Pelvic Fluid Research Articles

Index of Suspicion * Case 1: Irritability and Signs of Peritonitis in a Neonate * Case 2: Red Eye, Excessive Tearing, Photophobia, Irritability, and Splenomegaly in an Infant * Case 3: 2-year-old Girl Who Has Cough, Right Pulmonary Abnormalities

* ALL: : acute lymphoblastic leukemia CT: : computed tomography IVC: : inferior vena cava NA: : neonatal appendicitis NEC: : necrotizing enterocolitis WBC: : white blood cell A 7-day-old boy born at term is brought to the emergency department by his foster mother for refusal to feed for ∼20 hours and increased crying, although he is intermittently consolable. When given his bottle, the infant starts to suck but then cries as though in pain. He has not vomited, and his last bowel movement was yesterday. The stool has been moderately well formed without blood or mucus, and wet diapers have continued. There is no history of respiratory symptoms, lethargy, rashes, or jaundice. The biological mother is a 27-year-old woman with a known history of previous drug abuse; she had received some prenatal care. This infant was born by scheduled cesarean delivery. Initial physical examination reveals a crying but consolable neonate. His temperature is 37.7°C, heart rate is 170 beats/minute, and respiratory rate is 56 breaths/minute; the remainder of his findings are normal. His complete blood count (white blood cell [WBC] 11.7 × 109/L, 78.5% neutrophils, 11.4% monocytes, 9.8% lymphocytes), serum concentrations of electrolytes and glucose, urinalysis, and cerebrospinal fluid studies are normal. Cultures are obtained. An abdominal radiograph is normal and abdominal ultrasonography reveals trace pelvic fluid. He is given a bolus of normal saline and is started on antibiotics to treat possible sepsis. A few hours after admission, repeat examination is concerning for inconsolability, poor suck reflex, and lethargy. His abdomen is distended, firm, and tender to palpation. Bowel sounds are normal. Further studies are performed that reveal the diagnosis. A previously healthy 10-month-old boy is seen for a 2-week history of an erythematous left eye with tearing. Earlier, he was diagnosed as having conjunctivitis at an urgent care clinic and was treated with a 10-day course of polymyxin B/trimethoprim eye drops without improvement. He has felt warm intermittently but has not had a …

Abstract No. 115: Safety and efficacy of transvesical approach for pelvic fluid collection drainage

According to traditional teaching, anterior approaches for percutaneous pelvic collection drainage are often precluded because of intervening bowel or urinary bladder, and thus alternative approaches are needed. The aim of this study is to determine whether a transvesical approach for percutaneous drainage of pelvic fluid collections can be performed safely and effectively. As of this writing, a search of the radiology database at our institution had revealed 5 patients (ages 1 to 92 years) undergoing fluid collection drainage using a percutaneous transvesical approach. Imaging showed the pelvic collections were all directly posterior to the urinary bladder and not amenable to any traditional drainage approach. Additional data collected included clinical and imaging (CT, US, or fluoroscopy) follow-up and any complications. All five collections were successfully accessed and effectively drained. In two cases, a Foley catheter was clamped to distend the urinary bladder to displace the bowel superiorly to provide an access route through the bladder. Sonography was used for the initial puncture in three cases, with the additional use of fluoroscopy or CT. CT was the only imaging used in two cases. Initial access was achieved with either a 22G or 21G needle. The catheters ranged from 8F to 10F. In three patients, a Foley catheter was present prior to drainage; in one, a Foley catheter was placed on post procedure day 1 for urinary retention; a Foley catheter was not used in the remaining case. Catheters were removed after 7-31 days (median 10 days) without recurrent collections. Follow-up ranged from 10-53 days (median 14 days). No complications occurred, including no urine leaks or inability to void after catheter removal. Transvesical approach for percutaneous pelvic fluid collection drainage can be a safe, well-tolerated, and effective alternative to traditional percutaneous approaches.

Perirenal Fluid Collection after Kidney Transplantation

A 30-year-old male presented with pitting edema. He had received a kidney transplantation 3 months previously. His serum creatinine level was increased, and a renal ultrasound showed hypoechoic fluid collection in the perirenal space and pelvic cavity. We conducted sono-guided percutaneous drainage of the fluid collected in the pelvic cavity. The chemistry of the peritoneal fluid was more equivalent to serum chemistry values than to urinary values. Simple aspiration and treatment with antibiotics were performed. We have presented a case of lymphocele after kidney transplantation. This case suggests that physicians should remember how to differentiate the pelvic cavity fluid collection in patients who have received a kidney transplant.

Think Heterotopic: A Case Report of Heterotopic Pregnancy Detected on Thorough Ultrasonography

We present a case report of heterotopic pregnancy picked up on thorough ultrasonography in a clinically stable 22-year-old patient with low risk factors. Heterotopic pregnancy is a rare obstetrics phenomenon and carries a significant maternal morbidity and mortality due to the risk of rupture of the ectopic pregnancy. Clinicians and sonographers tend to be lulled into a false sense of security when an intrauterine gestation sac is seen. This results in inadequate inspection of the adnexae and remaining structures during ultrasonography despite a strong initial clinical suspicion of ectopic pregnancy. Hence, a thorough ultrasonography and holistic approach is needed in managing these patients, especially when there is a high suspicion of ectopic pregnancy or in the presence of pelvic free fluid even when an intrauterine pregnancy is identified. A new dictum ‘Think ectopic. If intrauterine gestation is seen, think heterotopic’ needs to be adopted. J Med Cases. 2012;3(5):326-328 doi: https://doi.org/10.4021/jmc779w

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery

The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer. The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings. Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient). EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

Postoperative Seromas Following Robotic/Laparoscopic Lymph Node Dissection in Patients with Radiation/Chemotherapy for Gynecologic Cancers

Postoperative pelvic fluid collections are common in patients with staging laparotomy for gynecologic cancer and can result in infectious complications (20%) during radiation (RT)/chemotherapy. With recent development of less invasive robotic/laparoscopic lymph node staging approaches, the incidence and clinical significance of postoperative seroma has not been described. The purpose of this study was to evaluate frequency and type of postoperative seromas, and RT/chemotherapy-related morbidity in gynecologic cancer patients following robotic lymph node staging.

Identification of tissue of origin in body fluid specimens using a gene expression microarray assay

Body fluid specimens may be the first and only pathologic specimen for clinical evaluation in metastatic cancer cases. The challenge of identifying the tissue of origin in metastatic cancer has led to the emergence of molecular-based assays, such as the microarray-based Pathwork Tissue of Origin gene expression test. The ability to use body fluid specimens in this test would be valuable in providing diagnoses to cancer patients without clearly identifiable primary sites. In the current study, the authors evaluated the Tissue of Origin Test for use with malignant effusion specimens. A total of 27 metastasis-positive body fluid specimens from different body sites, including pleural, ascites, pericardial, and pelvic wash fluids, were obtained from patients with known diagnoses. Nine specimens from nonmalignant body fluids were included as controls. RNA was extracted from formalin-fixed, paraffin-embedded (FFPE) tissue and gene expression analysis was performed with the Tissue of Origin Test. Seventeen of 27 metastasis-positive samples were non-necrotic with ≥60% tumor and yielded sufficient RNA. Of these samples, 94.1% (16 of 17) were in agreement with the available diagnosis. Of the 9 negative control samples evaluated, 7 (77.8%) demonstrated microarray expression profiles most similar to lymphoma, which is consistent with the predominance of inflammatory cells in these specimens. The results of the current study demonstrated that FFPE cell blocks from cytologic body fluid specimens yield adequate diagnostic material for the Pathwork test and can be used in the workup of patients with unknown primary tumors.

How Much Free Fluid Can a Pregnant Patient Have? Assessment of Pelvic Free Fluid in Pregnant Patients Without Antecedent Trauma

The amount of free fluid that can normally be present in a pregnant patient is unknown. Evaluation of pelvic free fluid in a population of pregnant patients without early history of trauma would help determine what amount of free fluid should raise suspicion of intra-abdominal injury in those who have suffered trauma. Patients presenting for routine obstetric ultrasound without an early history of trauma were offered participation in the study. Routine imaging of the cul de sac and ovaries was used for assessment of presence or absence of free fluid, with accompanying digitally recorded images. Depth of the fluid pocket was measured in millimeters. Six of 89 patients successfully scanned were found to have free fluid in to the cul de sac for an occurrence of 6.7%. Four patients had free fluid present during the first trimester with subsequent resolution by the late first trimester or early second trimester. Two of these patients had an identifiable cause for free fluid, one with right ovarian hyperstimulation and the second with idiopathic theca lutein cysts. Two patients had isolated free fluid appearing in the third trimester. These results suggest that the presence of pelvic free fluid in pregnant patients without antecedent trauma is very low. After blunt abdominal trauma, the presence of free fluid in the pelvis of a pregnant patient may not be physiologic, especially if there is >2 mm to 4 mm, and there is no history of ovarian hyperstimulation syndrome or other known associations.

Tuberculous Abdominal Cocoon

A 22-year-old male patient presented with the complaints of upper abdominal colicky pain, intermittent bilious vomiting, and abdominal distension of 3-month duration. There was no history of peritonitis, abdominal surgery, or long-term medication. Clinical examination was unremarkable. Routine laboratory investigations revealed hemoglobin of 11 gm/dL, erythrocyte sedimentation rate (ESR) of 80 min the first hour and normal leukocyte count, platelets, electrolytes, renal, and liver function tests. Chest and abdominal radiograph were normal. Clinical diagnosis of subacute intestinal obstruction was made. Barium meal follow through (BMFT) revealed adherent small bowel loops with delayed transit time (Figure 1). Mucosal pattern and illeoceacal junction were normal. Multi-detector computed tomography (MDCT) of the abdomen showed a 3-mm-thick membrane encasing the small bowel loops and forming a saclike structure (Figure 2A). Sagittal and coronal reformation better demonstrated the entire disease process (Figure 2B). Omental thickening, retroperitoneal adenopathy, and free pelvic fluid were also demonstrated. Ultrasound-guided fine needle aspiration cytology (FNAC) of the omentum revealed caseating granuloma and giant cells. After surgery a post-operative histology confirmed diagnosis of tuberculosis. Figure 1. BMFT image shows adherent small bowel loops clumped in the central abdomen. Figure 2. Multi-detector computed tomography (MDCT) of the abdomen axial (A) and coronal reformatted (B) images reveal a 3-mm-thick membrane encasing the small bowel loops and forming a saclike structure. Described by Foo and others,1 abdominal cocoon is a rare cause of intestinal obstruction characterized by encasement of the small bowel by a thick, fibrous membrane. Sclerosing encapsulating peritonitis (SEP) also known as abdominal cocoon primarily affects adolescent females. The SEP can be classified as idiopathic or secondary to long-term peritoneal dialysis, beta-blocker practolol intake, orthotopic liver transplantation, abdominal surgery, sarcoidosis, systemic lupus erythematosus, gastrointestinal malignancy, and abdominal tuberculosis.2 Abdominal cocoon secondary to tuberculosis is rare with few reported cases.3,4 Clinical manifestations of abdominal cocoon are non-specific and include intestinal obstruction and/or abdominal mass.1–5 A majority of the reported cases were diagnosed incidentally at laparotomy. Preoperative diagnosis of abdominal cocoon is difficult because of non-specific clinical features and reduced awareness. Imaging (barium meal follow through and CT) studies play an important role in the definitive preoperative diagnosis of abdominal cocoon. Radiographs are not specific and may show evidence of small bowel obstruction. The BMFT shows reduced transit time and serpentine or concertina-like configuration of dilated small bowel loops in a fixed U-shaped cluster. The CT best shows the fibrous membrane encasing the bowel loops; thus, helps in reaching a definite diagnosis. Recent reports have emphasized the role of MDCT with saggital and coronal reconstructions in demonstrating the extent of disease for surgical planning and in showing subtle radiological findings.6,7

Spontaneous massive hemoperitoneum: A potentially life threatening presentation of the wandering spleen

Context:Wandering spleen is an unusual condition characterized by the absence or maldevelopment of one or all of the ligaments securing the spleen in its normal position in the left upper abdomen. Pedicular tortion with a complete vascular disruption is a rare but known potential complication of this mostly congenital disorder. Spontaneous hemoperitoneum with acute abdomen however, is a life threatening situation that has not been adequately reported in the adult literature.Case Report:A forty four year old man presented to the emergency department with an acutely distended and rigid abdomen. His past medical history was only significant for mild mental retardation. The patient denies prior abdominal operation or recent trauma. On initial examination, he appeared to be anxious, pale, and tachycardic. Fullness in the midpelvic region was easily appreciated on palpation. An enlarged pelvic spleen and free intraperitoneal fluid consistent with blood were seen on a CT scan. The patient was promptly taken for an exploratory laparotomy where a large rush of blood was encountered upon entering the abdomen. A volvulus of the splenic pedicle with an infarcted spleen was found mandating a splenectomy.Conclusions:Abnormally located spleen, splenomegaly, and finding of hemoperitoneum are highly suggestive of wandering spleen with tortioned pedicle. Despite its life threatening presentation, immediate laparotomy and splenectomy invariably result in good outcome.

Stump appendicitis after laparoscopic appendectomy: case report

Stump appendicitis is a rare delayed complication of appendectomy. The delay in diagnosis is usually because of a prior history of appendectomy. We report a case of stump appendicitis diagnosed pre-operatively with a computerized tomography (CT) scan after laparoscopic appendectomy. An 18-year-old male presented with a one-week history of lower abdominal pain, nausea and vomiting. He had a history of laparoscopic appendectomy for acute appendicitis. Physical examination revealed tenderness and guarding in the lower abdomen. CT scan showed free pelvic fluid with a tubular structure of about 2.5 cm in length and 0.78 cm in diameter located posterior to the ileo-cecal junction. Laparoscopic exploration confirmed the findings. A residual appendiceal stump was found and dissected from the adhesion and removed. Histopathology showed a residual appendix with transmural neutrophilic infiltration associated with multifocal hemorrhagic necrosis. The postoperative period was uneventful. The diagnosis of stump appendicitis can be challenging. CT scan has proven to be a useful tool for the diagnosis of this rare condition.

Endoscopic ultrasonography‐guided ablation therapy

Endoscopic ultrasonography (EUS) imaging has undergone extensive technological advancement since its development in the 1980s, including improvement of echoendoscopes with larger channels and accessories.These advancements enable not only tissue procurement for diagnosis but also therapeutic interventions that hitherto would have required surgery, with its attendant risks. A wide array of interventional procedures are performed under EUS guidance, including celiac plexus neurolysis, drainage of pancreatic and pelvic fluid collections, drainage of obstructive pancreatic-biliary ducts, ablation of cyst neoplasms in the pancreas, and implantation of fiducial markers and radioactive seeds into gastrointestinal tumors. Various experimental procedures are also underway to evaluate the role of EUS in radiofrequency ablation, vascular therapy, and natural orifice transluminal endoscopic surgery. In this review, we examine the various EUS-guided ablation therapies currently undertaken in humans.

Sclerosing Peritonitis After Kidney Transplantation: A Not-So-Silky Cocoon

A 55-year-old woman with end-stage renal disease secondary to systemic lupus erythematosus had undergone two renal transplants over a 15-year period. Of note, her renal replacement between the two transplants was via peritoneal dialysis for a 5-year period while she awaited a deceased donor kidney. Her past medical history was also significant for hypertension, hyperlipidemia, anemia, and depression. Following her second successful kidney transplant, she had persistent nausea and vomiting, which she considered similar to her preoperative state and not disruptive to her daily activities. She was admitted to a community hospital several months following the transplant complaining of worsening vomiting over 3 weeks. She also experienced early satiety, belching, epigastric fullness, crampy abdominal pain and daily watery stools, and she had lost 30 lb over the preceding months. At the time of admission, her creatinine was elevated at 2.2 mg/dl, but corrected to 1.3 mg/dl with hydration. A computed tomography (CT) scan demonstrated edema of the bowel wall and a pelvic fluid collection. Upper endoscopy revealed mild duodenitis, gastritis, and an atonic and dilated stomach. She was transferred to Stanford University Medical Center with the preliminary diagnosis of gastroparesis. On our exam, she had a firm, mildly distended, but nontender abdomen. Total parenteral nutrition (TPN) was initiated. A gastric emptying study was attempted, but could not be completed due to vomiting. Repeat CT scan showed a large fluid collection in the abdomen and pelvis with a thick enhancing wall (Figs. 1, 2). There was also dilation of the duodenum and stomach with an abrupt transition at the proximal jejunum consistent with mechanical obstruction due to sclerosing peritonitis (Fig. 3). The interventional radiology team placed a drain in the abdomen and 1 l of sterile serosanguineous fluid was extracted. A nasogastric tube was placed for bowel decompression. Repeat endoscopy did not demonstrate any obstruction at the proximal jejunum, but did reveal reflux esophagitis. An upper GI series with small bowel followthrough then revealed high-grade obstruction at the level of the proximal jejunum (Fig. 4). Given the high-grade obstruction and her failure to improve with nonoperative management, she underwent exploratory laparotomy. At surgery, she was found to have thickened peritoneum encasing all of her small bowel. The entire small bowel contents were compressed into a tight ball or ‘‘abdominal cocoon.’’ She also had complete interloop adhesions. One loop of very proximal jejunum in the left upper quadrant appeared particularly kinked, near the site of obstruction that had been observed on the upper GI series. Extensive lysis of adhesions was performed during a 5-h operation. She did not undergo any bowel resection, but from the lysis of adhesions alone, it appeared that 25% of the small intestine had been deserosalized because it was not possible to effectively peal loops of bowel from one another. All of the serosa on the outer surface of the cocoon E. H. Morrow (&) Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA e-mail: emorrow@stanford.edu

Hydrosalpinx in a patient with complex genitourinary malformation

We describe an adolescent female patient born with a complex genitourinary malformation including bilateral duplex system and duplication of the müllerian structures (bicornuate uterus and septate vagina). She presented with a symptomatic hydrosalpinx. The typical imaging of this condition is described along with the issues associated with the differential diagnosis in this complex scenario. The diagnosis of hydrosaplinx should be suspected in patients with complex genitourinary malformations and a pelvic fluid collection. Associated genital and renal anomalies are noted in 30% of cases.

Spontaneous rupture of broad ligament and uterine vessels during pregnancy

Dear Sir, We recently observed spontaneous rupture of uterine vessels and the ipsilateral broad ligament in a pregnant woman and wish to call attention to this. Hemoperitoneum resulting from rupture of the uterine artery is a rare complication of pregnancy (1). Approximately 100 cases have been reported in literature, 60% directly related to labor. The associated maternal and perinatal mortality is as high as 40 and 30%, respectively. In 75% of the reported cases, the broad ligament was the site of rupture (2). Hemorrhage occurred from 10 weeks of gestation to as late as 21 days postpartum (3). The usual clinical presentation is acute severe lower abdominal pain, followed by signs of hypovolemic shock. Shortness of breath or shoulder pain may be accompanying symptoms (3). A pelvic ultrasound can be helpful in detecting free intraperitoneal fluid (4). A 33-year-old Surinamese (hindu) woman was admitted to our delivery ward at 36 weeks gestation. Relevant medical history included three elective abortions, an Arnold-Chiari malformation type II, gestational diabetes and thrombocytopenia (110/nl). During pregnancy, she had been admitted thrice due to abdominal pain. Extensive physical examination and repeated abdominal ultrasounds revealed no evident cause of pain. She was discharged pain-free each time. Upon admission to the delivery ward, she complained of severe acute abdominal pain which had started 1 hour previously. There was no vaginal bleeding, uterine contractions, abdominal trauma, recent intercourse nor drug abuse and the membranes were intact. On examination the right lower abdominal quadrant was extremely tender and the uterus tense. Her blood pressure was 157/91 mmHg and pulse 65 beats/min. Laboratory results showed a hemoglobin of 7.4 mmol/l, and thrombocyte count of 85/nl. Fetal heart rate tracings were optimal. Although abruption of the placenta was among our differential diagnoses, we wanted to exclude perforated appendicitis or intra-abdominal bleeding. Transabdominal ultrasound-guided aspiration of evident pelvic fluid collection revealed bright red blood. Under general anesthesia, a midline incision was made and a hemoperitoneum was found. The uterus was unruptured, a cesarean section done and a healthy son was born. There were no signs of placental abruption. Further exploration revealed a ruptured left uterine artery and a tear in the left broad ligament extending from under the insertion of the utero-ovarian vessels to the cervix (Figure 1). A small, old hematoma was seen on the utero-cervical transition. Adequate hemostasis was achieved by suturing, oxytocin and consecutive sulprostone infusion. Intraoperative blood loss was estimated at around 2,500 ml. After a 1-day admission to the intensive care and 5 days to the ward she was discharged home. Posterior view of the left broad ligament rupture, reaching from under the ovarian ligament to the uterine isthmus. Broad ligament injury in pregnant women is reported to occur following delivery or after non-obstetric pelvic trauma. However, to our knowledge there is only one published case of spontaneous injury in a woman not in labor and without preceding trauma (5). Arteriousvenous malformation, increased venous pressure, free anastomosis of the utero-ovarian vessels in the broad ligament, absence of valves of the ovarian veins and weakness of vessel walls may be factors responsible for spontaneous rupture of the uterine vessels during pregnancy (4). In the present case, we found no apparent cause for the rupture of the uterine vessels and broad ligament. However, the recurring abdominal pain that she experienced throughout pregnancy may be explained by the hematoma that we saw on the utero-cervical transition. Although only speculative, intra-abdominal adhesions could have contributed to pain through traction on parametrial structures and consecutive rupture.

Frequency and Importance of Small Amount of Isolated Pelvic Free Fluid Detected with Multidetector CT in Male Patients with Blunt Trauma

To retrospectively determine the frequency and importance of a small amount of isolated pelvic free fluid seen at multidetector computed tomography (CT) in male patients who have blunt trauma without an identifiable cause. Institutional review board approval was obtained, and the requirement for informed consent was waived for this HIPAA-compliant study. One thousand male patients with blunt trauma who underwent abdominopelvic CT at a level 1 trauma center between January 2004 and June 2006 were entered into this study. The CT images of the 1000 patients were reviewed independently by two abdominal radiologists. CT scan assessment included evaluation for presence or absence of pelvic free fluid, any traumatic or nontraumatic cause of the free fluid, pelvic free fluid attenuation and volume measurements, and determination of the location of pelvic free fluid. Interobserver agreement was determined with kappa statistics, and the Student t test was used to assess differences in the mean volume and mean attenuation of the pelvic free fluid in the patients with and those without injury. Pelvic free fluid was identified in 10.2% (102 of 1000) of patients. A small amount of isolated pelvic free fluid without any identifiable cause was identified in 4.8% (48 of 1000) of patients by reader 1 and in 5.0% (50 of 1000) of patients by reader 2 (kappa value, 0.76) and was located at or below the level of the third sacral vertebral body in all 49 patients with isolated pelvic free fluid. The mean volume and mean attenuation of the small amount of isolated pelvic free fluid were 2.3 mL +/- 1.5 (standard deviation) and 8.1 HU +/- 3.9, respectively. None of the patients in this group had an undiagnosed bowel and/or mesenteric injury. In male patients with blunt trauma, a small amount of isolated pelvic free fluid with attenuation equal to that of simple fluid and located in the deep region of the pelvis likely is not a sign of bowel and/or mesenteric injury.

Unilateral Non-communicating Cervical Atresia in a Patient with Uterus Didelphys and Unilateral Renal Agenesis

A 16-year-old adolescent girl presented with chronic pelvic pain. Pelvic ultrasound and MRI showing a uterus didelphys, normal left uterus and cervix, right pelvic fluid collection and right unilateral renal agenesis. After two unsuccessful vaginal surgeries for drainage of hematotrachelos and creation of an outflow tract, patient underwent unilateral total abdominal hysterectomy with final pathology confirming hematotrachelos and non-communicating cervical atresia on the right. Patient on postoperative follow-up doing well.

Successful pelvic abscess drainage by cecal biopsies in Crohn's disease

A 12-year-old child was admitted with a 6-month history of diarrhea, hematochezia, and weight loss. On physical examination, there was diffuse abdominal voluntary guarding without rebound tenderness. Laboratory test analysis revealed slight anemia (hemoglobin 10.2 g/dL, normal 12-16 g/dL), leukocytosis (23,000/mm3, normal 4,500-11,000 mm3) with a left shift, and elevated C-reactive protein level (80 mg/dL, normal <5 g/L). Contrast-enhanced CT disclosed a thickened loop of terminal ileum and multiple pelvic fluid collections surrounding the ileocecal region (A).

Endoscopic Management of a Spontaneous Gallbladder Perforation and Bile Leak

A 53-year-old man with a past medical history of alcoholic liver disease complicated by esophageal varices, ascites, hepatic hydrothorax, and hepatic encephalopathy presented to a local community hospital with 10-day history of abdominal pain. His pain was 10/10 in intensity, constant, worse in the supine position, increasing on the dependant side of the abdomen (when lying on the left side, the pain worse on left and vice versa), and improved in the upright position. The pain was not worsened by food and was not associated with fevers, chills, nausea or chest pain. He also reported shortness of breath and diarrhea, but denied rectal bleeding. When he was admitted to the local hospital, his white blood cell (WBC) count was 15,000/mm, predominantly bands and neutrophils. Because of concern for spontaneous bacterial peritonitis, empiric antibiotics were started and a nasogastric tube was placed. An abdominal ultrasound revealed a cirrhotic liver and a contracted gallbladder with mild gallbladder wall thickening. There was insufficient ascites to perform a diagnostic paracentesis. An abdominal radiograph series was negative for free air. Over the next 24 h, his pain continued to worsen and there was intermittent abdominal distention. A computed tomography (CT) of the abdomen and pelvis revealed a nodular liver capsule consistent with cirrhosis and large volume ascites (Fig. 1a). The gallbladder was contracted around dependent radio-opaque calculi (arrow, Fig. 1a). Two radio-opaque calcified structures in pelvis (arrow, Fig. 1b) consistent with gallstones with associated free fluid in pelvis were also seen. He was transferred to our institution. The patient’s past medical history was significant for alcoholic cirrhosis, and he had been on the liver transplant list. He also had a history of an incarcerated umbilical hernia that was repaired in 2008, as well as cholelithiasis. Upon transfer he was receiving piperacillin and tazobactam, vancomycin, ondansetron, pantoprazole, lactulose and hydromorphone as needed. He had no known drug allergies. He was single and did not smoke tobacco. The patient had discontinued alcohol use in 2008, and had no history of illicit drug use. Family history was negative. On physical examination, his vital signs were stable. The patient appeared to be in no acute distress with icteric conjunctiva and a nasogastric tube in place. There were decreased breath sounds bilaterally with a diffusely distended abdomen with tenderness to palpation in all quadrants. There was shifting dullness and a fluid wave consistent with ascites, but no guarding or rebound. The patient had scrotal and lower extremity edema but no asterixis. The patient had a WBC count of 10,300/mm, hematocrit 27.2%, mean corpuscular volume 84.7, platelet count 86,000/ mm, sodium 136 mmol/L, carbon dioxide 19 mmol/L, blood urea nitrogen 42 mg/dL, creatinine 1.5 mg/dL, albumin 3.1 g/dL, total bilirubin 8.3 mg/dL, alkaline phosphatase 130 U/L, aspartate aminotransferase 37 U/L, alanine aminotransferase 29 U/L, and international normalized ratio for C. Munroe (&) G. Triadafilopoulos J. Van Dam G. Lutchman Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford University Medical Center, 300 Pasteur Drive, Always Building, Rm M211, Stanford, CA 94305-5187, USA e-mail: camunroe@stanford.edu

Computed Tomography Appearance of Ovarian Cysts With Hyperenhancing Rim During the Menstrual Cycle in Women of Different Ages

To determine the frequency and computed tomography (CT) characteristics of ovarian cysts in women of different ages. Five hundred ninety-five contrast-enhanced CT studies performed in 430 females aged 10 or older between January 2001 and December 2006 were retrospectively reviewed. For each study, we recorded the presence of ovarian cysts larger than 5 mm in diameter, with or without a hyperenhancing rim (HR, NR). The frequencies and CT characteristics of HR and NR cysts were analyzed according to phase of the menstrual cycle and patient age. Independent-sample t test, analysis of variance, chi test, and Fisher exact test were used to compare continuous data and categorical data between groups. Ovarian cysts were more frequently seen on CT studies of women between the ages of 20 and 49 years than on those of women older than 50 years (P = 0.004). Cysts with no HR were seen in every age group; HR cysts were present only in patients younger than 50 years. Cysts with HR were seen more frequently during periovulatory and secretory phase than during menses and proliferative phase (P = 0.003). Cysts with HR had a mean volume of 1.8 cm; NR cysts had a mean volume of 5.3 cm (P = 0.004). Cysts with HR had a thicker wall (3.4 mm vs imperceptible) and a higher attenuation value (31.4 vs 14.8 Hounsfield units) and were more commonly associated with pelvic fluid (P = 0.005) than were NR cysts. Cysts with HR, previously proven to represent corpus luteal cysts, can be readily seen on contrast-enhanced CT studies in women of reproductive age. Familiarity of the varied CT appearance of these cysts is essential, lest they be misinterpreted as pathological entities.