Air-fluid Levels Research Articles

Varied Clinical Presentations of Abdominal Tuberculosis Causing Bowl Obstruction

Background: This study investigates the clinical presentations and surgical outcomes of abdominal Koch's disease, a common cause of intestinal obstruction, and the outcomes of surgical interventions.Objective: To evaluate the clinical presentations, surgical outcomes, and postoperative progress in patients with abdominal tuberculosis causing intestinal obstruction.Materials and Methods: A study of 50 patients diagnosed with abdominal TB at DHQ Teaching Hospital from 16 September 2021 to 16 September 2022 found that 80% were emergency cases, with a male-to-female ratio of 1:1.2, and a mean age of 24 years. The majority were Afghan nationals, with a majority coming from lower-middle socioeconomic backgrounds. Common symptoms included abdominal pain, distension, constipation, vomiting, weight loss, pallor, abdominal tenderness, and a mass in the abdomen. Laboratory findings included anemia, leukocytosis and raised ESR. Imaging findings showed distended small bowel loops and multiple air-fluid levels in 80% of cases, while 20% had evidence of coexisting pulmonary Koch's on chest X-rays.Results: Abdominal Koch's is diagnosed 50% of the time, with 35% of confirmed cases having positive clinical findings. Common lesions included strictures, ileocecal masses, and intestinal perforations. Surgical procedures varied, and patients received full antitubercular therapy postoperatively. Complications occurred in 30% of cases, and hospital mortality was 4%.Conclusions: Abdominal tuberculosis, a major cause of intestinal obstruction, but it is mostly asymptomatic and commonly affecting lower-middle socioeconomic groups. Surgical intervention and antitubercular therapy often led to improvement, but postoperative complications and mortality persist.Keywords: Abdominal tuberculosis, Intestinal obstruction, Mycobacterium tuberculosis.

Intussusception in children with celiac disease

ABSTRACT Celiac disease (CD) is a chronic illness. Blood testing for tissue transglutaminase antibodies is the initial screening test for the diagnosis of CD, and upper gastrointestinal endoscopy and duodenal/jejunal biopsy are used to confirm CD. Intussusception (IS) is the process in which a proximal segment of the bowel invaginates through the lumen of a distal segment. The association between pediatric IS and CD has been described but is still not widely recognized. Herein, we report a case of IS as the first manifestation of CD in a child. A 3-year-old girl presented to the emergency department with a 1-week history of marked abdominal distention and lethargy, but there was no history of fever, bleeding per rectum, or jaundice. A second-degree relative had a family history of CD. Clinical examination: The patient was a lethargic child with pale conjunctiva and bilateral lower limb edema. She was a febrile and had a normal hemodynamic status. The adipose tissue was diminished throughout the patient’s body; her weight was 8 kg (<5% weight percentile for girls), and her height was 81 cm (<5% height percentile for girls). Laboratory results included the following: Hb of 9 g/dL, serum ferritin of 10 ng/mL (30–400 ng/mL), normal liver function test results except for hypoalbuminemia at 21 g/L (35–52 g/L), and low blood cholesterol of 0.94 g/L (1.54–2.01 g/L). The patient’s blood sugar level was 98 mg/dL, and her renal function test results were normal, with negative septic screening. Abdominal radiography revealed several air–fluid levels, suggestive of an obstruction in the small bowel. Abdominal ultrasonography revealed typical features confirming the diagnosis of IS. Abdominal computed tomography demonstrated an enteroenteric IS with no other signs of organic causes, such as lymphoma or other tumors. Based on the high index of suspicion of CD, a workup confirmed the diagnosis. A gluten-free diet [A1] was started during the hospital course, and the patient improved dramatically regarding her symptoms and was discharged home. In conclusion, this case highlights the association between IS and CD. Intussusception is an emergency condition and usually idiopathic. However, in atypical or recurrent typical presentations underlying causes, we should do proper investigations to initiate appropriate management. [A1]Abbreviations are generally avoided for terms that are not repeated in the text. In this case, this abbreviation is not used elsewhere in the Abstract. Hence, I have deleted the abbreviation. Categories: Pediatrics, Gastroenterology.

039. Obstructive Ileus Caused by Colitis Tuberculosa: A Case Report

Background: Gastrointestinal TB (GTB) constituting approximately 1% to 3% of all TB globally and characterized including of any part of digestive system and its related organs. Results: A 61 years old man was admitted to emergency departement with abdominal pain and abdominal distention since 6 months and getting worse in 1 day. He also complained dispneu. On examination, the abdomen was rigid, distended, and tender and the lung has wheezing. The radiographs of abdomen revelved dilated loops of the small intestine with multiple air-fluid levels suggestive of small intestine obstruction. A chest radiograph showed active TB with opacity of the right lung. The patient was planned for exploratory laparotomy and founded anastomosis, peritoneal deposits, matted bowel, and a perforation of ileus. Intraoperative biopsy was taken from the ileus perforation and revelved tuberkulosa infected. Postoperatively, he was started antituberculous theraphy (ATT) of Rifampicin, isoniazid, and ethambutol (RHE). Conclusion: Obstructive Ileus is a complication of gastrointestinal tuberculosis in patients with a history of untreated latent tuberculosis.

Relationships Between Radiomorphometric Parameters of the Maxillary Sinus and Development of Sinusitis: A Cone Beam Computed Tomography Study.

The presence of maxillary sinusitis can complicate dental procedures. This study aimed to explore the relationship between maxillary sinus radiomorphometric factors, observed in cone-beam computed tomography (CBCT) images, and inflammatory sinus diseases. In this cross-sectional study, CBCT images from patients referred to a private radiology center between January 2018-January 2020 were analyzed. Sinuses were categorized as healthy or pathologic. Sinus pathologies were further classified into subgroups; mucosal thickening, retention cyst, partial opacification, complete opacification and air-fluid level. Radiomorphometric parameters, including ostium height, drainage length, ostium opening size, and drainage angle, were measured in the coronal plane. A p value less than 0.05 was considered statistically significant. A total of 433 maxillary sinuses from 258 patients were examined. Height of the ostium and drainage path length in the groups with various sinus pathologies was significantly higher than in healthy sinuses (p < 0.05 for each subgroup) except for air-fluid level (p = 0.334 and p = 0.520, respectively). Drainage path length was significantly longer in all patient groups. Maxillary ostium openings were significantly smaller in retention cyst and partial opacification subgroups, compared to healthy patients (p = 0.000 and p = 0.006, respectively) except for mucosal thickening or air-fluid levels conditions (p = 0.094 and p = 0.62). Drainage angle did not significantly differ. This study reveals that longer drainage length is associated with a higher risk of inflammatory sinus diseases, with increased severity. Smaller ostium openings are linked to retention cysts and partial opacification, while higher ostium locations increase the likelihood of sinus inflammation and disease severity.

Computed Tomography Analysis of the Nasal Septal Deviation and Related Paranasal Sinus Pathologies

Purpose: Nasal Septum Deviation (NSD), which is defined as a dislocated septum, is a prevalent condition that is mostly asymptomatic; however, it can cause difficulties such as nasal obstruction and rhinosinusitis symptoms. Other Paranasal Sinuses (PNS) disorders, e.g., Osteo Meatal Complex (OMC) obstruction, have been assumed to be correlated with NSD. This study investigates the possible correlation of specific radiological findings of PNS pathologies in patients with or without the existence and direction of NSD. We also discussed the different types of NSD and their incidence among different groups stored by age, gender, etc. Materials and Methods: This is a cross-sectional study conducted at multiple imaging centers in Iran between July 2019 and February 2020 to estimate the prevalence of deviated nasal septum and correlate between NSD and other findings using paranasal sinus scans. All the individuals who met the inclusion and exclusion criteria were included in the study. NSD types have been classified based on Mladina's method. Results: We prospectively reviewed PNS Computed Tomography (CT) scans obtained from 254 cases (82 men and 172 women), aged 18 to 81 years (mean: 35.53), evaluated over seven months. Out of 254 cases, 135 (53 %) patients had NSD, without any direction predominance (right-sided vs. left-sided), and equally distributed between genders. The most common NSD types were type V with a frequency of 42.22% and type III with a frequency of 24.44%. Other PNS CT findings were also investigated in our patients, like OMC obstruction, pansinusitis, mucocele, air-fluid level, mucosal thickening, and concha bullosa. There was no statistically significant correlation between any of these pathologies and NSD (P-value &gt; 0.05). Conclusion: Although NSD was observed in more than half of our cases' PNS CTs, there was no significant correlation between NSD and other findings in most subjects. This reveals that the effectiveness of septal repair surgeries in relieving patients' symptoms might not be as high as expected.

Double ileo-sigmoid volvulus: Report of three (03) cases of ileo-sigmoid node

IntroductionThe ileo-sigmoid node is a rare condition that causes mixed intestinal obstruction. It is difficult to diagnose preoperatively and requires medical and surgical management. We report on managing 03 cases of the ileo-sigmoid node. Case presentation02 male patients (25 and 37 years old) and one female patient (43 years old) were seen in emergency for occlusive syndromes. The abdominal X-rays in our patients showed air-fluid levels of the small intestine type in two cases and of the mixed type in one case. The diagnosis of intestinal obstruction by strangulation was accepted in all three patients. Hypovolaemic shock was found in the female patient. All three patients had received preoperative resuscitation. Laparotomy revealed type II ileo-sigmoid nodes in 02 cases and type I in one. We noted ileal and sigmoid necrosis in 02 cases and ileal necrosis in 01 case. All three patients underwent ileal and sigmoid resection followed by colorectal anastomosis and terminal ileostomy. Post-operative management was straightforward in all the 03 cases. Clinical discussionThe ileo-sigmoid node is a serious pathological situation, with the risk of rapid evolution of the intestines involved. It is a medical and surgical emergency requiring rapid and appropriate treatment. ConclusionThe ileo-sigmoid node is a serious condition with a complex preoperative diagnosis. It is a medical and surgical emergency requiring rapid and appropriate management.

253. CLINICAL USEFULNESS OF ENDOSCOPY, BARIUM FLUOROSCOPY, AND CHEST COMPUTED TOMOGRAPHY FOR THE CORRECT DIAGNOSIS OF ACHALASIA

Abstract Background The definite diagnosis of esophageal achalasia is established using manometry, which is per- formed in patients with suspected achalasia based on the findings of screening examinations, such as upper gastrointestinal endoscopy, chest computed tomography (CT), or a barium swallow test. However, the exact values of test characteristics in these supportive diagnostic examinations remain unclear. Methods We estimated the sensitivity and specificity of characteristic findings in the supportive diagnostic examinations for achalasia by comparing the data of a large number of achalasia patients and others with digestive symptoms. Patients Achalasia patients (n=119) and non-achalasia patients with suspected achalasia and repeated feelings of chest discomfort (n=37) who were treated in a single university hospital. Results Characteristic findings on chest CT (i.e. dilated esophagus, air-fluid level formation) and barium swallow tests were observed in more than 80% of achalasia patients but in less than 10% of non-achalasia patients. In contrast, conventional characteristic findings of upper gastrointestinal endoscopy (i.e. intra- esophageal food debris, feeling of resistance at the esophagogastric junction) were seen in only 40%-70% of achalasia patients. In particular, the feeling of resistance at the esophagogastric junction was observed by the examiner in only 30%-50% of patients. Conclusion Intra-esophageal food debris or resistance at the esophagogastric junction on upper gastrointestinal endoscopy will be positive in only about half of patients with achalasia. Other supportive diagnostic examinations, such as chest CT or barium fluoroscopy, should therefore be included in order to avoid overlooking the disease.

Clinical characteristics of apical segment lung abscess: a 10-year retrospective study.

Lung abscess in the apical segment of the lung is not rare and is often underestimated in clinical practice. However, the clinical features of apical segment lung abscess (AL) have scarcely been reported. Hence, this study aimed to determine the clinical characteristics of AL and explore moderate therapeutic strategies. This was a retrospective, single-center cohort study. We reviewed the medical records of consecutive patients who were admitted to Shanghai Pulmonary Hospital in Shanghai, China, from January 2009 to December 2018. This study collected information on patients with lung abscess, including demographics, symptoms, clinical findings, and treatment. The statistical methods used were descriptive statistics, Chi-squared test, Fisher's exact test, t-tests, and logistic regression analysis. Of 824 patients, 431 with lung abscess were finally eligible after a review of medical records. The patients were divided into two groups: the AL group (n=68) and the non-apical segment lung abscess (NAL) group (n=363). Compared with patients in the NAL group, those in the AL group had lower rates of chronic obstructive pulmonary disease (COPD) (5.9% vs. 17.4%, P=0.02), diabetes (14.7% vs. 32.2%, P=0.004) and hypoprealbuminemia (10.3% vs. 25.3%, P=0.007). Regarding clinical symptoms, patients in the AL group exhibited lower fever (38.2% vs. 58.4%, P=0.002) and less purulent sputum (32.4% vs. 45.5%, P=0.045). Moreover, regarding radiological features, the AL group had a lower proportion of air-fluid level on chest computed tomography (CT) (7.4% vs. 16.8%, P=0.047). In addition, the study demonstrated that the AL group had a shorter duration of intravenous antibiotic treatment [8 (7-8) vs. 10 (8-12) days, P <0.001]. Surprisingly, the AL group had a high rate of surgical treatment (36.8% vs. 15.4%, P<0.001). In multivariate analysis, surgical treatment occurred more frequently in patients with AL [odds ratio (OR): 2.58, 95% confidence interval (CI): 1.40-4.77, P=0.002], lower in patients who had fever (OR: 0.55, 95% CI: 0.31-0.98, P=0.04), and imaging features of liquefaction necrosis (OR: 0.32, 95% CI: 0.15-0.69, P=0.004). Patients with AL presented with atypical and relatively mild clinical symptoms. However, the rate of surgical treatment was significantly higher. These data should be considered when managing the AL.

Sigmoid volvulus with 25 episodes.

We report the case of a 74-year-old male with abdominal pain, distention and obstipation for 8 hours. He had a medical history of 24 sigmoid volvulus (SV) episodes, 23 of which treated with endoscopic detorsion, while one resolved spontaneously. Physical examination revealed abdominal distention, tenderness, hyperkinetic bowel sound and an empty rectum. Abdominal X-ray radiograph revealed dilated sigmoid loops with coffee bean sign. Computed tomography demonstrated dilated sigmoid loops with air-fluid levels and mesenteric whirl sign. Flexible colonoscopy showed a spiral-like luminal obstruction of the viable sigmoid colon at 18 cm from anal verge. A successful colonoscopic detorsion was performed. Due to the poor general health status of the patient (American Society of Anesthesiologists-ASA score 4) arising from serious comorbidities including coarctation of aorta and coronary disease, percutaneous endoscopic colostomy was suggested instead of elective sigmoid colectomy. He did not approve adjunctive therapy and was discharged following 24-hour observation.

Analysis of factors affecting the diagnostic yield for microbiologic diagnosis from percutaneous abdominal abscess drainage.

This study aimed to investigate the factors influencing the diagnostic yield of microbiologic diagnosis obtained through percutaneous abdominal abscess drainage procedures. We analyzed the influence of diverse clinical, radiological, and pre-procedural factors on the success of microbiologic diagnosis in this context. A retrospective analysis of patients who underwent percutaneous abdominal abscess drainage was performed to assess the factors affecting the diagnostic yield for microbiologic diagnosis. A total of 174 patients undergoing percutaneous abdominal abscess drainage was included. The use of antibiotics during the procedure and the spread of the abscess to other organs significantly increased the likelihood of obtaining a positive culture. Specifically, antibiotic use during the procedure raised the risk by up to 3.30-fold (OR = 3.30, 95% CI 1.48-7.65, p = 0.004), while abscess spread to another organ increased the risk by approximately 1.87-fold (OR = 1.87, 95% CI 0.98-3.61, p = 0.057). Additionally, abscesses containing air and abscesses with an air-fluid level were more common in patients with positive culture results. Other factors, such as gender, age, malignancy prevalence, and surgical history, did not significantly impact culture results. This study provides valuable insights into the factors affecting the diagnostic yield of microbiologic diagnosis from percutaneous abdominal abscess drainage. The findings underscore the importance of considering patient-specific variables and procedural aspects when planning and executing abscess drainage procedures. Further research can build upon these insights to develop evidence-based guidelines for optimizing the diagnostic yield of percutaneous abdominal abscess drainage procedures.

Relationship Between History/Physical Examination and Radiological Findings with Surgical Findings to Determine the Level of Obstruction

Objective: To assess the correlation between the clinical findings and radiological findings with surgical findings in patients with intestinal obstruction and the subsequent determination of the level and severity of the obstruction. Methods: This prospective observational study was done at the general surgery department of JPMC Karachi, during 12-month from January 2022 to December 2022. Adults aged 15 years and above, clinically and radiologically suggestive of intestinal obstruction and underwent surgical intervention were included. Clinical data was collected through thorough physical examinations and detailed medical history reviews. Parameters such as abdominal pain, distension, bowel sounds, and other relevant symptoms were documented. Radiological investigations were analyzed for evidence of obstruction and its location. Patients who undergone surgical intervention, their operative findings were correlated with clinical and radiological findings. Data analysis was done by using SPSS version 26. Results: Overall, 44 patients were studied with mean age of 38.59 ± 7.77 years, 56.8% were male and 42.3% female. Common clinical findings included inability to pass gas or stool (97.7%), constipation (95.5%), dehydration (93.2%), and tachycardia (93.2%). Radiologically, air-fluid levels with valvulae connivences were most frequent (52.3%). Intra-operatively, omental bands (22.7%) were the most common finding. There was a significant association between clinical symptoms, such as tenderness and anorexia, with specific intraoperative findings (p=0.004). Radiological findings, particularly air-fluid levels, were strongly associated with surgical diagnoses (p=0.001), highlighting their importance in guiding treatment. Conclusion: Clinical assessments and abdominal X-rays in diagnosing intestinal obstruction, applicable in only a few instances. It emphasizes the superior diagnostic capability of abdominal CT scans, may enhance the surgeon's understanding of the underlying pathology.

Recurrent spontaneous pneumothorax secondary to lung cystic lesions in a case of convalescent COVID-19: a case report and literature review

BackgroundWhile spontaneous pneumothorax has been documented in COVID-19 patients, reports on recurrent spontaneous pneumothorax due to cystic lesions in convalescent COVID-19 patients are scarce. The progression of these lung cystic lesions remains inadequately explored.Case presentation and literature reviewAn 81-year-old male, a non-smoker with a history of rheumatoid arthritis, presented with fever, cough, and expectoration for 14 days. Initially diagnosed with moderate COVID-19, he deteriorated to severe COVID-19 despite adherence to local treatment guidelines. Successive identification of three cystic lesions termed “bulla” or “pneumatocele”, and one cystic lesion with air-fluid level, referred to as “pneumo-hamatocele” (PHC), occurred in his lungs. Gradual improvement followed anti-inflammatory therapy and optimal supportive care. However, on day 42, sudden worsening dyspnea prompted a computed tomography (CT) scan, confirming a right spontaneous pneumothorax and subcutaneous emphysema, likely due to PHC rupture. Discharge followed chest tube implementation for pneumothorax resolution. On day 116, he returned to the hospital with mild exertional dyspnea. Chest CT revealed recurrent right pneumothorax from a remaining cyst in the right lung. Apart from our patient, literature retrieval identified 22 COVID-19 patients with spontaneous pneumothorax due to cystic lesions, with a male predominance (95.6%; 22/23). Diagnosis of pneumothorax and lung cystic lesions occurred around day 29.5 (range: 18–35) and day 26.4 (± 9.8) since symptom onset, respectively. Except for one patient whose pneumothorax occurred on day seven of illness, all patients eventually recovered.ConclusionsRecurrent spontaneous pneumothorax secondary to lung cystic lesions may manifest in convalescent COVID-19 patients, particularly males with COVID-19 pneumonia. Chest CT around 2 to 3 weeks post-symptom onset may be prudent to detect cystic lesion development and anticipate spontaneous pneumothorax.

A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children.

Surgery remains the mainstay in treating intussusception in developing nations. A correspondingly high bowel resection rate exists despite a shift to nonoperative reduction in high-income countries. We aimed to study the clinical profile of the patients with intussusception presenting to our hospital and to assess the clinical and radiological predictors of success or failure of nonoperative management of intussusception. This prospective study was conducted in the Department of Pediatric Surgery over a period of 3 years and included a total of 118 patients who presenting to our emergency division with features suggestive of intussusception and were managed accordingly either with hydrostatic reduction or by surgical intervention. We observed that the majority of the patients were males (65.5%). The mean age was 13.54 months. Intermittent pain was the most common symptom. Both pain and vomiting did not affect the outcome. Lab parameters like raised total leukocyte counts (TLC), C-reactive protein (CRP) and lactate levels were significantly associated with failure of hydrostatic reduction. Patients with air fluid levels on X-ray were more likely to end up in surgery. Ultrasound findings of bowel wall edema, aperistaltic gut loops and a pathological lead point was associated with failure of hydrostatic reduction as well. The overall success rate of hydrostatic reduction was 85.5%. Hydrostatic reduction of intussusception is a safe and effective method of management of intussusception whenever indicated. Factors that might reduce the chance of its success include continuous pain, irritability, tenderness, deranged lab parameters like TLC, CRP and lactate levels, air fluid levels on X-ray, bowel wall edema, aperistalsis and the presence of a lead point. Shah JY, Banday I, Hamdani HZ, et al. A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children. Euroasian J Hepato-Gastroenterol 2024;14(1):81-85.

A rare case of lipoid pneumonia due to diesel aspiration

Acute exogenous lipoid pneumonia is a rare chemical pneumonia following aspiration of volatile hydrocarbon compounds. In this case report, we present a 63-year-old male patient who developed acute exogenous lipoid pneumonia following accidental aspiration of diesel oil from the fuel tank of his vehicle with a hose. The patient presented with sore throat, cough, dyspnoea and tachypnoea. Posteroanterior chest radiography showed paracardiac infiltrations in the right lower and left lower lung fields.The patient presented again on the 21st day after aspiration with cough and sputum production. Chest X-ray showed a cavitary lesion with air-fluid level in the lower right probe. One month after the treatment, radiological regression of the consolidations was observed in the chest radiograph. In conclusion, this rare disease occurs after inhalation of hydrocarbon products. Symptoms and radiological findings develop rapidly and may lead to serious pulmonary complications and sequelae.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

Intestinal pseudo-obstruction as systemic lupus erythematosus complication: is it time to reconsider the role of surgery?: A case report of a tailored multidisciplinary managed 44-year-old male patient

Rationale: Intestinal pseudo-obstruction (IPO) represents an unclarified dysmotility disorder characterized by clinic-radiological signs of intestinal obstruction not associated with organic conditions. IPO may occur as a rare complication of autoimmune connective tissue diseases, including Systemic Lupus Erythematosus (SLE). Surgery is recognized as having a marginal management position for IPO patients: this case investigates its role, in the context of a multidisciplinary approach, in the diagnosis and treatment of acute complications of IPO. Patient concerns: An SLE-affected 44-year-old man with a history of recurring nonspecific abdominal sub-obstructive episodes was admitted to our department for constipation, vomiting, and unintentional weight loss. Clinical examination revealed a family history of eosinophilic gastroenteritis (EG). Laboratory tests, including Systemic Sclerosis screening, presented no significant alterations. Abdominal X-ray highlighted multiple air-fluid levels; contrast-enhanced CT showed fluid surrounding dilated loops, and fluid-filled ileal loops, without evidence of organic intrinsic/ab-extrinsic obstruction, perforation, or extraluminal gas. Considering these findings, stenosing-pattern Crohn disease and strictures-complicated EG were mainly suspected. However, ileum-colonoscopy with the histological analysis resulted in inconclusive for Crohn disease and EG. Diagnosis: The histological examination, by showing an SLE fibro-inflammatory pattern, not sparing the enteric plexus, infiltrating the intestinal wall of the surgical samples collected during the right hemicolectomy intervention, allowed the diagnosis of IPO. Interventions and outcomes: The patient, indeed, was initially managed conservatively with nasogastric decompression, immunosuppressive therapy, and parenteral nutrition by a multidisciplinary team including gastroenterologists, rheumatologists, and nutritionists. Unfortunately, 2 weeks later, the worsening symptoms required a lifesaving right hemicolectomy followed by ileostomy. Lessons: IPO should be suspected in SLE patients presenting treated-unresponsive GI symptoms. Its early recognition finalized to start a tailored multidisciplinary approach appears prognostically crucial. Surgery could represent a paramount diagnostic moment and therapeutic life-saving approach.

A RARE CASE OF TRANSMESOCOLIC HERNIATION OF SMALL BOWELTHROUGH A CONGENITAL DEFECT PRESENTING AS A CLOSED BOWEL OBSTRUCTION - A CASE REPORT AND LITERATURE REVIEW OF REPAIRS OF INTERNAL HERNIAS

Transmesocolic hernia is an uncommon type of Internal hernia with incidence ranging from approximately 5–10% of all Internal Hernias. To the best of our knowledge, this is the first reported case of a transmesocolic hernia in adults without any surgical history or trauma. Small bowel loops were found herniating into the supracolic compartment through a congenital defect in transverse mesocolon presenting clinically as Small Bowel obstruction. A 20-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency Exploratory Laprotomy was performedand bowel loops with discolouration seen enclosed in hernial sac in supracolic compartment which were milked out of defect and observed to have obtained vascularity almost immediately. The postoperative period was uneventful. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as Bowel gangrene, peritonitis and sepsis.

Pulmonary Cavitation as a Complication of COVID-19: Case Series and a Brief Review of the Literature

The COVID-19 pandemic has led to an unprecedented surge in respiratory illness cases worldwide. Although uncommon, pulmonary cavitation has been reported as a potential complication of COVID-19. This case series report describes four cases of COVID-19 patients with lung cavities, highlighting the various causes and clinical manifestations of this complication, and a review of the literature on the presence of lung cavities in COVID-19 patients. In two cases, the cavities were most likely due to secondary bacterial superinfections, with one case being complicated by multi-drug-resistant bacteria. Another case developed cavities secondary to a fungal infection, while the third case was directly caused by SARS-CoV-2 invasion in the lungs. The presence of cavities with or without air-fluid level or pneumothorax in COVID-19 patients should be considered as a potential complication of this infection, especially in those with respiratory symptoms. Physicians should remain vigilant for the development of pulmonary cavitation in COVID-19 patients, particularly those receiving high doses of steroids. Additionally, spontaneous pneumothorax should be considered an alarming sign in COVID-19 patients.

CASE REPORT ON OBSTRUCTED OBTURATOR RICHTER HERNIA MANAGED BY OPEN PREPERITONEAL MESH REPAIR

Introduction: Obturator hernia is rare abdominal hernia.It occurs when part of the pelvic contents protrude through the obturator foramen adjacent to Obturator vessels and nerve.It is a diagnostic challenge in the emergency department since the signs and symptoms are non-specific and the risk of strangulation is high in such hernias. It often occurs in elderly, emaciated and thin lean body mass women.The patient may present with intestinal obstruction with diffuse abdominal pain, nausea and vomiting and constipation,because of diagnostic difficulty they often present late and most of them are diagnosed introperatively. Case report: A 60 years old female patient presented to emergency General Surgery Department of GMERS Medical College Himmatnagar with pain in Right Groin region and diffuse pain abdomen and vomiting associated with constipation since 3 days,k/c/o Hypertension on medication Tab Amlodipine 5mg 1-0-0.On examination -Abdomen distended,tenderness present in Right groin region Abdominal girth 72 cm . Abdomen Xray revealed multiple air fluid levels ,USG Abdomen and pelvis suggestive of Right Groin Hernia and multiple dilated bowel loops with diameter of 3.5 mm suggestive of Intestinal Obstruction (Usg picture is uploaded in fig 2) and as patient was not affordable for CECT Abdomen and pelvis CECT Abdomen and pelvis was not done Discussion: Emergency lower midline exploratory laparotomy under General Anaesthesia was done and intraoperatively was diagnosed as Obstructed Obturator Hernia as the bowel was found to be protruding into Obturator foramen adjacent to Obturator vessels and Obturator nerve and the bowel was reduced from foramen and was found to be healthy ,single suture was taken over the coopers ligament and obturator foremen and peritoneum was closed as there was no bowel contamination preperitoneal space was created and 15X15 cm Macroporous light weight polypropylene Mesh was placed and fixed covering all the defects to prevent recurrence and any future groin and Inguinal hernia. Conclusion: Obturator Hernia is a rare form of abdominal hernia but can cause a severe Intestinal Obstruction if it not diagnosed and treated early bowel might result into ischemia and necrosis which can turn into a fatal complication.The elderly female with lean body mass and multiparous women presenting with diffuse pain abdomen and pain in Groin region with vomiting and constipation obstructed Obturator hernia and femoral hernia should always be kept as probable diagnosis.Radiological imaging may yield the diagnosis but in this case as patient was not affordable so ,CECT Abdomen with pelvis was not done and as patient Abdomen Xray had multiple air fluid levels .Emergency lower midline Exploratory laparotomy can be done and if obstructed bowel is found to be healthy then Preperitoneal mesh repair can be done and this procedure has got a good outcome increases the abdominal strength and has got a less recurrence chances.

Rapid pulmonary fistulization complicating a psoas abscess with intraoperative hypoxemia: a rare case report

Introduction and importance: Psoas abscess is a relatively uncommon condition that can present with vague clinical features. Patients with this condition often present in different ways to different specialties leading to delays in diagnosis and management. Case presentation: We present a 47-year-old woman with complaint of vague abdominal pain, fever and raised inflammatory markers who underwent CT examination. On CT, a collection was noted in the right iliac fossa that extended along the right retroperitoneum through the retrocrural space in the right lung base communicating with a cavitary pulmonary lesion with air-fluid level. The psoas abscess was drained. Clinical discussion: Our case presents a number of rare and intriguing features. Notably, the patient, who was immunocompetent, experienced a primary Staphylococcus infection that swiftly progressed to a sizable pulmonary abscess, a phenomenon uncommon in such hosts. The rarity further extends to the source of infection, originating abdominally but culminating in thoracic complications through contiguous spread from a retroperitoneal site. Despite the potential severity, the patient’s outcome was remarkably positive Conclusion: This case underscores the potential rapidity of pulmonary involvement in psoas abscesses, emphasizing the need for heightened awareness and consideration of respiratory signs during preoperative assessments