Free Intraperitoneal Fluid Research Articles

Ultrasound in the evaluation of necrotic bowel in children: A pictorial essay

Necrotic bowel is a serious condition involving death of gastrointestinal tissue. The diagnosis is difficult to make clinically, and plain radiography is often inconclusive. Ultrasonography is an inexpensive, portable and readily available complementary diagnostic tool. In some cases, ultrasonography can detect features of necrotic bowel earlier than plain radiography or when plain radiography is equivocal and does not correlate with the clinical findings. This pictorial essay aims to compare the ultrasonography features of normal bowel and necrotic bowel in children. The role of ultrasonography and the ultrasonographic features of necrotic bowel will be illustrated by discussing some of the causes of necrotic bowel in children. Correlation with plain radiographs and pathological specimens is made. Frequent causes of necrotic bowel in neonates include necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias. Causes in older children include intussusception, complications of Meckel's diverticulum, post-surgical adhesions, internal hernias and vasculitic abnormalities. Ultrasonography features suggestive of necrotic bowel include persistently dilated loops of aperistaltic bowel, increase or decrease of bowel wall thickness, intramural or portal venous gas, loss of bowel wall perfusion, and free intraperitoneal gas and fluid. The diagnosis of necrotic bowel may be made earlier on ultrasonography than on abdominal radiographs alone. This pictorial essay will familiarise the reader with the role of ultrasonography and the ultrasonographic features of necrotic bowel through a wide range of conditions that may cause necrotic bowel in children. Familiarity with these findings will facilitate timely imaging diagnosis of necrotic bowel before complications develop.

Non-operative management of perforated diverticulitis with extraluminal or free air – a retrospective single center cohort study

Objectives: The aim of this study was to describe patient characteristics and results of non-operative management for patients presenting with computed tomography (CT) verified perforated diverticulitis with extraluminal or free air.Methods: All patients treated for diverticulitis (ICD-10: K-57) during 2010–2014 were identified and medical records were reviewed. Re-evaluations of CT examinations for all patients with complicated disease according to medical records were performed. All patients diagnosed with perforated diverticulitis and extraluminal or free air on re-evaluation were included and characteristics of patients having immediate surgery and those whom non-operative management was attempted are described.Results: Of 141 patients with perforated diverticulitis according to medical records, 136 were confirmed on CT re-evaluation. Emergency surgical intervention within 24 h of admission was performed in 29 (21%) patients. Non-operative management with iv antibiotics was attempted for 107 patients and was successful in 101 (94%). The 30-day mortality rate was 2%. The presence of a simultaneous abscess was higher for patients with failure of non-operative management compared with those that were successfully managed non-operatively (67% compared to 17%, p = .013). Eleven out of thirty-two patients (34%) with free air were successfully managed conservatively. Patients that were operated within 24 h from admission were more commonly on immunosuppressive therapy, had more commonly free intraperitoneal air and free fluid in the peritoneal cavity.Conclusions: Non-operative management is successful in the majority of patients with CT-verified perforated diverticulitis with extraluminal air, and also in one-third of those with free air in the peritoneal cavity.

PS01.077: GASTRIC NECROSIS WITH PERFORATION AS LATE COMPLICATION OF NISSEN FUNDUPLICATION

Abstract Background Gastric necrosis and perforation after Nissen funduplication is a rare and life-treatening complication. Prompt diagnosis of acute gastric dilatation is mandatory to avoid gastric necrosis. A tight funduplication can cause a gastric dilatation because of the inability to vomit. Other causes of gastric dlatation include trauma, volvulus, anorexia and bulimia diabetes, polyphagia, acute infections and others. Methods A 56-year-old man was admited to emergency room with acute-onset epigastric pain and persistent nausea for the past 4 hours. Nine years ago he underwent a laparosocpic Nissen-Rossetti funduplication for a reflux disease.The examination showed abdominal distension and defense. Computed tomography of the abdomen (TAC) show a important pneumoperitoneum distributed diffusely throughout the abdomen, marked gastric distension with abundant content inside. Free intraperitoneal fluid and postsurgical changes in relation to Nissen fundoplication. An emergentcy laparotomy was indicated. Results Emergency laparotomy showed free peritoneal fluid with gastric dilatation and two areas of necrosis and perforation (localized in fundus and gastric body). We performed a total gastrectomy with esophagojejunal anastomosis. The patient sufferd a pulmonary embolism 8 days after laparotomy Pathological examination reported gastric dilatation and two areas of ischemia and trasnmural necrosis with perforation and peritonitis. Conclusion If the intragastric pressure excede gastric venous pressure can result in ischaemia and infarctation.Increased intragastric pressure is usually the result of a closed loop, secondary to mechanical compresion of the cardio-esophageaal and pyloroduodenal junctions, as can occur in patients with a Nissen procedure. CONCLUSION: Early diagnosis of gastric dilatation in these patients is mandatory to avoid major complications. Disclosure All authors have declared no conflicts of interest.

Comparative Study of Ultrasonography and Computed Tomography in the Evaluation of Blunt Abdominal Trauma at CMS-TH

Introduction: This study was conducted to compare the role of USG and CT as noninvasive imaging techniques for assessing the patient with blunt abdominal trauma.
 Methods: A prospective longitudinal study was performed at the College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan in the department of Radiodiagnosis, from January 2011 through July 2013. Where 150 patients following abdominal injuries were recorded, including patient age group, sex and mode of injury. Patient underwent USG and CT evaluation. The role of USG and CT was compared in the diagnosis of blunt abdominal trauma.
 Results: In our study, 80% of patient with blunt abdominal injury were male with the M:F ratio of 4:1. Road traffic accident was the most common cause of blunt abdominal trauma (72%). There were 95 (92.22%) patients positive for free fluid by USG and CT where 15 had no organ injury. CT revealed organ injuries in 88 (85.43%) patients whereas USG detected 72 (69.90%) organ injuries. Spleen 42 (47.72%) was the most common organ to be injured followed by liver29 (32.95%), kidney 7 (7.9%) and pancreas 3 (3.4%). 16 (18.18%) patients out of 88 positive for organ injuries were not associated with free fluid. Overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of USG for organ injury were 81.81%, 100%, 100%, 79.48% and 89.3% respectively.
 Conclusions: USG and CT are useful noninvasive tools in detecting free intraperitoneal fluid and organ injuries in patients with blunt abdominal trauma. CT is superior to detect organ injuries in patients with blunt abdominal trauma.

Intestinal Angioedema: Case Report and Literature Review

Hereditary angioedema (HAE) is the deficiency or dysfunction of C1 esterase inhibitor (C1-INH). However, it may also occur due to either increased activity of factor XII / estrogen levels or through an unidentified cause. It manifests the attacks of swelling involving the skin and / or the mucosa / sub mucosa of different organs. The attacks may be the result of a specific trigger or occur spontaneously. The intestinal angioedema is clinically presented with moderate or severe abdominal pain, associated with nausea, vomiting, diarrhea and / or ascites, and interpreted as an “acute abdomen”. The treatment is into three distinct phases: treatment for acute attacks, short-term prevention, and long-term prophylaxis. The 26-year-old woman with food and medication allergy presents with thirteen-year history of recurrent abdominal pain diffuse and associated with diarrhea, nausea and hands, lips and eyelids swelling. During this period, she did several exams and six laparoscopies that only revealed a small amount of free intraperitoneal fluid. Biochemical testing performed at that time revealed the C1 esterase inhibitor, decreased protein level, and C4 level, and she was, then, diagnosed in adults with intestinal involvement with HAE. After the adequate treatment and prophylaxis, she evolved with reduction of the number of attacks. The late diagnosis is associated with high morbidity. Therefore, it is extremely important the recognition and investigation of HAE with involvement in intestinal patients with recurrent attacks of unexplained abdominal pain.

İnce bağırsak obstrüksiyonlu hastaların tanısında bilgisayarlı tomografi bulgularının rolü

Aim: The goal of this prospective study is to evaluate the prognostic impact of computed tomography (CT) signs in the analysis of small bowel obstruction (SBO). Patients and Method: Sixty consecutive patients with acute abdominal pain who were examined using abdominal CT to diagnose SBO were included in the study. 47 patients of them (26 male; 21 female and mean age, 60 years), were evaluated. CT evaluation parameters were mesenteric congestion, transition zone, feces sign, intramural air and intraperitoneal free fluid. Results: There was a statistically significant association between the SBO diagnosis and CT findings for mesenteric congestion, transition zone and intramural air (p<0.05 for all). These CT signs had greatest sensitivity and positive predictive value (PPV) in diagnosis of SBO. The combination of mesenteric congestion, transition zone and in-tramural air showed a significant association in the diagnosis of SBO (p<0.05). Small bowel feces sign and intraperitoneal free fluid findings had no statistically significant value in the diagnosis of SBO (p>0.05). When three or more CT findings were seen together, there was a statistically significant association in the diagnosis (p<0.05). Conclusion: Mesenteric congestion and transition zone had the highest sensitivity and PPV in diagnosing SBO. The combination of mesenteric congestion, transition zone and intramural air and the presence of three or more CT signs markedly increase the specificity in diagnosis of SBO.

Diagnostic accuracy of Focused Assessment with Sonography for Trauma for blunt abdominal trauma in the Eastern Region of Saudi Arabia.

Objectives:To determine the diagnostic accuracy of Focused Assessment with Sonography for Trauma (FAST) in blunt abdominal trauma caused by motor vehicle accidents at our Hospital in Dhahran city.Methods:This descriptive, observational study was conducted in the Radiology Department at King Fahad Military Medical Complex Dhahran, Saudi Arabia between September 2016 and September 2017. All adult patients (n=105) involved in motor vehicle accidents with blunt abdominal injury on presentation were retrospectively reviewed for FAST and CT scans for detection of free fluid. Focused assessment with sonography for trauma studies were conducted or supervised by senior registrar of general surgery (trauma team leader). Computed tomography findings were reviewed by 2 experienced radiologists. High and low-grade solid abdominal visceral (liver, spleen, kidney) injuries were identified on CT scans. Focused assessment with sonography for trauma and CT scan findings were identified as ‘positive’ and ‘negative’ for presence and absence of free fluid respectively. Outcomes of FAST were presented on a 2x2 contingency table.Results:Sensitivity of FAST in detecting intraperitoneal free fluid was calculated as 76.1% (95% confidence interval [CI], 64.14-85.69%), specificity 84.2% (95% CI, 68.75-93.98%) and accuracy 79% (95% CI, 70.01-86.38%). Focused assessment with sonography for trauma detected free fluid in most cases of high-grade solid visceral injuries. Nearly half of true-negative cases were having low grade visceral or other injuries.Conclusion:Focused assessment with sonography for trauma is an important tool in initial assessment of suspected blunt abdominal injury patients with high sensitivity and specificity. A negative FAST does not exclude low grade solid visceral or other injuries.

Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents.

Introduction:Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT). Objective:We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.Method:In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation. Results:A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST. Conclusion:In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.

Interobserver Agreement on Focused Assessment with Sonography for Trauma in Blunt Abdominal Injury.

IntroductionTrauma constitutes a major public health problem. Ninty percent of world's fatalities on road occur in low and middle-income countries. Focused assessment with sonography in trauma (FAST) has a key role in trauma investigation, altering subsequent management in a significant number of patients. There is a rising trend of introducing FAST examination to non-radiologists and junior members of healthcare team to hasten triage of trauma patients.ObjectiveTo determine interobserver agreement on focused assessment with sonography for trauma in blunt abdominal injury between senior and junior residents.MethodsThis cross-sectional study was conducted at Aga Khan University Hospital. Three hundred patients with blunt abdominal trauma meeting inclusion criteria were enrolled. FAST was performed using standard curvilinear 3.5-5 MHz transducer. Agreement between junior and senior residents was measured and Kappa statistic was calculated.ResultsMean age of the patients included in the study was 30.04 ± 18.09 years. Among these 237 (79%) were male and 63 (21%) were female. Sixteen (5.3%) were positive for intraperitoneal free fluid while the remaining 284 (94.7%) were negative. A total of 19 FAST examinations were reported positive by junior residents, of which 15 (78.9%) were confirmed by a senior resident to be correct, while four (21.05%) were falsely labeled positive by a junior resident. A total of 281 negative FAST examinations were reported by junior residents, of which 280 (99.6%) were confirmed by a senior resident, while only one (0.003%) was falsely labeled negative. Kappa statistic was calculated for inter-observer agreement on FAST examination findings, which showed a kappa value of 0.84 (very good agreement), with a p-value of <0.001.ConclusionOur study suggests very good interobserver agreement on FAST examination between senior and junior resident in patients with blunt trauma to the abdomen. Results suggest that FAST can be easily learnt with minimal radiology training and may have greater applicability in trauma.

Predictive Factors for Intestinal Transmural Necrosis in Patients with Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is a serious and potentially fatal condition. No definite parameter can predict transmural bowel necrosis in patients with AMI to justify early surgical intervention. The current study aimed to identify the clinical, laboratory, and radiologic parameters that can successfully predict the onset of intestinal transmural necrosis in patients with AMI. Records of patients with AMI in the period of January 2013 to October 2017 were reviewed. Clinical parameters as patients' symptoms, vital signs, and signs of peritonitis along with the results of laboratory and radiologic investigations were analyzed to identify predictive factors for intestinal transmural necrosis using binary logistic regression analysis. One hundred and one patients (70 males) with mean age of 55years were included. Venous occlusion was the cause of AMI in 78 (77.3%) patients and arterial occlusion in 23 (22.7%) patients. Twenty-two patients completed conservative treatment successfully, whereas 79 patients required exploratory laparotomy. On laparotomy, six patients were found to have viable bowel. Overall, 28 patients had viable bowel and 73 had bowel necrosis. The significant independent predictors for transmural bowel necrosis were mesenteric arterial occlusion (OR: 26.5, p=0.02), leukocytosis (OR: 1.3, p<0.0001), acidosis (OR: 3.8, p=0.04), free intraperitoneal fluid (OR: 4.21, p=0.005), and combined portal vein and SMV thrombosis in CT scan (OR: 3.4, p=0.026). The independent predictors for transmural bowel necrosis were mesenteric arterial occlusion, leukocytosis, acidosis, free intraperitoneal fluid, and combined portal vein and SMV thrombosis in CT scan.

Impact of CT imaging on predicting the surgical management of acute diverticulitis.

PurposeThe incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment.MethodsThree hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index.ResultsAfter propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively).ConclusionThis study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Small Bowel Injury after Penetrating Abdominal Trauma despite normal Pre-operative Computerised Tomography. A Case Report of a Successful Laparoscopic Repair

Background: The surgical management of a patient with a penetrating injury can be challenging. We present a case of a patient with a small bowel injury after penetrating abdominal trauma and its successful management despite normal Computerised Tomography (CT).Case and methods: A 39-year-old female, suffering from an anterior abdominal stab wound (AASW), was transferred to Accident and Emergency Department (A&E) after attempting to suicide with a knife. During transfer and on arrival at A&E patient was haemodynamically stable. Primary survey (ABCDE) revealed no concerning findings and abdominal examination revealed a 3cm horizontal wound 4cm above umbilicus. Abdomen was soft, mildly tender. Resuscitation and basic investigations were performed according to ATLS principles. Decision was to proceed with CT scan of the abdomen and pelvis (CTAP). After CTAP, patient became hypotensive and was resuscitated with 1 unit of RBCs and tranexamic acid. CTAP showed no intraperitoneal injury with no free intraperitoneal gas or fluid. Patient was reviewed by surgeons and decision was to proceed with Diagnostic Laparoscopy.Results: Laparoscopy revealed peritoneal penetration, abdominal muscle haematoma with haemorrhagic fluid in pelvis and sero-muscular tear of the proximal ileum. Sero-muscular tear was repaired laparoscopically with an uneventful post-operative period.Conclusion: Detailed clinical examination and experienced surgeon with advanced laparoscopic skills can result to a successful management of stable patients with anterior abdominal stab wounds, faster recovery and avoidance of unnecessary CT scans and laparotomies.

Intraperitoneal Urinary Bladder Perforation with Pneumoperitoneum in Association with Indwelling Foley Catheter Diagnosed in Emergency Department

BackgroundIndwelling Foley catheter is a rare cause of urinary bladder perforation, a serious injury with high mortality that demands accurate and prompt diagnosis. While the gold standard for diagnosis of bladder injury is computed tomography (CT) cystography, few bladder ruptures associated with Foley catheter have been reported to be diagnosed in the emergency department (ED). Case ReportAn 83-year-old man with indwelling Foley catheter presented to the ED for hematuria and altered mental status. He was diagnosed to have intraperitoneal rupture of the urinary bladder in the ED using abdominal and pelvic CT without contrast, which demonstrated bladder wall discontinuity, intraperitoneal free fluid, and pneumoperitoneum. The patient was treated successfully with medical management and bladder drainage. Why Should an Emergency Physician Be Aware of This?To our knowledge, this is the first report of intraperitoneal urinary bladder perforation associated with Foley catheter diagnosed in the ED by CT without contrast. Pneumoperitoneum found in this case was a clue to the diagnosis and is a benign finding that does not necessitate urgent surgical intervention. The early and accurate diagnosis in this case allowed for effective management with good clinical outcome. The use of indwelling Foley catheter has a high prevalence, especially in long-term care facility residents, who are frequent visitors in the ED. Therefore, emergency physicians and radiologists should be familiar with the presentation and imaging findings of this potential injury associated with Foley catheters.

Primary segmental omental infarction as a rare cause of acute abdominal pain in childhood

Abstract Introduction Primary omental infarction (POI) has a low incidence worldwide, with most cases occurring in adults. This condition is rarely considered in the differential diagnosis of acute abdominal pain in childhood. Material and methods We present 2 cases of omental infarction in an obese 8-year-old boy and a 5-year-old boy who presented with acute abdominal pain in the right abdomen. Both patients were initially treated with intravenous fluids and analgesics with no improvement. Abdominal ultrasound of the first patient showed free intraperitoneal fluid, meteorism and distended bowel loops. The appendix was not visualized. With a presumptive clinical diagnosis of appendicitis the child underwent laparotomy. On entering the peritoneal cavity an omental infarction was seen and a portion of the omentum was resected. Appendectomy was performed. The second patient presented with acute abdominal pain in the right upper quadrant, which started 2 days before. There was a history of possible abdominal trauma about 3 weeks earlier. The patient had repeated ultrasound examinations and a CT scan of the abdomen which showed a omental infarction. He underwent laparoscopy and resection of the omental infarction, as well as incidental appendectomy. Results The postoperative period was uneventful. The first patient was discharged on day 3, the second patient on day 4 after surgery. Histology showed a normal vermiform appendix and an omental infarction in both cases. Conclusion and discussion Since the omental infarction as etiology of acute abdominal pain is uncommon in children, we emphasize the importance of accurate diagnosis and appropriate treatment of omental infarction.

Splenic rupture following synchronised direct current cardioversion

Atraumatic rupture of the normal spleen is a rare entity. Often, a triggering factor or minor physical event can be ascribed as the aetiology for rupture, including coughing, vomiting or...

In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of nonoperative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.

Diagnostic Value of Serial Ultrasound in Blunt Abdominal Trauma

Background Ultrasound has widely been used to assess patients with blunt abdominal trauma and detect free fluid in the abdomen. Nevertheless, different studies reported different false negative for this imaging technique. Objectives The present study was conducted to evaluate the diagnostic value of the repetitive ultrasound in diagnosis of free intraperitoneal fluid. Methods In this study, 125 patients with abdominal blunt trauma were recruited prospectively for ultrasound evaluation. Ultrasound and CT- scan were performed for all recruited patients in the study. In case of positive ultrasound or CT-scan (free fluid in the peritoneal cavity), patients underwent surgical operation. In the presence of negative ultrasound and CT-scan, and if the patient was alert and had stable vital signs, then, he/she would undergo exact supervision. In such patients, ultrasound and CT-scan were repeated 12 and 24 hours after admission. If any of the tests were positive, the patient underwent laparotomy. Moreover, if ultrasound and CT-scan examinations were negative 24 hours after admission, the patients with normal laboratory tests were discharged according to the surgeon's decision. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results Of the 125 patients with abdominal blunt trauma, 90 patients finally underwent laparotomy. Based on the surgical outcome as the gold standard, the initial, 12 hours, and 24 hours sensitivity were measured to be 19.8, 75.2, and 82.2, respectively. These numbers for specificity were 91.7, 75, and 70.8, respectively; they were 90.9, 92.6, and 92.2 for PPV, and 21.3, 41.8, and 48.5 for NPV, respectively. Conclusions The sensitivity of ultrasound to detect intraperitoneal fluid in blunt abdominal trauma cases will be increased by repeated ultrasound examinations.

Transcranial ultrasound detection of intracranial hemorrhages: time-frequency analysis with empirical and variational mode decomposition

Ultrasound imaging has become a standard method for evaluating patients who have suffered blunt trauma. Specifically, focused assessment with sonography in trauma, commonly known as the “FAST exam,” is regularly employed to detect free intraperitoneal, intrathoracic, and pericardial fluid in the setting of trauma. Currently, evaluation of the intracranial space remains a significant missing component of the FAST exam because the skull bone acts as a physical barrier to ultrasound transmission for existing approaches in pulse-echo ultrasound imaging. To address this shortcoming, we have explored a grounds-up re-evaluation of the way in which ultrasound can be used in neurosonography based on the hypothesis that backscattered signal from the intracranial space can be analyzed to identify the unique signature of pooling and coagulated blood. Preliminary experiments with tissue phantoms, ex vivo animal blood, and ex vivo human calvaria have established the parameters that optimize the SNR of pulse-echo transcranial ultrasound. The need to improve the sensitivity in isolating the desired signals have led to the exploration of several time-frequency signal analysis techniques, including the recently introduced empirical and variational mode decomposition methods. Our results have established the basis of a much-needed novel intracranial assessment technique to incorporate into the FAST exam.

Peritoneal fluid localization on FAST examination in the pediatric trauma patient

ObjectiveTo determine the location of intraperitoneal free fluid on FAST exam in pediatric patients undergoing evaluation for trauma. MethodsRetrospective review of all FAST exams positive for intraperitoneal free fluid performed in patients sustaining trauma between August 2009 and February 2016 in an urban pediatric emergency department. Positive results were categorized into one of nine potential intraperitoneal locations; 4 each in the right and left upper quadrants, and the pelvis. ResultsOne hundred and three complete positive studies were reviewed. The median age of patients was 10years (IQR 7–14) with 66% being male. Ninety-five percent had fluid present in the pelvis, 35% had fluid present in the RUQ, and 16.5% had fluid present in the LUQ. Overall, the most frequent location of fluid outside of the pelvis was found at the inferior tip of the liver, present in 83.3% of patients with fluid in the RUQ and 29% of all patients with a positive FAST. ConclusionsThe majority of pediatric trauma patients with a positive FAST exam will exhibit free fluid in the pelvis. Particular attention should be directed to the inferior tip of the liver in children as this represents the most common location for fluid collection outside the pelvis.

Spontaneous splenic artery rupture in a patient with an unclassified malignant spindle cell tumor of the spleen: report of a case.

The purpose of this paper was to describe an unusual manifestation of a sarcoma of the spleen and to raise awareness for spontaneous rupture of the splenic vessels in patients with splenic tumors. A 70-year-old man was admitted to our institution, suffering from left upper quadrant abdominal pain. Upon physical examination, a large and tender abdominal mass was palpated. Abdominal computed tomography showed a heterogenous enlarged spleen with active contrast extravasation from the splenic artery, free intraperitoneal fluid, and a retroperitoneal hematoma. The patient was treated with angioembolization of the splenic artery. Because of rebleeding, splenectomy was performed. Pathology revealed the spleen to be involved with an unclassified malignant spindle cell neoplasm. We concluded that in the case of spontaneous rupture of the splenic artery, accompanied with a radiologic appearance of an enlarged spleen, the diagnosis of sarcoma should be included in the differential diagnosis.