Cause Of Acute Abdominal Pain Research Articles

Primary omental infarction – a benign cause of acute abdomen

Abstract Objectives Omental infarction (OI) is an uncommon cause of acute abdominal pain. A high index of clinical suspicion is required for diagnosis of OI as the incidence is less than 1 %, presenting with abdominal pain. We report primary OI’s clinical and radiological profile from a single tertiary care hospital in India. Methods In this retrospective cross-sectional study, the electronic medical and radiology records of patients with abdominal pain were reviewed over seven years (2015–2022). Variables were systematically collected and analyzed. Results A total of 22 patients diagnosed with primary OI were included in this study. Male preponderance (63.6 %) was noted with a mean age of 47.45 years (SD ± 13.84; range: 18–72 years). Most patients belonged to class I obesity (according to the Asia-Pacific body mass index classification) with a mean BMI of 26.56 kg/m2 (SD ± 3.21 kg/m2). All patients had abdominal pain as the primary symptom, with a mean duration of 8.64 days (SD ± 10.15; range: 1–42 days). The most common locations of pain were the right hypochondrium (27.3 %) and diffuse (27.3 %), followed by the right iliac fossa (18.1 %). Most (95.45 %, n=21/22) patients were treated conservatively, and only one required surgical intervention. Conclusions Primary OI is a rare and benign cause of acute abdomen. Obesity is a risk factor but does not correlate with the size or severity of OI. Radiological imaging, like a computed tomography (CT) scan, is essential for diagnosis. A conservative management line should be the first approach in treating primary OI before considering surgical options.

Acute pancreatitis- a narrative review

Acute pancreatitis is a common cause of acute abdominal pain and can range from mild oedema to severe necrosis of the pancreas. It has a significant impact on morbidity, mortality and financial burden. The global prevalence of pancreatitis is substantial, with the highest rates observed in central and eastern Europe. Diagnosing acute pancreatitis involves considering clinical symptoms, elevated serum amylase and/or lipase levels, and characteristic imaging findings. The causes of acute pancreatitis include obstructive disorders, such as gallstones and biliary sludge, alcohol consumption, smoking, drug-induced pancreatitis, metabolic disorders, trauma, medical procedures, infections, vascular diseases and autoimmune pancreatitis. Appropriate management of acute pancreatitis involves determining the severity of the condition, providing supportive care, addressing the underlying cause, and preventing complications. Advances in classifying the severity of acute pancreatitis and implementing goal-directed therapy have contributed to a decrease in mortality rates. ---Continue

A rare cause of acute abdominal pain: Perforation of a hepatic hydatid cyst into the peritoneum

A rare cause of acute abdominal pain: Perforation of a hepatic hydatid cyst into the peritoneum

Unraveling the Enigma: Omental Torsion in a Patient with Non-specific Abdominal Pain

Omental torsion is a rare cause of acute abdominal pain, with an incidence rate of less than 0.37%. Due to its non-specific symptoms, it is often confused with other causes of acute abdominal pain, such as acute appendicitis. In this case presentation, we will discuss a 26-year-old male patient who presented to the emergency department with complaints of abdominal pain and was diagnosed with perioperative omental torsion. The diagnosis of omental torsion is challenging due to its non-specific symptoms. When a diagnosis cannot be established in acute pain, diagnostic laparoscopy should not be delayed. Omental torsion can be easily treated with laparoscopic omentectomy.

DETERMINATION OF ACCURACY OF 3-MILLIMETER THIN AXIAL SECTIONS OF 64-SLICE MULTI-DETECTOR COMPUTED TOMOGRAPHY SCAN IN DIAGNOSIS OF ACUTE APPENDICITIS

Acute appendicitis is a common cause of acute abdominal pain requiring urgent surgical intervention. Timely diagnosis is crucial to prevent complications such as perforation and reduce morbidity and mortality rates. Clinical diagnosis alone can be challenging, leading to false positives and negatives. Multidetector computed tomography (MDCT) has emerged as a valuable tool in diagnosing appendicitis, but its efficacy can be enhanced by optimizing imaging protocols, particularly by utilizing thinner reconstruction sections. We conducted a prospective study involving 150 patients with suspected acute appendicitis. Un-enhanced 64-slice MDCT was performed, and axial images reconstructed from 3mm thin sections were analyzed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were calculated using SPSS version 19. Our study demonstrated a sensitivity of 97.8% and specificity of 76.9% for diagnosing acute appendicitis using 3mm thin section MDCT. The NPV and PPV were 76.9% and 97.8%, respectively, with an overall accuracy of 96%. Utilizing 3mm thin axial reconstruction in 64-slice MDCT significantly enhances diagnostic accuracy for acute appendicitis. This approach holds promise in reducing negative appendectomies and associated morbidity and mortality rates. Implementation of this imaging protocol can aid in timely diagnosis, optimizing patient care, and reducing unnecessary hospitalizations. 64-slice MDCT with 3mm thin section reconstructed images emerges as a highly accurate technique for diagnosing or excluding appendicitis in patients with equivocal presentations, contributing to improved patient outcomes and healthcare resource utilization.

Towards an EKG for SBO: A Neural Network for Detection and Characterization of Bowel Obstruction on CT.

A neural network was developed to detect and characterize bowel obstruction, a common cause of acute abdominal pain. In this retrospective study, 202 CT scans of 165 patients with bowel obstruction from March to June 2022 were included and partitioned into training and test data sets. A multi-channel neural network was trained to segment the gastrointestinal tract, and to predict the diameter and the longitudinal position ("longitude") along the gastrointestinal tract using a novel embedding. Its performance was compared to manual segmentations using the Dice score, and to manual measurements of the diameter and longitude using intraclass correlation coefficients (ICC). ROC curves as well as sensitivity and specificity were calculated for diameters above a clinical threshold for obstruction, and for longitudes corresponding to small bowel. In the test data set, Dice score for segmentation of the gastrointestinal tract was 78 ± 8%. ICC between measured and predicted diameters was 0.72, indicating moderate agreement. ICC between measured and predicted longitude was 0.85, indicating good agreement. AUROC was 0.90 for detection of dilated bowel, and was 0.95 and 0.90 for differentiation of the proximal and distal gastrointestinal tract respectively. Overall sensitivity and specificity for dilated small bowel were 0.83 and 0.90. Since obstruction is diagnosed based on the diameter and longitude of the bowel, this neural network and embedding may enable detection and characterization of this important disease on CT.

Left-sided appendicitis managed laparoscopically: a case report

BackgroundAppendicitis is one of the most common causes of acute abdominal pain and remains the most common abdominal-related emergency seen in emergency room that needs urgent surgery (Yang et al. in J Emerg Med 43:980–2, 2012. 10.1016/j.jemermed.2010.11.056, Wickramasinghe et al. in World J Surg 45:1999–2008, 2021. 10.1007/s00268-021-06077-5). The characteristic presentation is a vague epigastric or periumbilical discomfort or pain that migrates to the lower right quadrant in 50% of cases. Other related symptoms, such as nausea, anorexia, vomiting, and change in bowel habits, occur in varying percentages. The diagnosis is usually reached through comprehensive history, physical examination, laboratory tests, and radiological investigations as needed. Nowadays, computed tomography of the abdomen and pelvis is considered the modality of choice for definitive assessment of patients being evaluated for possible appendicitis. Anatomical variations or an ectopic appendix are rarely reported or highlighted in literature.Case presentationLeft-sided appendicitis is a rare (Hu et al. in Front Surg 2022. 10.3389/fsurg.2022.896116) and atypical presentation and has rarely been reported. The majority of these cases are associated with congenital midgut malrotation, situs inversus, or an extremely long appendix (Akbulut et al. in World J Gastroenterol 16:5598-5602, 2010. 10.3748/wjg.v16.i44.5598). This case is of significance to raise awareness regarding an anatomical variation of the appendix that might delay or mislead diagnosis of appendicitis and to confirm safety of a laparoscopic approach in dealing with a left-sided appendicitis case (Yang et al. in J Emerg Med 43:980–2, 2012. 10.1016/j.jemermed.2010.11.056). We report a case of left-sided appendicitis in a 12-year-old child managed successfully via a laparoscopic approach.ConclusionAppendicitis remains the most common abdominal-related emergency that needs urgent surgery (Akbulut et al. in World J Gastroenterol 16:5598–5602, 2010. 10.3748/wjg.v16.i44.5598). Left-sided appendicitis is a rare (Hu et al. in Front Surg 2022. 10.3389/fsurg.2022.896116, Hu et al. in Front Surg 9:896116, 2022. 10.3389/fsurg.2022.896116) and atypical presentation and has rarely been reported. Awareness regarding an anatomical variation of the appendix and diagnostic modalities on a computed tomography scan help avoid delay in diagnosis and management of such a rare entity (Vieira et al. in J Coloproctol 39(03):279–287, 2019. 10.1016/j.jcol.2019.04.003). A laparoscopic approach is a safe approach for management of left-sided appendicitis (Yang et al. in J Emerg Med 43:980–2, 2012. 10.1016/j.jemermed.2010.11.056, Hu et al. in Front Surg 9:896116, 2022. 10.3389/fsurg.2022.896116).

Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis.

Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.

Efficacy of ultrasound as a primary mode of investigation in the diagnosis of non-traumatic acute abdomen in pediatrics patients

Background: The role of diagnostic imaging is to determine whether the condition is medically or surgically treatable and, if possible, to diagnose the exact nature of the disease. Chest radiography is also commonly used to demonstrate extra-abdominal causes of acute abdominal pain, such as pneumonia. Ultrasonography is the initial choice of investigation that is likely useful to conclude for the following reasons, namely, it is relatively inexpensive, lack of radiation exposure, less time-consuming, easy, painless, and rarely requiring sedation. Usually, no preparation is required except in a few cases. It is also the preferred imaging tool for evaluating the surgical and non-surgical causes of acute abdomen in children. Ultrasound is also the preferred screening method for children suspected of having intra-abdominal mass. Aim and Objective: The present study is undertaken: (1) To identify specific causes of non-traumatic acute abdominal (NTA) pain in children; (2) to adopt the diagnostic efficacy of sonography as an initial tool for assessing those patients with probable clinical diagnosis; and (3) to triage patients for conservative or immediate surgery with available clinical diagnostic methods. Materials and Methods: A retrospective study of 100 pediatric patients aged between 1 and 14 years of both sexes with a history of non-traumatic acute abdomen attending outpatient services, in-patient, and emergency department at the Chamarajanagar Institute of Medical Sciences (CIMS) was conducted between March 2016 and March 2018 (for 2 years) for sonography. Results: Among 100 individuals, we had males followed by females (53%; 47%). The most common clinical symptoms of children with NTA were pain. Other symptoms included vomiting (66.7%; 15%), fever (68.5%; 31.6%), diarrhea (40%; 60%), cough (50%; 50%), and constipation (1%; 1%). The maximum number of cases in the group was >5 years–14 years. The most common sonography findings in this study were non-specific mesenteric lymphadenitis 49.4%, appendicitis (18.7%), intussusception, and cystitis (6.7%). followed by renal hydronephrosis (5.3%). Conclusion: Sonography, along with the associated clinical features, is a valuable adjuvant for a probable diagnosis. Other investigations such as laboratory findings, contrast-enhanced CT scan as indicated by the patient’s condition and requirement can be supported. This is particularly important in C-grade locations where other higher modes of investigation may not be available.

Primary segmental omental torsion, mimicking acute appendicitis.

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative.

Omental Infarction: A Forgotten Entity

Omental infarction is a cause of acute abdominal pain. It is a challenging diagnosis to make due to its infrequent occurrence, low awareness, and non specific presentation. It is generally recommended to manage it conservatively because of its self-limited nature. However, some physicians opt for surgical management due to the potential risk of abscess formation with conservative treatment. Omental infarction commonly occurs following torsion. The anatomical features of the omental sheet, such as its increased length, freely mobile lateral edge, and a weak blood supply, make it more susceptible to twisting along its long axis, leading to congestion. If the twist is severe enough or if there is prolonged obstruction to venous flow, arterial inflow may be compromised, resulting in infarction and potential complications like necrosis. Here, the authors present a case of a 64-year-old diabetic male who presented to the Emergency Department with acute right upper quadrant pain. He was diagnosed with omental infarction through Computed Tomography (CT) of the abdomen. The authors attempted conservative management, but his pain persisted despite analgesics. Subsequently, the authors opted for surgical intervention and performed an omentectomy. In cases of acute abdominal pain, conditions like omental infarction are often overlooked and should be considered in the differential diagnosis.

APPENDICITIS INFLAMMATORY RESPONSE SCORE FOR DIAGNOSIS OF ACUTE APPENDICITIS AS COMPARED TO ALVARADO SCORE

Background: Acute appendicitis was first described by Reginald. H. Fitz in 1886. It is the most frequent cause of acute abdominal pain requiring surgical intervention. Annually appendectomy is the most common abdominal operation performed on emergency basis. Lifetime risk for developing acute appendicitis is 8.6% in men and 6.7% in women. Acute Appendicitis inciting event in most instances is obstruction of the appendix lumen. Acute Appendicitis is classified as catarrhal phlegmonus, gangrenous and perforated. This classification describes the evolutionary stage of disease. Acute appendicitis is more of a clinical diagnosis present as pain abdomen with classical migration from peri-umbilical region to right iliac fossa in 75% of patient nausea and anorexia. Clinical signs are mostly pyrexia, localized tenderness in the right iliac fossa, muscle guarding and rebound tenderness. Laboratory and radiological investigation are also important tool for the diagnosis. Scoring system have been designed to aid in the clinical assessment of patient with acute appendicitis. The most used scoring is the Alvarado score is best performing in validation studies. Alvarado score doesnt incorporate C reactive protein as a variable, many studies shows the importance of C reactive protein in assessment of patient with appendicitis. Objective: Appendicitis Inflammatory Response score as a diagnostic tool for acute appendicitis in our hospital setting. Study design: A Prospective Study. Study period: October 2016 – September 2018. Study setting: Department of General Surgery, Justice K. S. Hegde charitable hospital. Study population: Patients admitted with signs and symptoms of acute appendicitis at Justice K.S. Hegde charitable Hospital, Mangalore. Sample size: 123 patients using epiinfo software for diagnostic test with PPV 64% with article reference (12) confidence interval of 95% and power of study at 80%. Study group: Patients clinically diagnosed with acute appendicitis and giving consent for the study. Methodology: The present study was conducted in the Department of General surgery, Justice K.S. Hegde charitable Hospital Mangalore, in 123 patients, of any age, who were admitted with complaint of acute appendicitis. Patients included in the study were finally correlate with the histopathological report. Result: The maximum patients were in the age group of 11-20 year compromising around 30.9%. Most of the patients were female around 56.1%. Histopathological report showed around 82.1% as Acute appendicitis, 6.5% acute on chronic, recurrent appendicitis 8.9%, chronic appendicitis, granulomatous appendicitis & lymphoid hyperplasia of appendix were .8% each. AIR classified around 46.3% in low probability, 48% indeterminate and 5.7% in high probability group. Alvarado classified around 3.3% in unlikely, 51.2% in possible diagnosis, 37.4% acute and 8.1% in definite group. On spearman correlation coefficient there was found to be a strong positive correlation between both the scoring system and statistically significant p value of 0.0001. AIR score showed a sensitivity of 56.44% and specificity of 59.09% at score >4. Alvarado had a sensitivity of 98.02 % and specificity of 9.09% at score >4. Alvarado and AIR showed 9.90% and 6.93% at score >8 respectively. The specificity of Alvarado and AIR was 100% respectively. The AIR at a low and higher score had a high PPV and NPV, that may help in correctly diagnosing the patient with acute appendicitis and ruling out from non- appendicitis patient. Conclusion: 1. Alvarado score is better diagnostic tool for acute appendicitis as compared to the AIR score. 2. Alvarado score has higher sensitivity in score of >4 as compared to AIR. 3. AIR score with low sensitivity has low discriminatory power in ruling out patient with acute appendicitis.

Unusual Cause of Acute Abdomen by Foreign Body: Intentional Spoon Ingestion

Introduction There is a wide variety of uncommon and unusual gastrointestinal causes of acute abdominal pain in which foreign bodies are included. Case report 30-year-old patient with severe chest and epigastric pain, previous vomiting and loss of consciousness. A thoracic X-ray study revealed a 15-cm-long metallic object located in the esophagus and two more apparently located in the stomach. The patient underwent an emergent laparotomy, a transverse incision was made to the stomach (gastrotomy) at the perforation site, removing 4 metallic soup spoons; then, it was closed primarily. Conclusions Intentional ingestion of foreign large metallic bodies is infrequent but not uncommon. Diagnosis should be suspected primarily in patients with history of psychiatric disorders or substance use. Clinical manifestations may vary according to the site of the gastrointestinal tract perforation. A surgical approach may be the best option due to a large size of the objects, time of clinical presentation and risk of subsequent complications.

Acute abdominal pain

Abdominal pain is a common reason for patients presenting to primary care and has a wide range of differentials. It can be acute or chronic, with the latter being defined as lasting over 3 months. A myriad of conditions can cause acute abdominal pain, ranging from life-threatening to self-limiting. Common causes of acute abdominal pain include differentials from the gastrointestinal, urological, gynaecological, genitourinary, and vascular systems. This requires clinicians to have a breadth of knowledge to safely manage these patients. The differential diagnoses need to be established through a thorough history and physical examination, ultimately aiding the decision between management in primary versus secondary care. This article will highlight features within the history and examination required to distinguish the causes of acute abdominal pain and some to aid decisions on management, whether in primary care or needing referral to secondary care. The article will provide a brief overview of common causes of acute pain by location in the abdomen.

A rare occurrence: A case report of acute appendicitis and omental infarction unveiled by epigastric pain in a heavy smoker

Omental Infarction (OI) is a rare condition that can mimic common causes of acute abdominal pain, primarily affecting individuals aged 40 to 50, with a male predominance. Imaging techniques like ultrasound and computed tomography aid in diagnosis. Treatment options range from conservative management to surgery, depending on severity and complications. OI often leads to right-sided abdominal pain in 90% of cases, with histological features including focal necrosis and fibroblastic reactions. Acute appendicitis is a common cause of acute abdominal conditions, especially in children and adolescents. Having a patient simultaneously presenting with acute appendicitis and omental infarction is extremely rare, with only three cases reported in the literature to date to our knowledge. We present the case of a 32-year-old male, a heavy smoker, who presented with epigastric pain and vomiting. Initial clinical suspicion was a perforated ulcer, but imaging revealed swollen appendicitis with adjacent fat stranding and evidence of epiploic infarction near the stomach. Laparoscopic surgery confirmed the diagnosis of acute appendicitis, with an appendectomy performed and identification of the infarcted omentum, which was preserved. After the operation, the patient had a successful recovery and was discharged on the second postoperative day. This case firstly emphasizes the rarity of the association between acute appendicitis and omental infarction in the same patient and underscores the importance of considering Omental Infarction (OI) in the differential diagnosis of acute abdominal pain. Imaging plays a crucial role in accurate diagnosis, and a high degree of suspicion and prompt diagnosis are crucial for optimal patient outcomes.

The Efficacy of Appendicitis Inflammatory Response Score in Diagnosis of Acute Appendicitis

Background: Acute appendicitis is one of the most common cause of acute abdominal pain. The management of suspected appendicitis represents a prime target for improved decision-making in emergency surgical care (OPD, Emergency room). The aim of the work is to evaluate the appendicitis inflammatory response (AIR) score and compare its performance in predicting the risk of appendicitis to the Alvarado score. Objective: To evaluate the diagnostic performance of the AIR score and potential benefits of risk stratification to guide clinical decision making. Methods: This prospective observational study was conducted in the OPD and Emergency department, Sir Salimullah Medical College & Mitford Hospital, Dhaka. From June’2021 to May’2022. A total 240 patients with right lower abdominal pain. History, clinical examination, hematological, radiological investigations were done. AIR score was calculated. Considering histopathology report as gold standard the score was compared. Histopathology report was done in Pathology Department of SSMC, Dhaka. Results: Right iliac fossa pain (100%) was the most common symptom, followed by vomiting (58.3%), temperature (29.5%), and rebound tenderness. After applying AIR scorings, 44(18.3%) patients in low-risk group (0-4), 112(46.7%) patients in the intermediate risk group (5-8) and 84(35.0%) patients in the high-risk category (9-12). Amongst the 240 applying the AIR score, Sensitivity of inflammatory response score vs histopathology findings was 97.9%, specificity 78.4%, accuracy 93.8%, positive and negative predictive values were 94.4% and 90.9% respectively. Conclusion: Risk stratification of patients with suspected appendicitis by the AIR score could guide decision-making to reduce admissions, length of hospital stay, cost and case fatality rate, optimize utility of diagnostic imaging and to decrease negative exploration. Sir Salimullah Med Coll J 2023; 31: 47-52

Case Report: Rectus Sheath Hematoma in a Pregnant Women

Rectus sheath hematoma is a very uncommon cause of acute abdominal pain, especially during pregnancy. Misdiagnosis is likely due to the lack of specific symptoms, which could put the patient and her fetus in danger.. A patient  came with sudden severe left upper abdominal pain with history of cough for few days. She was referred from other hospital and diagnosed there as 32 weeks pregnancy preeclampsia with severe disease with HELLP syndrome. Uterus was tender and more prominent on left side, and patient was not in labour. Provisional diagnosis was   abruptio placenta with concealed haemorrhage or rupture uterus. But after laparotomy it was diagnosed as a case of rectus sheath haematoma(RSH). Different imaging modalities such as Ultrasonography and CT are the diagnostic methods. Active bleeding can be managed either surgically by evacuating the haematoma and ligating the bleeding vessels. We managed the patient by laparotomy and blood and blood product transfusion and by multidisciplinary approach, but the patient developed multiorgan failure and expired on 16 th  POD. The clinical and diagnostic symptoms of rectus sheath hematoma are highlighted in this case report. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(1): 71-74

Efficacy of magnetic resonance imaging among pregnant patients diagnosed with acute abdomen in the emergency department

Aims: Diagnostic procedures are very important for fetal safety during pregnancy. Magnetic resonance imaging (MRI) is characterized by a higher accuracy rate compared to medical follow-up and post-surgical diagnoses. However, it is very important to use it at the right time in order to maintain cost-effectiveness of the technique. In this study, we aimed to determine the efficacy of MRI in pregnant patients admitted to the emergency department with acute abdominal pain when the etiology has not been defined by other techniques.
 Methods: The data of pregnant patients who admitted to the emergency department due to acute abdominal pain between January 2013 and February 2018 were retrospectively analyzed. All these patients evaluated with pelvic magnetic resonance screening, as they could not be diagnosed by physical examination findings, laboratory tests, or ultrasonography. Diagnostic performance of MRI, sensitivity, specificity, and negative and positive predictive values were assessed.
 Results: The etiology of the pain was detected in 29 of 57 patients who applied to the emergency department with acute abdominal pain and evaluated with pelvic MRI. The most common cause of acute abdominal pain was acute appendicitis which all of them histopathologically confirmed (n=14). Pelvic abscess, severe hydronephrosis, giant ovarian cyst, pyelonephritis, ovarian torsion, and uterine fibroid torsion were among other causes. 
 Conclusion: MRI is a highly effective imaging method for diagnosing both acute appendicitis and other pelvic emergencies. Therefore, it would be beneficial for the diagnosis in pregnant patients with acute abdominal pain.

The Effect of Preoperative Imaging on the Negative Appendicectomy Rate.

Background Appendicitis is one of the most common causes of acute abdominal pain and appendicectomy is one of the most frequently performed surgical procedures. The proliferation of radiological imaging has reduced the number of patients who have a normal appendix removed, i.e., a negative appendicectomy. We aimed to assess the effect of preoperative imaging on the negative appendicectomy rate (NAR). Methodology All emergency appendicectomies performed at a district general hospital in the United Kingdom over two separate one-year periods were retrospectively analysed using emergency theatre log books. The timeframes were chosen based on the introduction of a diagnostic pathway to reduce the number of appendicectomies performed on patients later found not to have appendicitis or alternative abnormality, i.e., a negative appendicectomy. This pathway involved a greater emphasis placed on preoperative imaging (CT or ultrasound) for patients with suspected appendicitis. The study excluded any patients who were found to have an alternative pathology during surgery. Information technology databases were used to collect data on patient demographics, date of surgery, histology, and any preoperative imaging that was performed. All histological findings showing acutely inflamed appendices and those positive for malignancy were categorised as positive, whereas all other findings were categorised as negative. Results During our initial data collection period (April 2018 to April 2019), we collected data on 207 patients who underwent an appendicectomy. The NAR was 17%. During our subsequent data collection period (August 2020 to August 2021), we collected data on 184 patients. The NAR was 16%. In our adult population, the NAR decreased from 13% to 9%. Discussion At first glance, the NAR does not seem to have improved. On closer look, all patients over the age of 21 years in our re-audit underwent pr-operative CT, and there was a reduction in the NAR in these patients. The issue arises with younger patients, in whom justifying the radiation associated with a CT scan may be difficult. Although ultrasound does not carry the same radiation risk, previous audits at our trust have that shown its sensitivity and specificity for appendicitis is approximately 60%. We may have to explore alternative imaging modalities such as MRI in the paediatric population or accept the higher NAR.

Small Intestinal GIST A rare cause of spontaneous and abundant hemoperitoneum

Spontaneous hemoperitoneum is a rare cause of acute abdominal pain. When it happens, it may be fatal. The etiology includes generally hepatic, splenic, gynecologic, vascular causes, and bleeding disorders [1]. Gastrointestinal stromal tumors (GIST) are uncommon tumors with a diverse malignancy potential, habitually detected in the stomach and the small intestine [2]. This entity is exceptionally responsible for a spontaneous hemoperitoneum [3].