Peritonitis Research Articles

Establishment of a postoperative bowel adhesion model in Rats

Postoperative adhesive bowel obstruction is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive bowel obstruction can be managed non-operatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive bowel obstruction. Treatment recommendations are still controversial. Intestinal adhesions commonly occur in patients after abdominal surgery, often between intestines, between intestines and the abdominal wall, or within the peritoneum. Adhesions can lead to symptoms such as abdominal pain, constipation, and bloating, and may result in serious complications such as intestinal obstruction, bowel necrosis, acute peritonitis, and sepsis, which can be life-threatening. Therefore, reducing the occurrence of intestinal adhesions is crucial for abdominal surgery. To minimize adhesions, endoscopic techniques can be employed to reduce the abdominal opening area and thus decrease the probability of adhesion formation. However, this approach requires specialized equipment and surgical skills, making it somewhat challenging. Alternatively, anti-adhesion products can be used to lower the risk of adhesion formation. In this study, a murine cecal abrasion adhesion model was established and will be simulated common adhesion scenarios observed in patients after abdominal surgery. The efficacy of anti-adhesion gel materials will be then evaluated to assess their anti-adhesion properties. The record of gross adhesion severity assessment was performed. The adhesion status between the cecum and abdominal wall was observed on postoperative days 3 and 14. The results was shown that three days post-surgery operation, the group exhibited more severe adhesions upon gross examination. By day 14 post-surgery operation (at animal sacrifice), the histopathological analysis revealed that the group exhibited thicker fibrous tissue thickness, increased neovascularization, and higher collagen accumulation in the peritoneum. Therefore, based on the results of this experiment, a postoperative bowel adhesion rat is reliable and can be safely used to test the efficacy of novel anti-adhesive formulations to prevent intra-abdominal adhesions by using this model.

Analysis of patients with acute surgical abdomen due to trauma and evaluation of factors affecting mortality and the impact of COVID-19 pandemic process on patient admissions

Objective: To analyze the patients who developed acute surgical abdomen due to trauma, to evaluate the factors affecting mortality and to examine the impact of the COVID-19 pandemic process on patient admissions. Materials and Methods: The study was conducted retrospectively by analyzing the patients who applied to the emergency department of a secondary healthcare institution between 01.01.2019-31.12.2023 (5 years) and developed an emergency surgical abdomen secondary to trauma and were hospitalized and treated. All age groups were included in the study. Demographic data, type of trauma, type of treatment, site of injury, laboratory data, length of hospitalization and mortality status were analyzed. Comparative analysis of the injured regions according to the type of trauma was performed. Data of patients who were discharged and those who died were compared. Data collection was performed through hospital electronic data. Results: 123 patients were evaluated in the study. 78.9% (n=97) of the patients were male. The mean age was 36.43±14.81 years and the most common age range was 21-40 years (60.2%, n=74). At the time of presentation to the emergency department, the most common Glasgow Coma Score was 11-15 (83%, n=102). The most common reason for presentation was traffic accident (40.7%, n=50). Post-traumatic injuries to more than one organ or region in the abdomen were most common (28.5%, n=35). Surgical procedures were performed in 65.9% (n=81) of the patients. The mean duration of hospitalization was 7.14±5.40 days. Hemoglobin and platelet levels were found to be significantly lower at the time of admission in the patients who died (p

Cholecystopleural fistula: A case report and literature review.

Gallstone with acute cholecystitis is one of the most common diseases in the clinic. If the disease is serious, gallbladder gangrene, perforation, and sepsis may be caused. Gallbladder diseases rarely cause thoracic-related complications, especially pleural fistula, which is very rare in clinical practice. A 52-year-old male patient was admitted to the emergency department for 1 month with recurrent right middle and upper abdominal pain. Computed tomography diagnosis: cholecystitis and peri-inflammation, small abscess around the base of the gallbladder, local peritonitis, and bilateral pleural effusion. After admission, conservative treatment was given. On the 4th day of admission, the symptoms worsened, and an emergency catheter drainage was performed on the right thoracic cavity to extract 900 mL of dark yellow effusion. After the operation, a large amount of bili-like fluid was continuously drained from the thoracic drainage tube. After the iatrogenic biliary fistula caused by thoracic puncture was excluded, cholecystopleural fistula was considered to be cholecystopleural fistula. On the 6th day of admission, endoscopic retrograde cholangiopancreatography (ERCP) + cholecystography + Oddi sphincterotomy + laminating biliary stent was performed in the emergency department, and cholecystopleural fistula was confirmed during the operation. The patient recovered well after surgery, computed tomography examination on the 20th day after surgery indicated that pleural effusion was significantly reduced, and the patient was cured and discharged. The patient returned to the hospital 8 months after the ERCP operation to pull out the bile duct-covered stent. The patient did not complain of any discomfort after the postoperative follow-up for 3 years, and no recurrence of stones, empyema, and other conditions was found. Cholecystopleural fistula is one of the serious complications of acute cholecystitis, which is easy to misdiagnose clinically. If the gallbladder inflammation is severe, accompanied by pleural effusion, the pleural effusion is bili-like liquid, or the content of bilirubin is abnormally elevated, the existence of the disease should be considered. Once the diagnosis is clear, active surgical intervention is needed to reduce the occurrence of complications. Endoscopic therapy (ERCP) can be used as both a diagnostic method and an important minimally invasive treatment.

Source Control and Antibiotics in Intra-Abdominal Infections.

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Increased Intra-Abdominal Pressure as One of the Links in the Pathogenesis of Secondary Diffuse Purulent Peritonitis

Aim: to present literature data on the importance of intra-abdominal hypertension in the pathogenesis of peritonitis. Key points. Secondary purulent peritonitis is a severe and fairly common form of abdominal infection with high mortality. According to statistics, hospitalization of patients with signs of local or diffuse peritonitis is more than 15 % among patients with acute surgical pathologies. One of the factors in the development of complications and an unfavorable prognosis for this disease is increased intra-abdominal pressure. To measure this indicator, a Foley catheter inserted into the bladder is used in medical practice. According to reference values, the optimal level of intra-abdominal pressure does not exceed 5 mmHg. A persistent increase in pressure of 12 mmHg and above indicates the development of intra-abdominal hypertension. An increase in the level of intra-abdominal pressure indicates the progression of the inflammatory destructive process in the abdominal cavity and contributes to the development of multiple organ failure with subsequent fatal outcome with untimely treatment. With an indicator exceeding 20 mmHg, there is a risk of developing abdominal compartment syndrome. This condition is characterized by increased pressure in two or more anatomical areas, which leads to decreased blood flow and subsequent tissue hypoxia. Intra-abdominal hypertension also increases the risk of developing postoperative peritonitis in patients who have undergone laparotomy. Conclusion. To predict the course of secondary diffuse purulent peritonitis, reduce the risk of complications and mortality, it is necessary to focus on measuring intra-abdominal pressure as a mandatory manipulation in surgical patients. Despite its general availability and ease of implementation, this technique allows assessing the severity of organ dysfunctions.

A Diagnostic Dilemma of Emphysematous Liver Abscess with Gas under the Diaphragm: A Case Report and Review of Literature

Abstract A 53-year-old woman presented to the surgical emergency with complaints of high-grade fever accompanied by chills for 15 days and pain in the right upper abdomen for 10 days. X-ray of the abdomen and chest X-ray revealed free gas under the right hemidiaphragm. As there were no signs of generalised or localised peritonitis, emergency laparotomy was postponed. Subsequently, a contrast-enhanced computerised tomography scan of the abdomen suggested an emphysematous liver abscess, which was managed by ultrasonography-guided drainage of the abscess cavity.

Immune Clearance Mechanism for Hypoxia-Inducible Factor in Pelvic Peritonitis by Directly Targeting MiR-206a Using Magnetic Ferric Oxide Particles as a Carrier

miR-206a can directly target and regulate hypoxia-inducible factor, playing a role in inflammation and immune response. This study explored the effect of miR-206a using magnetic ferric oxide particles as a carrier to directly target and regulate HIF on immune clearance mechanism for pelvic peritonitis. A rat model of pelvic peritonitis was constructed and divided into NC group, NC group, Fe3O4 nanoparticle group, Fe3O4-miR-206a group, miR-206a gene knockout group, 740Y-P group, BKM120 group, Fe3O4-miR-206a+BKM120 group, PHD group, BAY 87-2243 group, Fe3O4-miR-206a+PHD group, 740Y-P+PHD group, BKM120+PHD group, and Fe3O4-miR-206a+BKM120+PHD group. We then detected serum C-Reactive protein (CRP), TNF-α and IL-6 levels, T lymphocyte, and miR-206a expression. HIF, TNF, IL-1, and IL-6 protein expressions were also detected. A rat model for pelvic peritonitis was also established, and magnetic ferric oxide particles carrying miR-206a nanocomplexes were successfully prepared. Levels of TNF-α, IL-6 and CRP were reduced under intervention by Fe3O4-miR-206a, and blood flow was reduced. All chemical indicators were reduced, and inflammatory response was significantly improved. After knocking out the miR-206a, the opposite results were observed. This study findings show that, miR-206a can directly target and regulate HIF to inhibit PI3K/Akt signaling pathway using magnetic ferric oxide particles as a carrier, thereby improving the immune clearance ability for patients with pelvic peritonitis, reducing inflammatory reactions, and thus improving prognosis. In addition, this research not only provides a new direction for management of inflammatory diseases, but also serves as a reference for treatment of immune diseases. Therefore, direct targeting and regulating HIF by miR-206a using magnetic ferric oxide particles as a carrier can become an effective strategy for the treatment of inflammatory and immune-related diseases.

New applications of Clioquinol in the treatment of inflammation disease by directly targeting arginine 335 of NLRP3

The NOD-like receptor protein 3 (NLRP3) inflammasome is essential in innate immune-mediated inflammation, with its overactivation implicated in various autoinflammatory, metabolic, and neurodegenerative diseases. Pharmacological inhibition of NLRP3 offers a promising treatment strategy for inflammatory conditions, although no medications targeting the NLRP3 inflammasome are currently available. This study demonstrates that clioquinol (CQ), a clinical drug with chelating properties, effectively inhibits NLRP3 activation, resulting in reduced cytokine secretion and cell pyroptosis in both human and mouse macrophages, with a half maximal inhibitory concentration (IC50) of 0.478 μM. Additionally, CQ mitigates experimental acute peritonitis, gouty arthritis, sepsis, and colitis by lowering serum levels of interleukin-1β (IL-1β), IL-6, and tumour necrosis factor-α (TNF-α). Mechanistically, CQ covalently binds to Arginine 335 (R335) in the NACHT domain, inhibiting NLRP3 inflammasome assembly and blocking the interaction between NLRP3 and its component protein. Collectively, this study identifies CQ as an effective natural NLRP3 inhibitor and a potential therapeutic agent for NLRP3-driven diseases.

Synthetic thymic hexapeptide in the correction of alterations of antibacterial immune defense and normalization of the profile of proinflammatory cytokines in immunocompromized Children with local unlimited acute peritonitis

The study of dysregulatory disorders of the immune system underlying the immunopathogenesis of severe purulent-inflammatory diseases (PIDs) is important for development of new therapeutic tactics of restoring antibacterial defense. Acute peritonitis (AP) is a severe PID of the abdominal cavity, the course of which are dependent on the treatment, cytokine balance and adequate functioning of the immunity. Objective: to evaluate the modulating effects on the immune system and the levels of proinflammatory cytokines of the synthetic thymic hexapeptide, active substance of Imunofan, included in the complex postoperative treatment (CPOT) of immunocompromised children with local AP. Clinical and immunological examination of 20 immunocompromised children aged 5–12 years with local AP was carried out before (study group 1, SG1) and after (study group 1a, SG1a) CPOT including synthetic thymic hexapeptide (Arginyl-alpha-AspartylLysyl-Valyl-Tyrosyl-Arginine, НР), alongside 20 conditionally healthy children (comparison group, SG). The content of T and B lymphocytes, natural killer cells (NK), levels of serum pro-inflammatory cytokines IL-1β, IL-6, TNFα, IL-8, IL-18, phagocytic and microbicidal activity of neutrophils (NG) were assessed. In SG1, before treatment, a decrease in the number of T lymphocytes, T helpers, CTL-lymphocytes, NK and an increase in the level of B lymphocytes was revealed. Defects in the effector functions of NG were determined: impaired bacterial antigen killing and decreased NADPH oxidase activity. It was established that in case of AP in immunocompromised children, the cytokine profile is characterized by overproduction of studied proinflammatory and neutrophil-associated cytokines. After complex treatment including immunomodulatory therapy, there was a restoration of the content of T lymphocytes, T helper cells, TCTL lymphocytes, an increase in the number of NK and decrease in the level of B lymphocytes. In addition, regression of the levels of inflammatory, including neutrophil-associated, cytokines and emergence of effector functions of NG due to restoration of NADPH oxidases activity, was noted. Thus, the restoration of immunological parameters in AP leads to earlier regression of the purulent-inflammatory process in the abdominal cavity and to the absence of postoperative complications. The clinical and immunological effects of the immunomodulatory therapy program with inclusion of the drug based on HP determines the feasibility of its use in the postoperative period in immunocompromised children with local AP.

Construction of a clinical prediction model for complicated appendicitis based on machine learning techniques

Acute appendicitis is a typical surgical emergency worldwide and one of the common causes of surgical acute abdomen in the elderly. Accurately diagnosing and differentiating acute appendicitis can assist clinicians in formulating a scientific and reasonable treatment plan and providing high-quality medical services for the elderly. In this study, we validated and analyzed the different performances of various machine learning models based on the analysis of clinical data, so as to construct a simple, fast, and accurate estimation method for the diagnosis of early acute appendicitis. The dataset of this paper was obtained from the medical data of elderly patients with acute appendicitis attending the First Affiliated Hospital of Anhui University of Chinese Medicine from January 2012 to January 2022, including 196 males (60.87%) and 126 females (39.13%), including 103 (31.99%) patients with complicated appendicitis and 219 (68.01%) patients with uncomplicated appendicitis. By comparing and analyzing the prediction results of the models implemented by nine different machine learning techniques (LR, CART, RF, SVM, Bayes, KNN, NN, FDA, and GBM), we found that the GBM algorithm gave the optimal results and that sensitivity, specificity, PPV, NPV, precision, recall, F1 and brier are 0.9167, 0.9739, 0.9429, 0.9613, 0.9429, 0.9167, 0.9296, and 0.05649, respectively. The GBM model prediction results are interpreted using the SHAP technology framework. Calibration and Decision curve analysis also show that the machine learning model proposed in this paper has some clinical and economic benefits. Finally, we developed the Shiny application for complicated appendicitis diagnosis to assist clinicians in quickly and effectively recognizing patients with complicated appendicitis (CA) and uncomplicated appendicitis (UA), and to formulate a more reasonable and scientific clinical plan for acute appendicitis patient population promptly.

Clinical Characteristics, Outcomes, and Interobserver Agreement of Point-of-Care Ultrasound Detected Mesenteric Adenitis in Nonsurgical Pediatric Abdominal Pain: A Retrospective Cohort Study.

Point-of-care ultrasound (PoCUS) in the emergency department (ED) may facilitate the diagnosis of nonsurgical sources of abdominal pain after surgical causes are excluded. Identifying mesenteric adenitis is a feasible PoCUS application due to its ease of use and speed. However, there are scant data regarding the diagnosis of mesenteric adenitis by PoCUS. The objective of this study was to describe the clinical characteristics, outcomes, and interobserver agreement of mesenteric adenitis identified on PoCUS in pediatric patients with nonsurgical abdominal pain. This was a retrospective review at a tertiary-care, urban pediatric ED. All cases of mesenteric adenitis diagnosed on PoCUS from January 2018 to August 2022 were reviewed. Demographics and clinical data, including relevant outcomes, were recorded. All PoCUS videos were reviewed by a senior sonologist-physician for determination of mesenteric adenitis in children 21 years and younger with nonsurgical abdominal pain. Interobserver agreement by Cohen κ was calculated between experienced and novice physician sonologists blinded to diagnosis, who reviewed 77 six-second video clips for presence or absence of mesenteric adenitis. Thirty-three subjects were identified by PoCUS to have mesenteric adenitis in the setting of nonsurgical abdominal pain presenting to our ED. Most common indications for PoCUS were for suspected appendicitis, suspected intussusception, or undifferentiated abdominal pain. Forty-six percent of patients were male; median age was 9 years (interquartile range, 4-14 years). On 4-week clinical follow-up, 1 patient returned to our ED with a surgical abdomen. Cohen κ values were 0.83 (95% confidence interval, 0.70-0.97) between experienced sonologist-physicians and 0.76 (95% confidence interval, 0.61-.90) between novice and experienced sonologist-physicians. PoCUS can identify mesenteric adenitis, typically a diagnosis of exclusion, in pediatric patients with nonsurgical abdominal pain, both by novice and experienced physician-sonologists. Use of PoCUS may help ED clinicians identify a common cause of nonsurgical abdominal pain in children.

Inflammatory suppression and immunity regulation benefits of honokiol in a rat model of acute peritonitis via the regulation of NLRP3 inflammasome and Sirt1/autophagy axis.

NLRP3 inflammasome and Sirt1/autophagy axis are potential targets for advancing acute peritonitis (AP). Honokiol (HNK), a bioactive substance, has the potential to improve AP. The AP model rats were established by cecal ligation and puncture (CLP). Rats were randomized into the Sham, Sham+HNK, CLP, and CLP+HNK groups. The therapeutic effects of HNK on organ infection, inflammation and immunity were observed in AP rats. The inflammation of RAW 264.7 cells was induced by lipopolysaccharide (LPS) and divided into the Control, HNK, LPS, and LPS+HNK groups. The effects of HNK on immunity and inflammation were observed. Moreover, the inflammatory cell model was further transfected with NLRP3 overexpressing plasmid, and the regulatory effect of HNK on NLRP3 in AP cells was detected. HNK treatment improved survival, biochemical indexes, and lung and kidney injury and inhibited inflammatory cytokine release and bacterial infection in CLP rats. In CLP rats and RAW 264.7 cells, HNK treatment improved the release of the CD4+ and CD8+ T cells, decreased the associated proteins' levels of the NLRP3 inflammasome, and activated the expression of proteins in the Sirt1/autophagy axis. It improved viability and reduced apoptosis and the degrees of TNF-α, IL-1β, and IL-6 mRNA in RAW 264.7 cells. In addition, HNK treatment antagonized the effect of NLRP3-overexpressed on inflammation and immunity. HNK improved AP by inhibiting NLRP3 inflammasome and activating the Sirt1 autophagy axis in vivo and in vitro.

Gallbladder torsion.

Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

Risk factors of peritoneal dialysis-related peritonitis in the Japan Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).

Peritoneal dialysis (PD)-related peritonitis is a major complication of PD. Wide variations in peritonitis prevention, treatment strategies and consequences are seen between countries. These between-country differences may result from modifiable risk factors and clinical practices. A total of 1225 Japanese PD patients were included and prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study phase 1 (2014-2018) and phase 2 (2018-2022). Associations between PD-related peritonitis and various risk factors were assessed by Cox proportional hazards survival models. During follow-up (median 1.52years), 539 peritonitis episodes were experienced by 364 patients. The country crude peritonitis rate was 0.27 episodes/patient-year. In the fully adjusted model, noticeable patient-level factors associated with experiencing any peritonitis included age {hazard ratio [HR] 1.07 per 5-year increase [95% confidence interval (CI) 1.01-1.14]}, serum albumin level [HR 0.63 per 1g/dl higher (95% CI 0.48-0.82)] and continuous ambulatory peritoneal dialysis (PD) [HR 1.31 versus automated PD (95% CI 1.05-1.63)]. The adoption of antibiotic prophylaxis practice at the time of PD catheter insertion [HR 0.63 (95% CI 0.51-0.78)] or when having complicated dental procedures [HR 0.74 (95% CI 0.57-0.95)] or lower endoscopy [HR 0.69 (95% CI 0.54-0.89)] were associated with lower hazards of any peritonitis, while a routine facility practice of having more frequent regular medical visits was associated with a higher hazard. Identification of risk factors in Japan may be useful for developing future versions of guidelines and improving clinical practices in Japan. Investigation of country-level risk factors for PD-related peritonitis is useful for developing and implementing local peritonitis prevention and treatment strategies.

Adnexal Torsion of a 28 cm Paratubal Cyst: A Case Report

Objective: To report a rare case of a 28 cm left adnexal torsion requiring surgical intervention including detorsion and salpingectomy Methods: Case report. Results: An 18-year-old nulliparous female with morbid obesity presented to the emergency department complaining of one week of sharp right lower quadrant pain with nausea and vomiting that had acutely worsened. Vital signs were notable for tachycardia, but otherwise within normal ranges. She had a significant leukocytosis. Her pregnancy test was negative. A CT abdomen/pelvis was obtained that demonstrated a large multiloculated complex cystic mass measuring 28.5 x 19.8 x 13.3 cm with possible origin from the ovaries that could represent a serous cystadenoma. Additionally, the scan was remarkable for a heterogeneous and enlarged left ovary measuring 7.6 x 5.9 x 7.2 cm, surrounded by free fluid and mesenteric edema. On examination, she did not demonstrate any surgical abdomen findings. Her pain improved with pain medication. She was admitted, tumor markers obtained, and an ultrasound ordered. The ultrasound demonstrated normal appearing right ovary with present doppler flow and a simple cyst measuring 6.6 x 5.1 x 6.1 cm. The left adnexa was noted to have a complex versus solid mass with unclear boundaries of the ovary. Also noted on the ultrasound were two large simple midline cysts measuring 10.5 x 9.1 x 11.8 cm inferiorly and 18.2 x 15.5 x 17.2 cm superiorly. No free fluid was seen within the right upper quadrant on ultrasound. The view of the left upper quadrant was suboptimal. Due to these findings, Gynecologic Oncology service was also consulted and after discussion, decision made to proceed urgently to diagnostic laparoscopy with robotic assisted cystectomy versus oophorectomy. Upon laparoscopic entry into the abdomen, a large necrotic-appearing left adnexal mass was visualized coming from the left fallopian tube. Both the left fallopian tube and left ovary were necrotic, with the left ovary being torsed numerous times. After resection of the large left fallopian tube and cyst, the left ovary was detorsed, and the decision was made to leave the ovary in situ. It still appeared necrotic, but its blood supply was intact. There was a large simple paratubal cyst on the right fallopian tube that was also drained and excised. Postoperatively, her right lower quadrant pain resolved, and she was discharged on post-operative day 1. She prescribed a two-week course of doxycycline and metronidazole as pelvic inflammatory disease could not be ruled out. At outpatient follow-up, she was asymptomatic and ready to begin working again. Her pathology report confirmed a large left paratubal cyst with associated findings of ischemia due to torsion and a large right paratubal cyst. Conclusions: Adnexal torsion is a rare gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support, which can negatively impact fertility. Prompt diagnosis is key, but definitive diagnosis is only by direct visualization. The differential diagnosis for acute onset of severe pelvic pain with nausea and vomiting is broad and includes ectopic pregnancy, pelvic inflammatory disease, endometriosis, ruptured ovarian cyst, urologic issues and gastrointestinal issues. Commonly, ultrasound is used to help evaluate a possible torsion with several classic findings that were not noted in this case, other than a mass. The two best known risk factors for adnexal torsion are a mobile ovarian mass and a history of prior torsion. Although large ovarian masses greater than 5 cm are more likely to cause torsion, some experts hypothesize that very large masses are less likely to torse given the constraints of the pelvis. However, such was not the case here. Additionally, it has been observed that adnexal torsion typically affects the right adnexa due to theoretical protection from the descending colon on the left. Given that the case presented did not have any of the typical imaging findings for adnexal torsion and that her pain was on the right but the torsion on the left, it is important to maintain a high level of suspicion when evaluating patients with acute onset pelvic pain of any location with nausea and vomiting.

Cholinergic macrophages promote the resolution of peritoneal inflammation

The non-neural cholinergic system plays a critical role in regulating immune equilibrium and tissue homeostasis. While the expression of choline acetyltransferase (ChAT), the enzyme catalyzing acetylcholine biosynthesis, has been well documented in lymphocytes, its role in the myeloid compartment is less understood. Here, we identify a significant population of macrophages (Mϕs) expressing ChAT and synthesizing acetylcholine in the resolution phase of acute peritonitis. Using Chat-GFP reporter mice, we observed marked upregulation of ChAT in monocyte-derived small peritoneal Mϕs (SmPMs) in response to Toll-like receptor agonists and bacterial infections. These SmPMs, phenotypically and transcriptionally distinct from tissue-resident large peritoneal macrophages, up-regulated ChAT expression through a MyD88-dependent pathway involving MAPK signaling. Notably, this process was attenuated by the TRIF-dependent TLR signaling pathway, and our tests with a range of neurotransmitters and cytokines failed to induce a similar response. Functionally, Chat deficiency in Mϕs led to significantly decreased peritoneal acetylcholine levels, reduced efferocytosis of apoptotic neutrophils, and a delayed resolution of peritonitis, which were reversible with exogenous ACh supplementation. Intriguingly, despite B lymphocytes being a notable ChAT-expressing population within the peritoneal cavity, Chat deletion in B cells did not significantly alter the resolution process. Collectively, these findings underscore the crucial role of Mϕ-derived acetylcholine in the resolution of inflammation and highlight the importance of the non-neuronal cholinergic system in immune regulation.

PREVALENCE OF BACTERIAL VAGINITIS AMONG WOMEN USING DIFFERENT TYPES OF IUDS

Background: A coil, also known as an intrauterine contraceptive device (IUCD or ICD), is a small birth control method that is put into the uterus to stop pregnancy. It usually starts in the endocervix and vagina and spreads up the body, causing endometritis, salpingitis, tubo-ovarian abscesses, parametritis, oophoritis, and/or pelvic peritonitis. objective: The objective of the current study was to investigate the prevalence of bacteria causing vaginitis among women using different types of intra uterine devices Materials and methods: The study was conducted in Kirkuk city from November 1, 2023, to April 30, 2024, using high vaginal swabs from 186 fertile women using intrauterine devices (IUDs). Demographic, medical, and gynecologic histories were recorded, and all patients underwent pelvic examinations. Swabs from the posterior fornix of the vagina were taken for microbiological analysis. The study included women aged 18-45 using IUDs, and excluded those who had received antibiotics, had preexisting systemic or infectious diseases, or experienced bleeding. Ethical approval was obtained, and informed consent was signed by all participants. The swabs were cultured on blood agar , MacConkey agar, Mannitol salt agar and deman rosa sharpe agar and Eosin methylene blue agar and incubated at 37°C for 24 hours. The colonies were picked, purified, and identified through a series of biochemical tests, including Gram staining, motility tests, and enzyme and fermentation tests. The Vitek 2 system was used for microbial identification and susceptibility testing. Results: In a study of 148 women using copper IUDs, 66 (44.59%) tested positive for vaginal swab cultures, while 82 (55.41%) tested negative. Similarly, among 38 women using hormonal IUDs, 17 (44.74%) had positive culture results, and 21 (55.26%) tested negative. Overall, out of 186 women tested, 83 (44.62%) had positive cultures. Among the 83 positive cases, 66 (79.52%) were in copper IUD users, and 17 (20.48%) were in hormonal IUD users. Escherichia coli was the most common bacterium, found in 40.91% of positive cultures, followed by Staphylococcus epidermidis (13.64%), and other bacteria including Staphylococcus aureus, Actinomyces israelii, and Proteus mirabilis, each at 9.09%. In women with positive cultures using copper IUDs, E. coli was most prevalent (47.06%), followed by Staphylococcus aureus and Staphylococcus epidermidis (17.65% each). Among women with positive cultures, 13.25% had diabetes, compared to 4.85% with negative cultures. Hypertension was present in 3.61% of women with positive cultures versus 1.94% with negative cultures. Duration of IUD use also showed a significant correlation with culture results. Women with positive cultures using copper IUDs had the highest percentage in the 1-2 year duration category (43.94%), while those using hormonal IUDs had the highest in the same category (47.06%). Antibiotic sensitivity testing revealed that Imipenem, Meropenem, Tigecycline, and Colistin were 100% effective against E. coli isolates from women using IUDs. However, high resistance rates were observed for Ampicillin/Sulbactam (71.79%) and Ciprofloxacin (84.62%). Ceftolozane/Tazobactam and Gentamicin had relatively high sensitivity rates, while Ceftazidime/Avibactam showed moderate sensitivity. Conclusions The study reveals a significant proportion of women with copper and hormonal IUDs tested positive for vaginal infections, with Escherichia coli being the predominant bacterium isolated,significant differences were noted in the clinical presentation and comorbidities of women with positive cultures compared to those with negative cultures.study identified antibiotics with high sensitivity rates against E. coli isolates, such as Imipenem, Meropenem, Tigecycline, and Colistin, highlighting potential treatment options for IUD-associated infections caused by multidrug-resistant strains. Conversely, antibiotics like Ampicillin/Sulbactam and Ciprofloxacin demonstrated high resistance rates

Temporary abdominal closure in oncological patients: Surgical characteristics and implications.

In critically ill patients, temporary abdominal closure (TAC) is utilized for conditions like abdominal compartment syndrome risk, gross abdominal contamination, and intestinal loop viability doubts. TAC techniques aim to safeguard abdominal contents, drain intraperitoneal fluids, and minimize fascia and skin damage. Our goal is to outline clinical characteristics and surgical outcomes in oncological patients undergoing peritoneostomy. Patients undergoing TAC with vacuum therapy at a tertiary oncological center were studied, with data sourced from an institutional database. Forty-seven patients (54.3% female), with an average age of 63.1 ± 12.3 years, were included in the study. The primary tumor site was predominantly gastrointestinal (78.2%). Patients presented systemic signs of chronic disease, reflected by a mean body mass index of 18.2 ± 7.6 kg/m², hemoglobin level of 9.2 ± 1.8 g/dL, and albumin level of 2.3 ± 0.6 g/dL. Additionally, most patients had a low-performance status (53% Eastern Cooperative Oncology Group 1/2, 44.8% Karnofsky score ≤80, and 61.2% Charlson Comorbidity Index ≥6). Emergency surgical complications were the main reasons for initial surgery (68%), with the majority attributed to fecal peritonitis (65.9%). Only 14.8% of patients achieved complete abdominal closure with an average of 24.8 days until closure. The in-hospital mortality rate was 85.2%. TAC is an alternative for oncological patients with surgical complications, but it carries a high mortality rate due to the compromised conditions of the patients.

Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis

BackgroundThe high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis.MethodsBetween January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis.ResultsLength of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy.ConclusionsA preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.

Effects of metaraminol and norepinephrine on hemodynamics and kidney function in a miniature pig model of septic shock.

To compare the effects of metaraminol and norepinephrine on hemodynamics and kidney injury in the treatment of septic shock, and calculate the conversion dose ratio between the two vasopressors. This randomized controlled study was performed on 15 Guizhou miniature pigs. Septic shock was induced by fecal peritonitis in 10 animals, and 5 were used as a sham-operated group (shams). Fluid resuscitation and vasopressors were initiated 30 min after the onset of septic shock. The septic shock pigs were randomly assigned to receive one of the two drugs to restore and maintain mean arterial pressure (MAP) ≥ 65 mmHg for 3 h. Hemodynamics and heart rate were continuously monitored. There was no significant difference in MAP, heart rate, cardiac output (CO) and central venous pressure (CVP) between the two groups after treatment. No arrhythmias such as atrial fibrillation and ventricular fibrillation presented during continuous monitoring. After septic shock, the animals showed obvious kidney injury. In addition, compared with norepinephrine, the creatinine at 3 h was significantly lower with metaraminol. According to propensity score matching, the ratio of 6: 1 was considered appropriate for the dose equivalence calculation of metaraminol (μg·kg-1·min-1): norepinephrine (μg·kg-1·min-1). Metaraminol has a similar pressor effect to norepinephrine in septic shock; it does not increase heart rate and aggravate kidney injury after shock compared with norepinephrine. And our research may provide some laboratory evidence for the clinical usage of metaraminol.