Emergency Department For Abdominal Pain Research Articles

Psychosocial Dimensions of Pain Disparities in Youth Diagnosed with Unspecified Abdominal Pain in an Emergency Department

Diagnosis ambiguity, paired with pain care inequities experienced by marginalized groups may increase risk for ongoing pain and impairment in children diagnosed with unspecified abdominal pain in the pediatric emergency department (PED). This cross-sectional study examined psychological, caregiver, cultural, and socio-ecological factors associated with pain-related impairment in an ethnically and socioeconomically diverse population diagnosed with unspecified abdominal pain in a PED. The sample included 111 children 8-17 years old (59.8% female, 72.7% Latinx) and their caregivers. Exclusion criteria included an Emergency Severity Index <2, psychiatric complaint, or not fluent in English or Spanish. Children completed the PROMIS Pain Interference Scale and reported pain intensity, pain duration, and pain catastrophizing. Caregivers reported language preference, pain catastrophizing, trait anxiety, and child internalizing symptoms. Area Deprivation Index quantified socio-ecological deprivation according to 9-digit zip code. Multivariable logistic regression analyses identified independent associations with likelihood of reporting severe levels of pain-related impairment. Approximately 35.3% of children reported severe levels of pain-related impairment. In logistic regression analysis, an increased likelihood of endorsing severe pain-related impairment was associated with pain for >1 month (OR=9.19, p=.044), higher child pain catastrophizing (OR=1.23, p<.001), caregiver Spanish language (OR=11.11, p=.044), and clinically significant caregiver trait anxiety (OR=58.16, p=.004). Results highlight the incidence of severe pain-related impairment in children diagnosed with unspecified abdominal pain in a PED. Moreover, findings underscore the importance of screening pain-related impairment and caregiver anxiety, and addressing language barriers in this PED population. PerspectiveThis paper highlights the incidence of severe pain-related impairment among pediatric patients diagnosed with unspecified abdominal pain in a pediatric emergency department (PED). Results could inform early assessment and targeted interventions in the PED to prevent outcome disparities.

Disparities in pain management among transgender patients presenting to the emergency department for abdominal pain.

Transgender and gender-diverse (TGD) individuals have a gender identity or expression that differs from the sex assigned to them at birth. They are an underserved population who experience health care inequities. Our primary objective was to identify if there are treatment differences between TGD and cisgender lesbian/gay/bisexual/queer (LGBQ) or heterosexual individuals presenting with abdominal pain to the emergency department (ED). Retrospective observational cohort study of patients ≥12 years of age presenting to 21 EDs within a health care system with a chief complaint of abdominal pain between 2018 and 2022. TGD patients were matched 1:1:1:1 to cisgender LGBQ women and men and cisgender heterosexual women and men, respectively. Propensity score matching covariates included age, ED site, mental health history, and gastrointestinal history. The primary outcome was pain assessment within 60 min of arrival. The secondary outcome was analgesics administered in the ED. We identified 300 TGD patients, of whom 300 TGD patients were successfully matched for a total cohort of 1300 patients. The median (IQR) age was 25 (20-32) years and most patients were treated in a community ED (58.2%). There was no difference between groups in pain assessment within 60 min of arrival (59.0% TGD vs. 63.2% non TGD, p = 0.19). There were no differences in the number of times pain was assessed (median [IQR] 2 [1-3] vs. 2 [1-4], p = 0.31) or the severity of pain between groups (5.5 [4-7] vs. 6 [4-7], p = 0.11). TGD patients were more likely to receive nonsteroidal anti-inflammatory drugs (32.0% vs. 24.9%, p = 0.015) and less likely to receive opioids than non-TGD patients (24.7% vs. 36.9%, p = <0.001). TGD and nonbinary patients, along with LGBQ cisgender women (24.7%) and heterosexual cisgender women (34%), were less likely to receive opioids than LGBQ cisgender men (54%) and heterosexual cisgender men (42.3%, p < 0.01). There was no difference in frequency of pain assessment, regardless of gender identity or sexual orientation. More cisgender men, compared to TGD and cisgender women, received opioids for their pain.

Accurate diagnosis of acute appendicitis in the emergency department: an artificial intelligence-based approach.

The diagnosis of abdominal pain in emergency departments is challenging, and appendicitis is a common concern. Atypical symptoms often delay diagnosis. Although the Alvarado score aids in decision-making, its low specificity can lead to unnecessary surgeries. By leveraging machine learning, we aim to enhance diagnostic accuracy by predicting appendicitis and distinguishing it from other causes of abdominal pain in the emergency department. Data were collected from 534 patients who presented with acute abdominal pain. Patient characteristics, laboratory results, and causes of pain were recorded. Machine learning algorithms (support vector classifier, random forest classifier, gradient boosting classifier, and Gaussian naive Bayes) were used to predict the cause of pain. Model calibration was assessed using the Brier score. The mean age was 46.89 (20.3) years, with an almost equal sex distribution (49% male, 51% female). Cholecystitis was the most prevalent outcome (37.07%), followed by appendicitis (25.84%). The Gaussian naive Bayes model exhibited superior performance in terms of accuracy (95.03% 95% CI 90.44-97.83%), sensitivity (87.18% 95% CI 72.57-95.70%), and specificity (97.54% 95% CI 92.98-99.49%), while the random forest model showed a sensitivity of 79.49%, specificity of 96.72%, and accuracy of 92.55%. The gradient boosting algorithm achieved a sensitivity, specificity, and accuracy of 89.74%, 95.90%, and 94.41%, respectively. The support vector classifier demonstrated a sensitivity of 89.74%, specificity of 92.62%, and accuracy of 91.93%. The use of modern machine learning methods aids in the accurate diagnosis of appendicitis.

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.