Abnormal Peritoneal Research Articles

Closed-loop obstruction due to internal hernia: An atypical clinical presentation of acute abdomen - A case report

Abstract Internal hernia is the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. They can be congenital or acquired after abdominal surgery. We report a case of a 58-year-old woman who presented with complaints of abdominal pain and nonbilious vomiting for 2 days. She underwent an abdominal hysterectomy 15 years ago. After baseline blood investigations and imaging, a diagnosis of subacute intestinal obstruction was made. As she clinically worsened over 24 h, CT imaging was done, which suggested acute small bowel obstruction secondary to adhesions. Surgery revealed herniation with incarceration of distal ileal loops through a defect in the sigmoid mesocolon. Bowel resection was done, and the defect was closed. The clinical presentation of internal hernias, especially transmesosigmoid hernia, is nonspecific, and they rapidly progress to bowel ischemia. Early intervention and surgical correction are prudent for good clinical outcomes.

Don't be thrown for a loop: a review of internal hernias for the abdominal imager.

Internal hernias are herniations of abdominal viscera, usually small bowel, through congenital or acquired openings of the peritoneum or mesentery. Congenital hernias may involve anatomic fossae such as the epiploic foramen as well as those related to abnormal peritoneal or mesenteric defects; these include left and right paraduodenal, transomental, transmesenteric, pericecal and broad ligament hernias. Acquired hernias are due to defects in the mesentery or peritoneum, usually resulting from prior surgeries, and include those associated with Roux-en-Y surgery as well as colorectal cancer resections. Internal hernias account for 5.8% of small obstructions. Obstructed internal hernias are considered surgical emergencies due to the high risk of bowel strangulation. This review summarizes the various types of congenital and acquired internal hernias, their relevant anatomy, embryology, associated surgical history and imaging appearance. We will also discuss a location-based approach to identifying internal hernias on CT, as well as complications and relevant signs, of which abdominal imagers should be vigilant.

Malrotation and Midgut Volvulus in Children: Diagnostic Approach, Imaging Findings, and Pitfalls

Malrotation and midgut volvulus are surgical emergencies that commonly occur within the first month of life. The classic symptom is acute bilious vomiting, while nonspecific symptoms such as recurrent abdominal pain may be present in older children. Malrotation can be associated with duodenal obstruction caused by an abnormal peritoneal fibrous band or congenital anomalies, such as an annular pancreas or a preduodenal portal vein. Volvulus can lead to bowel ischemia and a life-threatening condition, thus prompt and accurate diagnosis is crucial. Diagnosis can be made through upper gastrointestinal series, ultrasonography, and CT, with ultrasonography being preferred as a screening tool due to its rapid and accurate diagnosis, without radiation exposure, in children. This pictorial essay discusses the key imaging findings and diagnostic approaches for malrotation and midgut volvulus, as well as diagnostic pitfalls based on actual cases.

Unusual ascites post laparoscopic cholecystectomy in old patient: Case report and review of the literature.

IntroductionAscites that precede laparoscopic cholecystectomy is an infrequent event. Its actual mechanism is not identified, but an inflammatory or allergic peritoneal reaction has been proposed. It can a life-threatening or an acute serious condition; for instance, the bile duct or other visceral injuries are eliminated.Case presentationWe present a 83 years old, medically free, who presented with fever and right upper quadrant pain. Diagnosed with severe acute calculus cholecystitis. Diagnostic laparoscopy and laparoscopic cholecystectomy were done, with copious irrigation of the abdomen. Postoperatively, patient started to had tense with moderate tenderness abdomen. Drain output showed clear ascites fluid. Postoperative ascites culture returned back as negative. Ascites treated conservatively with fluid restriction and furosemide. As per our knowledge, this is the fourth case that was reported in the literature of medicine.DiscussionThis was a particular case related to ascites which emerged without any known cause. The medical history of a powerful allergic background is can be the reason for transudative ascites that take place following an uneventful, occasional laparoscopic cholecystectomy. There was a presumed abnormal peritoneal or allergic reaction to the diathermy. No specific aetiological aspect was known irrespective of an extensive search being carried out.ConclusionIn cases of idiopathic post-laparoscopic ascites, general care and support is needed and fluid restriction and possible diuretic might be needed with no need for surgical intervention. Further studies are recommended for understanding of the pathophysiology of the disease.

Re-thinking the prognostic significance of positive peritoneal cytology in endometrial cancer

BackgroundWhether abnormal peritoneal cytology (PC) is an independent prognostic factor in endometrial cancer (EC) remains controversial. This study aimed to re-think the prognostic significance of PC in not only all EC patients but also in various subgroups with similar clinicopathological and biological characteristics. MethodsEC patients who underwent primary surgery of at least a hysterectomy and were pathologically diagnosed with EC in four hospitals affiliated with the Jikei University School of Medicine were retrospectively reviewed. The prognostic significance of PC was evaluated with univariate and multivariate analyses in the entire cohort and subgroups stratified by surgical stages (early/advanced stages), tumor types (types 1/2), and risk classifications (low/intermediate/high). ResultsOf 1963 EC cases, 1616 met the inclusion criteria. Positive PC was identified as an adverse prognostic factor in analyses of all EC cases and in all subgroup analyses stratified by surgical stages and tumor types. In survival curve comparisons, the progression-free survival (PFS) and disease-specific survival in early-stage patients with positive PC were clearly located between those of stage II patients with negative PC and stage III patients. In the subgroup analyses stratified by risk classification in early-stage EC, positive PC was related to poorer PFS in the intermediate- and high-risk groups but not in the low-risk group. ConclusionPC status was an independent prognostic factor of EC in all stages and tumor types. Early PC-positive cases, except for the low-risk group, may be recommended for upstaging and should be carefully managed compared with PC-negative cases.

Abnormal Congenital Peritoneal Bands: A Retrospective Cadaveric Study

ntroduction: Peritoneal folds are double layered peritoneal membranes produced during reflexion of peritoneum from viscera to the body wall or between adjacent viscera. They are named as ligaments, mesenteries, omentum etc. Sometimes during the course of development some abnormal peritoneal folds develop, which are of surgical importance because these folds or bands may constrict a part of intestine leading to obstruction and gangrene. These sometimes produce peritoneal recesses, which are the potential sites for internal herniation. Aim: To study abnormal peritoneal folds in cadavers. Materials and Methods: This was a descriptive study, conducted on 40 cadavers during August 2010-July 2020. Abdominal cavity was dissected and carefully observed for organisation of viscera and peritoneal reflexions in the abdominal cavity. Results: Out of 40 cadavers, congenital abnormal peritoneal bands were found in four cases and two cases had multiple peritoneal bands. Three cases had associated congenital abnormalities of the gut. One case of nonrotation of gut was observed, where small intestine was situated on the right side and colon on the left side. In this case, the ascending colon was fixed by a peritoneal band to right upper abdominal wall. In the second case, there was incomplete fusion of descending mesocolon. The mobile segment of descending colon was fixed by an abnormal peritoneal band. In the third case, there was absorption of pelvic mesocolon. Conclusion: Though the cause of development of abnormal peritoneal band is not very clear, this study shows that they may be present in cases of abnormal rotation or abnormal peritoneal fixation of gut.

Internal Hernia through a Congenital Peritoneal Defect in the Pouch of Douglas causing Small Bowel Obstruction

An internal hernia is defined as the protrusion of visceral content, most commonly the small bowel, through a normal or abnormal peritoneal or mesenteric aperture within the abdominal cavity and the pelvis. An internal hernia may either be congenital or acquired in aetiology. These hernias can trap and/or twist small bowel, resulting in bowel obstruction. We herein describe an extremely rare case of a young female who presented with small bowel obstruction secondary to an incarcerated internal hernia caused by a peritoneal defect in the pouch of Douglas.

ANOMALOUS PERITONEAL FOLDS OF LIVER WITH INCOMPLETE FISSURE FOR IGAMENTUM TERES - A CASE REPORT

Liver is the largest organ in the human body occupying right hypochondrium, epigastrium and left hypochondrium. The organ develops in the ventral mesogastrium dividing the latter into a cranial part which forms the falciform ligament and lesser omentum and the caudal part which normally degenerates but may persist occasionally in the form of accessory fissures, ligaments and folds. The present case report describes the occurrence of exceptional and multiple abnormal peritoneal ligaments extending between the liver, diaphragm and abdominal wall. In concurrence, an incomplete fissure for ligamentum teres hepatis is reported which resulted in a communication between the left lobe and quadrate lobe of liver. The knowledge of the normal and the variant anatomy of such peritoneal reflections of liver is of colossal significance for surgeons performing the segmental resection of the liver and radiologists interpreting radiological findings related to liver.

Significance of abnormal peritoneal cytology on survival of women with stage I–II endometrioid endometrial cancer

ObjectiveTo examine survival of women with stage I–II endometrioid endometrial cancer whose peritoneal cytology showed malignant or atypical cells (abnormal peritoneal cytology). MethodsThis is a multi-center retrospective study examining 1668 women with stage I–II endometrioid endometrial cancer who underwent primary hysterectomy with available peritoneal cytology results between 2000 and 2015. Abnormal peritoneal cytology was correlated to clinico-pathological characteristics and oncological outcome. ResultsMalignant and atypical cells were seen in 125 (7.5%) and 58 (3.5%) cases, respectively. On multivariate analysis, non-obesity, non-diabetes mellitus, cigarette use, and lympho-vascular space invasion were independently associated with abnormal peritoneal cytology (all, P<0.05). Abnormal peritoneal cytology was independently associated with decreased disease-free survival (hazard ratio 3.07, P<0.001) and cause-specific survival (hazard ratio 3.42, P=0.008) on multivariate analysis. Abnormal peritoneal cytology was significantly associated with increased risks of distant-recurrence (5-year rates: 8.8% versus 3.6%, P=0.001) but not local-recurrence (5.2% versus 3.0%, P=0.32) compared to negative cytology. Among women with stage I disease, abnormal peritoneal cytology was significantly associated with an increased risk of distant-recurrence in the low risk group (5-year rates: 5.5% versus 1.0%, P<0.001) but not in the high-intermediate risk group (13.3% versus 10.8% P=0.60). Among 183 women who had abnormal peritoneal cytology, postoperative chemotherapy significantly reduced the rate of peritoneal recurrence (5-year rates: 1.3% versus 9.2%, P=0.039) whereas postoperative radiotherapy did not (7.1% versus 5.5%, P=0.63). ConclusionOur study suggests that abnormal peritoneal cytology may be a prognostic factor for decreased survival in women with stage I–II endometrioid endometrial cancer, particularly for low-risk group.

Spontaneous chylous ascites after laparoscopic cholecystectomy: a case report

Cholecystitis with cholelithiasis is a very common disease in clinical practice. Now a days it is treated by laparoscopic cholecystectomy very safely with minimal trauma, discomfort and short hospital stay. Rarely, it is complicated by post-operative chyle leakage in peritoneum. We present a case of spontaneous chylous ascitis after laparoscopic cholecystectomy. Probably idiopathic or caused by trauma of pneumoperitoneum, abnormal peritoneal reaction to various chemicals released during operative procedure and diathermy used during laparoscopic cholecystectomy. We discuss its review, clinical presentation, diagnosis, treatment and management of this case. Chyle leake is rare post-operative complication can be managed by simple conservative treatment.

Post traumatic acquired multiple mesenteric defects

INTRODUCTIONInternal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.1 Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.2 PRESENTATION OF CASEIn this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found. DISCUSSIONIn the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.11 Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. 16 CONCLUSIONThe diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.

Peritoneal Bands: A Review of Anatomical Distribution and Clinical Implications

The complexity of embryological development of the gastrointestinal tract and mesentery provides a platform for the formation of a wide variety of variant veils, folds, and membranes, collectively termed peritoneal bands. These structures, which represent anatomically unabsorbed portions of the omentum and mesentery, although often benign, have the potential to cause clinically significant manifestations in both the neonate and adult. Although these deviant structures may be identified over a broad range of the abdominal cavity, they are most commonly identified in the regions of the duodenum, duodenojejunal flexure, ileocecal junction, and ascending colon. As a result of the diverse location of these variant structures, clinical manifestations are highly variable, ranging from acute presentations of intestinal necrosis as a result of strangulated midgut volvulus to chronic, vague abdominal pain. This article seeks to highlight the importance of a thorough anatomical understanding of the distribution of the various abnormal peritoneal folds, bands, and ligaments, which may result from aberrations in embryonic gastrointestinal development and their respective clinical implications. Moreover, to advance the knowledge of peritoneal bands, this article discusses the appropriate diagnostic studies and treatment interventions required for these variant structures.

Unusual Cause of Intestinal Obstruction: Left Paraduodenal Hernia

Internal intestinal hernia has been defined as bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening. Paraduodenal hernias comprise 30%–53% of all internal intestinal herniations and account for 0.2%–0.9% of all bowel obstructions. In this paper, we aimed to present a male patient of 42 years of age who developed intestinal obstruction due to left paraduodenal hernias. Left paraduodenal hernia should be taken into consideration in the differential diagnosis in patients of relatively younger ages with no prior abdominal surgery who frequently have bowel obstruction episodes.

Congenital Intra-Mesosigmoid Hernia- A Case Report of a Rare Sigmoid Mesocolon Hernia

Internal hernia is the protrusion of the viscera through normal or abnormal peritoneal or mesenteric apertures within the confines of peritoneal cavities.

The “wandering” spleen

A 15-year-old girl presented with 7 days of intermittent lower abdominal pain. Contrast-enhanced CT demonstrated an enlarged “wandering” spleen (asterisk) within the pelvis (Fig. 1). The splenic vascular pedicle was elongated and whorled, suggesting torsion (Fig. 2). Imaging findings were confirmed at laparoscopy, and splenic detorsion and splenopexy were performed. Excessive splenic mobility and resultant ectopia are caused by abnormal peritoneal fixation, with the splenogastric and splenorenal ligaments being either absent or lax [1, 2]. While splenic shadow absence may suggest the

Cilostazol and pentoxifylline decrease angiogenesis, inflammation, and fibrosis in sponge-induced intraperitoneal adhesion in mice

Aims Adhesion formation following abdominal intervention is an abnormal peritoneal healing process. Our aim was to investigate the effects of controlling adhesion development by inhibiting its key components (angiogenesis, inflammation and fibrosis) using phosphodiesterase (PDE) inhibitors. Main methods Two PDE inhibitors including cilostazol a PDE3 inhibitor (40 and 400 mg/kg), and pentoxifylline (PTX), a PDE 1–5 inhibitor (50 and 500 mg/kg) were used for a period of 7 days to inhibit angiogenesis, inflammation, and fibrosis in a murine model of sponge-induced peritoneal adhesion. Angiogenesis was assessed by hemoglobin content, vascular endothelial growth factor (VEGF) levels, and morphometric analysis. Accumulation of neutrophils and macrophages was determined by measuring myeloperoxidase (MPO) and N-acetylglucosaminidase (NAG) activities, respectively. Levels of TNF-α were also determined. Fibrosis was assessed by determining the amount of collagen in the implant; TGF-β1 levels in the implant were also measured. Key findings Our results show that the treatments attenuated the main components of the adhesion tissue by reducing the amount of fibrovascular tissue that infiltrated the sponge matrix (wet weight). Hemoglobin content and VEGF levels were also decreased by approximately 40%. Neutrophil accumulation was unaffected by the compounds. However, NAG activity was reduced by pentoxifylline, but not by cilostazol. These compounds also decreased the levels of the pro-inflammatory and pro-fibrogenic cytokines TNF-α and TGF-β1, respectively, and collagen synthesis. Significance Our results suggest that cilostazol and PTX decreased the development of peritoneal adhesions in the model, which might be associated with cyclic nucleotide modulation. Therapies to intervene in these pathways may be beneficial for the prevention of these lesions.

Menstrual effluent in endometriosis shows no difference in volume, VEGF-A, MMP2 and MMP9 or sFLT

Since retrograde menstruation is considered a key event in the aetiology of endometriosis, this study sought to determine whether the menstrual effluent of women with this condition is different from that of those with a normal pelvis. As the amount of blood lost during menstruation is thought to be higher in this group, measured objective menstrual blood loss (MBL) was measured. In addition, factors enhancing both ectopic implantation of endometrium and its subsequent growth (by establishing a neo-vasculature) were chosen for study. Our hypothesis was that they are increased in the menstrual effluent of women with endometriosis. The study showed that at the time of menstruation, there is no difference in MBL or in the volume of menstrual effluent between women with endometriosis and those with a normal pelvis at laparoscopy. In addition, vascular endothelial growth factor-A (VEGF-A) message and protein, soluble truncated receptor sVEGF-R1 (sFLT), matrix metalloproteinase (MMP) 2 and MMP9 activities were also shown to be similar between the two groups. It is concluded that the enhanced expression of VEGF-A and MMP in the peritoneal fluid and ectopic lesions of endometriotic patients may be a secondary event, resulting from an innate difference in peritoneal and systemic factors rather than in the endometrium, causing an abnormal peritoneal response to menstrual debris and facilitating its ectopic implantation.

Plasma cell tumour-formation and antigen-binding myeloma proteins in mice.

Plasmacytoma can be induced in the inbred BALB/c mouse by the injection of mineral oil or implants of solid plastics. This induction depends on three factors: firstly, an abnormal peritoneal granulomatous tissue; secondly, genetically determined factors in the strain BALB/c genotype; and, thirdly, the presence of a gastrointestinal and respiratory microbial flora. The incidence of plasmacytomas following three injections of mineral oils or purified isoparaffins ranges from 40 to 600'. The tumours develop in the peritoneal oil granuloma and often remain localized in the peritoneal connective tissues. In several series of myeloma proteins in this strain of mice the IgA class predominates; 60-66%/' of all tumours that produce a detectable heavy chain class myeloma protein produce an IgA class protein. This finding strongly implies that a portion of the total immunocyte population is more prone to neoplastic transformation. Because IgA myeloma proteins in BALB/c mice are usually polymeric molecules, these proteins can be tested for their ability to bind polyvalent antigens by precipitin reactions. Using this method myeloma proteins with antigenbinding activity have been found to several different antigens. The chemical determinants have been identified for many and include: nitrophenyl compounds, al --3 dextrose (nigerotriose), methyl a-D-galactoside, methyl f3-D-galactoside (probably more specifically to p 1 -6 linked galactose), N-acetyl glucosamine in P1-+3 linkages, N-acetyl D-mannosamine, phosphoryl choline, choline, and a trypsin-sensitive determinant common to antigenic substances produced by salmonella. Other myeloma proteins have been found to precipitate with antigens of bacterial origin. The chemical determinants for these have not yet been established. The actual incidence of active M-components in a series of tumours ranges from 5 to 10% when test antigens containing the determinants mentioned above are used. Many of the antigens can be shown to be produced by organisms in the gastrointestinal and respiratory microbial flora. The chemical determinants, however, to which the myeloma proteins are directed may be found in some cases on autogenous macromolecules. Nevertheless, bacterial antigens containing these determinants are probably highly immunogenic and the precursors of the tumour cells were probably responding to these antigens before neoplastic transformation. The finding of several plasmacytomas of independent origin that produce myeloma proteins which identify the same antigen or chemical antigenic determinant supports this suggestion.

Failure of rotation of mid-gut loop

The case report of a fourteen year old boy with failure of rotation of the mid-gut loop associated with abnormal peritoneal bands causing volvulus and intestinal obstruction is presented. A brief resumé of the clinical status of the problem of intestinal rotation is given with a review of the literature. The early diagnosis of these cases can be made easily only if the occurrence of the condition is kept in mind. Early diagnosis together with our present day knowledge of the physiologic requirements, both preoperatively and postoperatively, will render our surgical corrections to be more successful than those of our predecessors.

Intra-Abdominal Hernia or Intestinal Incarceration: Two Verified Cases Pre-Operatively Diagnosed

THIS paper does not present anything original or new. Attention is simply called to a condition which can be diagnosed pre-operatively only by the roentgenologist, but by him very readily recognized. It is usually overlooked and found accidentally at operation or postmortem, yet the diagnosis is simple and obvious and is missed only because time is seldom taken to outline the jejunum with barium. This condition has been fully described in the literature and the literature, in turn, has been reviewed several times in recent years, the last review being presented by Alexander, in 1937. Paraduodenal or intra-abdominal hernia was described anatomically by Neubauer, 163 years ago, but the literature since then has not been voluminous. Treitz, in 1857, and Moynihan, in 1899, published monographs covering the condition in detail. A majority of the cases reported have been described by surgeons who have found an intra-abdominal hernia in the course of an operation, usually for small bowel obstruction or suspected appendicitis. In all, only a few over 200 cases of intra-abdominal hernia have been described, and of these only four were diagnosed pre-operatively, that is, by x-ray examination, the only means by which a pre-operative diagnosis can be reached. Kummer diagnosed a left-sided hernia in 1921, Taylor a right-sided hernia in 1930, and Exner one of each, reported in 1933. Alexander reported five cases, in 1937, in which he was able to make the diagnosis, but in none of these was surgery necessary, so that these cases have not been confirmed. In this communication, two more cases, diagnosed pre-operatively and confirmed, are added to the literature. Both are of the right-sided variety, although only about a third as many have been reported as having occurred on the right side as on the left. One case presents the anatomy usually described in the cases previously reported as paraduodenal hernias, except that failure of descent of the cecum was associated with the hernial sac. In the other case, there was no true hernial sac present. The cecum and ascending colon and hepatic flexure were attached by a true mesentery which formed a sac only when this portion of the colon was carried mesially. But these two cases are presented because basically the anatomic anomaly, abnormal peritoneal folds, is the same, and the diagnosis and treatment are identical with true intra-abdominal hernias. The exact cause of the occurrence of these peritoneal abnormalities has not been demonstrated. Treitz felt that fossæ about the junction of the duodenum and jejunum were the result of failure of fusion of the peritoneum during the third stage of the process of intestinal rotation. Moynihan thought the fossæ were the result of a failure of fusion of the mesenteric root with the peritoneum covering the posterior abdominal wall.