Air-fluid Levels Research Articles

Lung Abscess as a Delayed Complication in a COVID-19 Pneumonia Patient: A Case Report

Introduction: In March 2020, the World Health Organization (WHO) proclaimed coronavirus disease 2019 (COVID-19) a global pandemic. Indonesia is one of the nations that is still dealing with the COVID-19 outbreak. COVID-19 has several complications, including lung abscess in extremely rare cases. We presented the first reported COVID-19 patient in Indonesia with a delayed lung abscess. Case: A 30-year-old man presented to the hospital with breathlessness and tested positive for COVID-19. Chest X-ray revealed typical COVID-19 pneumonia. He was discharged after 16 days of hospitalization and was educated on using oxygen at home lest the breathlessness recurred. We planned to evaluate the patient’s chest X-ray after 2 weeks of being discharged. The follow-up chest X-ray revealed an air-fluid level in the upper lobe of the right lung, indicating a lung abscess. The patient was treated with antibiotics for 2–3 weeks. Clinical follow-up 4 weeks after the treatment revealed no symptoms, and chest X-ray showed significant improvement. Conclusion: Lung abscess is one of the rare complications of COVID-19. It is a pulmonary infection that creates an air-fluid level by forming a cavity in the lung parenchyma. Notably, this complication manifested 2 weeks after the patient was discharged. COVID-19 can have several unexpected complications, including lung abscess. It is crucial to monitor patients after being discharged for such complications, especially if they are symptomatic.

Anaerobic Lung Abscess with Complex Empyema

A 51-year-old man with advanced ALS and home mechanical ventilator dependence presented with fever, tachycardia, hypotension and leukocytosis. Chest radiograph showed a large left pleural effusion (Figure 1) and an unenhanced chest CT confirmed a loculated effusion with gas bubbles (Figure 2) and large air-fluid level (Figure 3).

P262 Clinico- microbiological profile of post-COVID pulmonary fungal infections encountered during the second wave of COVID-19 pandemic at a tertiary care teaching hospital in the Himalayas

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectiveThe study aims to generate preliminary data about post-COVID pulmonary fungal infections in the Himalayas and analyze patients’ micro-radio-clinical profiles and outcomes.MethodologyWe conducted a retrospective study at a tertiary care teaching hospital in the Himalayas to generate preliminary post-COVID pulmonary fungal infection data. Sputum, Endotracheal Tube (ET), and Bronchoalveolar lavage (BAL) samples of patients sent to the Mycology laboratory were subjected to KOH mount and aerobic inoculation on Sabouraud dextrose agar plates at 37°C. The patients’ symptoms, diagnosis, clinical-radiological profile, and outcome were collected from the hospital database.ResultsAmong n = 16 cases of post-COVID pulmonary fungal infections aged 53 +/- 13.38 years, n = 7 (43.75%) had Pulmonary Aspergillosis (n = 5 A. fumigatus, n = 1 A. flavus, n = 1 A. niger), n = 5 (31.25%) had Pulmonary Mucormycosis (Rhizopus arrhizus), and n = 4 (25%) had mixed infection. In 2 of 4 mixed infection patients, R. arrhizus was identified on KOH microscopy and A. fumigatus on SDA Agar. Both A. fumigatus and R. arrhizus were identified on KOH Microscopy of the third patient, while only A. fumigatus was cultivated on his SDA Agar. Aspergillus flavus and R. arrhizus were isolated simultaneously from the sample of the last patient, but only R. arrhizus was identified on KOH Microscopy.Clinical symptoms were similar among Pulmonary Aspergillosis and Mucormycosis patients, but hemoptysis was reported only among Pulmonary Aspergillosis patients. Pre-existing co-morbid end-organ damage, AKI, CKD, CLD, COPD, and CAD was more common among Pulmonary Mucormycosis patients and rare among Pulmonary Aspergillosis patients. Treatment requirements and clinical outcomes of patients infected with either mold were similar. The clinical profile of mixed infection patients was notably different from the others. All the patients were males, none complained of chest pain or expectoration, and none had a history of PTB, AKI, CKD, CLD, COPD, or CAD. Only 2 (50%) mixed infection patients needed supplemental high flow oxygen, unlike all (100%) patients diagnosed with single mold infection. None of the mixed infection patients required steroids. Moreover, none of the mixed infection patients died, unlike 60% mortality in cases of single-species infections.On radiological investigation, n = 6 had typical thick-walled cavitary lesions with air-fluid levels and multiple centrilobular nodules giving a tree in bud appearance, of which n = 4 had bilateral lung involvement, and n = 2 had only one lung involved. n = 1 patient had a well-circumscribed lung abscess.ConclusionCOVID patients from the Himalayas had a higher prevalence of invasive pulmonary fungal infections, probably due to the dense surrounding vegetation. The immuno-compromised state following COVID-19 infection/treatment might be responsible for the progression of regular exposure to invasive pulmonary infection.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study

IntroductionThe most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal. MethodsThis prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries. ResultsThe majority of the patients were in the age group 50–59 years in male and 40–49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality. ConclusionsPerforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

Intestinal obstruction due to appendicitis in a 3-month-old child

Appendicitis is the most common surgical abdominal emergency in children, but it is uncommon in infants. We present a 3-month-old boy with intestinal obstruction caused by appendicitis. The radiography image revealed multiple air fluid levels and dilated bowls. Appendicitis was discovered during laparotomy exploration and was surgically removed. The patient was discharged home in good health 3 days after surgery.

Regression of lung bullae after pulmonary infection: Two case reports and the aspect of radiologic and pathologic findings in one case

A sharply demarcated area of emphysema, bleb or bulla, is usually asymptomatic. Some could lead to pneumothorax or superimposed infection, the common complications, while some could be spontaneously resolved, of which mechanism remains unclear. We present two male patients who had asymptomatic bullae at their right upper lungs. The first patient presented with a low-grade fever for a month. His chest radiograph showed a new patchy opacity in right upper lung, which corresponds to an enhancing mass with central necrosis on the chest computed tomography. His tissue pathology from two specimens of pleura had proven as inflammation and fibrosis. After antibiotics treatment, the follow-up images showed partial regression of the bullae. Another patient presented with right pleuritic chest pain for 16 days and was diagnosed as pneumonia with an infected lung bulla. His chest radiograph showed a newly seen patchy opacity at the right middle lung zone and a new air-fluid level in the lung bulla in the right upper lobe. After he had been given antibiotics treatment, partial regression of the bulla was observed. He later underwent right upper lobectomy and successful smoking cessation. The follow-up chest images showed no new bleb or bulla.

Gastric Diverticula: An Uncommon Finding

Gastric Diverticula (GD) are extremely uncommon. They define as an out pouching of the gastric wall to form a sac-like structure. They can be congenital or acquired and are mostly located on the posterior surface of the gastric fundus. GD is asymptomatic in general; however, they may present with discomfort or vague abdominal pain. Rarely, GD can be revealed by a complication, such as ulceration, perforation, or hemorrhage. Abdominal CT scan demonstrates a thin-walled, cystic lesion located in the posterior wall of the fundic region. It may sometimes contain air bubbles or air-fluid level. Communication with the gastric lumen is easily demonstrated by ingesting a water-soluble contrast. Differential diagnosis includes adrenal, pancreatic, and renal cysts, duplication cysts, and bowel diverticula.

Improved esophagography screening for esophageal motility disorders using wave appearance and supra-junctional ballooning.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders (EMDs); however, it requires specialized equipment. The development of more accessible screening examinations is expected. We evaluated the utility of barium esophagography (BE) screening using two novel findings to diagnose EMDs. Between January 2013 and October 2020, 244 patients with suspected EMDs who underwent both HRM and BE were analyzed. The EMD diagnosis was based on HRM findings using Chicago Classification version 3.0. BE was performed using sequential esophagography with barium sulfate. Three conventional BE findings (air-fluid level, rosary-bead/corkscrew appearance, and absent/weak peristalsis) and two novel BE findings (wave appearance and supra-junctional ballooning) were used for diagnosis. The sensitivity and specificity of BE screening using the two novel findings and conventional findings to diagnose EMDs were 79.4% and 88%, respectively [area under the receiver-operating characteristic curve (AUC) = 0.837]. Without these novel findings, they were 63.9% and 96%, respectively (AUC = 0.800), respectively. Achalasia was highly correlated with the air-fluid level (88.7%). Absent contractility was highly correlated with absent/weak peristalsis (85.7%). Relatively high correlations were observed between distal esophageal spasm and rosary-bead/corkscrew appearance (60%), and between achalasia and wave appearance (59.7%). The intra-observer reproducibility and inter-observer agreement for individual BE findings were 84.4% and 75%, respectively. Wave appearance was associated with higher integrated relaxation pressure (IRP) and shorter distal latency. Supra-junctional ballooning was associated with higher IRP. BE screening using two additional novel findings to diagnose EMDs could be useful in general practice.

Risk factors associating with delayed gastric emptying after laparoscopic distal gastrectomy.

The aim of this study was to investigate the incidence of delayed gastric emptying among the patients receiving laparoscopic distal gastrectomy, and to explore their clinical features and risk factors. Clinical data were collected for 223 patients who underwent laparoscopic distal gastrectomy for gastric cancer. We retrospectively evaluated the clinicopathological features and analyzed the incidence of delayed gastric emptying among 223 patients. Delayed gastric emptying was diagnosed by patient's symptoms and the plane radiograph with an air fluid level and dilation of the remnant stomach. Delayed gastric emptying was found in five (2.2%) of the 223 patients. By univariate logistic regression analysis, greater American Society of Anesthesiologists Physical Status (ASA-PS) and older age were significantly related to occurrence of delayed gastric emptying. By multivariate logistic regression analysis, older age was independently significantly related to incident delayed gastric emptying. The area under the curve (AUC) ((95% CI) of the receiver operating characteristic (ROC) was 0.842 (0.561-0.957). The best cutoff for discriminating patients with and without delayed gastric emptying was 80 years (sensitivity 80% and specificity 83%). Our study found the occurrence of delayed gastric emptying is possibly correlated with age. Therefore, careful perioperative observation in elderly patients may possibly be important for possible development of delayed gastric emptying after laparoscopic distal gastrectomy.

A case of jejunal adenocarcinoma missed at cross-sectional techniques and diagnosed by capsule endoscopy

A 50-year-old woman with Lynch syndrome presented to the emergency department with a 1-week history of abdominal pain and vomiting. The patient had undergone recent gastroscopy and colonoscopy, with no pathologic findings. During physical examination she described mesogastric abdominal pain, and laboratory evaluation showed anemia (hemoglobin 8 g/dL). A plain abdominal x-ray revealed mild small-bowel distension and a few air-fluid levels. The patient was admitted for further evaluation. Abdominal CT with contrast medium and CT enterography were performed; neither examination detected pathologic findings except for a single enlarged jejunal mesenteric lymph node (11 × 12 × 12 mm) with moderate contrast enhancement (A).

An Unusual Case of Bowel Obstruction: Diagnosis and Treatment

Question: A 61-year-old man was admitted to the Emergency Department with progressive crampy periumbilical pain accompanied with nausea, abdominal distention, and vomiting for 2 days. He experienced recurrent abdominal pain, vomiting, and constipation for more than 40 years with around 2 episodes per year. Symptoms were not related to diet or labor but could be relieved by enema. Air fluid levels could be indicated by computed tomography (CT) or KUB examination during the attack of abdominal pain.

A double Meckel's diverticulum in a 5-year-old girl

Although Meckel's diverticulum (MD) is the most common congenital anomaly in the GI tract, it is usually located as one true diverticulum at the antimesenteric side of the small intestine. It is very rare to find MD as a double diverticulum. In literature, only four cases of a double MD were reported in pediatric population. A 5-year-old girl was brought to the emergency department complaining of periumbilical abdominal pain associated with frequent bilious vomiting. The only abnormal lab result was leukocytosis with neutrophilia. An erect abdominal X-ray revealed multiple air-fluid levels in the upper abdomen. On laparotomy, the intestinal loops were extensively dilated and adhesions were noticed. After releasing the adhesions, two different Meckel diverticula were surprisingly discovered, a small one located 15 cm from the ileocecal valve, and a large one causing the obstruction and located 35cm proximal to the ileocecal valve. A double diverticulectomy along with a primary repair was undertaken followed by an unremarkable postoperative course. Double MD is a rare and extraordinary entity that may be seen during the surgical practice, so it is crucial to trace the entire intestine during an exploratory laparotomy, especially the last 100 cm of the terminal ileum, to detect the associated congenital anomalies such as duplication or diverticula to avoid future mishaps.

SONOGRAPHIC GUIDED HYDROSTATIC REDUCTION OF INTUSSUSCEPTION-OUTCOME AND ITS DETERMINANTS

Objective: The objective of this study was to determine the success rate of hydrostatic reduction of intussusception and its determinants by using saline enema under ultrasound guidance.
 Study Setting: Department of Pediatric Surgery, Khyber Teaching Hospital, Peshawar.
 Study Design: Descriptive study.
 Material and methods: A total no of 55 patients meeting the inclusion criteria were included in the study and sonographic guided reduction was attempted with a saline enema. The outcome was labeled successful in cases where intussusception got reduced without complications and unsuccessful in case of failure or complications. Age, duration of symptoms, procedure time, number of attempts being continuous data were reported as mean and standard deviation. gender, palpable abdominal mass, bleeding per rectum, air-fluid levels on x-rays, was expressed in frequencies and percentages.
 Results: In this study mean age was 1 year with SD of ± 1.24. Sixty-two percent of patients were male and 38% of patients were female. Moreover, the success rate of hydrostatic reduction of intussusception by using saline enema was 78%. 
 Conclusion: In selected patients, the success rate of hydrostatic reduction of intussusception is a non-invasive acceptable option to be widely practiced.

A RARE CASE OF A 27-YEAR-OLD FEMALE PRESENTED WITH DUODENAL OBSTRUCTION DUE TO ANNULAR PANCREAS

Background. Annular pancreas is a rare congenital abnormality characterized by a ring of pancreatic tissue surrounding the descending portion of the duodenum. It is thought to originate from the incomplete rotation of the ventral pancreatic bud. Objective. To present a case description of a 27-year-old female with duodenal obstruction due to annular pancreas Material and methods. The clinical manifestations, laboratory and instrumental findings of a female patient. Results. We report the case of a 27-year-old female with 3 months history of upper abdominal pain, nausea, postprandial fullness, and recurrent vomiting. Physical examination revealed nothing except for the thin-built body. Routine biochemical and hematological investigations were within normal limits. The patient's standing direct abdominal graphy revealed air-fluid level and dilated both stomach and the first part of duodenum. Upper gastrointestinal series showed circumferential extrinsic compression on the 2nd portion of the duodenum. Abdominal computerized tomography (CT) and ultrasonography (USG) revealed a ring of pancreatic tissue encircling the second part of the duodenum. We present the clinical presentation, treatment plan which is performed through a duodenojejunostomy bypass procedure, and follow-up of the patient. Conclusions. Annular pancreas is associated with duodenal atresia. It usually appears in infancy but might become clinically evident in adulthood with obstruction of the duodenum. The symptoms include constipation, nausea, and vomiting. and usually arise due to obstruction to gastric emptying. In order to confirm the presence of annular pancreas, abdominal CT scans with high resolution and angiography protocols as well as magnetic resonance imaging are helpful.

Mature mediastinal teratoma with tumor rupture into airway

A previously healthy 16-year-old girl presented with hemoptysis in the setting of a persistent cough for two months. Imaging identified a large mediastinal mass with cystic and solid components, calcifications and fat suggestive of a germ cell tumor. There was associated right middle lobe consolidation with an air-fluid level concerning for a necrotizing pneumonia, right upper lobe bronchiectasis, hilar lymphadenopathy, and right upper lobe and right pleural-based nodules concerning for disseminated disease. Histologic analysis of a percutaneous biopsy revealed skeletal muscle, fibroadipose tissue, skin, and keratinous debris consistent with a mature germ cell tumor. Rigid and flexible bronchoscopy were performed and identified inspissated, purulent, and fibrinous material in the right upper and middle lobe bronchi. Microbial cultures grew Staphylococcus aureus. After 3 weeks of antibiotics, complete surgical resection was performed. No malignant components were identified. Her post-operative course was uncomplicated, and she remains without evidence of disease 6 months after resection. While mediastinal teratomas are common, rupture is uncommon with fewer than 60 reported cases in the literature. Rupture can be associated with inflammation and/or infection, resulting in diagnostic and treatment challenges.

Recurrent pneumothorax in a human immunodeficiency virus-positive patient with multidrug-resistant tuberculosis: a rare case of bronchopleural fistula: a case report

BackgroundHuman immunodeficiency virus/tuberculosis coinfections have amplified the multidrug-resistant tuberculosis pandemic in many countries in Sub-Saharan Africa, and multidrug-resistant tuberculosis has become a major public health threat. There is a paucity of data on severe complications of multidrug-resistant tuberculosis in the context of human immunodeficiency virus coinfection despite the increasing prevalence of multidrug-resistant tuberculosis/human immunodeficiency virus coinfection and the complexity of multidrug-resistant tuberculosis treatment. This report describes a rare case of complicated multidrug-resistant tuberculosis in a human immunodeficiency virus-positive individual.Case presentationA 39-year-old human immunodeficiency virus-positive Ugandan male on anti-retroviral therapy for 6 years, who had recently completed treatment for drug-susceptible tuberculosis from a public hospital, presented to the tuberculosis ward of Mulago National Referral Hospital with worsening respiratory symptoms including persistent cough with purulent sputum, fever, right chest pain, and shortness of breath. On admission, a diagnosis of drug-resistant tuberculosis was made following a positive sputum Xpert MTB/Rif test with rifampicin resistance. Culture-based tuberculosis tests and line probe assay confirmed multidrug-resistant tuberculosis. The patient was given multidrug-resistant tuberculosis treatment that included bedaquiline, isoniazid, prothionamide, clofazimine, ethambutol, levofloxacin, and pyrazinamide and switched to second-line anti-retroviral therapy that included tenofovir/lamivudine/lopinavir/ritonavir. Chest X-ray revealed a hydro-pneumothorax, following which a chest tube was inserted. With persistent bubbling from the chest tube weeks later and a check chest X-ray that showed increasing pleural airspace (pneumothorax) and appearance of a new air–fluid level, chest computed tomography scan was performed, revealing a bronchopleural fistula in the right hemithorax. The computed tomography scan also revealed a pyo-pneumothorax and lung collapse involving the right middle and lower lobes as well as a thick-walled cavity in the right upper lobe. With the pulmonary complications, particularly the recurrent pneumothorax, bronchopleural fistula, and empyema thoracis, cardiothoracic surgeons were involved, who managed the patient conservatively and maintained the chest tube. The patient continued to be ill with recurrent pneumothorax despite the chest tube, until relatives opted for discharge against medical advice.ConclusionsComplicated human immunodeficiency virus-related multidrug-resistant tuberculosis is not uncommon in settings of high human immunodeficiency virus/tuberculosis prevalence and is often associated with significant morbidity and mortality. Early diagnosis and treatment of multidrug-resistant tuberculosis, with rigorous monitoring for human immunodeficiency virus-positive individuals, is necessary to prevent debilitating complications.

Eustachian tube insufflation with thermal water: Effectiveness in the treatment of pediatric otitis media with effusion

PurposeOtitis media with effusion (OME) is the most common ear disease in childhood. The hearing loss associated with OME impacts on children's language development and behavior. Eustachian tube insufflation are among possible treatments for OME, but data regarding their effectiveness are scarce. The aim of this investigation was to analyze the effect of inhalatory thermal therapy and Eustachian tube insufflation in a consecutive cohort of pediatric patients with OME. Materials and methodsSeventy-four pediatric patients referred for OME to the thermal medical center “La Contea” (Battaglia Terme, Padova, Italy) were considered. Data from tympanometry and pure tone audiometry performed immediately before (T0), at the end of treatment (T1) and at a follow-up control (T2) were analyzed. ResultsData from 148 ears were available. The pressure values of tympanometry significantly improved from T0 to T1 (p = 0.0001), and further improvement was recorded at T2, when 60.8% of patients had normal tympanograms. A significant gain of the air-conduction threshold in the T0-T2 interval was observed (p = 0.0001). At otoscopy, a significant reduction of tympanic membranes with fluid or air-fluid levels presence (p < 0.00001) and a significant increase of normal tympanic membranes (p = 0.0001) were found. ConclusionEustachian tube insufflation represented a well-tolerated and effective treatment in children with OME. Further investigations should deepen these results in randomized, double-blind settings, possibly with long-term follow-up periods. A quality-of-life and cost-effectiveness evaluation of this treatment approach for pediatric OME could be helpful for public health decision-making.

Superior Mesenteric Artery Syndrome in an Adolescent With Anorexia and Suspected Pancreatitis.

A 17-year-old gender nonbinary patient presented with cachexia, nonbilious, nonbloody emesis, lower abdominal discomfort, and decreased oral intake for four days and 40 lb weight loss for 1 year. Emesis started 4 days before admission, and they denied prior episodes of vomiting. They were vegan and although their weight was 30.4 kg (<0.01%, z = –6.68), and BMI was 11.73 kg/m2 (<0.01%, z = –7.92), they were satisfied with their weight. Initial workup at the outside emergency room was significant for elevated lipase of 4544 U/L, sodium 131 mmol/L, bicarbonate 32 mmol/L, BUN 56 mg/dL, creatinine 1.3 mg/dL, and a normal abdominal ultrasound. Ultrasound showed a normal pancreas and no evidence of cholelithiasis or choledocholithiasis. Upon transfer to our institution for admission, they had persistent emesis, despite being on bowel rest. Due to concern about obstruction, CT abdomen and pelvis was performed, which showed a massively dilated stomach and duodenum with cutoff at the third portion of the duodenum, and the pancreas appeared homogenous and flattened secondary to the distended stomach (Fig. 1). During the exploratory laparotomy, findings were consistent with superior mesenteric artery (SMA) syndrome, and due to the severity of the obstruction, duodenojejunal anastomosis, and gastrostomy tube placement were performed. Adolescent medicine and psychiatry were consulted, and the patient admitted that their grandmother’s health was a recent stressor. There was a strong family history of depression leading to suicide, and the patient was diagnosed with anorexia nervosa, anxiety, and mood disorder. Lipase was trended and normalized within 4 days upon admission. G tube feeds were gradually advanced, and the patient fully transitioned to oral feeding upon transfer to an eating disorder unit.FIGURE 1.: KUB (left) shows mild stool burden. CT abdomen (middle and right) demonstrates the massively distended stomach, first and second portion of the duodenum and narrowing at the level of the origin of the SMA (arrow). SMA = superior mesenteric artery.SMA syndrome is a rare cause of small bowel obstruction due to compression of the third part of the duodenum between the abdominal aorta and SMA. It can be diagnosed with an aortomesenteric angle <25 degrees or a distance <10 mm (1). It has been associated with weight loss, scoliosis correction, short ligament of Treitz, duodenal malrotation, aneurysm, and neurological injury. Initially, treatment is conservative with fluid resuscitation, electrolyte correction, total parenteral, or enteral nutrition (2). However, when conservative measures fail, patients may undergo laparoscopic duodenojejunostomy with good prognosis (3,4). This case was instructive in several ways. The suspected cause of their SMA syndrome was from weight loss secondary to anorexia nervosa. The X-ray could have missed an obstruction due to lack of air fluid levels and poor delineation of a massively dilated stomach. The presence of nonbilious emesis despite duodenal obstruction, possibly from fecalization of gastric contents, may have further exacerbated gastric outlet obstruction. High lipase in the absence of other signs of pancreatitis should raise concerns for extrapancreatic sources, such as the stomach. Furthermore, when there is a mismatch between the clinical presentation and working diagnosis, the differential diagnosis should be broadened, since it can lead to lifesaving measures. ACKNOWLEDGMENTS The subject could not be reached for consent despite multiple attempts. Instead, the chief of the division provided the institution’s ethical clearance for the publication of this case.

LAPORAN KASUS: SELULITIS PRESEPTAL DENGAN ABSES FRONTAL

The objective of study is to report a case and management of preseptal cellulitis caused by dental infection. A case report, a 45 years old man presented at outpatient clinic with painful and swollen eyelids on the both eyes in 3 days, fever, and headache. The bumps in both eyes burst by themselves 1 day before hospital admission. The complaint begins with a toothache, then swelling in the cheek, then the swelling spreads to the eyes and head. Computed Tomograph (CT) scan examination revealed Soft tissue swelling in the right frontotemporoparietal region, left frontotemporoparietooccipital to periorbital bilateral and right maxilla with massive air density &amp; air fluid level on the left frontotemproparietooccipital according to the picture of Abscess. The patient consulted to neurosurgeon doctor and perform an abscess drainage incision. Adequate treatment and multidisciplinary management are needed to prevent more severe complications.

Eosinophilic Myenteric Ganglionitis with Degenerative Leiomyopathy

Background: Chronic intestinal pseudo-obstruction (CIPO) is an umbrella term for a range of different conditions characterized by repetitive episodes or continuous symptoms and signs of bowel obstruction, including radiographic evidence of dilated intestines and air-fluid levels, due to impaired propulsion in the absence of an anatomical occluding lesion. It is a diagnostic challenge and can mimic Hirschsprung's disease. Clinical Description: A 10-month-old boy presented with a history of recurrent episodes of constipation since the age of 6.5 months. The first two had resolved with symptomatic treatment. The third had been associated with bilious vomiting and required exploratory laparotomy. He was referred to us when there was no symptomatic improvement. The child underwent extensive workup that included a review of earlier investigations (contrast-enhanced computerized tomography abdomen, barium enema, and sigmoid biopsy) as well as upper gastrointestinal endoscopy, workup for secondary CIPO, esophageal and antroduodenal manometry, genetic studies, for primary CIPO. A laparotomy with concurrent adhesionolysis, appendectomy, gastrostomy, and ileostomy was undertaken, which included full-thickness biopsies at multiple sites. This revealed both degenerative leiomyopathy and eosinophilic myenteric ganglionitis (EMG). Known associations of CIPO, an underactive bladder, and sinus arrhythmias were also detected. Management: The infant was provided with supportive therapy. A trial of steroids was given for the EMG. The child had multiple bad prognostic factors and also protracted multiple nosocomial infections. He succumbed to his illness and complications after 40 days of hospitalization. Conclusion: The combination of EMG and degenerative leiomyopathy has not been reported in CIPO before.