Emergency Department For Abdominal Pain Research Articles

Diabetic ketoacidosis in a patient with type 2 diabetes induced by multiple triggers: a case report and implications for clinical practice

AbstractDiabetic ketoacidosis is a recognized side effect of SGLT‐2 inhibitors precipitated by several factors. A 58‐year‐old man with long‐standing, well‐controlled type 2 diabetes on dapagliflozin, metformin and gliclazide and subacute De Quervain thyroiditis treated with high dose prednisolone was evaluated in the emergency department for abdominal pain and tachypnea. Severe diabetic ketoacidosis related to dapagliflozin was diagnosed. De Quervain thyroiditis and treatment with high dose prednisolone were identified as potential triggering factors. Combined use of dapagliflozin and high dose prednisolone may increase the risk for SGLT‐2 inhibitors related diabetic ketoacidosis, especially in the course of acute illness.

Biliary ascariasis: an unusual cause of acute cholecystitis

Ascariasis is one of the most common gastrointestinal parasitic infections in developing countries. In humans, these parasites reside in the jejunum but can lodge in any part of the small intestine and can migrate to the biliary tract. We present the case of a 45-year-old female patient, with no relevant history, from a rural town in Mexico, who presented to the emergency department for abdominal pain in the right hypochondrium, nausea and vomiting of one week's evolution, acute cholecystitis was suspected and an ultrasound of the liver and biliary tract was requested, which reported acute cholecystitis and ascaris was observed in the gallbladder, was evaluated by the general surgery service and cholecystectomy was performed, anthelmintic treatment was started, the patient was cured without complications and was discharged home after 48 hours.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia.

Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias. Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound. We enrolled 493 patients meeting the criteria. Median age was 65years, with 54% (n=266) being male. Regarding outcomes, 40.5% (n=200) were hospitalized, 27.7% (n=137) underwent surgery, and 7.9% (n=39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n=3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p<0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p<0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p<0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p<0.05). Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Peritonitis Due to Haemophilus Influenzae in Peritoneal Dialysis: Report of An Exceptional Case

Case Description: 33-year-old woman with a history of end-stage renal disease on peritoneal dialysis, who came to the emergency department for abdominal pain of sudden onset associated with a change in the color of the peritoneal fluid. Clinical Findings: The patient had signs of systemic inflammatory response and generalized abdominal pain, with marked leukocyte response in peritoneal fluid cytochemistry. Treatment and Outcome: Empirical antibiotic treatment was started targeting the most prevalent microorganisms in abdominal infections associated with peritoneal dialysis, however with poor response to it and subsequent isolation of Haemophilus Influenzae for which antibiotherapy was modified with subsequent progressive clearance of peritoneal fluid and resolution of symptoms. Clinical Relevance: We describe the case of a patient on peritoneal dialysis who presented a bacterial peritonitis caused by H. Influenzae, an extremely infrequent germ in this type of infections. Although the presence of this germ is exceptional in peritoneal dialysis catheter-associated peritonitis, this microorganism should be ruled out in a patient with catheter-associated peritonitis that does not respond to the usual antibiotic therapy. To our knowledge only 8 cases have been reported in the literature and none in our setting.

An unusual etiology of acute pancreatitis

A 54-year-old woman consulted the emergency department for abdominal pain, vomiting and fever for 5 days. A biochemical assessment was performed and showed a lipasemia higher than 5 times normal range (264 UI/L). Hyperlipasemia is in favor of acute pancreatitis. On obtaining further history, the patient reported the SARS-CoV-2 infection two weeks ago with a laboratory investigations done the same day as the positive PCR showed a normal lipasemia. The imaging findings were suggestive of early acute pancreatitis. Acute pancreatitis secondary to SARS-CoV-2 infection is suspected.

THU213 Posterior Reversible Encephalopathy Syndrome As A Rare Presentation Of ACTH-dependent Cushing Syndrome In A Pediatric Patient

Abstract Disclosure: E.E. Bell-Sambataro: None. C. Tatsi: None. P. Chittiboina: None. S.A. Bowden: None. Background: Cushing disease (CD), caused by ACTH-secreting pituitary adenoma, is the most common cause of Cushing Syndrome (CS) in children &amp;gt; 5 years of age. Hypertension is reported in up to 50% of pediatric cases with CS. We report a challenging pediatric case with a rare presentation of hypertensive emergency associated with CD. Clinical Case: A 6-year-old female with 3 month-history of rapid weight gain (8 kg), round face, and hypertrichosis presented to emergency department for abdominal pain from nephrolithiasis and was noted to have severe hypertension. While in ED, she developed status epilepticus and altered mental status. Brain MRI findings were consistent with posterior reversible encephalopathy syndrome (PRES). Her hypertensive encephalopathy gradually improved with aggressive anti-hypertensive and anti-epileptic therapy. Further studies confirmed hypercortisolism with markedly elevated urine free cortisol of 1288 ug/day (&amp;lt;18 ug/day) and lack of diurnal variation of serum cortisol (8 AM cortisol of 47.9 ug/dL, midnight cortisol of 20.3 ug/dL). ACTH level of 23 pg/mL suggested ACTH-dependent CS. Low dose (1 mg) dexamethasone suppression test (DST) failed to suppress 8 am cortisol (31.4 ug/dL). High dose DST (120 mcg/kg) suppressed serum cortisol to 67%- borderline threshold for CD, likely due to increased dexamethasone clearance by anticonvulsant. Pituitary MRI did not reveal a visible lesion. Desmopressin stimulation test showed stimulation of ACTH by 700% and cortisol by 160% suggesting pituitary source. Inferior petrosal sinus sampling showed a mildly increased gradient in central to peripheral plasma ACTH of 1.7 at baseline (&amp;gt;2) and post-stimulation of 2.5 (&amp;gt;3). ACTH gradient did not reach cutoffs for pituitary source, likely due to insufficient catheterization of petrosal sinus from anatomically small blood vessels. Given her severity, she underwent surgical pituitary exploration. Postoperative morning cortisol was &amp;lt;5 mcg/dL, with decreased midnight salivary cortisol level obtained 2 months after surgery. She developed post-operative central hypothyroidism but did not have diabetes insipidus. She had a 4 kg weight loss with increased height percentile 5 months after surgery and remains under close monitoring. Conclusion: PRES is a clinical-radiographic disorder characterized by seizures, encephalopathy with neuroimaging findings of reversible cortical and subcortical vasogenic edema. Hypertension induced by marked hypercortisolism precipitated by pain is likely the etiologic factor. Prompt recognition and treatment of PRES are crucial to prevent further life-threatening complications and permanent neurological damage. Early diagnosis and treatment of CD are critical to prevent associated morbidities. Pituitary exploration by expert neurosurgery team should be considered in patients with MRI-negative CD. Presentation: Thursday, June 15, 2023

Appendiceal mucocele as an exceptional cause of ileocecocolic intussusception in adults: a case report

BackgroundIntussusception is a rare condition in adults, accounting for 5% of intestinal intussusception and being responsible for approximately 1% of all adult bowel obstructions. Neoplastic origin is the most common etiology of intestinal intussusception in adults, unlike pediatric intussusception, which is usually idiopathic. Intussusception due to the appendiceal mucocele is exceptional, and only a few cases have been reported in the medical literature.Case presentationWe report the case of a 25-year-old black African male patient with no medical history. He presented to the emergency department for abdominal pain, nausea, and bilious vomiting. The abdominal examination revealed typical signs of acute bowel obstruction. Enhanced abdominopelvic computed tomography showed an invagination of the last ileal loop, cecum, and ascending colon into the lumen of the transverse colon, with a rounded image with hypodense content and some calcifications compatible with an appendiceal mucocele. An emergency exploratory laparoscopy was performed and confirmed the ileocecocolic intussusception. Right hemicolectomy and ileocolic anastomosis were performed. The patient recovery postoperatively was uneventful, and he was discharged 4 days later. Histological examination of the surgical specimen confirmed the diagnosis of mucinous cystadenoma.ConclusionThe symptoms of bowel intussusception with the appendiceal mucocele as the lead point in adults are similar to any other bowel intussusception. Differential diagnosis is often carried out thanks to the injected abdominal computed tomography scan.

Influence of Body Mass Index on the Evaluation and Management of Pediatric Abdominal Pain in the Emergency Department.

Introduction: Childhood obesity is a serious concern in the United States, with over one third of the pediatric population classified as obese. Abdominal pain is one of the most common chief complaints among pediatric emergency department (ED) visits. We hypothesized that overweight and obese children being evaluated in the ED for abdominal pain would have higher resource utilization than their normal and underweight peers. Methods: This was a retrospective review of pediatric patients <18years who presented with abdominal pain to the ED of a tertiary care center from January 1, 2014-September 3, 2020. Patients were excluded if they did not have both a height and weight recorded. We categorized patients as underweight (body mass index [BMI] <5th percentile); normal weight (BMI 5th to <85th percentile), overweight (BMI 85th to <95th percentile); or obese (BMI ≥95th percentile). Descriptive statistics were used to examine the study population. We used chi-square tests to examine the differences in patient characteristics between normal/underweight patients and overweight/obese patients. The Kruskal-Wallis test was completed for examining differences in the medians. We used multivariable logistic regression to examine visit characteristics associated with overweight/obese patients, including ED interventions, testing, and length of stay (LOS). Results: Of the 184 subjects included in the analysis, nine (4.9%) were underweight, 108 (58.7%) were normal weight, 21 (11.4%) were overweight, and 46 (25.0%) were obese. Patients with a BMI of ≥85th percentile were older (median 15 vs 13years, P = 0.01). They were otherwise similar in demographics. There was no significant difference between normal/underweight and overweight/obese subjects in disposition (37% vs 43% discharge, P = 0.38), 72-hour return (7% vs 6%, P = 0.82), ED LOS (median 4.42 vs 3.95 hours, P = 0.195), or inpatient LOS (median 42.0 vs 34.2 hours, P = 0.06). There were no statistically significant differences in total number of ED tests or interventions received by overweight/obese patients compared to normal/underweight patients, and each subject received a median of six tests (interquartile range [IQR] 4-7) and two interventions (IQR 1-3). Conclusion: Among pediatric patients presenting to the ED with abdominal pain, we found that patient characteristics and ED resource utilization (including testing, intervention, disposition, and LOS) did not differ significantly across BMI categories.

Laparoscopia con preservación de órgano en lesión esplénica en dos tiempos por traumatismo cerrado de abdomen

Nonoperative management (NOM) of organ injuries in abdominal blunt trauma (ABT) is based on clinical and imaging test findings. We herein present a 16-year-old male patient with a history of recent blunt abdominal trauma was admitted to the emergency department for abdominal pain in the left hypochondrium. A protocol for NOM was established based on the clinical picture and imaging findings, but afterwards, in view of the unfavorable progression, the approach was modified to laparoscopic organ-preserving surgery.

Application effect of phloroglucinol injection in elderly patients with spastic abdominal pain in emergency department.

Although norepinephrine injection is commonly used in emergency situations, it is associated with risks for elderly patients with spasmodic liver pain. This study explores the safety and effectiveness of mebendazole injection, an alternative treatment option, for the emergency management of spasmodic abdominal pain, while minimizing adverse reactions, in elderly patients. To explore the development of norepinephrine injection and the adverse reactions of this drug in emergency elderly patients with spasmodic liver pain. The control group consisted of 56 elderly patients visiting our hospital from January 2021 to December 2021. After hospital admission, the control group was intravenously administered tolopin. The experimental group consisted of 56 emergency patients with spasmodic abdominal pain who visited our hospital until June 2022. After hospital admission, the experimental group was intravenously administered toloxazole. The two groups were treated for 3 d. The disappearance of clinical symptoms was observed before and after the treatment, and the difference in adverse reactions between the two groups was compared. The pain of the wife, fire, diarrhea, drowning, and surrounding time disappeared in the experimental group. No statistical difference was observed between the experimental and control groups in visual pain analog scale (VAS) scores before and after the treatment (P > 0.05). The VAS scores of abdominal pain severity after 0.5 h, 1.0 h, and after 6.0 h of treatment were significantly lower for the experimental group than for the control group. After the treatment, the therapeutic effect in the experimental group was higher and statistically significant than that in the control group (P < 0.05). The probability of adverse reactions before the treatment was lower in the experimental group than in the control group. During emergency, mebendazole injection exhibited a good therapeutic value when used for the clinical treatment of elderly patients with spasmodic stomach pain. It accelerated the disappearance of clinical symptoms such as stomach pain, reduced the stomach weight, and improved clinical activity. Reducing and promoting the frequency of high treatment safety with mebendazole injection is worthwhile.

Erector Spinae Plane Block Performed in the Emergency Department for Abdominal Pain: A Case Series.

Ultrasound-guided nerve blocks are fast becoming a core part of opioid-sparing, multimodal, acute pain management in the emergency department (ED) setting. The ultrasound-guided erector spinae plane block (ESPB) has been shown to be effective in treating a variety of musculoskeletal and neuropathic painful conditions in the ED. Here we report the effective use of the ESPB for pain control in four patients who presented with acute abdominal pain related to biliary obstruction in a resource-limited setting. The ESPB may be helpful in treating abdominal pain related to biliary obstruction, which is a novel indication for this well-established technique. This application is particularly relevant in resource-limited settings with significant delay in definitive surgical management. Further research is needed prior to widespread adoption.

The Efficacy of Patient Controlled Analgesia for Acute Non Traumatic Abdominal Pain in Emergency Department

INTRODUCTION: Patient-Controlled Analgesia (PCA) is an intravenous selfadministration of small doses of opioids (such as morphine) using a programmable pump, The goal of PCA is to efficiently reduce patients’ pain at patient's preferred dose and schedule. Thus, we conducted a study to compare patient PCA morphine with intravenous bolus morphine for acute abdominal pain of non-traumatic origin in the emergency department (ED). MATERIALS AND METHODS: A randomised, non-blinded clinical trial was conducted in patients presented with severe acute non traumatic abdominal pain of less than 24 hours requiring opioid analgesic based on numerical pain score of more than seven at triage. The primary outcome was visual analogue pain score (VAS) recorded at 0, 30th, 60th and 120th minutes during the management in the ED and after admission to wards, and the secondary outcomes were total dosage of morphine used and degree of patient satisfaction. RESULTS: A total of 62 participants who fulfilled study criteria were randomized into PCA morphine group or bolus morphine group. The average amount of analgesic used for bolus morphine group was lower compared to PCA morphine (4.23 mg)(s.d 1.89 vs 5.29 mg)(s.d 2.16) (p=0.027). Despite of significant VAS score changes within group analysis, between group repeated measure ANOVA (RMA) VAS score analysis was not statistically significant. [Bolus group (6.7+2.03) compared to PCA group (5.83 + 2.38)](p=0.089). Patient satisfaction was statistically significant for the PCA group [PCA (1.65+0.709) compared to bolus group (2.23+0.920)](p=0.007). CONCLUSIONS: There was no significant difference in pain score reduction between PCA and intravenous bolus of morphine for the management of severe acute non traumatic abdominal pain in ED. However, PCA provided more patient satisfaction and should be considered as an alternative modality of acute pain management in ED.

Systemic inflammation response index and systemic immune-inflammation index are associated with severity of acute pancreatitis

&lt;b&gt;Aim: &lt;/b&gt;Acute pancreatitis (AP) is a disease with inflammation, and patients present with severe acute upper abdominal pain in emergency departments. AP can result in higher mortality as its clinical severity increases. Therefore, in this study, we want to investigate the clinical utility of the systemic inflammation response index (SIRI) and systemic immune-inflammation index (SII) in showing the severity of AP.&lt;br /&gt; &lt;b&gt;Material and methods:&lt;/b&gt; Among the patients admitted to our emergency department between January 2020 and December 2022, 201 patients diagnosed with AP were included in the study. These patients were divided into two groups according to the severity of the disease as mild and severe AP (MAP and SAP). Demographic data and laboratory data of the patients (white blood cell count, such as SIRI, SII and C-reactive protein, SIRI, SII and C-reactive protein) were recorded. Differences between groups of AP patients divided according to disease severity were analyzed.&lt;br /&gt; &lt;b&gt;Results: &lt;/b&gt;165 (82.1%) patients had MAP and 36 (17.9%) patients had SAP. 52.8% of the patients were male. The mean of the SAP group was significantly higher than the SII MAP group (3165.71±3058.42 vs.1043.31±849.15; p&amp;lt;0.001). In addition, SII levels were significantly higher in the SAP group compared to MAP (11.19±6.27 vs. 3.12±3.01; p&amp;lt;0.001). In regression analysis, CRP, SIRI and SII was found to be able to predict SAP in patients with AP. &amp;nbsp;The power of SIRI and SII were found to be higher in predicting SAP [AUC for SIRI: 0.890; [AUC for SII: 0.859].&lt;br /&gt; &lt;b&gt;Conclusion: &lt;/b&gt;High SII and SIRI are useful markers that can show the severity of AP.&lt;br /&gt; &lt;b&gt;Key words: &lt;/b&gt;acute pancreatitis severity, SII, SIRI, biomarker

Idiopathic Perforated Intussusception in Adult – Case Report

Adult intussusception is typically less common as compared to paediatric population. Adult intussusception makes 5% of all the cases of intestinal obstruction and it may be primary or secondary in nature. Mostly patients present with abdominal pain in emergency department. CT scan is the preferred diagnostic imaging modality. Unlike in the pediatric population, where conservative management is often attempted, surgical intervention with formal resection is the preferred treatment approach in adults with intussusception because of high incidence of some associated pathology. We present a case report of a middle-aged woman who presented with signs and symptoms of intestinal obstruction and was diagnosed with intussusception and peritonitis. Exploratory laparotomy and formal resection of the affected bowel segment with ileostomy was performed, and no underlying pathology was identified that makes this case an unusual one.

P-049 DAMAGE CONTROL SURGERY FOR AN INCARCERATED GIANT UMBILICAL HERNIA IN A SUPEROBESE PATIENT

Abstract Aim To report the case of the emergency management of an incarcerated giant umbilical hernia in a superobese patient with a damage control surgery as the first step for its treatment. Material &amp; Methods We present the case of a 47-year-old man with a BMI of 62 kg/m2 who arrived to the emergency department for abdominal pain. Examination and CT scan revealed a giant umbilical incarcerated hernia with loss of domain, with an 8 cm hernia neck and containing the entire bowel except for the rectosigmoid and duodenum. Results The emergency managment was a laparotomy with a subcutaneous right lateral approach, opening first the hernia sac to verify bowel viability. Then, we performed a tranverse chelotomy on the right side of the defect, leaving the defect open and wider to prevent hernia strangulation. We left two drains in the subcutaneuos space and the wound was covered with vacuum therapy dressing. The patient recovery was uneventful and he was discharged in the sixth postoperative day. After this episode the patient started a very strict weight loss treatment, so we coul plan the final wall reconstruction surgery, which hasn't already been performed, but which will include botulinum toxin and progressive preoperative pneumoperitoneum. Conclusions We belive that damage control surgery was the most appropiate option as the first step for the management of an incarcerated complex hernia, so in a second time an elective complex wall reconstruction surgery could be performed.

Submucosal infiltrate of anisakis larvae. Rare cause of intestinal obstruction.

Patient aged 71 with a history of type 2 diabetes mellitus. He came to the emergency department for abdominal pain and vomiting. Laboratory tests showed an increase in acute phase reactants. Abdominal CT scan showed dilated jejunal loops, compatible with intestinal occlusion. Urgent intervention was performed, resecting the affected segment. The pathology report showed a prominent transmural inflammatory infiltrate and interstitial oedema, with moderate villous atrophy, identifying parasitic structures compatible with anisakis larvae (family Anisakidae). Given the mechanism of tissue invasion, the larvae are surrounded by a predominantly eosinophilic inflammatory infiltrate, organised as granulomas or abscesses.

What is happening in that urinary catheter bag?

An 86-year-old nursing home woman with an indwelling urinary catheter presented to our emergency department for abdominal pain, nausea, hyporexia after nine days of stubborn constipation despite the use of laxatives, on a background of IV stage Chronic Kidney Disease (CKD), type 2 diabetes, hypothyroidism, and bed rest syndrome with chronic pain treated with fentanyl transdermal patch. Blood tests showed a worsening of renal function (creatinine 5.7 mg/dL, nv 0.6-1; azotemia 177 mg/dL, nv 10-50), and increased C reactive protein value (5 mg/dL, nv &lt; 0.5). Glucose and serum electrolytes were normal. Abdomen X-ray was unremarkable, and PoCUS excluded hydronephrosis and bladder globe. The urine drainage bag was purple with smelly urine.

652 SUCCESSFUL SURGICAL REPAIR OF LEFT VENTRICULAR PSEUDOANEURYSM IN A PATIENT WITH SUBACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Abstract A 65-year-old man was admitted to the emergency department for abdominal pain begun 4 days before. Past medical history consisted of ischemic stroke and diabetes mellitus. Of note, he was not taking any medication. Vital signs: blood pressure 90/50 mmHg, heart rate 50/minute, respiratory rate 18/minute, body temperature 36.5°C; saturation oxygen level 93%. High-sensitivity cardiac troponin was mildly elevated (121 pg/mL). Electrocardiogram showed sinus bradycardia, Q waves with ST elevation in antero-lateral leads consistent with subacute STEMI. Transthoracic echocardiogram (TTE) revealed aneurysmatic expansion of apical left ventricular (LV) walls (ejection fraction 30%) with a large apical thrombus (35×15 mm). Coronary angiography showed complete occlusion of proximal left anterior descending artery and a critical stenosis of right coronary artery; percutaneous coronary intervention with stent implantation on right coronary artery was performed. He received triple antithrombotic therapy with aspirin, clopidogrel, intravenous heparin first and then oral anticoagulation with warfarin. During coronary care unit stay, the patient was asymptomatic and hemodynamically stable. However, a control TTE (day 6) in cardiology ward revealed the presence of pseudoaneurysm with an oval out-pouching (23 × 13 mm) from the apical aspect of LV septum, communicating with the LV chamber through a passage measuring 1.6 cm. Partially organized pericardial effusion was evident around right ventricular free wall (Figure 1). Thus, the patient was immediately transferred to the cardiac surgery department for urgent surgical repair. The LV anterior wall rupture with pseudoaneurysm was then treated with endoaneurysmectomy of the LV with dacron patch and freewall reconstruction with prolene sutures and teflon felt stripes. The patient was finally discharged 3 weeks after surgery with betablockers, ace- inhibitors, diuretics, statins and dual antiplatelet therapy with aspirin and clopidogrel. At one month follow-up visit, the patient was hemodynamically stable with acceptable functional capacity. Figure 1Modified five chamber view (a, b) and three chamber view (c, d) showing apical LV pseudoaneurysm (arrows) with moderate pericardial effusion (arrowhead); color Doppler through the passage (arrow) in 3 chamber view (d). LV, left ventricular.

C43 A CASE REPORT OF A GIANT RIGHT CORONARY ARTERY ANEURYSM: ROLE OF CONTRAST ECHOCARDIOGRAPHY

Abstract A giant coronary aneurysm is rare entity and it is defined if the diameter is 4–fold greater the reference vessel diameter or if it is &amp;gt; 20 mm in diameter. We report the case of a 73–years–old man without prior history of cardiac disease, admitted in Emergency Department for abdominal pain with normal ECG. Abdominal CT scan showed no pathological findings. At thoracic level it was reported a suspected pericardial cyst (75x80 mm), with partial compression of right chambers (Fig. 1). Echocardiography confirmed the presence of a giant round cystic–appearance lesion characterized by the presence of an anechoic space with internal echogenic swirling flow pattern at the level of right atrioventricular groove with mild compressive effect on right chambers. (Fig. 2). The color Doppler mode showed a faint signal, without a clear evidence of flow origin. A bubble test with agitated saline contrast medium injected through antecubital vein, shows no evidence of contrast uptake by the mass. In order to better characterize the lesion, we use echocardiographic contrast agent (SonoVue®), which showed a clear pattern of blood flow inside the mass with a probable origin at a very limited region (Fig. 2a–2b). At that level it was also possible to sample an ECG–synchronized systo–diastolic pulse–wave (PW)–Doppler pattern (peak velocity 125 cm/s), typical for a coronary artery flow. According to these echocardiographic findings, we supposed a giant right coronary aneurysm. Coronary Computed Tomography Angiography with 3D reconstruction showed a giant aneurysm of the right coronary artery at mid–level, preceded by a mild aneurysm of the proximal tract and two small aneurysms of the circumflex artery and diffuse atherosclerosis diseases with significant stenosis on mid left anterior descending artery (LAD). The coronary angiography confirmed the presence of the giant aneurysm in mild tract of right coronary artery preceded by a small one in the proximal tract andthe two small aneurysm of the circumflex artery and a critical stenosis of mid tract of LAD. The patient underwent surgical treatment of the aneurysm and coronary artery bypass graft (Fig. 3). Computed Tomography Coronary Angiography is the best method for coronary artery anatomy and coronary abnormalities. In case of giant coronary abnormalities, the use of echo contrast agent provides further important information about perfusion and/or flow assessment and it helped to clarify the diagnosis.

Hemostasis caused by stent-graft insertion followed by graft removal for pancreas graft bleeding due to chronic rejection: A case report

IntroductionLethal symptoms due to graft rejection warrant rapid removal of the transplanted graft to save the patient's life. We report a case of massive pancreas graft bleeding due to chronic rejection that necessitated graft removal after hemostasis by stent graft insertion. Case presentationA 39-year-old woman underwent simultaneous pancreas-kidney transplantation for type I diabetes and chronic renal failure nine years ago. She suffered irreversible kidney damage from severe chronic rejection due to drug non-compliance. She was admitted to the emergency department for abdominal pain and bloody stools. She presented with signs of shock based on her vitals due to massive bleeding in the stool a day after hospitalization and required systemic management in the intensive care unit (ICU). Enhanced computed tomography (CT) scan revealed active bleeding from the duodenal portion of the pancreas graft. Hemostasis was achieved by inserting a stent graft into the right external iliac artery. The respiratory and circulatory status of the patient improved after the intervention, and she was transported to our hospital day after treatment. The graft was removed along with the part of the anastomosed intestine, which was reconstructed with a functional end-to-end anastomosis. ConclusionWe encountered a patient with hemorrhagic shock due to bleeding from a rejected pancreas graft. The patient was successfully treated and saved using stent-graft hemostasis followed by graft removal. Clinicians and surgeons should be mindful of chronic rejection, which could lead to life-threatening hemodynamic complications.