Acute Abdominal Conditions Research Articles

A rare cause of small bowel diaphragm disease presenting with palpated abdominal mass

Small bowel diaphragm disease is a rare complication related to non-steroidal anti-inflammatory drug (NSAID) use. It presents with non-specific symptoms such as vomiting, abdominal pain, subacute bowel obstruction and occasionally as an acute abdominal condition. We report a case of diaphragm disease in a 33-year-old female who presented with vomiting, constipation and abdominal pain started 5 days earlier. Physical examination revealed palpated abdominal mass. The patient’s past medical history was remarkable for NSAID use. The patient was managed by surgical resection of involved intestine and diagnosis was confirmed by histological examination. Although there are few published cases of diaphragm disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing patients presenting with non-specific abdominal symptoms with remarkable past medical history of NSAID use.

Patient narratives of illnesses requiring abdominal surgery in Cambodia: Heroic/stoic, and dealing with ‘the ball of meat’

ABSTRACTThis study describes the illness narratives that inform treatment-seeking behaviours for acute abdominal conditions in Cambodia, and thereby explores factors impeding the timely delivery of surgical intervention. Semi-structured qualitative interviews were undertaken with patients who had undergone abdominal surgery at Siem Reap Provincial Hospital between 2011 and 2014. Interviews collected basic demographic information and also patient narratives based on Groleau’s McGill Illness Narrative Interview (MINI). Interviews were contemporaneously translated from Khmer to English and recorded for transcription. A content analysis of interview transcripts based on narrative enquiry was undertaken. Ninety-seven patients participated in the study and five themes emerged from the data. These were: Explanatory models about the causes of abdominal pain and effects of surgery; Pre-surgery stoicism and illness management; Fear of poor outcomes and death; Burden of treatment costs and anticipated recovery time; and, Enhancing community trust in surgery. Our findings add the patient voice to the limited evidence about access to surgery, and socio-cultural and financial barriers affecting treatment-seeking behaviours in Cambodia. By understanding the collective narratives surrounding experiences of abdominal surgery, efforts to improve surgical services in Cambodia may be better informed of the reasons patients delay treatment.

\u201cSigmoid diverticulitis mimicking cholecystitis\u201d a clinical challenge

Diverticular disease is a common disorder and its incidence increases with ageing. Pathophysiology is multifactorial. Lifestyle, including smoking, alcohol intake, decreased dietary fibres and lack of physical activity, plays a predominant role. Genetics seems also to contribute specifically for right-sided diverticular disease (RSD). The majority of the patients with diverticular disease are asymptomatic. Diverticulitis is the inflammation of the diverticula usually presenting with abdominal pain associated to nausea, vomiting, rectal bleeding, diarrhoea and fever. When the inflammation process affects the diverticula in the ascending colon, the condition represents a clinical challenge as it can be easily misdiagnosed with other acute abdominal emergencies. We reported a case of a 70-year-old female who presented to our Emergency Department (ED) with right upper quadrant pain and an initial clinical suspicion of cholecystitis. Ultrasound (US) and Computed Tomography (CT) demonstrated an anatomical variation of the sigmoid colon diverticulitis. This clinical report demonstrates that ultrasound plays a relevant part as first-step approach to the acute abdominal conditions and its accuracy increases together with other diagnostic tools such as Computer Tomography.

Postoperative Sepsis Among HIV-Positive Patients with Acute Abdomen at Tertiary Hospital in Sub-Saharan Africa: a Prospective Study

The incidence of HIV in Uganda as reported by UNAIDS (2012) was increased from 6.7% in 2004 to 7.6% to 2012. The main threat to HIV-infected patients following surgery is the development of sepsis. Inadequacy of surgical supplies and human resources further hastens and complicates the postoperative sepsis in HIV patients. The objective of the study was to determine incidence and risk factors associated with postoperative sepsis, among HIV seropositive with acute abdomen. A prospective study ran for a period of 11 months from October 2015 to April 2016 in Mulago Hospital in Kampala. Eligible patients were recruited and included. Study variables included postoperative wound sepsis, type of surgery, and CD4 counts. Thirty-eight data were collected using a questionnaire then entered in the Epidata software 3.1 and analyzed by Stata software version. Sixty-two patients were recruited; of these, 42 were male, 37 were HIV-negative and 25 were HIV-positive. The proportion of patients with postoperative sepsis in the HIV-positive group was 7 (28%) and in the HIV-negative group was 8 (21.6%). The number of patients discharged in HIV-positive group was 24 (96%) and in HIV-negative group was 35 (94.6%). Among the HIV-positive group was 1 out of 25 (4) % and HIV-negative was 2 out of 37 (5.4%). The overall postoperative sepsis incidence rate was 3 per 100 person days for under observation (95% CI 0.02–0.1), and the incidence rate ratio of HIV-positive patients and HIV-negative was 1.04 (95% CI 0.32–3.3; P = 0.47. The limited health resource was associated with developing postoperative sepsis. There was a higher risk of positive operative sepsis among HIV-positive compared to HIV-negative patients undergoing surgery for acute abdominal conditions.

Clinical study and management of small bowel obstruction in 20 cases in a large tertiary care teaching public health hospital in Department of General Surgery

Background: Small bowel obstruction is one of common and most challenging emergency faced by one in surgical practice. Bowel obstructions account for approximately 20% of all surgical admissions in patients with acute abdominal conditions. The aim of the study was to evaluate age and sex distribution along with different etiological factors in age groups, clinical features among with different etiological factors, benefits of early surgical intervention, causes of mortality and morbidity.Methods: A retrospective observational study was conducted in 20 patients for period of two years. All cases above age of 18years are included. Patients who are pregnant, with history of confirmed and strongly suspected peritoneal carcinosis, undergoing radiotherapy of the abdominal region are excluded from the study.Results: 20 cases with 60% males and 40% females were included in the study and majority of patients were between age group of 41 to 60 years (55%). Pain abdomen was the most common symptom. Abdominal tenderness was the most common sign present in all patients. Mortality rate was 20% out of which 40% death rate was present in patient operated after 24 hours of admission. Septicaemia was the most common cause of death.Conclusions: So the intra-abdominal adhesions are the commonest cause of small bowel obstruction while strangulation or obstructed hernia may account for high mortality. Conclusively it can be said that early detection and complete treatment including timely surgery are the essential aspects to decrease morbidities and ultimately decrease mortality.

Late presentation of congenital diaphragmatic hernia in children: A single-institution experience

Background: Congenital diaphragmatic hernia (CDH) with late presentation beyond the neonatal period is rare and often misdiagnosed, with delayed treatment. We report the management of a series of patients that presented after the neonatal period.Patients and method: we reviewed our experience over 4 years (2015-2019) in a single institution to determine the factors for late presentation of congenital diaphragmatic hernia, associated anomalies, complications and its management. Results: We had six patients diagnosed as late presenting CDH and operated in our institution over 4 years . The patients ranged in age from one year to 10 years with males to females ratio 2:1. All the hernia defects were left sided. Except one patient all have abnormal gut rotation. The mode of presentations were ; one patient presented with gastric perforation due to misdiagnosis of pneumothorax and ICD placement. Another one had irreducible gut gangrene, 2 cases have left lobe of liver along with small bowel, colon and spleen and stomach, The other 2 patients had small bowel, colon and spleen and stomach as hernia content. All cases were managed by primary repair of defect with interrupted non absorbable suture through transabdominal approach. Two cases had post op pleural effusion and pneumothorax and required intercostal tube placement, and all the patient were kept in intensive care for 48 hours but without any ventilator support.Conclusions: There should be a high index of suspicion in every case presenting with persistent vomiting along with abdominal pain, recurrent pneumonia, chronic respiratory conditions or acute abdominal condition with doubtful x-ray chest.

Sonographic and CT findings of intraperitoneal focal fat infarction and its mimics

Objectives The term of intraperitoneal focal fat infarction (IFFI) is a group of self-limiting and relatively rare acute abdominal condition essentially characterized by infarction and/or torsion of the omentum and epiploic appendages. The purpose of this exhibit is to demonstrate the sonographic and CT findings of IFFI and its mimics. Methods IFFI represents the grouping of various acute abdominal conditions with the common denominator of spontaneous fatty tissue necrosis. We retrospectively reviewed the sonographic results in patients with acute abdominal pain, and selected uncommon entities such as greater omental infarction, lesser omental infarction, epiploic appendagitis or encapsulated fat necrosis. We also selected its mimics such as diverticulitis, appendicitis, inflammatory bowel disease, colon cancer or other miscellaneous conditions. Results Regardless of differences of its anatomical location, the sonographic appearances of IFFI show similar as a hyperechoic, solid, non-compressible, ovoid, or cake-like mass with a location that corresponds to the region of maximum tenderness. The integrities of adjacent organs differentiate IFFI from the hyperechoic fat in cases of its mimics. We demonstrate sonographic findings of IFFI using diverse cases, highlighting the differential diagnosis at each location. Most of the cases were also correlated with CT imaging. Conclusion Familiarity and recognition of the sonographic appearances of IFFI can provide guidance for appropriate conservative managements that are essential for preventing an unnecessary surgery.

Mesenteric ischemia: can multidetector computed tomography angiography be a one-stop diagnostic solution?

Background Mesenteric ischemia is a medical condition in which inflammation and injury of the small intestine result from inadequate blood supply. Mesenteric ischemia is caused by a reduction in intestinal blood flow and is classified as acute (sudden onset of intestinal hypoperfusion) or chronic depending on the time course of symptoms. Multi Detector Computed Tomography MDCT has high sensitivity and specificity for diagnosing acute primary mesenteric ischemia. Aim and objectives Our objective was to evaluate the role of MDCT angiography in evaluation of patients with suspected mesenteric ischemia as regards vascular and intestinal abnormalities. Patients and methods This prospective study was performed on 60 patients clinically suspected of having mesenteric ischemia, referred to the radiology department of Cairo University hospitals from the emergency hospital and the out-patient clinics and in-patient departments of general surgery and of Endemic Infectious diseases and Hepatogastroenterology. Patients suspected clinically to have mesenteric ischemia were initially examined by Doppler and if showed mesenteric vascular suspicious findings by Doppler, they were referred to CT angiography examination. Results In our study we found that 40 patients (66.7%) out of 60 patients showed abnormal MDCT findings which explained the cause of mesenteric ischemia in these patients. The most prevalent CT findings in 40 patients with positive CT angiographic findings in acute mesenteric ischemia (AMI) were bowel wall thickening in 12 patients (30%), bowel distension in 8 patients (20%) and lack of mural enhancement in 10 patients (25%). Computed tomography angiography (CTA) detected accurately the cause of AMI where arterial thrombo-embolism was common cause of AMI (62.5%) and the SMA was the most frequent site in patients with AMI than mesenteric venous thrombosis with AMI (37.5%). 50% of patients with AMI showed pneumatosis intestinalis and surgical exploration revealed bowel infarction and resection anastomosis was done. Conclusion MDCT is fast, safe, accurate and non-invasive imaging modality of choice in patients with suspected mesenteric ischemia which is able to evaluate not only mesenteric vascular structures but also evaluate bowel wall changes and adjacent mesentery, thus detecting the primary cause of mesenteric ischemia that can lead to earlier diagnosis and intervention, also confirmation or exclusion of various other differential diagnoses of acute abdominal conditions.

Natural history and clinical outcomes in patients with portal vein thrombosis by etiology: A retrospective cohort study

BackgroundPortal vein thrombosis (PVT) is an unusual-site thrombosis commonly encountered in patients with malignancies, cirrhosis, and acute abdominal inflammatory conditions (AIC). Current recommendations suggest that anticoagulation may improve recanalization rates but there is limited information on venous thromboembolism (VTE) recurrence rates and whether the etiologies of PVT respond similarly with anticoagulation. ObjectiveTo characterize the natural clinical course and outcomes of patients diagnosed with PVT based on etiology. Patients/methodsPatients with a diagnosis of PVT between 2005 and 2015 who were followed for at least one year and had revised imaging at 12 months ± 3 months were identified. Comorbidities, demographics, anticoagulation choice and clinical outcomes including VTE recurrence, cavernous transformation, PVT recanalization, progression and mortality were obtained. ResultsOf 698 patients diagnosed with PVT, 85 patients were evaluable according to criteria: 54 had cirrhosis (63.5%), 15 malignancy (17.6%) and 16 AIC (18.8%). Mean age was 55.6 ± 13.1 years. At presentation, 40% patients were symptomatic and 29.4% received anticoagulation. Patients with AIC were anticoagulated more frequently compared to those with malignancy or cirrhosis (87.5% vs. 33.3% vs. 11.1%). Overall, patients with cirrhosis had lower rates of PVT progression (0% vs. 13.3%, p = 0.02) and patients with AIC had higher rates of cavernous transformation compared to cirrhosis or malignancy-associated PVT (31.3% vs. 7.4% vs. 0%, p = 002). Among untreated patients, those with malignancy had significantly higher rates of VTE recurrence and PVT progression than patients with cirrhosis (20% vs. 4.2% and 20% vs. 0%). ConclusionsThe natural course of PVT differs among etiologies. In the absence of anticoagulation, patients with malignancy are more prone to VTE recurrence and PVT progression compared to patients with cirrhosis. Given the high rate of VTE recurrence at 12 months in patients with malignancy-associated PVT, anticoagulation should be considered for this group.

Interrupted Midline Fascial Closure to Prevent Burst Abdomen in Emergency Laparotomy: Comparison between Continuous and Interrupted closure

Burst abdomen represents one of the most frustrating and difficult postoperative complication that concerns every abdominal surgeon. It occurs because of various predisposing factors which can be prevented to some extend by having knowledge regarding them. Despite many years of experience, the optimal technique of laparotomy closure remains controversial. The varieties of surgical excess as well as the varieties of abdominal closure techniques are the main difficulties in the proper standardization of this procedure. In this paper a randomized prospective study was designed to compare with a interrupted and continuous technique for closing a midline abdominal fascia in emergency laparotomy. A total of 300 patients of acute abdominal condition who underwent laparotomy were randomized into two groups of 150 patients in each group. Total 22(7.33%) of 300 patients developed burst in the postoperative period. Fourteen (14) (9.33%) in continuous arms and eight (08) (5.33%) patients in interrupted arms developed burst. Burst abdomen occurring mostly 40-60 years age group with a male to female ratio of 1.68: 1. Cough, anemia, malnutrition, DM, intraperitoneal sepsis, wound infection, uremia and abdominal distension were the important predisposing factors for the incidence of burst abdomen. Interrupted suturing was associated with significantly reduced the burst abdomen when comparing with continuous closure.TAJ 2017; 30(2): 69-75

Evaluation of Role of Laparoscopy in Diagnosis and Treatment of Non-Traumatic Acute Abdomen

Background: abdominal pain is a common complaint seen in emergency departments in United States. Abdominal pain is the leading reason for visits to the emergency department (ED), accounting for 6.8% of all visits in 2006. Aim of the Work: this study aimed to evaluate the diagnostic role of laparoscopy in acute abdominal conditions and its therapeutic role in perforated peptic ulcer, acute cholecystits and acute appendicitis. Patients and Methods: this study was conducted prospectively on 40 patients presented with acute abdomen to AlAzhar University hospitals from March 2018 till August 2018. 24 (60%) of patients were females and 16 (40%) were males. The age ranged from 20 to 60. Results: we accomplished complete laparoscopic diagnosis in 90% of cases, and avoided negative laparotomy in 5% of cases. We converted about 10% of laparoscopically diagnosed cases to open surgery for therapeutic purposes with significant reduction in complications in laparoscopic cases and mean hospital stay 2.6 days in laparoscopic cases vs. 5.3 days in open cases. Conclusion: laparoscopy was an excellent diagnostic tool. It was a very good therapeutic tool in acute appendicitis, acute cholecystitis and perforated peptic ulcer. It was also safe and satisfactory; also it saved more hospital beds.

The Overuse of Empiric Antibiotic Treatment for Enterocolitis Diagnosed by Abdominal CT (OVERACCT)

Introduction: The current ACG guidelines for the management of acute diarrhea discourage the use of empiric antibiotic therapy, unless justified by the clinical presentation, including duration of symptoms, recent traveling, fever or bloody diarrhea. Computed tomography (CT) is a widespread and easily accessible imaging tool for the investigation of abdominal symptoms. However, the incidental finding of nonspecific bowel wall thickening, often results in a radiological diagnosis of enterocolitis, irrespective of the symptoms, with subsequent inappropriate use of antibiotic therapy. Methods: A retrospective, observational, IRB approved study was conducted at an inner-city hospital from July 2015 to July 2017. A total of 184 subjects who experienced gastrointestinal symptoms such as abdominal pain, nausea, vomiting, or diarrhea were identified by the enterocolitis ICD diagnosis code. Patients with comorbidities such as AIDS, cancer, or immunocompromised were excluded from the analysis. Of the remaining subjects, 121 underwent abdominal CT to rule out acute abdominal conditions. Chart review included medical history, recent travel, inflammatory markers and stool studies. Clinical outcomes comprised symptoms resolution, length of hospital stay and final GI diagnosis. Chi-square test was used for data analysis. Results: Among 184 patients identified, 116 (63%) were women with a mean age of 46 ± 26 years. The majority of patients (66%) presented with acute diarrhea, lasting less than 72 hours, without a history of recent travel. A radiological diagnosis of enterocolitis was reached with abdominal CT in 80 patients, of which 71% received antibiotic treatment. There was a significant correlation between positive CT findings and antibiotic use (p=0.005). Surprisingly, 61% of patient with the radiological findings received antibiotic treatment despite the absence of diarrhea (p=0.006). Antibiotic treatment did not impact the clinical outcomes (p=ns). Almost 65% of the patients required only supportive treatment based on ACG guidelines. Conclusion: Patients with CT findings suggestive of enterocolitis were more likely to receive antibiotic therapy, irrespective of the presence or absence of diarrhea. This study highlights the widespread antibiotic misuse for the treatment of enterocolitis based on imaging modalities without adequate clinical correlation. Unwarranted radiological testing and antibiotic therapy were identified in 65% of this cohort, while their clinical outcomes remained unchanged.167_A Figure 1 No Caption available.167_B Figure 2. χ2 Calculations. Two way contingency table.167_C Figure 3. χ2 Calculations. Two way contingency table.

Impact of clinical history on choice of abdominal/pelvic CT protocol in the Emergency Department.

IntroductionRadiologists and other specialty consultants play a role in diagnosing patients with acute abdominal conditions. Numerous Computed Tomography (CT) protocols are available and radiologists’ choices are influenced by the clinical history provided. We hypothesize that the quality of the initial communication between referring physicians and radiologists greatly affects the utilization of health resources and subsequent patient care. The purpose of this pilot study was to employ a grading system to quantitatively evaluate a provided history. We also sought to evaluate inter-rater reliability by having radiologists evaluate sample histories and finally, to assess whether the quality of history has an impact on the number of CT protocols radiologists choose as potentially appropriate, with less potential protocols being seen as a positive outcome.MethodsFour reviewers, (2 attendings and 2 residents) evaluated 350 consecutive clinical histories provided for patients presenting to a tertiary care Emergency Department (ED) between September–October, 2012. Reviewers graded histories on a 5-point scale using 4 categories of criteria. This includes a) presenting complaint, b) relevant past medical history or symptom evolution, c) objective laboratory or prior examination results and d) differential diagnosis.ResultsThere was substantial agreement among all four reviewers when evaluating the quality of history, ICC 0.61, (95% CI 0.48–0.71). In particular, agreement amongst attending radiologists was substantial, with ICC 0.69 (0.48–0.80). Significant negative correlation was observed between history grade and number of potentially appropriate protocols in 3 of 4 reviewers (Spearman’s rho: -0.394, -0.639, -0.864, p <0.0001 for these reviewers). This correlation was significantly stronger for attending radiologists (Spearman’s rho: -0.763, 95% CI -0.7933 to -0.731; p<0.0001). Agreement was poor among reviewers when asked exactly how many protocols could potentially be used to answer the clinical question based on provided history, ICC 0.08, (95% -0.03–0.13).ConclusionAlthough there is still variability in radiologists’ approach to protocoling urgent studies, a more comprehensive requisition history narrowed the number of protocols considered.

A three-step approach to patients with suspected acute diverticulitis in the emergency department: An interdisciplinary algorithm proposal

Patients with acute abdominal pain due to acute colonic diverticulitis are a frequent cause of hospital admission. Diverticuar disease increases with age. In Western populations, diverticular disease is diagnosed in 50% individuals over 70 years and 80% over 85 years of age. The identification of patients with acute diverticulitis is a considerable challenge, since numerous other acute abdominal conditions mimic its clinical characteristics. Another problem is the atypical presentation in older patients. A high index of suspicion in the setting of a compatible history and physical examination serves as the cornerstone of early diagnosis. The purpose of this review is to underline the importance of an intimately integrate multidisciplinary approach between emergency physicians, radiologists and surgeons.

Urinary long non-coding RNA H19 may serve as a biomarker for early diagnosis of acute intestinal necrosis

To explore the value of urinary long non-coding RNA(lncRNA) H19 in the differential diagnosis of acute intestinal necrosis against other abdominal emergencies. Surgical specimens of necrotic intestinal tissues, adjacent normal intestinal tissues, and serum and urine samples were collected from 51 patients with acute intestinal necrosis, and analyzed along with the serum and urine samples from 51 healthy controls, patients with 10 different acute abdominal conditions(35 cases for each condition), and patients with breast cancer, gastric cancer, bladder cancer, acute myeloid leukemia, and lung cancer(10 cases for each malignancy). The expression levels of H19 were measured with quantitative PCR in the collected samples. Receiver-operating characteristic(ROC)curves were used to determine the diagnostic value of serum and urine H19 levels for acute intestinal necrosis. The 51 patients with acute intestinal necrosis included 35 women and 26 men(mean age of 74.4 years) with arterial thrombosis as the dominant etiology(26 cases). Compared with that in normal intestinal tissues, H19 was significantly overexpressed by 11.2 times in necrotic intestinal tissues(P < 0.001). Serum and urine H19 expression levels did not differ significantly among the healthy controls, patients with other acute abdominal conditions and malignancies(P > 0.05). Serum and urine H19 levels were significantly up-regulated in patients with acute intestinal necrosis as compared with those in the other subjects included in the analysis(P < 0.001). In patients with acute intestinal necrosis, H19 levels in the necrotic intestinal tissue, serum and urine samples were significantly correlated with correlation coefficients of 0.974(tissue vs serum), 0.967(serum vs urine), and 0.917(tissue vs urine). In ROC curve analysis, the areas under curves(AUCs)of serum and urine H19 for diagnosis of acute intestinal necrosis were 0.951 and 0.915, respectively; their diagnostic sensitivities were 94% and 79.6%, respectively, and they both had a diagnostic specificity of 100%. In patients with acute intestinal necrosis, H19 is overexpressed in necrotic intestinal tissues, from which it is released into the blood circulation and urine. Urinary H19 may serve as a novel and non-invasive biomarker that assists in early diagnosis of acute intestinal necrosis.

The open abdomen: analysis of risk factors for mortality and delayed fascial closure in 101 patients.

The core concepts of damage control and open abdomen in trauma surgery have been expanding for emergent general surgery. Temporary closures allow ease of access to the abdominal cavity for source control.The aim of the current study was to assess the outcomes of patients who underwent open abdomen management for acute abdominal conditions and evaluate risk factors for worse outcomes and inability of fascial closure during the initial hospitalization. We conducted a retrospective analysis of 101 patients submitted to laparostomy in a single institution from January 2009 to March 2017. The evaluated outcomes were mortality, local morbidity, and rate of primary fascial closure. The most common indications for open abdomen were bowel perforation, bowel ischemia, and necrotizing pancreatitis. Global in-hospital mortality rate was 62.4%. For the 37 patients discharged from the hospital, a definitive abdominal closure was attained in 28.Multivariable logistic regression analysis revealed that people older than 60 years of age and with Acute Physiology and Chronic Health Evaluation (APACHE II) scores over 18.5 had higher in-hospital mortality rates. Definitive fascial closure was statistically associated with a lower number of re-interventions and ICU stay. Open abdomen management may be appropriate in these critically ill patients; however, it continues to be associated with significantly high mortality, especially in elder patients and with higher APACHE II scores. Recognition of risk factors for fascia closure failure should promote the investigation for a tailored surgical approach in these patients.

A Prospective Study on Advantages of Laparoscopic Over Open Appendicectomy in a Tertiary Care Teaching Hospital

Background: Appendix has no known function and is commonly termed as a 'vestigial' organ, yet diseases of the appendix loom large in surgical practice; and therefore, appendicitis continues to be the most common acute abdominal condition that requires immediate surgical treatment. Methods: This Prospective Study was undertaken for a period of 6 months on patient diagnosed with appendicitis and admitted to surgery ward at Pacific Medical College and Hospital, Udaipur, Rajasthan. Patients were enrolled on the basis of inclusion and exclusion criteria and written inform consent was taken from the patients before the commencement of study. Results: Proved that laparoscopic procedures cause less post-operative pain than their conventional counterparts. Analgesic requirement for post-operative analgesia was significantly less in LA (mean 4 inj. doses) compared to the OA (mean 6.5 inj. doses). Hospital stay was less for LA (1.55 days) than OA (4.5 days) Full recovery on the basis of return to normal activity was earlier in LA (5.45 days) as compared to OA (9.56 days). Conclusion: LA holds a promising prospect and may replace OA in the near future as the method of choice for effective and qualitative clinical management of appendicitis in emergency and in elective set up.

MRI of Acute Abdominal and Pelvic Non-obstetric Conditions in Pregnancy

The evaluation of abdominal and pelvic pain in the pregnant patient presents unique challenges due to altered physiology and implications of radiation exposure on the fetus. In many instances, a radiologist must consider the potential risk of fetal injury from ionizing radiation and maintaining diagnostic quality imaging. This article will focus on the role of MR imaging and its applications in a variety of acute abdomen and pelvic non-obstetric conditions potentially affecting the pregnant patient. Non-contrast MR imaging is routinely employed in the presence of an initial equivocal ultrasound. However, MR is playing an increasingly more important role in the imaging of the pregnant patient, potentially surpassing the utility of conventional imaging techniques. As radiologists become more comfortable interpretating abdominal and pelvic MRI, MR will play a bigger role in imaging the pregnant patient in the emergency room, in the years to come.

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing.

BackgroundIn low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings.MethodsThis costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices.ResultsOf 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent).ConclusionThe intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

Is the risk of contrast-induced nephropathy a real contraindication to perform intravenous contrast enhanced Computed Tomography for non-traumatic acute abdomen in Emergency Surgery Department?

Background: Contrast enhanced Computed Tomography (CCT) is the most used imaging test to investigate acute abdominal clinical conditions, because of its high sensitivity and specificity. It is mandatory to make a correct and prompt diagnosis when life threatening abdominal diseases as mesenteric ischemia are suspected. Contrast medium administration was linked to acute renal failure, therefore radiologist often prefer to perform CCT without contrast in patients needing to undergo the exam with increased serum creatinine. The aim of the review was to focus on the incidence of contrast induced nephropathy in patients presenting non-traumatic acute abdominal clinical conditions, who underwent CCT with intravenous contrast agent administration in emergency setting.Materials and Methods: The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocol (PRISMA-P). Quality of the evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: The strongest currently available evidence on the incidence of post-contrast acute kidney injury (AKI) following intravenous contrast agent administration consists in a meta-analysis of observational studies. Data extracted from meta-analyses demonstrate that, compared with non-contrast CT, CCT was not significantly associated with AKI. Moreover, the risk of AKI (RR=0.79; 95% confidence interval [CI]: 0.62, 1.02; P=.07), death (RR=0.95; 95% CI: 0.55, 1.67; P=.87), and dialysis (RR=0.88; 95% CI: 0.23, 3.43; P=.85) is similar, compared with the risk of AKI in the non-contrast medium group. Furthermore, intravenous low-osmolality iodinated contrast material is a nephrotoxic risk factor, but not in patients with a stable SCr level less than 1.5 mg/dL, therefore many factors other than contrast material could affect PC-AKI rates. Discussion and conclusions: The benefits of diagnostic information gained from contrast enhanced TC in assessing AA are fundamental in some clinical scenarios. The risk of contrast induced nephropathy (CIN) is negligible in patients with normal renal function but the incidence appears to rise to as high as 25% in patients with pre-existing renal impairment or in the presence of risk factors such as diabetes, advanced age, vascular disease and use of certain concurrent medications. The incidence of CIN/AKI after intravenous contrast administration is very low in general population. Radiologists and referring physicians should be familiar with the risk factors for renal disease, CIN and preventing measures. (www.actabiomedica.it)