Intra-abdominal Pathology Research Articles

Giant Ovarian Cyst That May Be Confused With Mesentery Cyst

Ovarian cysts may reach giant size and may usually be confused with intraabdominal mesentery cysts, acid accumulation or inclusion cysts. They usually appear with intestinal system findings and abdominal distention. Computed tomography (CT) may be used for the detection of size and origin of the cysts. Midline laparotomy should be preferred due to the likelihood of malignity and confusion with other intraabdominal pathologies. Treatment protocol is determined based upon the patient’s fertility. A 52-year-old female patient, who was admitted with constipation and abdominal distention, and was detected to have a mucinous cystadenoma measuring 25 cm originating in the left ovary, is presented in this paper. J Med Cases. 2014;5(6):326-328 doi: http://dx.doi.org/10.14740/jmc1776w

English

INTRODUCTION: The diagnosis and treatment of patients of abdominal injuries is evolving and newer techniques are emerging. Focused abdominal sonography is indicated for unstable patients. Laparoscopy could be appropriate for patients with seat belt injuries where intestinal injuries are suspected. A thorough diagnostic laparoscopy for identifying intestinal injury and exclude intraabdominal pathology. Laparoscope should be inserted thorough umbilicus .Stab injury entrance site should be closed for allowing creation of pneumoperitoneum .Diagnostic laparoscopy from gunshot is generally performed for excluding peritoneal breach. For laparoscopy, patient should be placed supine, x-ray chest should be seen prior to patients of penetrating injuries chest. An occult pneumothorax with positive pressure ventilation could cause tension pneumothorax. The evaluation of patient with penetrating abdominal trauma is evolving and used for stable patients. Diagnostic laparoscopy could be used for select patients for anterior abdominal stab injuries. Laparoscopy has an important role for thoracoabdominal stab injuries especially on left where there is diaphragmatic injury which could develop diaphragmatic hernia. The purpose of laparoscopy is to exclude or confirm intra-abdominal injury. Appropriate use of diagnostic laparoscopy reduces the incidence of non-therapeutic celiotomies. For penetrating injury, diagnostic laparoscopy could be used for excluding peritoneal breach or diagnose enteric injury.

Incidental Pancreatic Cysts

The widespread adoption of multidetector computed tomography and magnetic resonance imaging (MRI) for evaluation of intraabdominal pathology has resulted to a steady increase in the number of incidentally discovered pancreatic cysts in clinical practice during the last decades. The differential diagnosis of these cysts is broad including pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. The MRI has an important role both in the initial characterization of incidentally detected pancreatic cysts and the follow-up of these lesions and has become an integral part of the diagnostic algorithm for pancreatic cysts at many institutions. The inherent soft-tissue contrast of magnetic resonance cholangiopancreatography provides the vehicle for providing a specific diagnosis in many pancreatic cysts. Furthermore, an MRI-based characterization of pancreatic cysts allows for selection of those cysts that are more likely to benefit from endoscopic ultrasound and fine-needle aspiration for analysis of the fluid contents. Moreover, small asymptomatic incidental pancreatic cysts without concerning MRI features such as internal septae and/or nodularity may be safely followed with serial imaging. The lack of risk associated to repeated exposure to ionizing radiation and its ability to characterize pancreatic cysts are strong arguments for selecting MRI as the preferred imaging modality for following up these lesions. However, the recommendations for imaging follow-up continue to evolve, and several of the proposed guidelines are reviewed in this manuscript.

Microbial Spectrum of Intra-Abdominal Pathology of Patients Requiring Surgical Intervention in a Rural Teaching Hospital

Background: Intra abdominal pathologies requiring surgical intervention include appendicitis , malignancies, trauma ,perforation peritonitis etc. The most common organism isolated at the time of surgery was E. coli.We studied the spectrum of microbes at the time of laparotomy/laparoscopy to help us to know the emerging trends in microbiological spectrum and the sensitivity pattern in this medical college hospital. Objective: To study the microbial spectrum and sensitivity pattern in patients with intra abdominal pathology requiring surgical interventions. Methodology: After ethical committee approval was obtained, data for this retrospective study, with a sample size of 93 cases were collected from theGeneral Surgery Records and analysed. Result: Of the 93 cases studied, E. coli dominated in 75% cases of acute appendicitis and Enterococcus was found in 16.2%. In cases of hollow viscous perforation 50% were E.coli and 15.3% were K.pneumoniae. In acute appendicitis with peritonitis 64.25% were E.coli, K.pneumoniae and Enterococcus were 21.4% each.In case of colonic malignancy 28.5% of patients were infected by E. coli followed by enterococcus with 21.4%. E.coli and K. pneumoniae were more sensitive to carbapenems, colistin and fluroquinolones, while Enterococcus was more sensitive to Linezolid. Conclusion: E. coli is the organism that predominates in intra abdominal pathology requiringsurgical intervention and the common organisms are mostly sensitive to the carbapenems, linezolid , Colistin and

Acute abdominal pain after intercourse: adrenal hemorrhage as the first sign of metastatic lung cancer.

Although the adrenal glands are a common site of cancer metastases, they are often asymptomatic and discovered incidentally on CT scan or autopsy. Spontaneous adrenal hemorrhage associated with metastatic lung cancer is an exceedingly rare phenomenon, and diagnosis can be difficult due to its nonspecific symptoms and ability to mimic other intra-abdominal pathologies. We report a case of a 65-year-old man with a history of right upper lobectomy seven months earlier for stage IB non-small cell lung cancer who presented with acute abdominal pain after intercourse. CT scan revealed a new right adrenal mass with surrounding hemorrhage, and subsequent FDG-PET scan confirmed new metabolic adrenal metastases. The patient's presentation of abdominal pain and adrenal hemorrhage immediately after sexual intercourse suggests that exertion, straining, or increased intra-abdominal pressure might be risk factors for precipitation of hemorrhage in patients with adrenal metastases. Management includes pain control and supportive treatment in mild cases, with arterial embolization or adrenalectomy being reserved for cases of severe hemorrhage.

Giant Ovarian Cyst That May Be Confused With Mesentery Cyst

Ovarian cysts may reach giant size and may usually be confused with intraabdominal mesentery cysts, acid accumulation or inclusion cysts. They usually appear with intestinal system findings and abdominal distention. Computed tomography (CT) may be used for the detection of size and origin of the cysts. Midline laparotomy should be preferred due to the likelihood of malignity and confusion with other intraabdominal pathologies. Treatment protocol is determined based upon the patient’s fertility. A 52-year-old female patient, who was admitted with constipation and abdominal distention, and was detected to have a mucinous cystadenoma measuring 25 cm originating in the left ovary, is presented in this paper. J Med Cases. 2014;5(6):326-328 doi: https://doi.org/10.14740/jmc1776w

Basic techniques in endoscopic ultrasound-guided fine needle aspiration for solid lesions: Adverse events and avoiding them.

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.

Neuropathic truncal pain in patients with type 2 diabetes mellitus relieved by topical cream and nerve block

Neuropathic truncal pain in patients with type 2 diabetes mellitus relieved by topical cream and nerve block

Omental torsion.

Torsion of greater omentum is one of the rare causes of acute abdominal pain. It can be primary or secondary. Primary Omental Torsion (POT) occurs because a mobile, thicken segment of omentum rotates around a proximal fixed point in the absence of any associated or secondary intra-abdominal pathology. Secondary omental torsion is associated with a number of pre-existing conditions most common among them is inguinal hernia, other causes include tumours, cysts, internal or external herniation, foci of intra-abdominal inflammation and postsurgical wound or scarring. Torsion of omentum causes twisting of omentum along its long axis resulting in impaired blood supply. This rare condition is more predominant in middle-aged males. It clinically mimics acute appendicitis. It should be kept in mind as a differential diagnosis for acute abdomen. Laparoscopy can aid in diagnosis and management but explorative laparotomy is the definitive and therapeutic procedure of choice. However the condition is not life threatening as omentectomy reduces the inflammation and focus of adhesions within the abdomen.

How to distinguish between surgical and non-surgical pneumoperitoneum?

Not all cases of pneumoperitoneum found on abdominal X-ray or computed tomography (CT) scan are caused by hollow viscus perforation. Non-surgical or spontaneous pneumoperitoneum is a repeatedly described entity. However, not all physicians in emergency departments are aware of it, and in such cases unnecessary laparotomy is often performed which reveals no intra-abdominal pathology. Non-surgical pneumoperitoneum can have thoracic, abdominal, gynecological, or other causes. When we acknowledge the possibility of non-surgical pneumoperitoneum, the primary goal is to discern surgical from non-surgical pneumoperitoneum. Identifying cases in which laparotomy can be avoided is important to prevent unnecessary surgery and its associated morbidity and financial costs. In this paper we propose a practical algorithm which may help the attending physicians to distinguish between surgical and non-surgical pneumoperitoneum.

Robotic surgery of the pancreas.

Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.

Abdominal pain: an approach to a challenging diagnosis.

Acute abdominal pain represents the cardinal symptom of a large number of intra-abdominal pathologies. Because of multiple organ systems, varied pathology from life threatening to benign, and differences in presentation related to sex and age, identifying a final diagnosis is a challenge. The clinician's goal for patients with acute abdominal pain is to rapidly identify whether the underlying cause requires an urgent or immediate surgical intervention. By developing a systematic approach to evaluating patients with abdominal pain, clinicians can generate a differential diagnosis to ensure appropriate treatment and improved patient outcomes. The purpose of this article is to provide clinicians with a framework for evaluating the complaint of acute abdominal pain and recognizing patients who require expedited evaluation.

Central Line–Associated Bloodstream Infection in Neonatal Intensive Care Units

Describe the epidemiology of central line-associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) participating in a standardized and mandatory CLABSI surveillance program. Retrospective cohort. Setting. We included patients admitted (April 2007-March 2011) to 7 level II/III NICUs who developed a CLABSI (as defined by the National Healthcare Safety Network). CLABSIs/1,000 central line-days and device utilization ratio were calculated; χ(2) test, Student t test, Kruskal-Wallis, and Poisson regression were used. Overall, 191 patients had 202 CLABSI episodes for a pooled mean rate of 4.0 CLABSIs/1,000 central line-days and a device utilization ratio of 0.20. Annual pooled mean CLABSI rates increased from 3.6 in 2007-2008 to 5.1 CLABSIs/1,000 central line-days in 2010-2011 (P - .01). The all-cause 30-day case fatality proportion was 8.9% (n = 17) and occurred a median of 8 days after CLABSI. Coagulase-negative Staphylococcus was identified in 112 (50.5%) cases. Staphylococcus aureus was identified in 22 cases, and 3 (13.6%) were resistant to methicillin. An underlying intra-abdominal pathology was found in 20% (40/202) of CLABSI cases, 50% of which were reported in the last year of study. When adjusted for mean birth weight, annual CLABSI incidence rates were independently associated with the proportion of intra-abdominal pathology (P = .007) and the proportion of pulmonary pathology (P = .016) reported. The increase in CLABSI rates in Quebec NICUs seems to be associated with an increased proportion of cases with underlying intra-abdominal and pulmonary pathologies, which needs further investigation.

NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model

We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure. We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy. We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications. Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.

Acute Pancreatitis in a Patient With Diabetic Ketoacidosis and Normal Lipase Levels

The diagnosis of acute pancreatitis requires clinical, biochemical, and occasionally imaging information. Biochemical criteria include serum lipase levels, which are considered both sensitive and specific for the diagnosis of acute pancreatitis. Patients with diabetic ketoacidosis often have abdominal pain that may be related to the ongoing metabolic derangement or to precipitating intra-abdominal pathology. The pain severity in diabetic ketoacidosis helps determine whether abdominal disease should be further investigated. We present a patient with diabetic ketoacidosis and acute pancreatitis who had no significant elevation of amylase and lipase. The patient had abdominal pain that persisted despite ongoing treatment with intravenous insulin for ketoacidosis. The pain was initially located in the epigastrium and then migrated to the right lower quadrant. An abdominal computed tomography scan was obtained to exclude acute appendicitis, and this study revealed peripancreatic fluid consistent with acute pancreatitis that extended into the right lower quadrant anterior to the psoas muscle. A literature review of previous case reports and possible explanations for normal lipase levels are discussed. In conclusion, normal lipase levels do not exclude the diagnosis of acute pancreatitis and imaging criteria may be needed. It is also important to recognize that laboratory studies have limitations, and these should be taken into account when confirming a diagnosis.

The feasibility score for the Laparoscopic Appendicitis Score

We appreciate the comment of Liu and Lu on our article. In response to their first concern about the fecaliths, we agree with the statement that fecaliths are associated with appendicitis and perforation of the appendix. We are unsure whether the presence of fecaliths should be an item in the Laparoscopic Appendicitis Score (LAPP score). Therefore, we retrospectively analyzed all high-definition videos we took from the 25 normal appendices. As described in our Methods section, all appendices were thoroughly evaluated by the surgeon, and this was captured on video. In none of the 25 normal appendices a fecalith was present. Therefore, in our opinion, a fecalith in a normal appendix is very rarely seen and probably not relevant. However, we believe that in our planned large multicenter study, we should prospectively register the presence of fecaliths. We agree with the authors that a thickened peritoneum around the appendix caused by other intraabdominal pathology should not be a reason for an appendectomy. In our view, it is not difficult for surgeons to differentiate a thickened appendix or mesoappendix from appendicitis or from peritonitis caused by other pathology. We do not agree with the last concern raised by Liu and Lu. In our view, there is no literature on the interval between the onset of symptoms and the intraoperative appearance of the appendix. We speculate that in case the patient has right iliac fossa pain from appendicitis, there is peritonitis and thus the peritoneum or appendix is thickened. We saw 17 of our patients within 12 h of their initial complaints, and we did not notice any difference between the appearance of their appendices and those of patients with a longer duration of symptoms. Notably, 5 of these 17 appendices were necrotic (29 %), and 7 of the patients had pus around their appendix (41 %). In comparison, for all the patients with appendicitis (n = 109), this was a 28 % rate for necrosis and a 53 % rate for pus.

Laparoscopic Management of Omental Cyst in a Child Using Two Ports Technique: A Case Report and Review of Relevant Literature

Background: Omental cysts are rarely intra-abdominal pathology. We report a case of omental cyst successfully resected by laparoscopy using two ports only with excellent outcome. Case Presentation: Our patient was a seven year old girl who presented with complaints of lump in abdomen, in which laparoscopy aided in making a correct final diagnosis and the surgical management. Preoperative diagnostic work-up included Ultrasonography and Computed Tomography scan (CT scan) of abdomen which revealed huge intraabdominal cystic lesion of unknown origin. Extensive diagnostic workup did not reveal the etiology of his problem. Diagnostic laparoscopy led to the correct diagnosis and appropriate surgical treatment with complete relief of his complaint. Histopathology of the excised specimen was suggestive of lymphangioma. Conclusions: On six months of follow up, the patient is doing well and asymptomatic with no evidence of recurrence.

Dermo-hypodermites nécrosantes du tablier abdominal chez l’obèse. À propos de deux cas cliniques révélateurs d’infections profondes abdomino-pelviennes

Necrotizing dermohypodermitis of abdominal wall in obese is a rare disease with high mortality. We report two cases of 50 and 62years old patients whose intra-abdominal infectious pathology (appendicular abscess for one and pyosalpinx for the other) was revealed by a necrotizing dermohypodermitis of the abdominal wall. The diagnosis has been established on the basis of converging clinical arguments (abdominal pain, crackles and necrotic appearance of abdominal wall in a septic shock context), linked with a CT-scan. The treatment consisted of a large excision of the abdominal wall necrosis and surgical eradication of deep infection source, with an intensive care and a broad spectrum antibiotic therapy. Both these patients present morbid obesity (BMI>40) whose implication must be taken into consideration in the way the disease appears. Indeed, the necrotizing dermohypodermitis of abdominal wall in these patients must lead first in looking for a deep infection with few symptoms. It must be identified quickly to propose an early and multidisciplinary surgical treatment.

AN AUDIT OF LAPAROTOMIES;

Objective: To make an audit of laparotomies carried out at Combined Military Hospital Pano Aqil over a three year period.Study design: Cross sectional, retrospective study. Place and duration of study: Study was carried out at surgical department ofcombined military hospital Panno Aqil over a period of three years from Jan 2009 to Dec 2011. Patients and methods: Patients withsignificant intra-abdominal pathology presenting as acute abdomen and who underwent laparotomy were included in study. Patientswere either electively admitted via outpatient department or through Accident and Emergency (A&E) department. Patient charts andrecords were used to collect data. Results: All 174 patients underwent laparotomy. In (27.6%) cases, intestinal perforation was theunderlying cause; gynaecological pathology was found in (21.2%) patients. In 19.5% cases blunt and penetrating abdominal trauma wasthe cause of acute abdomen. Acute intestinal obstruction was found in (21.3%), tumors were found in (7.9%) and miscellaneous causeswere identified in (2.3%) cases. Conclusions: Laparotomies carried out at Combined Military Hospital Pano Aqil fulfilled the evidencebased medicine criteria.

MEDULLARY SPONGE KIDNEY AND VON MEYENBURG COMPLEX

(2013). MEDULLARY SPONGE KIDNEY AND VON MEYENBURG COMPLEX. Acta Clinica Belgica: Vol. 68, No. 1, pp. 73-74.