Lower Tenderness Research Articles

Parâmetros de produção e qualidade da carne de frangos Label Rouge em diferentes idades de abate

ABSTRACT: This study evaluated the performance parameters, carcass characteristics, and meat quality of Label Rouge chickens raised under an alternative system as a function of age at slaughter. The design was completely randomized with a 5×2 factorial arrangement, with slaughtering at five ages (70, 90, 120, 150, and 180 days) and two sexes. A total of 240 birds (Pescoço Pelado strain) were used, including 120 females and 120 males. Performance, carcass, physicochemical, proximate composition, and muscle fiber traits were evaluated. Rearing time and sex had significant effects on performance-related traits, with better results for males. The interaction between slaughter age and sex had a significant effect on the carcass and physicochemical parameters, which cause different responses in males and females with increasing slaughter age. For the proximate composition and muscle fiber analysis, the interaction between the parameters studied only had a significant effect on ether extract in the breast. The increase in age resulted in chickens with higher live and carcass weight at slaughter but lower performance indices. Females had lower carcass yield and greater deposition of abdominal fat. Females had lower tenderness in the drumstick and males in the breast with increasing slaughter age, and both cuts had more intense color and redness and reduced lightness starting at the slaughter age of 90 days.

Application of simultaneous ultrasonic curing on pork (Longissimus dorsi): Mass transport of NaCl, physical characteristics, and microstructure

This study aimed to investigate the effect of ultrasound curing with various working modes and frequency combinations, including mono-, dual- and tri-frequency, on the content of NaCl and tenderness of pork loins (Longissimus dorsi). The physical qualities, myoglobin, moisture migration, distribution, and microstructure of pork were also evaluated. The results displayed that the NaCl content of samples cured by simultaneous ultrasound (100W/L) working mode with a frequency combination of 20, 40, and 60kHz was higher than that of other ultrasound working modes. The effect of ultrasonic brining was significantly better than the static curing when the saline solution was >35mL. In addition, the samples cured by simultaneous ultrasound had better physical qualities, including more pickling absorptivity, less cooking loss, and lower hardness, tenderness, and chewiness value. The intensity of lightness was reduced, although redness and yellowness remained unaltered compared to static curing. The myoglobin content decreased drastically without changing the oxygenation level, and the relaxation time of T2b and T21 was delayed. The microstructure indicated that the ultrasonic treatment could promote changes in meat texture. Overall, the simultaneous ultrasound at various frequencies could efficiently accelerate NaCl penetration and improve pork quality.

Case report on severe splenic injury following colonoscopy with disproportionately stable presentation: A rural hospital perspective

Detection of splenic injury following routine colonoscopy is slowly on the rise. Mostly presenting as left upper abdominal or shoulder tip pain along with a sharp fall in haemoglobin level and hemodynamic instability, sometimes the presentation and initial workup may be vague and falsely reassuring. This is demonstrated in the case of a 72year old male who presented with vague but severe left lower abdominal pain following colonoscopy, during which one caecal polyp was removed and no intraoperative complications were reported. On emergency presentation, abdominal examination was not particularly concerning with only mild left lower tenderness and minimal guarding. Vital signs remained largely normal and blood counts were reasonable. Close to being discharged, patient demonstrated brief hypotension post ambulation which was easily reversed with a fluid bolus. Upon surgical review, a high index of suspicion prompted further investigation which revealed an unsuspected complication necessitating urgent laparotomy and splenectomy. Splenic injury is slowly becoming an increasingly reported complication following colonoscopy. While many cases present with typical features, others may only display subtle signs of deterioration, and warrant a high degree of suspicion. Rural doctors should be aware of and able to recognise this potentially fatal complication to ensure timely successful management.

Effects of Slaughter Age of Holstein Friesian Bulls on Meat Quality: Chemical Composition, Textural Characteristics, Sensory Attributes and Fatty Acid Profile.

This study aimed to investigate the effects of slaughter age (young vs. old), muscle type (Longissimus dorsi (LD), Gluteus medius (GM)) and fat deposits (kidney knob and channel fat, subcutaneous fat, intramuscular fat) on chemical, organoleptic, textural characteristics and fatty acid composition of Holstein Friesian bull meat. For this purpose, the carcasses of 26 Holstein Friesian bulls that had been fattened on the same private farm were assigned to two experimental groups based on their age at slaughter: a young group (YG) (average age: 17.0 ± 1.0 months old) and an old group (OG) (average age: 22.0 ± 1.0 months old). The percentage of crude protein, panel tenderness score, polyunsaturated fatty acid (PUFA) and saturated fatty acid (SFA) content, the PUFA/SFA ratio and the hypocholesterolemic fatty acid (DFA)/hypercholesterolemic fatty acid (OFA) ratio of the bull carcasses decreased significantly with increasing slaughter age. By contrast, the OFA content of the carcasses significantly increased (p < 0.05) with increasing slaughter age. Advanced slaughter age resulted in lower panel tenderness scores. Additionally, the meat of the bulls in the OG was considered to be less healthy because of the less desirable fatty acid composition and nutritional indices, such as the PUFA/SFA and hypocholesterolemic/hypercholesterolemic ratios, compared to the meat from the bulls in the YG. Furthermore, the intramuscular fat and internal fat contained high percentages of PUFA and SFA and high PUFA/SFA and hypocholesterolemic/hypercholesterolemic ratios. Interestingly, the percentage of OFA content in the internal and intramuscular fat tissues decreased with increasing slaughter age. In conclusion, this study provided evidence that slaughter age and muscle and fat type are essential sources of variations in the textural characteristics, sensory panel attributes and fatty acid profile of meat from Holstein Friesian bulls.

Venous Thromboembolism in Hospitalized Patient with Heart Failure, Does Heart Failure Increase the Risk of Dvt?

Background: Deep vein thrombosis (DVT) is frequently observed in patients with chronic heart failure (CHF), increasing the risk of pulmonary embolism (PE). Clinical evaluation of CHF patients with suspected acute PE is challenging since these diseases share several symptoms and signs such as dyspnea.&#x0D; &#x0D; Objective: The aim of this study was to analyze whether heart failure increases the risk of DVT.&#x0D; &#x0D; Method: This study uses a qualitative approach with a case study model that analyzes and identifies venous thromboembolism in hospital patients with heart failure, does heart failure increase the risk of DVT?&#x0D; &#x0D; Result: DVT (Deep Vein Thrombosis) is the formation of a thrombus or blood clot that often attacks the deep veins of the lower extremities (such as the calf, femoral and popliteal veins) or deep veins in the pelvic area, more frequent in proximal than distal DVT. This condition is potentially dangerous, leading to morbidity and mortality that can essentially lead to disease. This happens all over the world. In general these diagnoses are combined in VTE (Venous Thromboembolism). In patients with DVT without PE, short-term mortality rates of 2–5% were reported. Recurrence risk is high, especially within first 6 months.&#x0D; &#x0D; Conclusion: From the results obtained we can know that Symptomatic patients with proximal DVT may present with lower extremity pain, calf tenderness, and lower extremity swelling (Kesieme et al., 2011) Same with this case, Patient was admitted to the hospital with complaints swelling of the whole body, especially the legs accompanied by pain, redness, feel warmed a few hours before the patient going to hospital.

Young Man With Abdominal Cramps and Bloody Stools

A 35-year-old man presented with left side abdominal cramps and bloody stools that persisted for 1 week. Physical examination revealed a body temperature of 38.5 °C (101.3 °F), normoactive bowel sounds, and left lower quadrant tenderness. A standing abdominal radiograph showed a nonspecific small bowel gas pattern and a smooth radiolucent descending colon without haustration (Figure 1), indicating a typical lead pipe sign. Ultrasonography of the left side of the abdomen revealed a straight, smooth-walled descending colon filled with blood-like heterogeneous echogenic materials (Figure 2 and Video E1).

394: A CASE OF EXTENSIVE NECROTIZING FASCIITIS DUE TO STRING TEST-NEGATIVE KLEBSIELLA PNEUMONIAE

Introduction: Monomicrobial Klebsiella pneumoniae necrotizing fasciitis is rare in North America. The strain that causes necrotizing fasciitis is thought to be hypermucoviscous or hypervirulent K. pneumoniae (hvKP). hvKP is responsible for increasing numbers of cases within the US due to the prevalence of travel and immigration. Description: A 57-year-old Caucasian female with diabetes and history of IV drug use presented to the emergency room with 3 days of left calf pain. Venous doppler was negative for DVT. She was discharged home with medication for musculoskeletal pain. Eleven days later, she returned with worsening left lower extremity pain, edema, and weakness. Physical exam revealed left lower extremity tenderness to palpation and crepitus with scars from drug injections. The laboratory risk indicator for necrotizing fasciitis (LRINEC) score was 9, indicating high suspicion for necrotizing fasciitis. X-ray of the tibia-fibula and femur revealed subcutaneous gas. Broad spectrum antibiotics were initiated, and the patient underwent emergent surgical debridement. Despite aggressive surgical intervention, she continued to worsen with increasing vasopressor requirements due to septic shock. Imaging of the abdomen and pelvis showed extension of the necrotizing fasciitis. Gas was identified within a complex left perirenal abscess, the epidural space and intervertebral disc space of the lower lumbar spine and sacrum, as well as within the urinary bladder. The patient returned to the operating room for further debridement. Wound, blood, and urine cultures yielded Klebsiella pneumoniae and the lab was directed to perform a string test, which was negative. On hospital day two, she had worsening multiorgan failure, and the family elected to withdraw care. Discussion: hvKP with a negative string test is a unique phenotype that is not well described in the literature. Usually, hvKP is identified by a string test and rarely genotyping. Most cases involve patients of Asian descent or recent travel to Asia. As this patient was Caucasian with no recent travel, we suspect that she contracted the organism through IV drug use. The unique aspects of this case may help us understand this new emerging strain in the US.

Acute urachal cystitis in two children

Persistent Urachal cysts (UC) are rare congenital pathologies caused by failure of obliteration of urachal remnant. This can lead to potential morbidities including infection and fistula formation. Presentation of such pathology varies resulting in significant delay in diagnosis. This article reports mysterious presentations of UC in children investigated for non-specific abdominal pain. Two cases presented with worsening central abdominal pain associated with occasional vomiting for the previous 4–6 months. Physical examination of the girl revealed tenderness over peri-umbilical area with no palpable masses. She had normal white cell (WCC), neutrophil count and C-Reactive Protein (CRP). Her Ultrasound scan noted a cylindrical hypoechoic structure in keeping with a urachal cyst. However, the boy experienced lower abdominal tenderness with on masses felt and an elevated WCC and neutrophil count but normal CRP. USS reported a rounded, fibrosed lesion with a fibrosed tract, in keeping with non-complicated urachal remnant. Laparoscopic findings for first case, noted UC with a visible midline patent tract connecting to urinary bladder; such connection confirmed using injected saline. During the second case, the cystic structure, was connected to the umbilical stump. In both cases, both the UC and tract were dissected off and completely resected. Both had an uneventful post-operative recovery, with no further episodes of abdominal pain during follow-up appointments. Persistent UC could be easily mis-diagnosed with other commoner surgical abdominal pains. High suspicion, careful examination, and relevant radiological investigations, lead to earlier diagnosis and proper surgical management.

Favourable outcomes of conservatively managed acute abdomen associated with multisystem inflammatory syndrome in children during the COVID-19 pandemic.

Abdominal pain is one of the most common symptoms of multisystem inflammatory syndrome in children (MIS-C). Abdominal pain can vary from mild to severe and may present as acute abdomen. Severe abdominal pain in patients with MIS-C should be differentiated from surgical causes of acute abdomen to prevent unnecessary surgery. The diagnosis of MIS-C was based on WHO and CDC recommended criteria. Records of children treated for MIS-C between September 2020 and January 2021 were reviewed retrospectively. In a short time, we encountered seven patients who were diagnosed with MIS-C and showed acute abdomen findings. There were four male and three female patients. The median age was 9 years. Fever, abdominal pain and distension were present in all. The median duration of symptoms was 4 days. Five patients had general abdominal tenderness mimicking acute abdomen. Three patients had right lower quadrant tenderness mimicking acute appendicitis. After the initiation of immunomodulatory therapy and antibiotics, the physical examination findings were improved step by step in all. The median time to initiate oral feeding was 2 days. The median length of hospitalization time was 8 days. Serial abdominal examinations performed by the same surgeon enabled us to follow these patients conservatively and thus avoid unnecessary surgical intervention.

8346 Polypoid Endometriosis: A Distinct Variant

<h3>Study Objective</h3> To examine a case study of polypoid endometriosis and perform a literature review. <h3>Design</h3> Case Report. <h3>Setting</h3> Academic institution <h3>Patients or Participants</h3> 1 Patient. <h3>Interventions</h3> Surgical resection. <h3>Measurements and Main Results</h3> A 34-year-old nulliparous woman with complex adnexal masses and severe left hydronephrosis presented for consultation. Menarche occurred at 12 years-old, followed by regular monthly menses lasting 5 days. The patient reported multiple emergency room visits for severe dysmenorrhea and was taking combined hormonal contraceptives with good effect since adolescence. Of note, she had discontinued her contraceptives as she was trying to conceive. Examination revealed a non-obese female with bilateral lower abdominal tenderness to palpation. Initial labs showed elevations in CA125, HE4, and CA19-9. Imaging demonstrated a complex 7cm right adnexal mass with severe left hydronephrosis secondary to enhancing fibrosis in the left hemipelvis. This was suspicious for deep infiltrating endometriosis. The patient underwent robotic bilateral ovarian cystectomy, excision of endometriosis, right salpingectomy, left ureteral reimplantation with psoas hitch, appendectomy, and cystoscopy. Stage IV endometriosis was noted intraoperatively. Intraoperative frozen pathology was benign. Her recovery was overall uncomplicated. Final pathology was consistent with polypoid endometriosis. Follow up imaging revealed recurrence of bilateral complex adnexal masses. <h3>Conclusion</h3> Polypoid endometriosis is an uncommon, distinct variant of endometriosis with histological features suggestive of an endometrial polyp. Unlike usual-type endometriosis, which commonly affects reproductive-aged women, polypoid endometriosis primarily affects older patients with a mean age of 52.5-years-old. Patients with polypoid endometriosis often present with mass effect or vaginal bleeding. It is characterized by a tendency to mimic neoplastic processes clinically, intra-operatively, and on gross examination. Polypoid endometriosis also demonstrates a high rate of recurrence after surgical excision, as seen in our case study. Given the ability of polypoid endometriosis to mimic malignancy, intraoperative frozen pathology may prevent a more extensive surgery and excessive resection in patients of childbearing age.

S1729 Drug-Induced Pancreatitis: Meth, Cannabis, or Meth-Laced Cannabis?,

Introduction: Drug-induced pancreatitis (DIP) is a rare entity with a 0.1 to 2% incidence of acute pancreatitis cases. Methamphetamine is a serotonergic drug used as a stimulant. It has infrequently been observed to cause pancreatic and hepatic damage due to its keen vasoconstrictive properties. Cannabis in its recreational form has also been linked with drug-induced pancreatitis. We report a 36-year-old female who presented with findings of acute pancreatitis revealing a drug-induced etiology. Case Description/Methods: The patient is a 36-year-old previously healthy female who presented with diffuse, sudden in onset abdominal pain, radiating to the back, aggravated with food without alleviating factors of 3 days duration. She reported nausea on the first day of her pain along with a single episode of nonbilious vomiting that had self-subsided. Social history was remarkable for smoking marijuana since her teenage years unremarkable for alcohol and tobacco use. She reported resorting to street, methamphetamine laced marijuana, the past month. The patient was vitally stable with a physical exam remarkable for epigastric and left lower quadrant tenderness with negative peritoneal signs. Laboratory tests showed elevated lipase, amylase, and CRP with normal liver function tests, hematocrit, BUN, bilirubin, triglycerides, and phosphocalcium balances. Ultrasound was done corroborating the absence of obstruction. Computed tomography (CT) abdomen was subsequently performed showing irregular contour of the pancreatic margins, blurring of peripancreatic fat planes, soft-tissue stranding, and trace-free fluid at the pancreatic body and tail without bile duct dilatation. Serological survey for mumps virus, cytomegalovirus (CMV), epstein barr virus (EBV), and human immunodeficiency virus (HIV) was negative. Anti-nuclear antibodies (ANA), neutrophil anti-cytoplasmic antibody (ANCA), and serum Ig G4 were also negative. She was diagnosed with mild acute pancreatitis with the culprit agent being methamphetamine-laced cannabis. The patient was followed up 3 months after agent cessation with marked symptomatic improvement and unremarkable lab work. Discussion: This case highlights that methamphetamine might also be the precipitating cause of pancreatitis in street marijuana-associated pancreatitis cases. Drug-induced pancreatitis is often challenging because there are no unique clinical characteristics to distinguish drugs from other etiologies, let alone the possibility of identifying one potential drug versus another.

S2983 Drug-Induced Liver Injury Due to Chronic Kratom Use

Introduction: Kratom (Mitragyna speciosa) is an herb with opiate and stimulant like properties. It is marketed as an herbal supplement. It can be exploited as a recreational drug and is popular for self-treatment of opiate withdrawal and pain. It was previously unknown what pathological changes could occur with chronic Kratom use. New evidence suggests that Kratom can cause a drug induced liver injury (DILI). There is little published evidence of the toxic effects of Kratom, yet there is increasing self-treatment of opioid withdrawal and reports of adverse events and lethal overdoses. We describe a case where chronic use of Kratom caused severe DILI. Case Description/Methods: A 39-year-old male with no significant medical history presented to the emergency department with sharp abdominal pain and diarrhea. Physical exam revealed jaundice, scleral icterus, and left lower quadrant tenderness. Initial labs were AST 791 units/L ALT 1841 units/L, total bilirubin 7.4 mg/dL, alkaline phosphatase 449 units/L and INR of 1.2. A CT demonstrated scattered porta hepatis lymph nodes. The patient reported no medication or recreational drug use. He underwent extensive testing including viral hepatitis panel, stool studies, toxicity screen, anti-smooth and anti-mitochondrial antibodies which all produced negative results. Magnetic resonance cholangiopancreatography and right upper quadrant ultrasound were unremarkable. A liver biopsy revealed grade-III inflammatory activity with significant eosinophilia, highly suspicious for drug interaction. On hospital day 5, the patient admitted to several months of kratom consumption. His AST level peaked at 1190 units/L, ALT peaked at 2261 units/L, total bilirubin peaked at 20.2 mg/dL and alkaline phosphatase continually declined. Given the strong correlation with his biopsy results, the likely etiology of this liver injury was determined to be hepatocellular toxicity due to chronic Kratom use. The patient symptomatically improved and in outpatient follow-up there was normalization of liver function after discontinuation of Kratom. Discussion: Kratom’s mechanism and scope of toxicity is not well understood. It remains legal in our state, Georgia, but is banned in some other states and countries around the world. As it remains commercially available, policy regarding this substance should be reviewed closely and studies should be conducted to evaluate its toxicity. Fortunately, this case demonstrates reversible toxic effects to the liver.

S3558 A Tale of Two Sisters: Two Pediatric Cases Within a Familial Cluster of Hereditary Diffuse Gastric Carcinoma

Introduction: We report a case of HDGC in two sisters, (10 and 15 years old) and their father (41 years old). Case Description/Methods: Our patient is a 15-year-old Caucasian female who initially presented to our clinic with a 4-month history of right lower quadrant tenderness and generalized abdominal pain, which she characterized as “stabbing pain.” Review of systems was significant for intermittent diarrhea and constipation. Family history was significant for a paternal great-aunt who reportedly died from gastric cancer at age 28. Abdominal ultrasound showed no significant abdominal pathology and no appreciable stomach wall thickening. EGD revealed diffuse mild inflammation of the stomach with normal appearing rugae without ulceration or masses and normal proximal duodenum. Biopsy results from the antrum revealed poorly differentiated signet ring cell carcinoma. The patient underwent a second EGD and imaging to confirm and stage the cancer. The patient subsequently underwent a laparoscopic roux-en-Y esophagojejunostomy, jejunojejunostomy with exploratory laparoscopy. Based upon the unusual occurrence of SRCC in a young female, the patient and her family underwent genetic testing. The patient was found to be positive for a CDH1/E-cadherin mutation. It was found that the patient’s father and her 10-year-old sister also carried this mutation. The 10-year-old sister and the father underwent screening EGD with greater than 40 biopsies taken throughout the stomach, esophagus, and duodenum in representative areas. Surprisingly, both patients were found also to have gastric SRCC. The father has since undergone chemotherapy, radiation, and a laparoscopic roux-en-Y esophagojejunostomy, jejunojejunostomy. The family is opting for conservative management at this time for the 10-year-old patient with plans to undergo the same surgery when she is older (Figure). Discussion: Gastric carcinoma in the pediatric population is exceedingly rare. HDGC should be considered when a patient presents with gastrointestinal symptoms and has a positive family history of gastric cancer among 1st and 2nd degree relatives, particularly if a relative was diagnosed before the age of 50. For carriers of the CDH1 mutation, prophylactic total gastrectomy is recommended with intraoperative confirmation of squamous epithelium in the esophagus at the proximal margin and duodenal mucosa at the distal margin. If gastrectomy is contraindicated, yearly endoscopic surveillance with random biopsies is recommended.Figure 1.: Biopsy from gastric antrum demonstrating poorly differentiated signet ring cell carcinoma present in the lamina propria.

S3242 A Case of Isolated Hepatic Tuberculosis in an Immunocompromised Patient

Introduction: Primary hepatic tuberculosis is a rare clinical entity with non-specific clinical and imaging features that can mimic other liver diseases, presenting a diagnostic challenge. We present a case of a patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) who developed fevers of unknown origin and elevated liver enzymes. Liver biopsy was key to diagnosis as it revealed necrotizing granulomas consistent with tuberculous hepatitis. Case Description/Methods: The patient is a 54-year-old female with uncontrolled HIV/AIDS (CD4 6/1%) who presented with fever, encephalopathy, and abdominal pain. She was febrile to 38, tachycardic to 103, blood pressure 144/115, 96% on room air. She was ill-appearing, altered, nonverbal, with epigastric and lower abdominal tenderness on exam. Complete metabolic panel, complete blood count, lipase, and lactic acid were all within normal limits on presentation. CT of the abdomen and pelvis was unrevealing. On admission, she was found to have community acquired pneumonia, a urinary tract infection, a pulmonary embolism, and HIV-associated neurocognitive disorder. She was started on antiretrovirals and improved until she developed fevers of unknown origin and newly elevated liver enzymes (aspartate transaminase 400s, alanine aminotransferase 300s, alkaline phosphatase 1200s, total bilirubin 12.4, direct bilirubin 7.1) over the course of her prolonged hospitalization. A hepatic workup was largely unrevealing for etiology. Hepatitis panel, drug panel, cytomegalovirus, and Epstein-Barr virus were all negative. Autoimmune workup was weakly positive for anti-nuclear and anti-smooth muscle antibodies, but these were felt to be clinically insignificant due to low titers. The patient was also trialed on intravenous steroids with little improvement, further arguing against the diagnosis of autoimmune hepatitis. Liver biopsy revealed lobular necrotizing granulomas with scattered histiocytes and lymphocytes, consistent with tuberculous granulomatous hepatitis. She started tuberculosis therapy and tolerated it well. Discussion: Primary hepatic tuberculosis with no clinical extrahepatic manifestations is a rare presentation and sporadically reported in the literature. This clinical case highlights the diagnostic difficulty of hepatic tuberculosis, which should be considered in immunocompromised patients with elevated liver enzymes and unrevealing initial workup. Liver biopsy is essential for diagnosis.Figure 1.: a) Lobular necrotizing granuloma; b) Center of necrotizing granuloma with histiocytes (black arrow) and lymphocytes (blue arrow).

S2202 A Rare Case of Colonic Intussusception After Self Expandable Metal Stent Placement

Introduction: Endoscopically placed colonic stenting is a palliative measure that can be used for unresectable etastatic colon cancer. It is a relatively safe procedure with a low mortality rate of about 1%. Intussusception is a rare complication of colonic stenting that occurs when the bowel telescopes about itself, possibly leading to obstruction or ischemia. Here we present a patient with intussusception 6 days after placement of a self-expandable rectosigmoid metal stent. We demonstrate successful reduction of rectosigmoid intussusception through a colonoscopy with air insufflation. Case Description/Methods: A 35-year-old female presented with 3 days of constant and progressively-worsening rectal pain, bloody rectal discharge, and thin stool. Her past medical history was significant for metastatic colon cancer treated with sigmoid colectomy and chemotherapy 2 years prior, with recurrence of disease requiring palliative self-expandable rectosigmoid metal stent placement 6 days prior to arrival. Vital signs were normal. She did not appear in acute distress and was hemodynamically stable. Pertinent examination findings included lower abdominal tenderness, normal bowel sounds, and normal rectal tone. Labs revealed WBC 12.4, Hgb 13.2, Plt 443, AST 14, ALT 8, ALP 77, total bilirubin 0.7, and a lactate of 0.9. CT scan of the abdomen and pelvis revealed intussusception at the proximal sigmoid colon without evidence of bowel obstruction. Colonoscopy revealed ball-shaped mucosa with a dusky appearance at the proximal end of the stent, consistent with intussusception and ischemic colitis. The intussusception was successfully reduced with air insufflation through colonoscopy. The patient tolerated the procedure well and was started on a diet the next day with an improvement in her rectal pain and resolution of rectal discharge (Figure). Discussion: Endoscopic colonic stenting remains a valuable palliative treatment for metastatic colon cancer. Survival rates of metastatic colon cancer do not significantly differ between palliative colonic stenting and colonic resection. However, there are fewer complications with colonic stenting than colectomy, making palliative stenting a preferred option. Intussusception is a rare complication of colonic stenting that is often treated surgically in adults. Here we demonstrate successful reduction of intussusception through colonoscopic air insufflation. We hope to bring awareness of this complication and consideration to air insufflation as first-line therapy.Figure 1.: A. A view of the distal aspect of the rectosigmoid stent revealing adequate translocation of tumor mass without evidence of obstruction. B. A view of the proximal aspect of the rectosigmoid stent revealing a dusky appearance,with thickening of the bowel. C. A view of the proximal aspect of the stent with the ball-shaped mass in a dusky appearance consistent with intussusception, as seen by arrows.

Bilateral torsion of an ovarian dermoid cyst in a nullipara, exploratory laparotomy, right ovariectomy and left cystectomy: A case report

Background: Ovarian torsion is a common gynecological emergency prompt diagnosis and treatment results in favourable outcome. This may be unilateral or bilateral in rare cases. However, bilateral Adnexal torsion (AT) is a gynecological emergency which occurs in approximately 2.7-3.5% of women of all ages globally. Aim: To present this uncommon clinical condition and offer management modality. Presentation of case: AC was a 28 -year- old nulliparous woman, who presented to our institution with a history of sudden onset of severe lower abdominal pain and nausea. On physical examination, she was acutely ill-looking, in mild painful distress, and her vital signs were within normal limits. On abdominal examination, there was no distension but there was lower abdominal tenderness, with muscle guarding. A pelvic examination revealed bilateral adnexal tenderness. Ultrasound examination showed a right ovarian cyst of size about 9 × 7 cm poor visualization of the left ovary. An impression of torsion of right ovarian dermoid cyst was made. She had exploratory laparotomy for ovarian torsion, right ovariectomy and left cystectomy. Her post-operative period was uneventful and was discharged in her 6th post-operative day in stable clinical state. Conclusion: We have presented 28-year-old nullipara who had bilateral ovarian and laparotomy with cystectomy. Prompt intervention of similar cases results in better prognosis.

Hydronephrosis and free fluid identified by point-of-care ultrasound leads to diagnosis.

A 64-year-old man with a history of hypertension presented for evaluation of sudden-onset, right lower quadrant abdominal pain radiating to the right flank with associated non-bloody, non-bilious emesis. He denied dysuria, hematuria, fevers, chills, history of similar symptoms, or previous abdominal surgeries. On physical examination, he was afebrile and hypertensive to 189/113, with vitals otherwise within normal limits. He appeared uncomfortable, with moderate right upper and right lower quadrant tenderness with mild guarding but no costovertebral angle tenderness. Point-of-care ultrasound was performed, which identified moderate hydronephrosis with associated free fluid surrounding the right kidney, concerning for obstruction and collecting system rupture (Figure 1). A contrasted computed tomography of the abdomen and pelvis confirmed high-grade obstruction attributed to 5-mm calculus within the proximal ureter causing dilatation of the ureter with hydronephrosis and perinephric fluid (Figure 2). Findings were consistent with calyceal rupture, resulting in urology consult. The urology team took the patient to the operating room for ureteral stenting, antibiotics, and staged ureteroscopy and lithotripsy. Spontaneous rupture of the renal pelvis is a rare but critical diagnosis in patients with acute abdomen.1 A retrospective review found that 74% of cases were attributed to ureteric stones; less common causes included benign or malignant extrinsic ureteric compression, pelvic–ureteric junction and vesico–ureteric junction obstruction, bladder outlet obstruction, and iatrogenic disease.2 Treatment is tailored to the cause and is often managed conservatively with antibiotics but may require urologic intervention.3 Ultrasound is a helpful tool in identifying abnormalities consistent with calyceal rupture, which include hydronephrosis and perinephric free fluid.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study

AimTo determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.Materials and methodsThis retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.ResultsSymptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.ConclusionsThe COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.

Optimizing Clinical Outcomes of Acute Appendicitis

Background: Appendectomy is a common emergency procedure in general surgery. The objective of this study was to identify factors that impact on outcomes following appendectomy for acute appendicitis. Methodology: A chart review of all patients with a diagnosis of acute appendicitis who underwent appendectomy at Aga Khan University Hospital between January 2018 and December 2019 was performed. Results: Most of the patients (male-tofemale ratio, 2:1; mean age, 35±15.6 years) presented with acute uncomplicated appendicitis within an average of 2.98 days from symptom onset. The most common clinical sign was right lower quadrant tenderness. Abdominal ultrasound had a low sensitivity (33%), but computed tomography of the abdomen, which is the preferred imaging modality, had a high sensitivity (93%). The overall complication rate was 10.9%, with no statistically significant difference between open and laparoscopic appendectomy in terms of duration of surgery, length of hospital stay, and complication rates. The negative appendectomy rate was 6%. Conclusion: The complication rates of acute appendicitis in this setting are within international rates, but the negative appendectomy rate remains high. A more accurate interpretation of available imaging modalities is needed to improve this rate.

Daily Gastrointestinal Symptoms And Weight Loss In A Young Female Athlete

HISTORY: 21-year-old female college ice hockey player with PMH of depression/anxiety on sertraline presents with a 3-month history of abdominal pain, nausea, vomiting, and diarrhea. This was accompanied by a 15-pound weight loss since freshman year of college. She states that she experiences emesis and diarrhea daily, however feels like she has a normal appetite and eats until she feels full. She presented to the ED, prior to our visit, for abdominal pain and vomiting, and was prescribed a PPI with no lab work at the time. At our visit, she did report feeling anxious as she had ended a 3-year long relationship which she described as being “toxic.” PHYSICAL EXAMINATION: General Appearance: Anxious appearing young Caucasian female in no acute distress with mild hand tremor Abdominal: Tenderness to palpation over the epigastric region without rebound tenderness. Prominent aortic pulse noted in abdomen. No lower quadrant or right upper quadrant tenderness to palpation. Resp: No acute respiratory distressCV: Regular rate and rhythm. No murmurs or clicks. No cyanosis of the fingers or lips. DIFFERENTIAL DIAGNOSIS: 1) Gastroesophageal reflux disease 2) Inflammatory Bowel Disease/Irritable Bowel Syndrome 3) Celiac disease4) H. Pylori TEST AND RESULTS: Fecal studies (calprotectin feces, stool culture, stool leukocytes, H Pylori stool, stool ova and parasites, FOBT) returned negative. TSH levels returned undetectable with free thyroxine levels returning elevated at 5.45. CMP returned borderline abnormal with mildly decreased CO2 and mildly increased BUN. CBC, ESR, CRP, celiac disease panel all negative. FINAL WORKING DIAGNOSIS: Thyrotoxicosis secondary to Grave’s disease TREATMENT AND OUTCOMES: The athlete was held from sporting activity due to concern for caloric deficiency as well as increased cardiac load to due hypermetabolic state. She was referred to Endocrinology where her thyrotropin receptor antibody returned positive consistent with Grave’s disease. She was initiated on atenolol for symptomatic control.