Intra-abdominal Pathology Research Articles

Spontaneous inflammation and necrosis of the falciform and round ligaments: a\xa0case report and review of the literature

BackgroundNecrosis of the falciform and round ligaments is extremely rare, thus making the diagnosis challenging. It is often misdiagnosed as gallbladder pathology due to the presenting symptoms. Due to the rarity of this pathology, there is limited literature available.Case presentationA 53-year-old white man presented to our hospital with signs and symptoms of gallbladder pain but turned out to have the rare entity of necrosis of the falciform and round ligaments. An extensive review of the world literature was performed using PubMed. Manual cross-referencing of reference lists was performed to obtain all available articles. The personal operative log of the senior author was also searched to reveal one additional case. Statistical analysis was descriptive only, given the small number of reported cases. Thirty-nine articles were found, among which forty-three case were identified, and one additional case was extracted from the operative log of the senior author. Unlike previous reports, we found that isolated inflammation and necrosis of the ligaments occurs at nearly the same frequency in both men and women, not predominantly in women as previously reported in smaller series. The mean age at presentation was 59.5 years old, and cases were typically initially diagnosed as gallbladder pathology, most commonly acute cholecystitis. Computed tomography more frequently than ultrasound revealed the falciform and round-ligament pathology.ConclusionsIsolated falciform and round-ligament inflammation and necrosis is a rare condition that is difficult to diagnose because it can present mimicking a wide variety of intra-abdominal pathologies, particularly gallbladder pathologies. It is often best treated by laparoscopic resection. Unlike prior reports, our review of the literature, which is the largest that we know of to date, shows that males and females are equally affected. Greater awareness of this entity will aid in future diagnosis.

Characteristics and outcomes of acute colitis diagnosed on cross-sectional imaging presenting via the emergency department in an Irish academic medical centre.

A significant proportion of patients presenting to the Emergency Department with gastrointestinal symptoms that result in cross-sectional imaging receive a radiological diagnosis of colitis. We aimed to review the characteristics, outcomes, and final diagnoses of new emergency department presentations with colitis diagnosed on cross-sectional imaging. A radiology database was interrogated to identify patients admitted from the Emergency Department of St James's Hospital whose cross-sectional imaging demonstrated colitis. Baseline demographic data, information on inpatient investigations, final diagnoses, and outcomes were recorded.Adverse outcomeswere defined as a requirement for surgery, intensive care unit(ICU) stay, or mortality RESULTS: A total of 118 patients, 67% female, were identified with a median age of 64years (range 16.9-101.2). Median (range) admission duration was 10days (1-241). Final colitis diagnoses were infectious (28%), undefined (27%), reactive (18%), inflammatory bowel disease (11%), ischaemic (9%), chemotherapy-associated (3%), diverticular (3%), and medication-associated (1%). Colonic perforation, colectomy, and mortality occurred in 1%, 5%, and 13% of the cohort respectively. On univariate analysis, low haemoglobin, lowalbumin, high lactate, and male gender were associated with adverse outcomeswith the following odds ratios (OR) and 95% confidence intervals (95%CI) were lowhaemoglobin 1.49 [1.15-1.92] P= 0.002, low albumin 1.16 [1.07-1.25] P= 0.0002, lactate 1.65 [1.13-2.42] P= 0.009, and male gender 3.09 [1.23-7.77] P= 0.019. On multivariate analysis, male gender was associated with adverse outcomes. Patients presenting to the Emergency Department with a colitis, requiring an abdominal CT are a heterogenous group with a proportion having concomitant intra-abdominal pathology resulting in critical illness. Hence their is a significant morbidity and mortality observed in this cohort which should not be extrapolated to a general population of patients presenting with colitis. In this cohort of patients, anaemia, hypoalbuminaemia, and elevated lactate in patients presenting to the ED with acute colitis are significantly associated with adverse outcomes. Early recognition of these prognostic factors may identify the cohort of patients who are best managed in a high-dependency setting.

Abdominal wall dehiscence in emergency midline laparotomy: incidence and risk factors

Background Burst abdomen is a very serious postoperative complication associated with high morbidity and mortality. It has a significant effect on health care cost, for both the patients and the hospitals. Purpose The aim of this study was to assess the incidence and perioperative risk factors of burst abdomen in patients undergoing emergency midline laparotomy. Patients and methods A prospective cohort study was conducted on 250 patients who underwent midline laparotomy at Kasr Al-Ainy Hospital Emergency Department, Cairo University, from August 2017 until August 2018. Factors such as age, sex, BMI, substance abuse, previous laparotomy, malignancy, diabetes mellitus, ascites, albumin, renal functions, bilirubin, hemoglobin, intra-abdominal pathology, suture material, creation of stoma, postoperative chest infection, postoperative paralytic ileus, leakage, and wound infection were observed and analyzed. Results Incidence of burst abdomen was 12.4%. Wound infections (87.1 vs. 18.7%, P Conclusion Important risk factors according to our study were wound infection, anemia, previous laparotomy, creation of stoma, hypoalbuminemia, ascites, diabetes, type of intra-abdominal pathology, with maximum incidences in peritonitis, postoperative cough, and postoperative leakage. Patient sex, age, associated morbidities such as jaundice and uremia, previous use of steroids, suture material used in closure, and postoperative paralytic ileus were not significant in our study.

Kızlarda inguinal herni kesesinin laparoskopik koterizasyonu: Burnia tekniği

INTRODUCTION: Inguinal hernia repair is one of the most common surgical procedures in pediatric surgery. In parallel with the advances in the field of medicine, various laparoscopic techniques have been developed in inguinal hernia repair. The Burnia technique is one of the latest published techniques and it is the cauterization of the inguinal hernia sac laparoscopically without using sutures in girls. The aim of this study is the investigation of the use of Burnia technique in clinical practice, and its postoperative outcomes. Any article concerning the use of this technique in Turkey has not been encountered. METHODS: The demographic features of patients, preoperative, peroperative, postoperative and follow-up results of 41 patients who had been operated with Burnia technique by a single surgeon within 2 years were reviewed retrospectively. Laparoscopically, the camera was first placed at an inclination of 30 degrees to the umbilical region using Hasson technique, and then, a single port was used for cauterization of the hernia sac. The Hernia sac was pulled into the abdominal cavity and cauterized. RESULTS: Burnia technique was applied to 62 inguinal hernia sacs in 41 girls. Their ages ranged from 1.5 to 16 years (median 36 months) with body weights ranging between 3.5 kg-40 kg (median 12 kg). Preoperatively 15 patients had right (37%), 19 patients left (46%), 7 patients bilateral inguinal hernias (17%). During surgery, 14 of the unilateral inguinal hernias were found to have a hernia sac on the contralateral side, and the rate of bilateral hernia increased to 51 percent. In one patient ovary was in the inguinal canal, and after its reduction, we proceeded with the operation Unexpectedly. in one patient, right ovarian torsion was detected which was detorsioned, and hernia surgery was performed in the same session. The duration of the operation was 5-35 min (median 15 min) for unilateral and 8-45 min (median 20 minutes) for bilateral hernias. None of these patients developed peroperative and postoperative complications. Follow-up time was minimum 10 months, and maximum 3 years. Recurrence was not detected. DISCUSSION AND CONCLUSION: Burnia technique seems to be effective and safe. The contralateral side and other intra-abdominal pathologies are explored. The cosmetic appearance is its another advantage. The operation time is very short due to the fact that only the hernia sac is cauterized. Comparison of this technique with other laparoscopic techniques is planned in the future study.

Ultrasonographic evaluation of gastrointestinal system involvement in chronic inflammatory rheumatic diseases

Aim: Although chronic inflammatory rheumatic diseases (CIRDs) primarily affect the joints due to arthritis; involvement of other systems and organs is not rare. Ultrasound evaluations are particularly useful in the detection of pathologies observed in the gastrointestinal tract. The aim of this study was to investigate and compare the results of abdominal ultrasonography in gastrointestinal system of some common chronic inflammatory rheumatic diseases.Material and Methods: 96 patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis were included in the study. The data of patients were retrospectively reviewed from patient files and hospital database. Patients with abdominal ultrasound performed for the check-up indication in the last 6 months and updated laboratory tests in the last 1 month were included in the study. The patients were divided into three groups according to the diagnosis and the results were compared.Results: No gastrointestinal system involvement was observed in the patients except liver and gallbladder pathologies. The most frequent liver pathologies were hepatosteatosis (49.0%) and hepatomegaly (41.7%), respectively. The rate of patients with cholecystectomy was 8.3% and 6.3% of the patients had gallstones. When the results were compared between the groups, it was seen that only the incidence of gallstones was significantly higher in the psoriatic arthritis group than in other groups.Conclusion: In the course of chronic inflammatory rheumatic diseases, many organ and system involvement may be observed. Abdominal ultrasound imaging, especially in patients with additional risk factors, may be useful for early detection of many intra-abdominal organ pathologies, especially the gastrointestinal tract.

Minimally Invasive Surgery for Congenital Abdominal Cystic Lesions in Newborns and Infants.

In the variety of congenital abdominal cystic lesions (CACL) of different origin, ovarian cyst is the most common intra-abdominal pathology in female neonates. The prognosis and timing of treatment varies depending on the nature of CACL. This study aimed to assess the results of diagnostics and treatment of CACL. A retrospective analysis was performed of 39 cases of CACL, with the spectrum including ovarian, enteric, mesenteric and pancreatic origin. Outcome of minimally invasive surgery, open surgery or conservative approach was analyzed. Twenty-eight neonates underwent surgery, while 11 were treated conservatively. Twenty patients were treated with a laparoscopic technique and eight with laparotomy combined with laparoscopy. Final diagnosis included: Fifteen cases of ovarian pathology (ovarian torsion in 11 cases), 12 treated laparoscopically and three with laparotomy, six enteric duplications (four laparoscopic and two laparotomic), three mesenteric cysts (one laparoscopic and two laparotomic), two pancreatic cysts (both laparoscopic only), two duodenal stenoses, including duodenal septum (both laparotomies with Heineke-Mikulicz plasty). No blood transfusion apart from two cases requiring re-laparotomy and no early complications were observed in any case; no death occurred. With the strategy of management based on ultrasound and laboratory data, a laparoscopically assisted minimal access approach resulted in minimal risk of complications and complete recovery in all patients, leading to exclusion of oncological risk.

Peritoneal Fluid Analysis of the Newborn Calves with Intestinal Atresia - a Clinical Approach

Background: Anomalies and fetal problems are encountered in all animals. Intestinal atresia is a congenital anomaly of both humans and animals. Intestinal atresia has four morphological types, and they can be observed in jejunum, ileum, cecum, colon, rectum and anus (type I: mucosal atresia, type II: atretic ends separated by fibrous cord, type III: atretic ends separated by a “V” shaped mesenteric gap or atretic end coil like an “apple peel”, type IV: multiple atresia). In calves, it is also commonly encountered; it is still a question to be replied about the exact prognosis of the patients with intestinal atresia. Thus, the main objective of the present study was to evaluate peritoneal fluid analysis results of calves with intestinal atresia.Materials, Methods & Results: Twenty-two calves were presented with abdominal distension and lack of defecation. Clinical and radiological findings pointed out the intestinal atresia. Blood samples were collected for routine hematological and serum total protein (TP) analysis. Peritoneal fluids were aspirated with sterile technique from the caudal abdomen, and biochemical features, cell contents and microbiological cultures of the peritoneal fluids were analyzed. Following to preoperative, surgical and necropsy findings, intestinal atresia were diagnosed as type II, III and IV in calves. Neutrophilic leukocytosis was observed in calves with type IV intestinal atresia. Red blood cells and platelet counts were determined in the peritoneal fluids. TP and density values of the peritoneal fluid were high in all cases. These results pointed the presence of the acute infection and peritonitis. Statistical comparison of each parameter showed that there was no significant difference between the types of intestinal atresia. Microbiologically, fecal origin bacteria were cultured in 12 calves.Discussion: In general, four types of intestinal atresia are encountered in calves, and all types are fatal pathologies; thus, surgery should urgently be planned as soon as diagnostic work-ups are completed after birth. Peritoneal fluid analysis is a useful diagnostic choice because changes in the peritoneal fluid parameters help to diagnosis of the intra-abdominal pathology. Intestinal atresia as more common anomaly in Holstein, Jersey and Montafon breed calves. In animals with intestinal atresia, surgical treatment is not usually recommended due to economic reasons and small chance of postoperative success. Long-term survival rate of surgically treated animals depends on the type of intestinal atresia and applied surgical technique. Atresia recti and ani may occur simultaneously with atresia coli, and all atresias (atresia coli, ani, recti or ani et recti) can be successfully treated by surgery. Continuous distention of the large intestinal segments leads to ischemia, necrosis, peritonitis and bowel perforation. Peritoneal fluid analysis should include the classic parameters for diagnosis, but these analyses are often insufficient to identify the etiology or pathogenesis of the disease. An increase in total WBC count and percentage of the neutrophil cells in the peritoneal fluid indicate the acute infectious origin inflammation. Additional parameters in the peritoneal fluid analysis have been established to improve diagnostic precision and specific information. Presence or absence of the bacteria in the peritoneal fluid samples is important to characterize the transudate and exudate. Changings in the peritoneal fluid values does not related to type of the intestinal atresia in calves.

Efficacy of celiac plexus block in chronic pancreatitis in pediatric age group

Neurolysis of the celiac plexus has been found to be an effective way of palliating chronic pain due to non-pelvic intra-abdominal organ pathologies such as upper abdominal malignancies and chronic pancreatitis. We assessed the effectiveness of celiac plexus block (CPB) for pain due to chronic pancreatitis in pediatric age group. Eleven children between the age group of 3–10 years suffering from abdominal pain due to chronic pancreatitis underwent CPB through transaortic approach. Assessment of pain relief compared to pre-procedure status was done using Wong-Baker Faces Pain Rating Scale. Ten out of 11 children had symptomatic relief post-procedure and on 6 months follow-up. One child had relapse of pain after 3 months of CPB. We conclude that CPB is a promising solution for tackling intractable pain due to chronic pancreatitis in pediatric age group.

Innocent Children in the Syrian Civil War.

Our aim is to present the clinical and surgical characteristics of the children affected by the Syrian civil war. Medical records were reviewed retrospectively for Syrian war victims between the ages of 0 and 18 who were brought to the emergency department of the Education and Research Hospital between March 2011 and March 2019. Each patient was evaluated with respect to demographic data (gender, age), type of injury, history of operations in Syria, injured organ(s), accompanying traumas and the mortality and trauma score. The majority of our study population of 147 patients were male (108/147, 73.46%), and 39 of the total were girls (26.53%). The mean age of the patients was 9 (7.5 ± 4). The mean age of the girls was 8.5 (range: 7 months to 16 years), and the mean age of the boys was 9.2 (4 months to 17 years). Seventeen patients who had abdominal surgery in Syria were operated on again after clinical and radiological observations. A total of 83 patients were operated on in Turkey. For 66 of those patients, the operation in Turkey was their first surgery on their war injuries. Seventeen patients were operated on in Syria but needed surgery again in Turkey. War affects not only the battlefield, but also the neighboring countries in many aspects such as medical, social, and economic. Hollow organ injuries are the most common intraabdominal pathologies. Delayed intervention is associated with increase mortality and morbidity.

THE CASE OF A DISGUISED PNEUMOTHORAX

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A multitude of causes can be associated with secondary spontaneous pneumothorax (SSP). Over 70% of cases are associated with chronic obstructive pulmonary disease. Other causes range from genetic risk factors (Cystic fibrosis/Marfans), necrotizing pneumonia (Pneumocystis Jiroveci /Staph Aureus) or lung cancer. Although there are various causes, the presentation is most often the same. Most patients present with dyspnea and chest pain. It is rare that a pneumothorax is diagnosed by abdominal computer tomography (CT). This report examines a case about an elderly female who was found to have a spontaneous pneumothorax secondary to pneumonia that presented with abdominal pain with diffuse tenderness. CASE PRESENTATION: A 77 year old female presented as an outside hospital transfer for altered mental status from a nursing home. Patent originally had a cough with was associated with shortness of breath and was initially prescribed Augmentin by the nursing home physician. Unfortunately, patient’s condition did not improve and she started to rapidly decline, eventually requiring assistance with daily activates. A chest x-ray (CXR) was remarkable for a right lower lobe infiltrates. Patient was febrile with a leukocytosis that lead to a diagnosis of pneumonia, and was started on broad-spectrum antibiotics. With treatment, her mentation started to improve along with her leukocytosis. Four days after initiation of treatment, she was found to be hypotensive with systolic pressure in the 80s, tachycardic and hypothermic. Portable CXR was read as resolution of the right lower lobe infiltrates with development of right upper lobe atelectasis. On examination, diffuse abdominal tenderness was noted. An abdominal CT with contrast was performed that was remarkable for a large right sided pneumothorax with no intra-abdominal pathology. A subsequent CT chest was performed that revealed a 20% collapse of the right lung with no tracheal deviation. At this point, a pigtail catheter was placed which lead to resolution of her abdominal tenderness, tachycardia and hypotension. The pigtail was in place for three days then removed with no subsequent complications. DISCUSSION: Secondary pneumothorax is a challenging diagnosis, especially when the etiology is infection. Among SSP, 11% of cases were linked to infectious causes. Age and gender play a substantial role in the incidence of SSP. Per 100,000 of the general population, the rate in men is 6.3 cases, where as its 2.0 for women. Additionally,the ages of 60 to 65 seem to have the highest incidence of SSP in the general population. CONCLUSIONS: Our patient’s presentation was far from the norm of most patients with SSP. Ninety-five percent of affected patients complain of acute chest pain accompanied by shortness of breath. None of these symptoms were present in our patient despite the severity of her pneumothorax. Unlike most, this pneumothorax was disguised. Reference #1: Choi WI. Pneumothorax. Tuberc Respir Dis (Seoul). 2014;76(3):99-104. Reference #2: Zarogoulidis P, Kioumis I, Pitsiou G, et al. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014;6(Suppl 4):S372-6. Reference #3: Takuya Onuki, Tomoyuki Kawamura, Shuntaro Kawabata, Masatoshi Yamaoka, Masaharu Inagaki. (2019) Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study. Journal of Cardiothoracic Surgery DISCLOSURES: No relevant relationships by Mahwish Hussain, source=Web Response No relevant relationships by Karan Panchal, source=Web Response No relevant relationships by Sunil Ramaswamy, source=Web Response

3042 It's Appendagitis, Not Appendicitis!

INTRODUCTION: Epiploic appendages are small peritoneal fat pouches located around the colon. There are no specific etiologic factors leading to EA. Because this disorder involves the sigmoid colon, descending colon, and cecum, symptoms often imitate diverticulitis and appendicitis. Although they are found spread all over the serosal surface of the colon, they are much more abundant and larger on the sigmoid and transverse colon walls. Two retrospective studies reported that men (70%) were affected more than women with an age range of 26 to 75 years. CASE DESCRIPTION/METHODS: 66-year-old gentleman with past medical history of hypertension, type 2 diabetes mellitus and hyperlipidemia presented to the outpatient clinic with 1 day history of right lower quadrant pain. Pain was gradual in onset, 6/10 in intensity, throbbing in quality, non-radiating and associated with some nausea and four episodes of non-bloody vomiting. He denied fever, chills, back pain, bloating, hematochezia, constipation, diarrhea or heartburn. Lab work that was done was complete blood count, comprehensive metabolic panel, lipase, and urinalysis which showed a white blood cell count of 11,100 with 9,210 neutrophils but was otherwise unremarkable. CT scan of the abdomen and pelvis demonstrated epiploic appendagitis involving the sigmoid colon. Patient was advised to continue diet and over-the-counter painkillers as analgesia. Patient's symptoms resolved in the next 2 days and he was back to baseline. DISCUSSION: Epiploic appendagitis has been reported in 2-7% of patients with a presumed clinical diagnosis of acute diverticulitis and 0.3-1% of those suspected of having acute appendicitis. Owing to the nonspecific nature of presenting symptoms, physical signs, and laboratory findings, it is extremely difficult to make the correct diagnosis before radiological investigations. Therefore the vast majority of cases are detected incidentally on CT scans while ruling out other intra-abdominal pathologies. CT scan is the gold standard of diagnosis. Our case report is meant to shed light on the diagnosis and management of the condition. It requires only conservative management. Therefore physicians should keep in mind to avoid unnecessary hospitalizations, antibiotic use and surgical interventions. Nevertheless, more common and serious pathological conditions that necessitate urgent surgical or medical interventions should always be ruled out.

1992 Hematochezia? Think Histoplasmosis

INTRODUCTION: Histoplasmosis is the most common mycosis in North America, responsible for more hospitalizations and deaths than any other endemic mycosis in the United States. While it most commonly presents with pulmonary manifestations, we present a case of a 68-year-old female with history of renal transplantation who was transferred to our tertiary-care hospital with hematochezia, abdominal cramping, and emesis. CASE DESCRIPTION/METHODS: A 68-year-old female with history of renal transplant on immunosuppressive medications was transferred to our tertiary-care hospital with hematochezia. Prior to arrival at our hospital, she was transfused with 2 units of packed red blood cells for a hemoglobin of 5.3 g/dL. A diagnostic nasogastric lavage was negative. She underwent a colonoscopy which did not reveal active bleeding, however the mucosa throughout the entire colon was abnormal, described as nodular with focal areas of blanching and hemorrhagic appearance. The gross appearance was concerning for lymphoma, specifically posttransplant lymphoproliferative disease given her transplant history. As a result, she was transferred to our facility for further management. Chest CT revealed mesenteric and mediastinal lymphadenopathy as well as scattered calcified and noncalcified pulmonary micronodules. She had no pulmonary symptoms. Additional work up revealed a positive Histoplasma galactomannan urinary antigen. Additional staining of colonic biopsies revealed numerous histiocytes in the lamina propria with small round intracytoplasmic yeast microorganisms (GMS and PAS positive and mucicarmine negative) confirming the diagnosis of disseminated histoplasmosis. Patient was treated initially with a two-week course of amphotericin B before being transitioned to oral itraconazole. DISCUSSION: Disseminated histoplasmosis is most common in patients with a history of organ transplant, HIV or immunosuppressive medication regimen. T cell dysfunction accounts for a 10-fold higher risk for dissemination of histoplasmosis with nearly 1 in 2000 acute histoplasmosis infections becoming disseminated. Early diagnosis is the key to effective treatment. A simple urinary test can rule out the diagnosis and should be among one of the first steps in the workup of such patients. We propose clinicians maintain a high index of suspicion and that histoplasmosis be considered in patients with history of immunosuppression who present with acute onset bloody diarrhea with negative work-up for another intra-abdominal pathology.

1320 Out of Gas: A Rare Case of Spontaneous Hepatic Portal Venous Gas

INTRODUCTION: Hepatic Portal Venous Gas (HPVG) was first described between 1955-1960 and is identified by the presence of tubular, branching translucencies in the non-dependent part of the liver, distributed within 2 cm of the periphery owing to centrifugal blood flow. The exact mechanism for the formation of gas in the portomesenteric venous system is still unclear. Bowel ischemia is the primary etiology of HPVG (70% cases), and when together they are related to transmural necrosis in 91% and mortality in 85%. Thus HPVG is an indication for surgery in the presence of mesenteric ischemia. CASE DESCRIPTION/METHODS: A 69-year-old male with a history of atrial fibrillation and congestive heart failure presented to the ER complaining of weakness, palpitations and dark stools. On physical exam, he was found to have BRBPR and tachycardia with an irregularly irregular rhythm. Days in to the admission, the patient was found to be hypotensive with sinus bradycardia and acutely altered. He was intubated and paced. CT scans showed portal venous gas within the superior mesenteric vein and right common iliac vein, causing hepatic portal vein gas, suggestive of ischemic disease, which led to a recommendation for surgery. A repeat showed thickened loops of ascending, transverse and proximal descending colon in the distribution of the superior mesenteric artery along with free air in the abdomen anteriorly. A colonoscopy showed an extended area of colitis in the ascending colon, transverse colon, splenic flexure, and descending colon with erythema and ulceration concerning for ischemic colitis. Multiple biopsies showed inflammatory related ulceration. Based on the clinical improvement of the patient, medical management was recommended. A repeat CT of the abdomen revealed spontaneous resolution of the hepatic and biliary pneumatosis. Upon recovery, the patient denied previous history of sphincterotomy or any hepatic or biliary manipulation. DISCUSSION: HPVG can be a diagnostic sign, indicating serious intra-abdominal pathology requiring emergent surgical intervention in patients. As CT scans and ultrasound modalities increase, we have the capability to detect severe disease earlier, thus allowing immediate treatment and reducing mortality rates. As with this case, the need for surgical intervention is becoming questionable, even in the presence of ischemia. As clinicians we must be abreast of all information and treatment options. Medical management may allow for less complications and shorter recovery times.

PUNCTURE FROM A TOOTHPICK: AN ATYPICAL PRESENTATION OF PYLEPHLEBITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Septic thrombophlebitis comprises of a spectrum of venous thrombi arising as a sequelae of inflammation in the setting of bacteremia. Pylephlebitis describes a septic thrombophlebitis involving the portal vein. We report a unique case of pylephlebitis resulting from endovascular foreign body perforation of the gastric wall. CASE PRESENTATION: A 69 year old female presented to our Emergency Department with 1 week of progressive abdominal pain, bloating and anorexia complaining of dark stools. She was noted to have sepsis and was started on broad spectrum antibiotics. Workup for sepsis revealed gastric antral thickening (Figure 1). Subsequent esophagogastroduodenoscopy (EGD) showed a toothpick perforating the gastric antral wall (Figure 2). Despite of removal, she continued to have abdominal pain and fever, prompting repeat CT abdomen. It showed infected portal venous, superior mesenteric venous (SMV) thrombus and portal venous gas (Figure 3). Blood cultures grew Streptococcus anginosus and Rothia mucilaginosa. Despite appropriate antibiotics, she developed septic shock and DIC, prompting another CT abdomen revealing a 1.4 cm abscess adjacent to the left anterolateral aspect of the SMV, thrombosis of the left portal vein with extensive portal venous air in the left lobe consistent with septic thrombophlebitis of the superior mesenteric vein and portal venous system (Figure 4). She was taken to OR for exploratory laparotomy, repair of gastric perforation, abdominal abscess drainage, portal vein thrombolysis. She was started on anticoagulation and was given extended course of antibiotic therapy at discharge. DISCUSSION: Pylephlebitis describes a septic thrombophlebitis involving the portal vein. The etiology of pylephlebitis is the pathophysiologic development of localized pockets of inflammation as an humoral immune response to an infection. Thrombophlebitis in small veins either embolize or extend into larger downstream veins, coalescing into the apogee of a portal vein thrombosis. While most cases involve thrombosis involving the SMV (42%), involvement of intrahepatic branches of the portal vein (39%) and the splenic vein (12%) is common. Pylephlebitis may arise from intra-abdominal or pelvic infection through direct downstream sequelae caught in the portal system. While of cases of pylephlebitis occur more commonly in the setting of diverticulitis, pylephlebitis remains a rare complication. Due to the paucity of data regarding pylephlebitis, it is difficult to assert that there is any greater association with extragastric complications when compared to other abdominal disease states. Gastric perforation from tooth pick with secondary pylephlebitis is a very unique clinical presentation. On review of available literature, only one case similar case was found. CONCLUSIONS: Physicians should have a high index of suspicion in cases of intra-abdominal pathology who remain unstable. Reference #1: Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804. Reference #2: Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114. Reference #3: Peters, Thomas G., et al. “Suppurative Pylephlebitis Caused by Toothpick Perforation.” Southern Medical Journal 1988; 81:414-415. https://doi.org/10.1097/00007611-198803000-00034. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Brian Boden, source=Web Response No relevant relationships by Rajeev Fernando, source=Admin input No relevant relationships by Steve Georgopoulos, source=Admin input No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Najia Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by ahsan khan, source=Web Response No relevant relationships by Paul Poidomani, source=Web Response No relevant relationships by Richard Ricca, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Amanda Stashin, source=Web Response

2583 Omental Infarction as a Cause of Acute Abdominal Pain

INTRODUCTION: Although rare, omental infarction is becoming an increasingly recognized cause of acute abdominal pain. The purpose of this vignette is to recognize omental infarction as a cause of acute abdominal pain and to discuss its management. CASE DESCRIPTION/METHODS: A 58-year-old male with history of aortic rupture, coronary artery disease, internal jugular thrombus, and prior stroke presented with three days of progressively worsening, constant, and sharp RUQ abdominal pain. It did not radiate and was unrelated to food intake. He had no relief with OTC pain medication. He denied fevers, nausea, vomiting, inability to tolerate food or liquids, change in bowel habits, or blood in his stool or urine. He denied alcohol, tobacco, or illicit drug use. On exam, the patient appeared uncomfortable; however, was afebrile with normal blood pressure, respirations, and heart rate. He had tenderness in the RUQ and epigastric regions with voluntary guarding but no rebound tenderness. Initial work up was without leukocytosis, transaminitis, acidosis, kidney injury, or elevated lipase. Abdominal x-ray was without free air. An abdominal CT was performed and showed a fat-containing mass lesion within the RUQ anterior to the liver measuring 2.7 × 1.9 cm with adjacent inflammation representing an omental infarction. The patient was managed with IV fluids and pain medication. No surgical intervention was warranted, and the patient was admitted to the medicine team for conservative management. Following 24 hours of observation, he was transitioned to an oral pain regimen and was advanced to a regular diet. He was discharged with pain medication to follow up with his primary care provider. DISCUSSION: Over 400 cases of omental infarction have been described in the literature. It most commonly occurs in middle-aged men. Pain is usually right sided, which may be secondary to longer, more mobile omentum that increases the risk of torsion and disruption of blood supply. Omental infarction can be both idiopathic or secondary to the presence of intra-abdominal pathology. Suspected risk factors for idiopathic presentations include obesity, laxative use, trauma, and excess exercise/strain. CT scan alone is sufficient for diagnosis given specific findings that include fatty oval shaped mass or hyper attenuating streaky infiltration. Management is typically conservative with IV fluids, pain control, and observation. Surgery is reserved for those with acute decompensation or progression of pain despite conservative measures.

2037 Intestinal Spirochetosis: An Unexpected Cause of Massive Gastrointestinal Bleed

INTRODUCTION: Human intestinal spirochetosis (HIS) is a condition characterized by the presence of spirochetal microorganisms attached to the apical cell membrane of the colorectal epithelium leading to chronic diarrhea. The invasive form of this disease is more often seen in HIV patients or homosexual individuals. Here, we present a rare case of HIS presenting as lower gastrointestinal (GI) bleed and abdominal pain in the absence of diarrhea. CASE DESCRIPTION/METHODS: A thirty-year-old male with a history of peptic ulcer disease (PUD) and HIV (CD4 >250) presented to the emergency department with a two-days duration of severe, generalized abdominal pain and bleeding per rectum. On presentation, the patient was hypotensive (mean arterial pressure < 65) and tachycardic (heart rate 120). Physical examination revealed generalized abdominal tenderness with normal bowel sounds but no rebound tenderness or guarding. Labs were significant for anemia (Hemoglobin 6.5 g/dl; baseline >14 g/dl). The rest of his labs including serum chemistry, white blood cells, amylase, lipase levels, were within normal limits. Due to the patient’s significant history of PUD and concern for rapid GI bleed, aggressive fluid resuscitation and proton pump inhibitor infusion were initiated. He also received two units of packed red blood cells with good toleration. CT scan of the abdomen/pelvis did not reveal any acute intraabdominal pathology. Despite the achievement of hemodynamic stability, the patient continued to have bright red blood per rectum. Extensive infectious workup (including blood cultures and stool tests such as stool culture, ova, and parasites) were negative. Esophagogastroduodenoscopy was performed and revealed well healed PUD without any signs of bleeding. Colonoscopy, however, revealed pan-colonic ulcers, most pronounced in the descending colon. Histopathology revealed spirochetal microorganisms attached all the way from the ascending colon to the rectum consistent with invasive HIS. Metronidazole was initiated with significant clinical improvement and he was subsequently discharged home with appropriate outpatient follow up. DISCUSSION: Most cases of HIS are asymptomatic and often diagnosed during screening/surveillance colonoscopy. Thus, data regarding symptomatic patients is scant. The few cases describing affected patients generally associate infection with chronic watery diarrhea, acute appendicitis or intermittent hematochezia. Metronidazole is an effective treatment of choice in symptomatic patients.

1905 Appendiceal Neuroendocrine Tumor in an Inverted Appendix Discovered on Screening Colonoscopy

INTRODUCTION: Appendiceal carcinoid tumors are the most common appendix neoplasm. Most cases are diagnosed incidentally after an appendectomy. We present a rare case of neuroendocrine neoplasm from an inverted appendix manifesting as cecal polyp seen on a screening colonoscopy. CASE DESCRIPTION/METHODS: Patient is a 58-year-old female with no significant past medical history or family history of colon cancer who presented for colorectal cancer screening. She denied any fevers, night sweats, flushing, palpitations, weight loss, abdominal pain, or changes in bowel habits. She denied any prior abdominal surgeries. Patient underwent colonoscopy which revealed internal hemorrhoid, two polypoid lesions in the cecal area measuring 8 mm, and 1.3 cm. A total of 6 mL of normal saline was injected underneath to lift them up and snaring polypectomy technique applied. Endo Clip was applied at the base of the large polyp and the specimen was retrieved and sent to the pathology. Pathology revealed well-differentiated neuroendocrine tumor, grade 1, 0.4 cm, involving submucosa and muscularis propria of probable inverted appendix/appendiceal stump. IHC stains for CDX 2, Pankeratin, Chromogranin, and Synaptophysin were positive. Stains for CK7/CK 20/PAX 8/Vimentin were negative. Patient returned for a follow-up office visit and was doing well after the procedure. She was later referred for a CT abdomen pelvis with contrast which failed to show an appendix, any cecal masses, or other acute intra-abdominal pathologies. Patient was then referred to a general surgeon for further evaluation who recommended a one-year surveillance colonoscopy. DISCUSSION: Neuroendocrine tumors are the most common tumor of the appendix. They are typically discovered incidentally from an appendectomy but rarely manifest in an inverted appendix. Additionally, they are usually located in the distal 1/3 of the appendix and for that reason most patients do not present with obstructive symptoms. Management of tumor depends on the size of the tumor. If the carcinoid is < 2 cm, appendectomy is generally sufficient. In this case the tumor was only 0.4 cm and was completely excised endoscopically in the inverted appendix.

Is the presence of echo-rich periportal cuffing in the liver indicator for abdominal inflammation in pediatric patients?

Hyperechoic/echo-rich periportal cuffing (ErPC) is defined as an increase in echogenicity relative to the adjacentliver parenchyma. Thickening in the periportal area may occur with proliferation of bile ducts, hemorrhage, oedema, fibrosis,inflammatory changes or a combination of these. The aim of this study is to determine which intraabdominal inflammatory diseases are associated with the presence of ErPC in the pediatric population and to calculate the sensitivity and specificity of this finding. In this prospective study 200 consecutive children who underwent abdominal ultrasonography (US) were included: group 1, the patient group (100 children with appendicitis, gastroenteritis, mesenteric lymphadenitis, intestinal infection, terminal ileitis and invagination as cause of intra-abdominal inflammation) and group 2, the control group (100 children). The ErPC was positive in 74 (74%) cases in the patient group and in 3 (3%) in the control group. According to final diagnoses, we found ErPC in most of patients with gastroenteritis (16/17), perforated appendicitis (10/11), mesenteric lymphadenitis (5/6) and acute appendicitis (27/37). The sensitivity of ErPC in indicating intra-abdominal inflammation was 0.80 and its specificity was 0.87. No significant correlation between ErPC and age, gender and CRP was found but a moderate and significant positive correlation between ErPC and WBC (p=0,010; r=0.255) was detected. Very good concordance between observers in terms of the presence of ErPC on abdominal US was found (concordance 97% and kappa 0.93). We consider that the presence of ErPC in pediatric patients, when evaluated alongside clinical and laboratory findings, has a high sensitivity and specificity for inflammatory intra-abdominal pathology.

ABDOMINOPLASTY IN THE SURGICAL TREATMENT OF PATIENTS WITH COMPLEX ABDOMINAL WALL DEFECTS

Patients with complex abdominal wall defects usually have deformations of the abdomen, which may remain after the operation, and require the solution of a whole ramge of problems. Quite often, abdominal wall defects are combined with a variety of aesthetic deformities that are associated with abnormal postoperative scars, trophic ulcers, and fistulas. Though the restoration or improvement of abdominal wall functionality is the main goal of alloplasty for complex abdominal wall defects, the cosmetic aspects of the operation, sometimes far more important for patients, deserve special attention. The choice of optimal operative access largely depends on lateral surgery, but most surgeons do not pay special attention to it and mainly use framing incisions above the defect or protrusion. By this time, such values ​​as the type, size of the incision, depth, and borders of flaps flaking are reported empirically and often lead to additional deformation of the operative area and the development of complications. Abdominoplasty is one of the most controversial operations in aesthetic and plastic surgery, where complications reach 27.5-30.8%. The concept of "abdominoplasty" provides techniques for the operational correction of abdominal wall deformities presented by excess skin and subcutaneous fat, pathological postoperative scars, as well as defects of the muscular aponeurotic layer in abdominal area. There are several abdominoplasty techniques. The purpose of this work is to determine the efficacy of the modified abdominoplasty in the surgical treatment of complex abdominal wall defects. Materials and methods. The study involved 360 patients with complex abdominal wall defects operated on at the surgical department of the Poltava Municipal Hospital №1 in for the last 10 years. Various deformities of the abdominal wall were detected in 289 patients (80,3%). Localization of the defects can be described as following: M – 306 (85%), L – 31 (8,6%), ML – 23 (6,4%). The size of the defects: W1 – 103 (28,6%), W2 – 188 (52,2%), W3 – 69 (19,2%). Additional diastase rectus muscles were detected in 179 patients (49,7%). The combined surgical diseases were found in 332 patients (92,2%); 18,1% of them were diagnosed to have intra-abdominal pathology. Results and discussion. The following types of dermatolipectomy were used: longitudinal - 77 cases (28,1%), by Babcock - 114 cases (41,6%), by Kelly - 6 cases (2,2%), by Fernandes - 63 cases (22,9%), modified Fernandez - 7 cases (2,5%), by Berson - 3 cases (1,1%), by Torek - 2 cases (0,8%), by Hrazer – 2 cases (0,8%). Simultaneous operations were performed on in 65 patients (18,1%). Types of alloplasty used: «onlay» - 3 cases (0,8%), «sublay» - 289 cases (80,3%), «sublay-inlay» - 38 cases (10,6%), «inlay» - 3 cases (0,8%), Ramirez – 4 cases (1,1%), intra-abdominal - 2 cases (0,6%), combine – 21 (5,8%). Conclusions. The term abdominoplasty has a broader definition than it was considered previously. Differentiated surgical tactics for patients with complex abdominal wall defects improves the abdominoplasty outcomes.

Epiploik Apendiks Enflamasyonu: Primer Epiploik Apandajit

Epiploic appendices are extensions of omentum which covers most of the colon. Most of the pathologic changes are related with spontaneous torsion or venous thrombosis culminating with inflammation and is referred as primary epiploic appendagitis (PEA). There is no pathognomonic symptom, finding or laboratory test for this relatively rare intra-abdominal inflammation. A non-toxic patient with acute onset localized abdominal pain in the right or left lower quadrant is the typical presentation. Imaging studies such as ultrasound and tomography with the awareness of PEA in differential diagnoses of intra-abdominal pathologies are the key to correct diagnosis. Since the conservative treatment is sufficient in most of cases, accurate and timely diagnosis can ensure the appropriate patient management and can prevent unnecessary hospitalizations and interventions.