Acute Abdominal Distension Research Articles

Deaths from surgical conditions in Malawi\xa0- a randomised cross-sectional Nationwide household survey

BackgroundRelatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility.MethodsThe study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey.ResultsThe survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care.ConclusionIn Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.

Aleukemic myeloid sarcoma of small intestine: masquerading as subacute intestinal obstruction: Review of literature

Background: Myeloid sarcoma (MS) is an extramedullary disease of immature myeloid cells with incidence of 1-2% among all acute myeloid leukemia (AML) cases. Less than twenty cases of aleukemic MS with initial presentation as intestinal mass have been described in the English literature.
 Case report: Here we report a case of 45 year old female with normal haematology workup who presented with acute abdominal pain and distension. On evaluation, she was found to have ileocolic intussusception of gangrenous bowel, so managed by limited right hemicolectomy and initially reported as Non Hodgkin lymphoma (NHL).During follow-up she was found to have a globular mass in right lumbar region that was diagnosed as myeloid sarcoma. On further followup, her TLC count was gradually increasing. 
 Conclusion: The index case highlights the unusual presentation of isolated intraabdominal MS which was clinical diagnosed as subacute intestinal obstruction in a young female with normal hematological profile.

Acute Gastric Dilatation in a 13 Year Old Child. A Case Report

Summary Acute gastric dilatation is a rare and life threatening disease. The usual symptoms of acute gastric dilatation can vary and be nonspecific, including acute abdominal pain, abdominal distension, nausea and vomiting. Many aetiologies of acute gastric dilatation are described. This article presents a case of a 13 year old girl who presented in our clinic with acute gastric dilatation after an orthopaedic operation. Clinical signs and a diagnostic pathway are presented in the report. In the early treatment of acute gastric dilatation, nasogastric tube insertion was used for gastric decompression. As a surgical approach jejunostomy insertion was used to ensure enteral feeding. Our case study shows that the optimal treatment for this pathology is mainly conservative.

Mystery of a Family with Recurrent Male Infant Deaths- Solved by Autopsy and Molecular Tests

The authors report a case of a six weeks old boy who presented with acute febrile illness and progressive abdominal distension. There was a significant family history of early male sibling deaths. Autopsy showed multiorgan abscesses. Molecular test revealed final diagnosis of the child.

Uncommon Cause of Acute Abdominal Pain in an Elderly Patient Undergoing Peritoneal Dialysis

A 65-year-old male patient who had been undergoing peritoneal dialysis (PD) for end-stage renal disease (ESRD) for 5 years visited the emergency department because of acute abdominal pain and distension during PD. On examination, dialysate flow dysfunction was observed. After blood tests and peritoneal dialysate fluid analysis, PD-related peritonitis was excluded. When the PD catheter was ＂milked,＂ a fibrin clot was extracted. The abdominal pain and distension were relieved. He self-administered tranexamic acid on the presumption that he had hematuria. In clinical practice, when gastrointestinal, genitourinary, or gynecological bleeding occurs in ESRD patients, the bleeding is usually treated with tranexamic acid. We share our experience to increase the awareness of the possibility of increased fibrin thrombus formation in the PD catheter due to tranexamic acid administerationed in PD patients.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

A unique presentation of superinfected pseudomyxoma peritonei secondary to a low-grade appendiceal mucinous neoplasm

BackgroundPseudomyxoma peritonei (PMP) is an uncommon condition characterized by diffuse mucinous material in the abdomen and pelvis, generally arising from a perforated epithelial neoplasm. Typically, the disease presents as suspected acute appendicitis, ovarian mass, abdominal distension, or ventral hernia. Our case represents a very rare presentation of superinfected PMP.Case presentationA 46-year-old female with a past medical history notable for depression, asthma, and uterine leiomyomas presented to an urgent care with 5 days of progressive abdominal pain, bloating, nausea, and subjective fevers. The patient had a diffusely tender abdomen, without peritonitis, was mildly tachycardic, and had a white blood cell count of 15 K. A CT of the abdomen/pelvis was consistent with PMP with a ruptured appendiceal mucocele versus PMP secondary to an adnexal ovarian neoplastic pathology with an infectious component. The patient initially improved on antibiotics but ultimately required two surgeries, the first of which controlled intraabdominal sepsis while the second permitted definitive management of PMP with cytoreductive surgery (CRS) and HIPEC.ConclusionSuperinfected PMP is a rare entity with very few documented cases. A staged approach that incorporates clearing the peritoneal infection, with or without resection of the primary tumor, followed by rehabilitation and definitive surgery appears to be a safe and effective management strategy.

Ileal volvulus due to ascaris lumbricoides: a diagnosis revisited

Ascariasis infestation is a common helminthic disease in developing countries with a wide spectrum of clinical presentations, one of which can be acute abdomen. Small bowel volvulus is a serious life-threatening emergency. The aetiology may be primary as is often seen in Africa and Asia, while in Western countries other predisposing conditions usually initiate the volvulus. Ascariasis is highly prevalent in India and so, a myriad of different presentations is quite obvious. Here the authors have reported a case of a 6year old boy presenting with features of acute intestinal obstruction-central abdominal pain, repeated vomiting and abdominal distension. After evaluation with abdominal radiography and ultrasonography, exploratory laparotomy was planned. A secondary ileal volvulus compact with worms of ascaris lumbricoides was found. Resection of non-viable ileum was done after evacuation of worms by enterotomy followed by primary anastomosis. Prompt clinical diagnosis, a high index of suspicion for complications and early surgical intervention are critical in minimizing morbidity in cases of Intestinal Ascariasis.

Pylorogastric intussusception in a puppy with a congenital intrahepatic portosystemic shunt – a case report

A sixteen-week-old female Akita-inu puppy was presented for investigation of acute vomiting, diarrhoea, and abdominal distension. Abdominal ultrasound revealed a single congenital right-sided intrahepatic portosystemic shunt and pylorogastric intussusception, which spontaneously resolved during the next three days after initial examination. Owners elected for euthanasia due to the clinical deterioration of the patient that reflected in development of clinical signs associated with liver insufficiency, guarded prognosis and financial concerns for transjugular coil embolisation.

UNUSUAL CASE OF EOSINOPHILIC ASCITES AND PERIPHERAL EOSINOPHILIA

Introduction Drug reactions and atopic disease are common etiologies of peripheral eosinophilia in the United States, while helminthic infections, malignancy and hypereosinophilic syndrome (HES) are rare. Here we describe a patient with an unusual etiology for peripheral eosinophilia. Case Description 24-year old previously healthy female presented with acute abdominal pain, distension and diarrhea. She had traveled to Brazil and Italy in the previous three years. Initial peripheral absolute eosinophil count (AEC) was 4.67 k/uL. Abdominal ultrasound showed moderate ascites. Paracentesis yielded 2.3L of ascites fluid; analysis showed 3165 WBC with 92% eosinophils. Stool culture grew few Blastocystis hominis. Pathology showed 12 esophageal and >100 colonic eosinophils/hpf without significant abnormality in the stomach or duodenum. Bone marrow biopsy did not show evidence of malignancy. Allergy skin testing demonstrated sensitization to several aeroallergens. HES workup was normal. Gastroenterology considered treatment for eosinophilic gastroenteritis versus parasite infection. She was treated with metronidazole for Blastocystis, and symptoms improved over the following 8 weeks. Peripheral AEC decreased to 0.48 k/uL by 12 weeks post-treatment, without return of symptoms. Discussion Blastocystis hominis is a protozoan parasite rarely implicated in human disease or peripheral eosinophilia. It can be found in stool of healthy individuals, though gastrointestinal symptoms may require treatment. Eosinophilic ascites has been associated with eosinophilic gastroenteritis, which may self-resolve or require corticosteroid treatment. Steroid treatment during parasitic infection, however, can lead to disseminated disease. In this case, where etiology of the eosinophilia was unclear, it was important to treat a possible parasitic infection prior to considering corticosteroid treatment. Drug reactions and atopic disease are common etiologies of peripheral eosinophilia in the United States, while helminthic infections, malignancy and hypereosinophilic syndrome (HES) are rare. Here we describe a patient with an unusual etiology for peripheral eosinophilia. 24-year old previously healthy female presented with acute abdominal pain, distension and diarrhea. She had traveled to Brazil and Italy in the previous three years. Initial peripheral absolute eosinophil count (AEC) was 4.67 k/uL. Abdominal ultrasound showed moderate ascites. Paracentesis yielded 2.3L of ascites fluid; analysis showed 3165 WBC with 92% eosinophils. Stool culture grew few Blastocystis hominis. Pathology showed 12 esophageal and >100 colonic eosinophils/hpf without significant abnormality in the stomach or duodenum. Bone marrow biopsy did not show evidence of malignancy. Allergy skin testing demonstrated sensitization to several aeroallergens. HES workup was normal. Gastroenterology considered treatment for eosinophilic gastroenteritis versus parasite infection. She was treated with metronidazole for Blastocystis, and symptoms improved over the following 8 weeks. Peripheral AEC decreased to 0.48 k/uL by 12 weeks post-treatment, without return of symptoms. Blastocystis hominis is a protozoan parasite rarely implicated in human disease or peripheral eosinophilia. It can be found in stool of healthy individuals, though gastrointestinal symptoms may require treatment. Eosinophilic ascites has been associated with eosinophilic gastroenteritis, which may self-resolve or require corticosteroid treatment. Steroid treatment during parasitic infection, however, can lead to disseminated disease. In this case, where etiology of the eosinophilia was unclear, it was important to treat a possible parasitic infection prior to considering corticosteroid treatment.

Desmosis Coli − a Case Report and Review of The Literature

Desmosis coli is a rare pathology presenting as slow transit constipation. In this case we would like to discuss the presentation and management of desmosis coli. A 14-month-old female hailing from western India with a history of chronic constipation presented with acute massive abdominal distension and vomiting. At laparotomy, a hugely dilated transverse and sigmoid colon with a transition zone at the lower sigmoid was found. A transverse stoma was done after taking multiple seromuscular biopsies. The patient underwent re-exploration on day 14 because of the non-functioning of the stoma and a fixed bowel loop. The histopathology report was suggestive of normal ganglion cells. Unfortunately, the stoma continued not to function. A dye study showed dye in the colon after 24 hours ruling out any anatomical obstruction. Histopathology slides were reviewed multiple times and reported lack of connective tissue of the colonic wall leading to the diagnosis of desmosis coli. The patient was started on gradual feeds and pro-kinetics and over the next 2 weeks the stoma started functioning slowly. Desmosis coli is a rare cause of constipation which should be suspected in cases where aganglionosis has been ruled out and the constipation is refractory to conventional therapy.

Intussusception caused by heterotopic gastric mucosa in small intestine: a case report

BackgroundIntestinal intussusception is the most frequent cause of small bowel obstruction in children between the ages of 2 months and 5 years and often remains idiopathic in etiology, even after surgery. On microscopic examination, in intussusception normal mucosa is noted but in a few cases heterotopic tissue can be seen. Heterotopic gastric mucosa in the small intestine is extremely rare except for its occurrence in remnants of Meckel’s diverticulum. In view of the rarity of this condition, we report a case of ectopic gastric mucosa in the small intestine that was not associated with remnants of vitelline duct.Case presentationA 6-year-old boy of Indo-Aryan ethnicity from India presented with episodes of acute abdominal pain and distension with vomiting and non-passage of stools. On ultrasonography intussusception was suspected. A laparotomy was done and the ileal segment (tip of intussusception) was sent for histopathological examination. On histopathology, sections from the tip of intussusception showed extensive gastric metaplasia of the mucosa.ConclusionsA definitive diagnosis of heterotopic gastric mucosa is established by histopathological examination and it is important to differentiate heterotopia, which is a developmental anomaly, from metaplasia, which is an acquired condition. Heterotopic gastric mucosa is usually clinically silent and surgical intervention can be considered in patients with complications such as gastrointestinal hemorrhage and intestinal obstruction.

Giant megacolon: An unusual surgical emergency

Giant megacolon (GMC), an advanced form of chronic megacolon, is an uncommon diagnosis that may evolve into a surgical emergency. Here, we demonstrate a case of an elderly male who presented to our hospital with complaints of acute abdominal distention and diffuse abdominal pain. He was emergently taken to the operating room where necrotic cecum was found. The patient underwent total abdominal colectomy with end ileostomy. Radiographic and operative images of GMC are presented. The authors also discuss the pathophysiology and clinical management of this surgical condition. The following core competencies are addressed in this article: Medical knowledge, Patient care.

Clinical Relevance and Treatment Selection of Ureteral Injury After Cesarean Section.

The aim of this case series was to report the clinical relevance and management outcomes of ureteral injuries acquired secondary to cesarean section. This was a retrospective case series from January 2007 to September 2014. Description of the patients' characteristics, diagnostic tools for investigation, management, and postoperative follow-up was conducted on postcesarean section patients who developed symptoms of urine leakage after cesarean section and necessitated secondary surgery for ureteral injury. Descriptive statistics was used for demographics and operative data. A total of 5619 cases were managed by cesarean section during the study period. Six (0.107%; 95% confidence interval [CI], 0.1069%-0.1071%) patients had ureteral injury related to the cesarean section. Of 6 cases, 3 (0.053%; 95% CI, 0.0529%-0.0531%) had ureterouterine fistula. Three cases were managed by ureteroneocystostomy, 1 by ureteroneocystostomy with Boari flap, 1 by transureteroureterostomy, and the other one by ureteral stenting via ureterocystoscopy. Three patients had immediate operation because of an acute abdomen and 3 patients had delayed operation. The left ureter was the most common site of ureteral injury (5/6). The postoperative course was uneventful for all cases. Continuous urinary leakage and acute abdominal distention associated with fluid accumulation after emergency cesarean section should be considered as "red flag" symptoms of ureteral injury and ureterouterine fistulae complications. Delayed management for ureteral repair may not be associated with bad outcomes for management of ureterouterine fistula. Delayed management was associated with less blood loss, less operating time, and acceptable outcome among patients with ureterouterine fistulae when the renal function is not compromised.

Neonatal sigmoid volvulus

BackgroundNeonatal sigmoid volvulus is a rare entity. It is associated with Hirschsprung's disease. Presentation is acute abdominal distention, vomiting and obstipation. Abdominal radiograph will show the “coffee bean” sign, but this is frequently missed and the diagnosis requires a high index of suspicion. Treatment options include contrast enema, colonoscopy or laparotomy, depending on the condition of the baby and local availability. Population and resultsDuring the last 6years, 6 infants with sigmoid volvulus were treated in our department. Four presented during the first 48h since birth, and 2 presented at the age of 2 and 7weeks of age. One child was operated and 5 had primary contrast enema with radiologic de-volvulus. Rectal biopsy was performed in all cases; three children had Hirschsprung's disease. Those with normal biopsies responded well to rectal washouts. Two patients had early one stage transanal pullthrough and one had 2 further occasions of sigmoid volvulus prior to definitive surgery. All three recovered with an uneventful course. ConclusionsNeonatal sigmoid volvulus requires a high level of suspicion. Contrast enema is efficient for primary de-volvulus. Rectal biopsy should be performed and if positive for Hirschsprung's disease, surgery should be performed sooner rather than later.

A Case of Duodenal Varices

A 73 year old woman with a history of untreated hepatitis B and C infection presented to the hospital with a complaint of acute onset jaundice and abdominal distension. Laboratory studies were notable for an anemia, transaminitis and a direct hyperbilirubinemia. An abdominal ultrasound revealed a cirrhotic liver with a hepatic mass, consistent with a hepatocellular carcinoma on CT. Upon presentation she was noted to pass melena and her hemoglobin fell from 8.5 g/dL to 6.2 g/dL. She was started on octreotide and antibiotics. An EGD revealed a non-bleeding esophageal ulcer, gastric varices at the cardia (without stigmata of bleeding), portal hypertensive gastropathy and a large duodenal varix with red spots; no intervention was performed. She then experienced coffee ground emesis and hypotension. Interventional radiology was consulted for treatment of duodenal varices, but the patient become mentally altered and the procedure was aborted. With lactulose her mental status returned to baseline. With regained capacity, she opted for no further therapies and decided to pursue home hospice, to which she was discharged. Duodenal varices are ectopic varices caused by dilated splanchnic veins or portosystemic collaterals and are outside the common pathologic sites (i.e. gastroesophageal and rectal sites). They are an effect of global portal hypertension or splanchnic venous occlusion. Despite responsibility for only 2-5% of gastrointestinal variceal bleeding, they have a four-fold increased risk of bleeding as compared to esophageal varices. Duodenal varices account for 17% of ectopic varices. Diagnosis can be difficult as endoscopy may overlook them if they are serosal or submucosal in location. They can sometimes be localized on CT angiography or with multiplanar reconstruction, as noted in some case reports. Given the limited data on duodenal varices there remains no definitive best treatment for these lesions. There are case reports of success with endoscopic therapies (injection sclerotherapy, variceal ligation) as well as shunt procedures. Some studies suggest that sclerotherapy may be an effective and safe alternative to a TIPS procedure. In our case, the patient likely experienced a significant gastrointestinal bleed from her duodenal varix. With further investigation, therapy for duodenal varices may become standardized. Clinicians must remain alert to this potential source of gastrointestinal bleeding, so appropriate and timely therapy can be implemented.Figure 1

Appendiceal Adenocarcinoma Masquerading as an Ovarian Mass: A Case Report

Introduction: Primary appendiceal carcinomas are rare neoplasms of the gastrointestinal tract that have seen an increase in diagnosis over the past 10 years. The most common presentation is acute appendicitis or abdominal distension, although occasionally they may present as an adnexal mass due to their anatomical location. We present a case report of the diagnosis of an appendiceal adenocarcinoma found on colonoscopy that presented as a gynecological neoplasm. Case: A 77 year old female was referred to the office from gynecological oncology for evaluation an 8cm x 7cm right pelvic mass seen on CT scan. The CT was ordered due to complaints of several months of weakness, 30lb weight loss, and intermittent localized right lower quadrant abdominal pain. The mass was extensive and was causing deviation of her bladder and severe right-sided hydroureter. A colonoscopy done about 10 years ago was normal. History was significant for right-sided breast cancer status post right radical mastectomy, total abdominal hysterectomy, and 25 pack year history of smoking. Her family history was positive for esophageal cancer in her mother, but denied breast, ovarian, gastric, and colon cancers. Her vitals were within normal limits. Her abdominal exam was significant for tenderness to palpation in the right lower quadrant with fullness. On pelvic exam, there was a large, non-tender, fixed right-sided adnexal mass. Lab studies revealed CEA = 416.2; CA-125 = 11; and CA 19-9 = 1. A colonoscopy was performed prior to her planned surgical resection. Initial observation was unremarkable, including examination of the distal terminal ileum. The markedly elevated CEA level and location of the lesion warranted more aggressive investigation, and the appendiceal orifice was gently probed with a closed cold forceps. This revealed a large friable, appendiceal mass which was biopsied. The biospies revealed adenocarcinoma, with markers suggesting colon over ovarian etiology. An attempt was made to resect the tumor, but due to the extent of the disease and co-morbidities, this was not done and a palliative bypass was performed. Discussion: In this case, based on the right lower quadrant/pelvic mass, ovarian and colonic tumors were considered. On colonoscopy, care was given to search for tumors, particularly inside the appendiceal orifice. With a known elevated CEA in a patient with a right lower quadrant mass, a diagnosis of appendiceal adenocarcinoma was able to be made preoperatively on colonoscopy. Diagnosis of appendiceal adenocarcinoma is rarely made on colonoscopy and is often found incidentally on appendectomy.

English

Diverticulosis of small intestine is an uncommon disease, with variable clinical presentation. Among the small bowel diverticulae, distal jejunal diverticulae form the most common subset. Diverticulosis of proximal jejunum represents an uncommon pathology of the small bowel. The condition is usually asymptomatic and should be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain or discomfort. Complications such as diverticulitis, perforation, bleeding or intestinal obstruction appear in 10-30% of the patients increasing morbidity and mortality rates. We herein report a case of a 45 year-old man, who presented at the emergency department with acute abdominal pain, vomiting and abdominal distension. Preoperative radiological examination followed by laparotomy revealed multiple proximal jejunal diverticulae, filled with food, adherent to and compressing upon the terminal ileum, causing intestinal obstruction.

Severe Liver Injury while Using Umbilical Venous Catheter: Case Series and Literature Review

Proper position of umbilical venous catheter (UVC) is of importance to avoid severe complications. We review clinical presentations of neonates with UVC who developed catheter-associated liver injury. We reviewed institutional intensive care database (2008-2013) and identified neonates with UVCs who developed severe hepatic injury. We recorded admission diagnosis, gestational age, birth weight, number of days the umbilical catheter was in place, its radiological position at insertion and at the time of injury, presenting clinical signs, and outcomes. Of 1,081 neonates, 9 (0.8% [95% exact binomial confidence interval, 0.4-1.6%]) with UVC developed severe hepatic injury. All had the UVC malpositioned within the liver circulation. All presentations were life threatening, with acute abdominal distension (hepatomegaly) being the most consistent sign. Two neonates died from complications which were unrelated to catheter-associated liver injury. In all neonates with liver injury, UVC was malpositioned within the portal circulation. Despite the fact that our report provides only circumstantial evidence for the mechanism of injury, it supports reports which suggest that "low" UVC position increases potential for this type of complication. Acute onset of abdominal distension in a neonate with UVC should prompt ultrasonographic evaluation of position of the catheter tip.

GASTROINTESTINAL TORSIONS AND INTUSSUSCEPTION IN NORTHERN KOALAS (PHASCOLARCTOS CINEREUS) AT SAN DIEGO ZOO (1976–2012)

The recent classification as threatened status of the northern koala (Phascolarctos cinereus) by the Australian Government highlights the importance of the conservation and health management of this iconic Australian marsupial. This case series describes gastrointestinal torsion and intussusception in six northern koalas (three males, three females, 2-11 yr old) at the San Diego Zoo from 1976 to 2012. Two koalas died shortly after presentation. Diagnoses of ileocecal intussusception, resulting from enteritis in one case and cecal torsion in the other, were made at postmortem examination. One koala died 4 days after an exploratory laparotomy, with negative findings, and an acute double colonic intussusception was diagnosed at postmortem examination. Two small intestinal mesenteric torsion and one proximal colon mesenteric torsion cases were successfully corrected surgically. In the case of colonic mesenteric torsion, the koala had recurrent clinical signs 2 wk later, and a second surgery requiring resection and anastomosis of ischemic jejunum was performed, with the koala dying shortly afterward. One koala with small intestinal torsion had a recurrence of torsion 22 mo later and subsequently died. The koala with the second case of small intestinal torsion remains alive 14 mo postsurgical correction. All six koalas presented with signs of colic that included anorexia, lethargy, depression, acute abdominal distension, abdominal stretching, decreased fecal output, open-mouth gasping, or a combination of symptoms. Abdominal radiographs may show stacked gastrointestinal linear gas patterns and contrast stasis. Prevalence of torsion and intussusception is low at this institution (2%), although recurrence in individuals is common (50%) and overall survival is poor (83%), which emphasizes the importance of timely recognition, surgical correction, and postoperative management. While inciting etiologies were unable to be determined in these cases, monitoring generalized gastrointestinal health and differing Eucalyptus sp. effects on individual koala's gastrointestinal function, parasite control, and stress minimization through standardized husbandry practices are likely important.