History Of Severe Abdominal Pain Research Articles

Gossypiboma, a rare cause of failure in surgical intervention: a case report and review of literature

Gossypiboma (GB) is a rare but avoidable cause of failure in surgical intervention due to retention of a surgical swab in the body after an operation. It leads to potentially fatal complications with far reaching medico-legal implications. We report a case of a 28-year-old female who presented with a month history of severe abdominal pain following a myomectomy surgery. Abdominopelvic ultrasound and Computed Tomography (CT) reported an ill-defined mass in the abdomen. Exploratory laparotomy revealed extensive peritoneal adhesions, and a hard mass walled off by the greater omentum and adherent to the jejunum. Histopathological evaluation of the excised mass showed gauze-like material surrounded by intense granulomatous inflammation, adherent to intestinal segments. She was subsequently treated with ceftriaxone, metronidazole and pentazocine, and discharged home after an uneventful postoperative period.

Pancreatic follicular dendritic cell sarcoma: a rare case report and systematic literature review of 7 cases

IntroductionPancreatic follicular dendritic cell sarcoma (FDCS) is an exceptionally rare and low-to-moderate malignancy, with only seven reported cases to date. Clinical diagnosis of FDCS is challenging due to the lack of distinct biological and radiographic features.Case presentationA 67-year-old woman presented to the hospital with a 4-day history of severe abdominal pain. Imaging studies (CT and MRI) revealed a large cystic mass located at the tail of the pancreas, which was suspected to be myeloid sarcoma (MS) based on EUS and CT-guided pancreatic puncture. Postoperative pathology and immunohistochemistry confirmed the diagnosis of pancreatic FDCS. After the diagnosis was confirmed, the patient received postoperative chemotherapy with the CHOP regimen. At 11 months of follow-up, there was no evidence of recurrence. Seven published cases have been reviewed to comprehensively summarize the clinical characteristics, diagnosis, and treatment options of FDCS.ConclusionWhile imaging can be useful in detecting pancreatic FDCS, it should be interpreted with caution as it can be challenging to differentiate from other pancreatic tumors. Pathology and immunohistochemistry are considered the gold standard for diagnosis, with CD21, CD23, and CD35 being specific tumor cell markers. However, preoperative diagnosis of pancreatic FDCS remains difficult, and the pancreatic puncture may further increase the risk of misdiagnosis. The disease is highly prone to recurrence and metastasis, and surgery is the preferred method for both diagnosis and treatment of localized disease.

SUCCESSFUL ANAESTHETIC MANAGEMENT OF A CASE OF OPEN NEPHRECTOMY FOR GRADE 5 RENAL INJURY

Blunt trauma to the abdomen can cause damage to vital organs like spleen, liver, kidney and intestines and is associated with high morbidity. Hereby we are presenting a case of Grade 5 Renal Injury(shattered kidney) following blunt injury abdomen. A 21 year old male presented to our Emergency Room with history of RTA. He revealed history of severe abdominal pain. He presented with severe tachycardia (HR−140⁄minute),blood pressure and saturation were normal and GCS was 15⁄15. His CECT abdomen revealed shattered left kidney with subcapsular and perinephric collection with renal vascular injury. His hemoglobin was found to be 5.7g/dl, rest of the blood investigations were within normal limits. He was shifted to OT immediately and was proceeded with open nephrectomy. Post induction he devoloped severe hypotension and was started on iv crystalloids and colloids and minimal Nor adrenaline support. Intraoperatively 4 units of PRBC and 3 units of FFP were transfused. Around 1 litre of blood, bladder clots and a concealed hematoma in messentry were evacuated. Post transfusion ABG revealed metabolic acidosis. He was shifted to ICU with the ET Tube. He made an uneventful recovery in ICU and was extubated.Physiologically, hemodynamic compensatory mechanisms maintain vital organ perfusion till about 30% TBV loss, beyond which there is a risk of critical hypoperfusion. Massive blood loss is best managed by following the massive transfusion protocol (MTP).

EP-25 Double Gastric Outlet Obstruction Caused by an Incarcerated Right Inguinal Hernia, a Rare Presentation

Abstract We report a case of an 84-year old man who presented with double gastric outlet obstruction from an incarcerated right inguinal hernia that contained part of the stomach, most of the small bowel, omentum, appendix, caecum, ascending and transverse colon, causing a double gastric outlet obstruction. Several intra-abdominal organs have been reported in groin hernias including the appendix, bladder, small and large bowel and ovaries. There are approximately 60 cases of inguinal hernias containing the stomach, the majority were before 1980. It's believed that the emphasis of early repair minimized the occurrence of complications and decreased presentations of these cases. Two cases were published in the UK with a similar condition in 2014 of which one was treated conservatively and the other had an open inguinal hernia repair with mesh. He presented to the emergency department with a 1 day history of severe abdominal pain and dark brown vomiting due to incarceration of inguino-scrotal hernia which he had for the last 24 years with no symptoms. His abdomen was soft and non-tender with large right inguino-scrotal hernia which was tender on palpation and irreducible. The diagnosis was confirmed with a CT scan. The P-Possum score was calculated, 2.56% mortality and 49.5% morbidity. He was taken to the theatre, after resuscitation for exploratory laparotomy, omentectomy and inguinal hernia Lichtenstein repair with Vicryl® mesh. At the end, it is thought that long-standing traction on the greater omentum and its attachments may be responsible for the descent of the stomach into the hernia sac.

An Uncommon Finding in the Artery

Question: A 56-year-old woman with diabetes mellitus, hypertension, and dyslipidemia presented with 1-day history of severe abdominal pain with diarrhea. She has had intermittent episodes of postprandial crampy abdominal pain 2 weeks before her initial presentation. She denies any fever or any hematochezia. Examination revealed generalized abdominal tenderness, with lactic acidosis. A computed tomography scan of the abdomen was urgently performed.

Iliac Extension Trimming, Resheathing, and Deployment for Emergent Repair of Abdominal Aortic Pseudoaneurysm

An 18-year-old woman presented with a 3-week history of severe abdominal pain radiating to the back and left thigh, without trauma or fever. Clinical examination revealed pulsatile swelling in the umbilical region. Computed tomography angiography showed a large pseudoaneurysm (measuring 8.4 × 4.1 × 6.8 cm) arising from the left lateral aspect of the infrarenal abdominal aorta, with a narrow neck (8 mm) (Fig 1a–c). Circumferential mural thickening involving the descending thoracic aorta causing diffuse luminal narrowing was noted (Fig 1c), with multiple enlarged cervical and mediastinal necrotic lymph nodes.

Second trimester Abdominal Pregnancy: A Case Report in a Resource Limited Setting

Introduction: Abdominal pregnancy is a rare form of ectopic pregnancy with very high feto-maternal morbidity and mortality. Diagnosis and management can pose difficulties in low-resource centres. High index of suspicion is vital in making a prompt diagnosis. Case Presentation: A 23year old, gravida 2, para 1, who presented with a two-day history of severe abdominal pain was referred from a satellite clinic. Abdominal ultrasound scan revealed a live 18week 5day intra-abdominal pregnancy. Emergency laparotomy showed an intact gestational sac at the superior aspect of the uterus with massive hemoperitoneum. The placenta was attached to the right ovary, omentum, and fimbriae of the right fallopian tube. Conclusion: Abdominal pregnancy is a rare occurrence and requires a high index of suspicion for prompt diagnosis. Massive hemoperitoneum can be life threatening and prompt surgical intervention is key in saving the life of the mother.

Acute gastric outlet obstruction due to an impacted gallstone: the Bouveret’s syndrome

A 59-year-old woman presented to the emergency department with a 3-day history of severe abdominal pain and recurrent vomiting. On admission, the patient reported that the pain was accompanied by...

Brief Report: Associations Between Self-injurious Behaviors and Abdominal Pain Among Individuals with ASD-Associated Disruptive Mutations.

Self-injurious behaviors (SIB) are elevated in autism spectrum disorder (ASD) and related genetic disorders, but the genetic and biological mechanisms that contribute to SIB in ASD are poorly understood. This study examined rates and predictors of SIB in 112 individuals with disruptive mutations to ASD-risk genes. Current SIB were reported in 30% of participants and associated with poorer cognitive and adaptive skills. History of severe abdominal pain predicted higher rates of SIB and SIB severity after controlling for age and adaptive behavior; individuals with a history of severe abdominal pain were eight times more likely to exhibit SIB than those with no history. Future research is needed to examine associations between genetic risk, pain, and SIB in this population.

Abdominal Pain and Fever in an Elderly Patient with Diabetes Mellitus.

A 62-year-old man presented to the emergency department with a 5-day history of severe abdominal pain with low-grade fever. Medical history included diabetes mellitus and hypertension. He had tachycardia, hypotension, and diffuse abdominal tenderness. Investigations showed white blood cell counts of 22,400/mm3 (4000–10,000/mm3), blood urea of 180 mg/dl (9–43 mg/dl), creatinine of 1.8 mg/dl (0.66–1.25 mg/dl), and procalcitonin of 180 ng/ml (<0.5 ng/ml). Urinalysis showed plenty of white blood cells and red blood cells on microscopy. Contrast-enhanced computed tomography scans showed multiple air bubbles in the bladder wall, suggestive of emphysematous cystitis (EC) (Figure 1A), with tracking of the gas in the pelvicalyceal system of the left kidney (Figure 1B). Two ill-defined saccular …

2706 Ischemic Duodenal Ulcer: A Rare Complication of Embolization of the Gastroduodenal Artery in Yttrium-90 Radioembolization Therapy

INTRODUCTION: Selective internal radiation therapy (radioembolization) with yttrium-90 (Y-90) resin microspheres is an effective and increasingly popular treatment option for unresectable primary and metastatic liver malignancies. Gastric complications are detected in 4% to 27% of liver radioembolization cases. Most of these cases arise from non-targeted flow of microspheres with aberrant deposition into various non-selected organs. The gastroduodenal artery is routinely embolized prior to deposition Y-90 microspheres to decrease the risk of non-targeted dissemination of the microspheres. We present a rare case of duodenal ulcer which developed as a result of ischemia induced by embolization of the gastroduodenal artery. CASE DESCRIPTION/METHODS: A 68 year-old woman with a history of stage IV colon adenocarcinoma with metastasis to the liver presented to the hospital with a several week history of severe abdominal pain two months after receiving radioembolization therapy with Y-90 microspheres. She was found to have a duodenal ulcer and was treated with acid suppression therapy. She was re-evaluated six months later for severe abdominal pain. Repeat endoscopy showed a larger duodenal ulcer with multiple coils eroding through the center of the ulcer bed suggesting ischemic injury caused directly from the embolization coils. She was treated with acid suppressive therapy with resolution of her symptoms. DISCUSSION: Radioembolization with Y-90 microspheres is now a widely performed locoregional treatment for primary and metastatic liver lesions not amenable to resection. Our case is unique because the patient’s duodenal ulcer was likely ischemia-induced from mechanical occlusion of and direct injury to the gastroduodenal artery from the embolization coils. It is imperative that clinicians caring for patients who have received radioembolization therapy be familiar with the many gastrointestinal complications associated with this therapy. There is increasing awareness of radiation-induced mucosal injury in the literature. However, providers should also know that despite the presence of multiple collaterals in the gastroduodenal territory, chronic coil-induced ischemia can also form ulcers as a complication of selective embolization of the gastroduodenal artery.

2586 Renal Cell Carcinoma Presenting as Paraneoplastic Syndrome Involving the Gastrointestinal Tract

INTRODUCTION: We present a case of a patient who presented with abdominal pain and a small bowel obstruction and was found to have renal cell carcinoma causing a paraneoplastic vasculitis affecting his bowel. CASE DESCRIPTION/METHODS: A 57 year old Caucasian male with no significant past medical of family history presented to the Emergency Department complaining of a 2 day history of severe abdominal pain, nausea, vomiting and a bilateral non-blanching rash on his lower extremities that extended up towards his umbilicus (Figure 1). Initial XR Abdomen revealed a small bowel obstruction. A CT abdomen/pelvis was done which showed focal bowel wall thickening of distal duodenum and proximal jejunum with some mucosal edema and stranding of adjacent mesenteric fat concerning for duodenitis/enteritis. A CT renal mass protocol was ordered which revealed a 3.1 cm enhancing left renal mass highly suspicious for Renal cell carcinoma. An NG tube was inserted for decompression. On day three of admission patient had EGD performed which revealed multiple partially obstructing ulcerations throughout the second and third portion of the duodenum (Figures 2 and 3). Biopsy samples of the duodenum showed severe active duodenitis with erosions that was negative for CMV. A colonoscopy revealed an ulcer at the ileocecal valve which was biopsied and showed acute inflammation. There was non-specific erythematous mucosa throughout the colon. The patient began to experience swelling and pain in his wrist and the small joints of his hand and the rash continued to spread. Rheumatology performed an autoimmune workup which was normal save for mildly elevated C3, C4 and a high CRP. An extensive infectious disease workup was negative. Skin biopsy of the lesion was consistent with medium/large vessel vasculitis and the patient was started on high dose steroids. The patients clinical course improved drastically and he was discharged on a prolonged steroid taper. He underwent a nephrectomy 1 month from hospital discharge with pathology revealing clear cell renal cell adenocarcinoma with clear margins. He was continued on a steroid taper until resolution of his symptoms at 6 months follow up. DISCUSSION: Paraneoplastic vasculitis in patients with solid tumors has been described, and can very rarely affect the gastrointestinal tract. It can cause local or diffuse pathologic changes in the gastrointestinal tract, resulting in nonspecific paralytic ileus, mesenteric ischemia, submucosal edema, hemorrhage, or even bowel perforation.

Congenital transmesenteric internal hernia; A rare cause of bowel ischemia in adults: A case report

Konjenital transmesenterik fitiklar, nadir gorulen ve yayinlanmis literaturde az sayida bildirilmis vaka ile eriskinlerde nadir gorulen bir barsak tikanikligi ve barsak iskemi nedeni olan cok kucuk bir ic fitik grubunu temsil eder. Hastaligin preoperatif tanisi zordur, erken mudahale ve cerrahi duzeltme, icsel fitik vakalarina bagli yuksek morbidite ve mortaliteyi onlemede uzun bir yol kat eder. Daha once cerrahi oykusu veya travmasi olmayan 31 yasinda bir kadin hastada gercek konjenital transmesenterik herni olgusunu sunuyoruz. Siddetli karin agrisi oykusu ve hem diski hem de flatusun kesilmesi ile basvurdu. Abdominal BT taramasi taniyi dogrulayamadi. Hasta abdominal agrinin artmasi ve sokla iliskili distansiyon nedeniyle ameliyat edildi. Bir kesif laparotomisi, barsak ilmeklerinin fitiklandigi ve kangrenli hale gelen dogustan bir transmesenterik defekti ortaya cikardi, rezeksiyona ve bir stomi turu Bouilly Volkmann'a neden oldu.

AN UNUSUAL CASE OF PORTAL, SPLENIC AND MESENTERIC VENOUS THROMBOSIS PRESENTING WITH ACUTE ABDOMEN

Porto-spleno-mesenteric vein thrombosis is a rare, life-threatening condition of extrahepatic portal venous system thrombosis. We report a rare case of a 49-year-old lady with late presentation of acute portal vein thrombosis in a non-cirrhotic liver with an incidental finding of left adnexal teratoma. She presented with a one-week history of severe abdominal pain associated with vomiting and diarrhea. She gave no history of prior risk for venous thromboembolism or liver diseases. Physical examination revealed a tender mass extending from suprapubic to left iliac fossa. Abdominal computed tomography scans showed a well-defined fatcontaining left adnexal mass, likely a benign teratoma, with no involvement of surrounding structures or calcification. There was evidence of porto-splenic-mesenteric vein thrombosis with liver infarction, bowel and splenic ischemia. Management of the extensive thrombosis causing multi-organ failure includes resuscitation, supportive care and treatment of thrombosis. Treatment options include early anticoagulation and if feasible, thrombolysis. Keywords: Acute Abdomen, Mesenteric Vein Thrombosis, Non-Cirrhotic Vein Thrombosis, Portal Vein Thrombosis,Splenic Vein Thrombosis

Unique Presentation of Isolated Intestinal Angioedema Without ACE-I Involvement

1651_A Figure 1. Diffuse bowel wall thickening involving stomach, small bowel and colon with suggestion of mucosal enhancement and submucosal edema.1651_B Figure 2 No Caption available.Case reports of intestinal angioedema are well documented in the literature. However, the majority of these cases are due to angiotensin-converting enzyme inhibitor (ACE-I) induced angioedema. We present an unusual case of a patient who had isolated intestinal wall angioedema without taking ACE-I and normal C1 inhibitor levels. The inciting event was ingestion of a food allergen, which is not well described in the literature. The patient is a 63 year old female who presented for 1 day history of severe abdominal pain. The patient was in her usual state of health when she drank her daily smoothie. The only addition to her smoothie was parsley. Upon ingestion, she immediately developed severe cramping pain in her abdomen associated with nausea, vomiting, and watery diarrhea. She denied itching or rash. Upon presentation to the hospital, the patient was noted to be tachycardic and tachypneic. The patient admitted to having a similar reaction years ago to ingestion of kiwi fruit. Her physical exam demonstrated non distended abdomen with diffuse tenderness to palpation and normoactive bowel sounds. Her hospital course entailed a 1 day course of antibiotics and anti-emetics. Her diet was advanced and after a 3 day hospital stay was discharged home. Labs were notable for WBC of 18,000, lactate of 5.9. The remainder of the labs including blood cultures, stool analysis, ESR, C-ANCA, P-ANCA, C1-Inhibitor, complement levels were normal. Angioedema is one of the most common allergic disorders that results in hospitalization. Any hollow viscera are prone to this type of temporary swelling. The severity of presentation of intestinal angioedema can be varied, from mild colicky pain to severe vomiting and diarrhea. Most often the inciting agent is ACE- I. This reaction is well documented but still rare with only 21 cases described in the literature. We present a case of isolated intestinal angioedema following an ingested allergen. What is unique is that this sequela occurred in the absence of ACE-I use. Furthermore, the patient presented with isolated intestinal angioedema which is unreported in literature. No signs of systemic anaphylaxis or oral angioedema were noted which is typical in food allergies. Another unique finding was normal C1 inhibitor levels making hereditary angioedema unlikely. In this instance, the mechanism was most likely due to first time parsley ingestion causing IgE mediated mast cell degranulation releasing histamine leading to intestinal swelling.

Pneumatosis Coli Complicating Clostridium difficile Pseudomembranous Colitis

Pneumatosis intestinalis (PI) is a rare radiographic sign characterized by gas-filled cysts within the subserosal and/or submucosal regions of the intestinal wall. The source of this gas and its translocation across the mucosa is incompletely understood. We report a case of pneumatosis coli in a patient with recurrent C-diff. A 58-y.o. female with history of type 2 DM, HTN, and ESRD presented to ER with 3-day history of severe abdominal pain, nausea, vomiting and watery diarrhea. She had constant peri-umbilical cramps. Diarrhea was 6-7 times per day, worse after eating, and without melena or hematochezia. Patient completed a course of oral vancomycin for C-diff diarrhea 3 weeks prior and her previous symptoms had resolved. Examination showed fever of 101 F, soft non-distended abdomen, hyperactive bowel sounds, tenderness to palpation above the umbilicus, and no guarding or rebound. Blood work was unremarkable with no leukocytosis. Lactic acid was normal. CT abdomen without IV contrast showed extensive pneumatosis coli involving the transverse colon with associated mesenteric and intrahepatic portal venous gas with no overt perforation, free air, or abscess (image1,2). C-diff was positive again for this admission. Patient was started on supportive therapy with aggressive fluid resuscitation, IV metronidazole and oral vancomycin. Surgery recommended medical therapy. Patient improved markedly and was discharged home to complete a course of oral vancomycin for recurrent C-diff. Supportive care and appropriate antibacterial agents sufficed to alleviate symptoms and resolve pneumatosis coli on repeat imaging (image 3). It is important to recognize that PI is a clinical sign and is, per se, not a diagnosis. About 85% of cases of PI are associated with variable medical conditions and 15% are idiopathic. Because it represents a wide spectrum of diseases, management of PI ranges from surgical intervention to outpatient observation. Since PI is infrequently encountered, clinicians may be unfamiliar with its diagnosis and management. This unfamiliarity, combined with the potential necessity for urgent intervention, may place the clinician confronted with PI in a precarious medical scenario.Recognizing this uncommon but important association can prevent high costs from unnecessary testing and invasive surgical explorations. We should consider pseudomembranous colitis as the cause of pneumatosis coli in patients who have received antibiotics, once gut ischemia is ruled out.1455_A Figure 1. CT abdomen without IV contrast shows extensive pneumatosis coli1455_B Figure 2. CT abdomen shows intrahepatic portal venous gas1455_C Figure 3. CT abdomen one month later

Elderly woman with painless hardened umbilical nodule

An 87-year-old woman presented to the emergency room with 3-day history of severe abdominal pain, gross abdominal distention and absolute constipation, in addition to mental confusion and lowering of consciousness level in the last 12 hours. She had past history of appendectomy and left oophorectomy 40 years ago. Patient's daughter reported a painless hardened nodule in the umbilical region for 45 days. The umbilicus nodule had been diagnosed as an umbilical hernia by the general practitioner and the patient was awaiting outpatient evaluation by a general surgeon. Examination revealed a blood pressure of 140/86 mmHg, a heart rate of 108 beats/min, and oxygen saturations of 96% on room air; positive findings included marked abdominal distension, generalized abdominal tenderness without peritonitis, tinkling bowel sounds and a painless erythematous-umbilical nodule measuring 2.2x1.8cm (A). Laboratory testing was remarkable for elevated white blood cells at 15,180/mm3, C-reactive protein of 66.2 mg/dl, and serum CA125 of 139.9 Units/ml. Computed tomography scan of the abdomen and pelvis showed ovarian mass with extrinsic compression of intestinal loops with significant dilatation upstream of the obstruction point; an umbilical nodule was present (B, C). In view of patients with acute abdominal condition exploratory laparotomy was performed and intraoperatively moderate ascites, severe intestinal loops distension and a large and unresectable ovarian mass were observed. Ascitic fluid analysis was positive for atypical cells and histopathology of the umbilical nodule showed solid low-grade carcinoma with numerous atypical mitoses, karyorrhexis and abundant necrosis. After the discussion with patient's caregivers, palliative care was started and unfortunately the patient died 14 days after the surgery. Sister Mary Joseph nodule is an eponym to describe cutaneous metastasis of an underlying abdominal malignancy to the umbilical cicatrix. This ominous finding is uncommon although accurate sign of advanced primary visceral cancer.

Cholangiocarcinoma in HIV Patients: Is There an Association?

CASE REPORT: The patient is a 40-year-old male with history of HIV on Stribild and HTN presented with 1 month history of severe abdominal pain and 25lb weight loss. He had elevated LFT's and abdominal USG showed gall bladder sludge, no wall thickening or bile duct dilatation. HIDA scan showed chronic cholecystitis. ERCP showed pancreatic duct and distal CBD strictures requiring stent placement. Cytology brushings were obtained and initial pathology was negative for malignancy. Patient underwent laparoscopic cholecystectomy and was discharged home. He was re-admitted 2 weeks later with worsening abdominal pain concerning for acute pancreatitis likely secondary to HAART. FISH analysis was concerning for high grade dysplasia or malignancy of the pancreatobiliary tract. CA 19-9 was normal. Pancreatitis was treated conservatively and patient underwent ERCP/EUS which revealed severe CBD stricture requiring stent placement. FNAC performed in the body of the pancreas was concerning for cholangiocarcinoma (CC). 2 weeks later, he underwent exploratory laparotomy and Whipple procedure. PET/CT was concerning for a metastatic disease with plan to start chemotherapy with gemcitabine/cisplatin. He continues to have severe abdominal pain likely from chronic pancreatitis. DISCUSSION: In general, HIV is associated with increased risk of malignancies. Non-Hodgkin's lymphoma and Kaposi sarcoma are AIDS defining diseases and Hodgkin's Lymphoma, myeloid leukemia are linked to HIV. Biliary neoplasms are not commonly associated with HIV. CC is a rare adenocarcinoma of bile duct epithelium seen commonly in males. Clinical presentation and lab studies can be non specific. CT or MRI abdomen can reveal a mass but ERCP/ EUS are preferred imaging and diagnostic modalities. Treatment options include surgery followed by chemo-radiation. HIV/AIDS infected patients have high risk of neoplasm involving the liver. HIV related cholangitis/cholangiopathy are often associated with an infective etiology like CMV, cryptosporidium etc. It has been postulated in many studies that cholangitis in HIV patients can cause CC due to chronic inflammation/chronic cholestasis, either diectly from HIV or from opportunistic infections. There is data postulating ART or immuno suppresion causing CC. There is still no clear understanding of relationship between HIV infection, cholangitis and cholangiocarcinoma, necessitating the need for increasing body of supporting literature and case reports.Figure: EUS image showing invasion into pancreatic head.Figure: Cholangiogram showing bile duct stenosis.Figure: EUS image showing diffusely thickened bile duct wall.

Endovascular treatment of splenic artery pseudoaneurysm

Splenic artery pseudoaneurysms are rare complication of chronic pancreatitis or, somewhat less often, acute pancreatitis. We present a case of 34 year old male of acute on chronic pancreatitis admitted with history of severe abdominal pain, radiating toward back. CT revealed a large pseuoaneurysm involving the splenic artery. Endovascular approach was taken to occlude the neck of pseuoaneurysm with a graft stent.

A case report of spontaneous pneumoperitoneum after sexual intercourse following a total laparoscopic hysterectomy, bilateral saplingo-oophorectomy and infra-colic omentectomy

The finding of pneumoperitoneum on a chest radiograph is most commonly associated with an underlying viscus perforation (Mularski et al. West J Med 170:41–46, 1999). Urgent surgical intervention, in particular emergency laparotomy, is often required in these cases. However, in 10 % of patients, a perforated viscus is not the precipitating cause of a pneumoperitoneum (referred to as a spontaneous or non-surgical pneumoperitoneum (SP). These cases are rarely associated with peritonitis and are usually managed conservatively (Mularski et al. West J Med 170:41–46, 1999; Pitiakoudis et al. J Med Case Rep 5:86, 2011). We present a case of a 28-year-old female presented to the Accident and Emergency department with a 6-h history of severe abdominal pain and bilateral shoulder tip pain. She reported that the pain developed 2 h following sexual intercourse. She had undergone a laparoscopic total hysterectomy, bilateral saplingo-oophorectomy and infra-colic omentectomy for borderline ovarian tumours 25 days previously. The most likely cause of this patient’s acute abdominal pain was a spontaneous pneumoperitoneum secondary to sexual activity. Clinicians should be aware with the potential non-surgical causes for the presence of a pneumoperitoneum, particularly in patients who are not presenting with the other characteristic clinical features of an acute gastrointestinal perforation such as peritonitis, fever and elevated white cell count. These particular patients can be largely managed conservatively.