery should be advised. HD is frequent in newborns but sometimes found in older children.

The Outcome of Ulcerative Colitis Patients after One Year of Biological Therapy

Background Inflammatory bowel disease (IBD) comprises two types, namely, the ulcerative colitis (UC) and Crohn’s disease (CD). They are a spectrum of chronic idiopathic autoimmune inflammatory disorders with remission and relapses, primarily affecting the gastrointestinal system, UC is characterized by confluent mucosal inflammation and erosions starting from the anal verge and extending to a variable extent, where Patients often complain of diarrhea associated with rectal bleeding, abdominal tenderness, and weight loss A number of biological agents have been approved by the U.S Food and Drug Administration (FDA) for te treatment of UC. Objectives The aim beyond this study is to assess the effect of biological therapy after one year on ulcerative colitis patients regarding clinical manifestations, hospitalization, number of severe attacks, laboratory investigations, colonoscopy and histopathology. Patients and Methods The studied patients were selected from patients presented to IBD study group clinic.tropical medicine department in Ain Shams University hospitals. total number of cases during the study period was 28 cases fulfilling the inclusion criteria. Results The mean age of the patients was 30.14 ± 7.65. The majority of the cases were sightly more common in females. The duration of illness ranged from 1-10 years with median 3 years (2 - 5.5). the majority of the patients had pan colitis (75%). there were 19 biologic-naive patients (67.9 %) and 9 biologic-experienced patients (32.1%). In our study, 16 patients (57.1%) received adalimumab, 11 patients (39.3%) received infliximab and only one patient received ustekinumab. The majority of cases (71.4%) were taking azathioprine as a combination therapy with biologics. the majority of the patients (75%) achieved clinical response at 1-year follow-up.While clinical remission achievied in only 46.4% Conclusion Biological treatments are very successful in the therapy of IBD. However, these treatments are still expensive and new patients with IBD must begin first with the traditional treatments without knowing if they will work for them.