Free Intraperitoneal Fluid Research Articles

Superb microvascular ultrasound is a promising non-invasive diagnostic tool to assess a ventriculoperitoneal shunt system function: a feasibility study

The objective of this pilot study was to assess the reliability of superb microvascular ultrasound (SMI) for the measurement of the cerebrospinal fluid (CSF) flow within VPS systems as an indirect sign for shunt dysfunction. Asymptomatic hydrocephalus patients, with a VPS system implanted between 2017 and 2021, were prospectively enrolled in the study. Using SMI, the CSF flow within the proximal and distal catheters were analysed. Before and after pumping the shunt reservoir, intraabdominal free fluid, optical nerve sheath diameter (ONSD), and papilla diameter (PD) were evaluated and correlated with the amount of valve activation. Nineteen patients were included. A flow was detectable in 100% (N = 19) patients in the proximal and in 89.5% (N = 17) in the distal catheter. The distal catheter tip was detectable in 27.7% (N = 5) patients. Free intraabdominal fluid was initially detected in 21.4% (N = 4) patients and in 57.9% (N = 11) at the end of the examination (P = 0.049). ONSD was significantly lower after pump activation (4.4 ± 0.9 mm versus 4.1 ± 0.8 mm, P = 0.049). Both peak velocity and flow volume per second were higher in proximal compared to distal catheters (32.2 ± 45.2 versus 5.6 ± 3.7 cm/sec, P = 0.015; 16.6 ± 9.5 ml/sec versus 5.1 ± 4.0 ml/sec, P = 0.001, respectively). No correlation was found between the number of pump activations and the changes in ONSD (P = 0.975) or PD (P = 0.820). SMI appears to be a very promising non-invasive diagnostic tool to assess CSF flow within the VPS systems and therefore affirm their function. Furthermore, appearance of free intraperitoneal fluid followed by repeated compression of a shunt reservoir indicates an intact functioning shunt system.

Medical Students' Competency in EFAST (Extended Focused Assessment Sonography for Trauma) Components: A Prospective Observational Study.

Ultrasound training in undergraduate medical education is developing, and its incorporation into the curriculum requires careful planning. Extended Focused Assessment Sonography for Trauma (EFAST) is commonly taught to medical students as one of the primary applications of ultrasound. Because false-negative EFAST scans can affect patients' clinical outcomes, it is essential to evaluate the individual components of this skill. We aim to determine which EFAST components students perform sub-optimally after initial training. In this prospective observational study, 90 medical students from two final-year cohorts were assessed in EFAST components after uniform training during the emergency medicine clerkship. All validated components of the standard EFAST exam were assessed, and a descriptive analysis of individual components of EFAST was performed. The hepatorenal space, splenorenal space, and pelvic space fluid investigations had the lowest completion rates. Pericardial fluid, pelvic free fluid, and right thoracic pleural fluid investigations were often incorrectly applied. Fanning was most commonly missed in hepatorenal, splenorenal, and pelvic free fluid investigations, and between 12% and 50% of EFAST components had omitted reporting. There were significant incomplete assessments for free intraperitoneal fluid, primarily due to a lack of fanning in the hepatorenal, splenorenal, and pelvic areas. Trainers can effectively enhance student performance and outcomes by targeting these challenging areas. Further research might reveal whether residents and physicians show similar trends in EFAST completion.

Spontaneous rupture of hepatic hemangioma: case report and literature review

Hepatic lesions represent a potential etiology of spontaneous hemoperitoneum. Among these, hepatic hemangiomas, characterized by congenital vascular malformations, stand out as the most likely benign liver neoplasms, frequently presenting as asymptomatic entities. However, spontaneous rupture constitutes the gravest complication associated with these lesions, underscoring the imperative of prompt diagnosis. Notably, the global mortality rate attributed to spontaneous rupture of hepatic hemangiomas remains elevated. Hence, achieving an accurate diagnosis of this condition is paramount for informing. Hepatic hemangioma stands as the prevailing benign hepatic neoplasm, with autopsy studies indicating a prevalence ranging between 3% and 20%. In a clinical scenario, a 64-year-old patient presented at Sant’Anna and S. Sebastian Hospital with severe abdominal pain, hypotension (blood pressure 70/40 mm Hg), tachycardia (heart rate 120 bpm), and abdominal muscle guarding upon physical examination. Ultrasound assessment revealed the presence of free intraperitoneal fluid. However, the ultrasound examination could not be completed due to the patient’s deteriorating hemodynamic status and manifestation of instability. Consequently, an urgent exploratory laparotomy was deemed necessary and promptly undertaken in the operating theater.

Primary splenic angiosarcoma: a rare case of embolization as a bridge to splenectomy

Primary splenic angiosarcoma is the primary malignant vascular neoplasm of the spleen. This tumor is highly aggressive and extremely rare with a nonspecific clinical presentation. Prognosis is poor and almost all patients die within one year of diagnosis. We present the case of a 69-year-old healthy woman with left-sided abdominal tenderness. An ultrasound examination of the abdomen was performed to evaluate the cause of abdominal pain and showed splenomegaly with inhomogeneous echotexture and the presence of free intraperitoneal fluid. An emergency abdominal contrast-enhanced computed tomography confirmed the splenomegaly and showed hemoperitoneum and a splenic mass with heterogeneous contrast enhancement. Due to the sudden worsening of the patient’s clinical conditions (hemoglobin level of 7 g/dl) and the unavailability of the operating room, embolization of the splenic artery was performed as a bridge to subsequent splenectomy under the suspicion of splenic rupture. Histological examination demonstrated a primary splenic angiosarcoma and the patient was referred to an oncological center. Due to the rarity of this malignancy, the optimal treatment of primary splenic angiosarcoma remains under investigation. Transcatheter splenic artery embolization is not common, but it could be useful for temporarily stabilizing the patient as a bridge to the subsequent splenectomy.

Perforated duodenal ulcer after Roux-en-Y gastric bypass: an unusual complication.

Bariatric surgery is increasingly being accepted as a viable treatment for managing the growing obesity epidemic. Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures. Perforated duodenal ulcer following RYGB is a rare condition with a low incidence. We report a case of a patient with a perforated duodenal ulcer post RYGB, and the surgical approach. A 66-year-old man with hypertension and a history of laparoscopic RYGB for class III obesity was admitted to the emergency department with severe epigastric pain radiating to the right side of his abdomen and right shoulder, associated with nausea and vomiting. Computed tomography (CT) showed intraperitoneal free fluid, a thickened wall of the duodenum and free air, duodenal perforation was suspected. The patient underwent exploratory laparoscopy that revealed a perforated duodenal ulcer that was closed with an absorbable barbed suture and omental patch. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis, and clinicians should be aware of and have a low threshold for diagnostic laparoscopy. Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures in bariatric surgery. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis. The pathophysiology of this perforation is not clear, but several mechanisms have been proposed. Helicobacter pylori has been implicated. Clinicians should be aware and have a low threshold for diagnostic laparoscopy for a patient who has acute abdominal pain after RYGB, despite negative diagnostic measures.

Focused abdominal ultrasound

A focused point-of-care abdominal ultrasound is an examination performed at the patient's location and interpreted within the clinical context. This review gives an overview of this examination modality. The objective is to rapidly address predefined dichotomised questions about the presence of an abdominal aortic aneurysm, gallstones, cholecystitis, hydronephrosis, urinary retention, free intraperitoneal fluid, and small bowel obstruction. FAUS is a valuable tool for emergency physicians to promptly confirm various conditions upon the patients' arrival, thus reducing the time to diagnosis and in some cases eliminating the need for other imaging.

Spontaneous Rupture of the Urinary Bladder: A Case Report

Spontaneous rupture of the bladder (SRUB) is a rare occurrence globally (<1%). The most common cause of bladder rupture is trauma (96%). We present a case of a 34-year-old man with a history of heavy alcohol consumption and significant smoking history. He presented with diffuse abdominal pain and urinary retention. On blood tests, he was found to have increased creatinine. A urinary catheter was inserted and there was improvement in his kidney function. However, on removal of the catheter, his creatinine function would elevate. This occurred two times before further investigations were performed. CT cystography was performed and there was a significant amount of free intraperitoneal fluid found in the pelvis. After retrograde filling of the bladder with contrast material, a tear in the dome of the bladder was discovered. The patient underwent a surgical repair of the tear and there were no complications during surgery. In summation, spontaneous urinary bladder rupture is a rare emergency which can cause acute abdomen, oliguria, peritoneal effusion and abnormal renal function. In patients with heavy alcohol consumption and especially without an associated trauma history, physicians should consider SRUB. CT scan can help in diagnosis. Diagnostic laparoscopy or explorative laparotomy should not be delayed.

Closed bowel loop obstruction by a fibrous band mimicking paraduodenal hernia

Abstract Background A closed-loop obstruction occurs when a section of the intestine becomes blocked at two locations along its pathway, increasing the likelihood of volvulus and ischemia. Frequently, a single adhesive band is the primary cause of a closed loop, although internal hernias from congenital defects or iatrogenic intervention in the mesentery or omentum can also become other factors. In closed-loop obstruction, computed tomography (CT) often displays a distinctive pattern where the bowel appears dilated and filled with fluid, forming a ‘C-shaped’ configuration. Case presentation A 43-year-old female patient presented to the emergency department complaining of acute abdominal pain and repeated bilious vomiting with no history of absolute constipation. By examination, there were tenderness, guarding and rigidity. Her medical history includes type 1 diabetes since the age of 9 years and her surgical history included a onetime cesarean section and negative history of laparoscopic interventions. Ultrasound was done as a first-line investigation. It showed a few dilated bowel loops in addition to moderate intraperitoneal free fluid and could not detect the cause of bowel dilatation; therefore, non-contrast CT scan was requested and revealed the following findings: Two bowel loops exhibited distension and mucosal edema, and the configuration of bowel loops resembled a distinctive C-shape. Conclusion Distinguishing between adhesive small bowel obstruction (SBO) and paraduodenal hernia relies on clinical history, imaging features, and risk factors. Adhesive SBO often stems from prior surgery or inflammation and may exhibit ‘beak’ or ‘whorl’ signs on CT scans.

Ruptured Parasitic Dermoid Cyst in Blunt Abdominal Trauma.

Ruptured parasitic dermoid cyst is one of the rare conditions that results from auto-amputation and re-implantation following torsion from the ovary and omentum, among other sites. Due to trauma to the abdomen, it may rupture, resulting in spillage of its contents and causing chemical peritonitis. The diagnosis is based on clinical presentation complimented by abdominal ultrasound in low resource settings. A case of a 44-year-old (Iraqw by tribe) who presented with clinical features of acute generalized abdominal pain and distension for two days following blunt abdominal trauma. The abdominal ultrasound revealed a mass of mixed echogenicity with intraperitoneal free fluid. She underwent laparotomy, revealing ruptured parasitic dermoid cyst adhered to the anterior abdominal wall and urinary bladder, then excised. The high degree of suspicion of ruptured parasitic dermoid cyst is justified in adult patient with chemical peritonitis manifestation. The laparotomy is surgical management of choice in low-resource settings followed by prolonged follow-up.

Adhesive small bowel obstruction: predictive factors of laparoscopic failure.

The adoption of laparoscopy for the management of adhesive small bowel obstruction (ASBO) patients is debated. The laparoscopic approach has been associated with a considerable conversion-to-open rate. Nonetheless, reliable predictors of conversion are still unclear. The present study aimed to identify factors associated with conversion to open in ASBO patients who underwent laparoscopic surgery. Patients who underwent laparoscopic surgery for ASBO and were admitted to our unit between December 2014 and October 2022 were retrospectively evaluated. The patients were categorized into two groups: patients who underwent complete laparoscopy approach (Group 1) and patients converted to open technique (Group 2). Demographic, clinical, and radiological features, intraoperative findings, and postoperative outcomes were compared. A total of 168 patients were enrolled: 100 patients (59.5%) were included in Group 1, and 68 patients (40.5%) were included in Group 2. The rate of ischemia (p = 0.023), surgical complications (p = 0.001), operative time (p < 0.0001), days of nasogastric tube maintenance (p < 0.0001), time to canalization (p < 0.0001), and length of hospital stay (p < 0.0001) were significantly higher in Group 2 than Group 1. Following univariate analysis, the presence of feces signs (p = 0.044) and high mean radiodensity of intraperitoneal free fluid (p = 0.031) were significantly associated with Group 2 compared with Group 1. Following multivariate analysis, the feces sign was a significant predictive factor of conversion (OR 1.965 [IC 95%]; p = 0.046). Laparoscopic treatment is a safe and effective approach in patients affected by ASBO. The feces sign may be a predictive factor of conversion and could guide the surgeon in selecting the appropriate management of patients affected by ASBO.

Local education measures are insufficient at ensuring timely imaging in acute pancreatitis

Abstract Aims The Royal College of Radiologists (RCR) has outlined specific criteria for imaging in acute pancreatitis. The presence of pancreatic necrosis, free intraperitoneal fluid and extensive perihepatic fat stranding is associated with worse outcome. Timely computed tomography (CT) scanning 72 to 96 hours following onset of symptoms leads to more accurate diagnosis of pancreatic necrosis. Furthermore, ultrasound examination of the gallbladder is also recommended within 24 hours of admission to demarcate cause. Methods Two plan-do-study-act (PDSA) cycles were run between January to October 2022 and January to September 2023 in the surgical emergency unit. 50 patients were randomly selected amongst all pancreatitis admissions for each cycle. Outcome measures were percentage of CT scans adhering to optimal timing and percentage of ultrasound scans that were carried out within the first 24 hours. Cycle 1 findings were presented locally to staff as a teaching intervention. Results CT scans were performed in 60% and 66% of patients in cycle 1 and 2, respectively. Of these, 39% and 70% had optimal CT scan timing during cycle 1 and 2, respectively. Furthermore, only 33% of patients had US scans performed within 24 hours of admission during both cycles. Conclusion The above findings suggest that local teaching interventions are inadequate at meeting the recommended standard of 95% compliance defined by the RCR. This is likely due to rotating staff, lack of knowledge and incomplete prompting when ordering imaging. Further audit with an information technology based intervention is suggested to improve compliance.

Renal trauma during a rugby tackle

Rugby-related renal trauma is rare and identification of a young patient with renal trauma secondary to sports who requires observation versus further radiological evaluation in the emergency department (ED) poses a diagnostic challenge. We report a case of a 16-year-old girl who presented to the ED with abdominal pain after being tackled during a game of rugby. Examination revealed tenderness over the right lateral lower ribs and right flank. Blood tests were normal and bedside ultrasound did not show any free intraperitoneal fluid. Urinalysis showed gross hematuria. She was pain-free after analgesia but had a syncopal episode in the ED. A computed tomography (CT) scan of the abdomen and pelvis showed a complex right lower pole renal laceration and she was admitted to the Intensive Care Unit. She remained stable and was discharged. Assessment with urinalysis, hematocrit, and creatinine is required during the evaluation of a patient with suspected renal trauma. CT scan is the imaging modality for the diagnosis and grading of renal injury. Conservative treatment is the mainstay of therapy, but some patients require angioembolization of surgical intervention. Patients must discuss with their physician regarding the optimal timing of return to rugby. Rugby-related renal trauma is rare and poses a challenge for emergency physicians regarding their evaluation and management in the ED. AAST-OIS grading of renal trauma on CT imaging helps guide appropriate management decisions.

Isolated splenic peliosis: a case report

BackgroundPeliosis is a rare condition with anatomopathological characteristics that affect the liver. However, splenic peliosis is even more unique and rare. Patients with such abnormality usually exhibit no symptoms. Moreover, this is a lethal condition due to the high probability of splenic rupture accompanied by shock.Case presentationWe present a case of a 29-year-old Arab female who was admitted to the hospital with severe upper abdominal pain that started 1 week from the date of admission, associated with nausea, anorexia, low-grade fever, and vomiting, with no past medical history or comorbidities. A computerized tomography scan with contrast showed intraperitoneal free fluid along with multiple hypodense splenic cysts. Hence, an emergent exploratory laparotomy with splenectomy was performed. Splenic peliosis was confirmed by the histopathological examination.ConclusionFurther investigations are warranted if peliosis is confirmed in one organ, for example, the liver, to detect its presence in any other potential organs that can be affected by peliosis. Splenic peliosis is extraordinarily rare. Furthermore, such a disease has no established management plan. Definitive treatment is surgical. Many aspects of splenic peliosis remain puzzling requiring more research in the near future.

Role of FAST in blunt trauma abdomen: A promising diagnostic tool to evaluate management in patients and comparison of its accuracy with CT and laparotomy

Background: Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid. In the context of traumatic injury, free fluid is usually due to hemorrhage and contributes to the assessment of the circulation. Performed in the trauma room by properly trained and credentialed staff, it allows the timely diagnosis of potentially life-threatening hemorrhage and is a decision-making tool to help determine the need for transfer to the operating room, computed tomography (CT) scanner, or angiography suite. The FAST scan is a 4 view scan reliant on detecting the presence of fluid within the pericardium and most dependent zones of the peritoneum in the horizontal patient. It is capable of detecting more than 100–250 mL of free fluid. CT scanning, in comparison, is capable of detecting more than approximately 100 mL of free fluid in the abdominal cavity. As a “rule of thumb,” a rim of 0.5 cm of fluid in Morison’s pouch represents approximately 500 mL of free fluid, and a 1 cm rim represents approximately 1000 mL. Aims and Objectives: The aims of this study were as follows: Role of FAST in blunt trauma abdomen: A promising diagnostic tool to evaluate management in patients and comparison of its accuracy with CT and laparotomy. Materials and Methods: The FAST scan was performed by Color Doppler Siemens Sonoline G-50 machine using either 2–5 MHz convex transducers or 5–10 MHz linear transducer department of Radiology L.L.R. Hospital, Kanpur. At FAST examines four areas for free fluid, perihepatic and hepatorenal space, perisplenic, and pelvis pericardium. Results: Sensitivity of FAST: 87.5%, specificity of FAST: 75%, and negative predictive value (NPV) of FAST are 80%. CT scan had sensitivity of: 97%, specificity of: 95%, and positive predictive value of CT scan: 92% NPV of: 100%. Laparotomy was GOLD standard with specificity of 100%. Conclusion: FAST was positive in 62.5% cases of blunt trauma abdomen. Sensitivity of FAST: 87.5%, specificity of FAST: 75%, and NPV of FAST are 80%. CT scan had sensitivity of: 97%, specificity of: 95%, positive predictive value of CT scan: 92%, and NPV of: 100%. Laparotomy was GOLD standard with specificity of 100%.

Festina Lente: Bradycardia as a Presenting Feature of Life-Threatening Intra-Abdominal Hemorrhage

Introduction:Trauma is one of the leading causes of death in patients under 40 years of age. The Advanced Trauma Life Support (ATLS) Guidelines are widely accepted as the standardized approach to trauma and classify hemorrhagic shock according to heart rate (HR), blood pressure (BP), urinary output, and mental status. Paradoxical bradycardia (defined as HR &lt;60 bpm) in hemorrhagic shock is an uncommon presenting feature and presents a diagnostic challenge to the physician; its true incidence is unknown.Method:A case of paradoxical bradycardia was examined as a presenting feature in hemorrhagic shock.Results:A 17-year-old male patient presented to our Emergency Department (ED) with collapse and abdominal pain following a collision with another player during a sports match.The patient was hypotensive (BP 92/42) and bradycardic at triage, with a heart rate of 50. He was pale and diaphoretic with a Glasgow Coma Scale of 13/15, thready pulses, and localized peritonitis in the left upper quadrant of his abdomen.An increase in blood pressure was observed following initial fluid resuscitation; however, this was transient and preceded the onset of profound hypotension (BP 64/30). Bradycardia with a heart rate between 50-60bpm was persistent despite resuscitative efforts.Abdominal ultrasound demonstrated intraperitoneal free-fluid, and Computerized Tomography confirmed the presence of a grade V splenic laceration. He was taken to the operating theater for emergency laparotomy and underwent splenectomy. A 2.3 liter hemoperitoneum was found intraoperatively. There were no further complications post-operatively, and he made a full recovery.Conclusion:Tachycardia is a potentially unreliable marker of blood loss, especially in young, healthy patients. A high index of suspicion is necessary to prevent this uncommon but life-threatening feature of hemorrhagic shock from being overlooked.

Accuracy of Focused Assessment with Sonography for Trauma Performed by Emergency Medicine Residents

Aim: To evaluate the accuracy of focused assessment with sonography for trauma (FAST) performed by emergency medicine residents to detect intra-peritoneal free fluid in blunt trauma patients. Design: Randomized control trial. Place and duration of study: Accident &amp; Emergency Department, Mayo Hospital Lahore from 6th April 2022 to 5th November 2022. Methodology: One hundred and twenty one patients were included. FAST scan was performed in each patient by emergency resident as well as radiology resident. FAST was performed under direct supervision of radiology consultant. Furthermore, FAST reports were confirmed by patient follow up in first 24 hours by checking final outcome of patient based on results of abdominal computed tomography (CT), exploratory laparotomy or conservative management by admitting in surgical ward for observation and hemodynamic status change. Results: Focused assessment with sonography for trauma scan done by emergency residents showed free fluid in 20 patients (16.5%) while FAST done by radiology residents was positive in 21 (17.4%). Sensitivity of FAST performed by EM residents was 85.7% and specificity was 98%, while FAST done by radiology residents had sensitivity of 95.25 and specificity of 99%. Accuracy of FAST done by EM residents was 95.8% as final outcome. Conclusion: After training, emergency residents can perform FAST with high accuracy, similar to radiology residents in blunt abdominal trauma patients. Keywords: Focused assessment with sonography for trauma (FAST), Trauma, Blunt abdominal trauma

Bowel Perforation after Extracorporeal Wave Lithotripsy: A Review of the Literature.

Extracorporeal wave lithotripsy (ESWL) is considered a first-line treatment for renal and ureteral stones up to 10-20 mm in diameter. Complications are uncommon, with a reported rate of 0-6% in the literature. Bowel perforation has only been described in a few case reports but requires rapid diagnosis and treatment. A review of the literature from PubMed/Medline, Embase, Cochrane, and Web of Science databases was performed including studies reporting bowel perforation secondary to ESWL between January 1990 and June 2022. We found 16 case reports of intestinal perforation in the literature. Although some patients had previously undergone abdominal surgery or had inflammatory intestinal disease, others were without comorbidities that could lead to complications. Abdominal pain was the main symptom and imaging was required to confirm the diagnosis, which usually necessitated a surgical intervention. As regards the ESWL technique, it appears that the combination of a high energy level and the prone position constitutes a risk factor for these rare complications. At the authors' centre, only one case has been reported among 24,000 ESWL procedures over 20 years: A 59-year-old female who underwent ESWL for a distal right ureteral stone presented acute abdominal pain and free intraperitoneal pelvic fluid on ultrasound. A CT scan revealed a small bowel perforation requiring open laparotomy with primary closure. In conclusion, although bowel perforation after ESWL is rare, progressive abdominal pain with tenderness at physical examination requires proper imaging evaluation to exclude bowel perforation and prompt intervention if required.

Internal Bleeding Management in Patient with Blunt Abdominal Trauma at Rural Hospital: A Case Report of 40-Year-Old Male with Spleen Rupture

Background&#x0D; Abdominal injury caused by blunt trauma is a common presentation in the emergency room.[1] Especially in developing countries like Indonesia, the number of motor vehicle accident in public roads is still high. Eighty percent of traumatic injury is blunt injury with the majority of deaths are caused by hypovolemic shock.[2]&#x0D; Case description&#x0D; A 43-years-old man arrived at the emergency room after motorcycle accident 2 hours before. AMPLE and primary survey was conducted: clear airway, spontaneous breathing, BP 70/palpation mmHg, HR 123 times per minutes and altered consciousness in which showed the patient was undergoing hemorrhagic shock. The patient was hemodynamically stable after given 1 liter of normal saline through two intravenous line. FAST was conducted, intraperitoneal free fluid was seen in Morison’s pouch, left hemithorax, and the pouch of Douglass. Chest X-Ray showed fracture of ribs 7, 8, 9 left lateral aspect with minimal hemothorax. After supporting examination was performed, the patient’s BP dropped to 60/40 mmHg, showed patient was a “transient responder”, indicating the patient should undergo laparotomy. The patient was given 500mL colloid with systolic target 80 – 90 mmHg in accordance to permissive hypotension theory. ±1500ml blood was found inside the abdomen during operation, a splenic rupture grade V was the cause. In the fifth day after surgery, the patient discharged.&#x0D; Conclusion&#x0D; Since blunt abdominal trauma could cause intraperitoneal bleeding that leads to hemorrhagic shock, therefore immediate diagnosis is needed.[1] Multiple trauma management at rural hospital should be concordant to ATLS and Schwartz’s Principles of Surgery.

A new risk scoring system for early prediction of surgical need in patients with adhesive small bowel obstruction: a single-center retrospective clinical study.

Cases of adhesive small bowel obstruction are a nuisance to surgeons. There have been years of ongoing discussions, and various guidelines have been published for the management of this disease. Both surgical and conservative approaches can have their own complications. It is often difficult to decide which treatment to apply to which patient. We aimed to create a multiparametric scoring system for the optimal management of adhesive small bowel obstruction patients. The retrospective laboratory, clinical and radiological records of 100 patients who were hospitalized and followed-up/treated for adhesive small bowel obstruction secondary to surgery in the General Surgery Clinic of Haydarpaşa Numune Education and Research Hospital (Istanbul) between 2011 and 2021 were reviewed and statistically analyzed. Admittance CRP and the largest diameter of the small intestine in the horizontal section of the admittance CT scans were significantly higher (P = 0.006 and P = 0.007), and the admittance albumin and sodium values were significantly lower (P < 0.001 and P = 0.031) in patients operated on for adhesive small bowel obstruction than in patients not operated on. Free intraperitoneal fluid in CT scans was detected at a higher rate in the operated group. An adhesive small bowel obstruction surgery score above 3.5 points out of 7 was found to be significant (P < 0.001). With this easy and applicable scoring system, complications of existing disease may be avoided by considering earlier surgical intervention in patients with a score of 4 and above.

An unusual case of proctalgia: kerosene rectal injury.

Kerosene has been described as an uncommon burn injury agent(1). We report a case of a 47-year-old male who presented to the Emergency Department with proctalgia after self-administration of an unknown enema in the context of cocaine intoxication. Physical examination revealed severe perianal inflammation (Figure 1.A) without suppuration and computerized tomography (CT) scan showed free air in mesorectum and retroperitoneum without intraperitoneal free air or fluid (Figure 1.B and 1.C). Rigid rectoscopy demostrated erythematous rectal mucosa without perforation. Subsequently, perineal drainage and debridement were performed. On the fifth postoperative day, the patient reported worsening proctalgia. Examination under anesthesia revealed the presence of new-onsetanal ulcers (Figure 1.D), rigid rectoscopy identified deep ulcers limited to the rectal mucosa and colonoscopy ruled out colon involvement. During reevaluation, the patient disclosed the use of sailboat engine lubrican as the enema, with kerosene being one of its components. These findings were consistent with rectal burn injuries resulting from exposure to kerosene. A laparoscopic end-loop colostomy was performed without any postoperative complications. Follow-up examinations with rigid rectoscopy showed improvement of rectal ulcers (Figure 1.E and 1.F). To our knowledge, this is the first case of rectal burn injuries after kerosene exposure(2,3). Aggressive washout, early colostomy and serial follow-up scopes are key components in the management of these rare injuries.