Massive Intraperitoneal Hemorrhage Research Articles

Prognostic value of instrumental research methods in the diagnosis of complicated forms of liver malignant tumors

Objective: To determine prognostic value of instrumental methods in the diagnosis of complicated forms of malignant forms of focal liver lesion.Material and methods: The experience of treating 112 patients with primary and secondary tumor lesions of the liver was analyzed. Life-threatening complications, such as spontaneous rupture of the tumor node leading to massive intraperitoneal bleeding and cancerous peritonitis, were noted in 32 (28.5%) cases. Clinical and echographic signs of the threat of this complication developing were observed in 26 (23.2%) patient. Ultrasound (US) and CT semiotics of the tumor node rupture included signs of hemoperitoneum, focal heterogeneous formation with the presence of perilesional hematoma, active extravasation of contrast medium, and focal discontinuity of the liver contour at the site of the focal formation.Results and discussion: Most often, the size of the tumor node exceeded 8.0 cm (in 65% of patients). Protrusion of the tumor through the liver surface was noted in 23 (39.6%) cases. Invasion of the tumor into adjacent organs and tissues was observed in 16 (27.5%) patients. Sites of phlebothrombosis, predominantly in the system of hepatic veins, detected by echo-Dopplerography of liver vessels, were present in 12 (20.6%) patients.Conclusion: Predictors of spontaneous rupture of the tumor node may include: size of the formation more than 5 cm; protrusion of the tumor through the liver surface; phlebothrombosis by tumor masses, leading to increased intramural pressure; extraliver invasion of the tumor into adjacent organs and tissues.

Preoperative Transcatheter Arterial Embolization for Spontaneous Rupture of Huge Amebic Liver Abscess with Massive Intraperitoneal Hemorrhage

An 18-year-old male developed a huge liver abscess with severe anemia over the course of 2 weeks. Abdominal contrast enhanced computed tomography showed ruptured huge liver abscess in the right liver lobe with signs of active hemorrhage (contrast extravasation). Serology examination confirmed amoeba as the suspected pathogen of cause. Angiography was performed followed by transcatheter arterial embolization to localize and control the hemorrhage. Embolization using a combination of polyvinyl alcohol and gelfoam successfully controlled the active hemorrhage. Exploratory laparotomy was performed to evacuate and debride the huge abscess. Metronidazole was given and showed good results. Huge liver abscess size is a predictor of conservative management failure and requires a gradual step-up intervention. The purpose of this paper is to explain the importance of imaging in detecting liver abscess and active hemorrhage along with the role of interventional radiology in this case.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge

BackgroundSpontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial.Case presentationWe report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient’s emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell–Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient’s history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease.ConclusionsMassive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

Gallbladder perforation and massive intraperitoneal bleeding secondary to haemorrhagic cholecystitis

A 76-year-old man on apixaban presented with abdominal pain, vomiting, and signs of haemorrhagic shock. Imaging showed large volume haemoperitoneum with active arterial extravasation in the gallbladder fossa. The patient proceeded to emergency laparotomy, where haemorrhage was thought to arise from within a perforated gallbladder. Cholecystectomy was performed and haemostasis was achieved. Histology showed features of subacute on chronic cholecystitis, with some sections suggestive of an underlying arteritis. Haemorrhagic cholecystitis is rare, and gallbladder perforation with massive intraperitoneal haemorrhage is rarer still. This article presents a case report and literature review of this entity.

A rare case of spontaneous rupture of renal artery pseudoaneurysm in a previously hypertensive patient

Introduction. The renal artery and segmental renal artery pseudoaneurysm is a rare and usually asymptomatic vascular lesion which in most of the cases thrombose spontaneously, but at same time it can be a source of life-threatening hemorrhage and shock. Today, these pseudoaneurysms are discovered with increasing frequency due to unrelated abdominal imaging or on screening work-ups for hypertension, as well as widespread use of angiography. Typically, they are seen in patients after trauma, inflammation, or renal surgery or biopsy. Case outline. In our case, a 52-year-old male patient with no prior history of surgery, significant abdominal trauma and systemic disease, presented with left flank pain and signs of hypovolemic shock that manifested before the admission to the surgical emergency room. The CT scan promptly demonstrated rupture of a large retroperitoneal hematoma with massive intraperitoneal hemorrhage. The angiography confirmed the rupture of the renal artery pseudoaneurysm. The patient underwent urgent operation. A life-saving nephrectomy was performed while intraperitoneal hemorrhage and retroperitoneal hematoma was evacuated. Fourteen days after surgery the patient was discharged fully recovered, with normal diuresis and serum levels of creatinine and urea within referential values. During the period of hospitalization, he was diagnosed with and treated for hypertension. Conclusion. Rupture of pseudoaneurysms followed by hemorrhage into the intraperitoneal cavity and retroperitoneum is a life-threatening condition, as proven with this case, in which hypovolemic shock manifested itself before the admission. We would like to highlight the importance of high blood pressure control and the importance of regular check-ups.

Death due to rupture of tubal pregnancy

Ectopic pregnancy (EP) is defined as a pregnancy in which the implantation of the embryo occurs outside the uterine cavity, most frequently in one of the two fallopian tubes or, more rarely, in the abdominal cavity. The result of an undiagnosed ectopic pregnancy is rupture of the fallopian tube with intra-abdominal bleeding, leading to hemorrhagic shock and death. Here, we present a case of 26-yearold recently married female who was brought for postmortem examination with history of sudden death following pain abdomen. Postmortem examination revealed findings suggestive of ectopic pregnancy. Histopathology revealed multiple vascularized branching villi lined trophoblasts and syncytiotrophoblasts along the lumen. The significance of ectopic pregnancy lies in the fact that it often goes undiagnosed with massive intraperitoneal bleeding. This case emphasizes the need for mandatory pregnancy screening in female patients of reproductive age groups who present with abdominal pain.

Abdominal ectopic pregnancy following a frozen embryo transfer cycle: a case report

BackgroundAbdominal ectopic pregnancy (AEP) is a rare form of ectopic pregnancy. As the number of in-vitro fertilization (IVF) procedures continues to increase, the incidence of AEP will also rise. However, the rarity and atypical presentation of AEP make early diagnosis challenging.Case presentationHerein, we report an AEP following frozen-thawed embryo transfer (FET) in an artificial cycle. The patient was misdiagnosed with implantation failure when the serum human chorionic gonadotropin (hCG) level was detected as 2.59mIU/ml at fourteenth day after embryo transfer. Therefore, she was suggested to stop luteal phase support. However, a ruptured AEP was developed 33 days following embryo transfer, which was diagnosed by laparoscopic surgery.ConclusionsThe case highlighted the delayed serum β-hCG and massive intraperitoneal hemorrhage may be clues to make early diagnosis of AEP. Clinicians must attach great importance to close monitoring and bear in mind the possibility of abdominal pregnancy.

English

Placenta percreta and uterine rupture are associated with possible massive intraperitoneal bleeding, which can be fatal if not recognised. We describe a case of a 40-year-old multigravida with a history of two instances of placenta percreta and three instances of uterine rupture, previous artificial abortion, and uterine curettage. The patient’s uterus had been preserved after undergoing an emergency uterus repair operation and a scheduled caesarean within 5 years. This case report aimed to contribute to the knowledge of the early diagnosis of placenta percreta and highlights the advantages of uterus preservation, including psychological reasons and the ability to bear children in the future. In summary, it is clear that the steadily increasing rate of deliveries may result in an increased number of abnormal placentation cases. Abnormal placentation is one of the most important risk factors of severe obstetric complications, including perinatal massive haemorrhage. Therefore, prenatal diagnosis and identification of abnormal placentation are vital in order to plan appropriately the date, place, and mode of delivery, as well as to ensure the availability of highly qualified specialists in the field of obstetrics and anaesthesia and ensure availability of a sufficient amount of blood products and blood substitutes. Key words: Placenta percreta, uterine rupture, pregnancy.

A Case of Segmental Arterial Mediolysis:Subarachnoid Hemorrhage Followed by Abdominal Bleeding

We describe a case involving subarachnoid and intraperitoneal hemorrhage due to segmental arterial mediolysis(SAM). A 77-year-old female patient with sudden subarachnoid hemorrhage was immediately transferred to our institution. The hemorrhage was classified as grade 2 according to the World Federation of Neurosurgical Societies system. The patient was a non-smoker and did not drink alcohol regularly. A right internal carotid aneurysm was detected using CT angiography and was clipped during frontotemporal craniotomy. Bleeding was observed from the anterior wall of the internal carotid artery, and the tear was clipped. The patient had an uneventful postoperative course until sudden cardiopulmonary arrest eight days after craniotomy. She died of massive intraperitoneal hemorrhage. Autopsy revealed that the hemorrhage was due to dissection of the celiac artery. Tunica media denaturation was observed not only in the celiac artery, but also in the splenic and internal carotid arteries, which exhibited ruptured aneurysms, and the patient was diagnosed with segmental arterial mediolysis(SAM). SAM is an arterial degenerative disease affecting the medial layer of the arterial and dissecting walls. Multiple lesions are sometimes found. Radiographic imaging findings of SAM are similar to those of dissecting aneurysms, which are characterized by a single continuous dissection of the medial layer. As observed in this case, abdominal bleeding caused by SAM can occur after intracranial bleeding. When surgeons encounter unusual intracranial dissecting aneurysms, SAM should be considered as a differential diagnosis.

Scleroderma renal crisis with coexisting segmental arterial mediolysis presenting as intraperitoneal bleeding: a case report

BackgroundSegmental arterial mediolysis is a rare nonarteriosclerotic and noninflammatory vascular disease that may cause intraperitoneal bleeding. Scleroderma renal crisis is a rare complication of systemic sclerosis, leading to severe hypertension and renal dysfunction. To the best of our knowledge, this is the first reported case of a patient with concurrent systemic sclerosis with scleroderma renal crisis and pathologically confirmed segmental arterial mediolysis.Case presentationWe report a case of a 68-year-old Chinese woman diagnosed with systemic sclerosis who was found to have coexisting segmental arterial mediolysis. She presented with back pain, and massive intraperitoneal bleeding was detected by computed tomography. She underwent laparotomy, and the bleeding was found to originate from the gastroepiploic artery. The pathological examination demonstrated gastroepiploic arterial dissection caused by segmental arterial mediolysis. After surgery, she developed severe hypertension with hyperreninemia and progressive renal dysfunction. Given the risk factors of corticosteroid administration and the presence of anti-ribonucleic acid polymerase III antibody, she was diagnosed with scleroderma renal crisis. The patient was proved to have a very rare case of coexisting scleroderma renal crisis and segmental arterial mediolysis.ConclusionsThere is no known etiological connection between segmental arterial mediolysis and systemic sclerosis or scleroderma renal crisis, but it is possible that coexisting segmental arterial mediolysis and scleroderma renal crisis may have interacted to trigger the development of the other in our patient.

A Rare Case Of Hemoperitoneum Due to Rupture of Vessels Over The Surface of Leiomyoma

Hemoperitoneum due to rupture of veins on the surface of uterine leiomyoma leading to hypovolemic shock is extremely uncommon .Only 100 cases have been reported in the past and it is a life threatening emergency. Here we re-port a case of massive intraperitoneal haemorrhage due to rupture of vessels on the surface leiomyoma. Diagnosis was made by ultrasound guided ascitic tap which revealed hemoperitoneum. The patient underwent emergency laparotomy and abdominal hysterectomy. Surgery revealed 3.8L of hemoperitoneum and engorged and tortuous surface veins over the uterine fibroid with active bleeding. Pathology was consistent with intraoperative findings. She required transfusion of numerous blood products perioperatively. Her postoperative course was uncomplicated. Hence differential diagnosis of rupture of surface vessel of leiomyoma as a cause of hemoperitoneum should be considered, when there is no history trau-ma, ruptured ectopic or other findings. Keywords – Leiomyoma, Hemoperitoneum, Laparotomy

Розрив розшаровуючої аневризми черевного відділу аорти (випадок з практики районного спеціаліста)

Cardiovascular diseases, especially in the elderly, are ranked first in the structure of morbidity and mortality. They serve as abackground for the development of other pathological conditions. In our case, diffuse arterio-atherosclerosis of the vessels in the patient, especially the aorta, led to the development of adissectinganeurysm of the abdominal aorta, which was complicated by the rupture with acute massive intraperitoneal haemorrhage, hemoperitoneum, leading toa fatal end. The diseaseoften starts unnoticed or with insignificant gastrointestinal discomfort. Aim. Drawing attention to the complexityof timely diagnosis and effective treatment of the dissectingabdominal aortic aneurysm. Material and Methods. The clinical case of the disease in the patient O., 75 years old, was analyzed; the results of the laboratory-clinical and instrumental examination were presented. However, the true cause of the severity of the patient's conditionwas not established on time. Results and Discussion. Throughout life and in the process of industrialactivity, amodern person consciously or unknowingly undergoes the influence, sometimes simultaneous and combined one, of various factors, the effect of which is sometimes detrimental to theirhealth. Over time, their negative effects are accumulated,, targetingprimarily cardiovascular and nervous system. Disturbances of macro- and microcirculation often serve as a background for the development of other pathological conditions. With age, an individual is"overgrown" with a number of interconnected, concurringdiseases; there is a polymorbidity with a syndrome of mutual exacerbationin their course. For example, today an unhealthy brand is popular: during a feast people overeat, consuming foodstuffs incompatible in the digestion and absorption (saturated with preservatives, stabilizers, flavors, etc.), accompanied bydrinking alcohol, coffee and smoking. So to what limits does one need to overload, stimulate and excite one’sbody by resorting to the above-mentioned harmful habits?! It is necessary to practice moderation in all respects. The described clinical case clearly demonstrates the difficulty in establishing the etiology of the disease, that is, not always the diagnosis lies on the surface. The beginning of the formation of aortic aneurysms is very difficult to notice in practice. The period of insignificantstretching of the aortic walls, which lasts from a few months toyears, actually does not manifest itself. A milddiscomfort in the abdomen usually goes unnoticed, especially at an older age. The available to us methods of examination and laboratory diagnostics failed contribute to the detection of this gravestate. Unfortunately, only the autopsy of the deceased has had the final say in revealing of the true cause of the serious condition of the patient. Conclusion. The following description of the disease of the patient O. confirms the pointabout the difficulties in the diagnosis of this pathology, due to the presence of nonspecific, sometimes slightly expressed, gastrointestinal symptoms, which arenot paid timely attention byeitherpatients orhealthcare workers. The ultrasound and computer methods of vascular diagnostics, available at present, should be used earlier, more frequentlyand in dynamics, especially in unclear pathological conditions, all the morein the elderly. Detecting and treating morbid conditions at the present time is not always smooth and easy. For some reason, in recent years little attention has been paid to preventing disease. &nbsp

Hemorrhagic Pancreatic Pseudocyst

Bleeding from pancreatic pseudocyst is an extremely rare complication, however it is a common finding in patients with history of pancreatitis and alcohol abuse. Pseudoaneurysm complicating pseudocyst is a rare occurrence and is reported in 10% of patients with chronic pancreatitis. 1 We report a 34 year old man with a hemorrhagic pseudocyst due to splenic artery pseudoaneurysm. 34 year old man with ongoing ETOH abuse and history of acute pancreatitis presents with 4-5 days of dark stools and 2 months of left sided abdominal pain. On physical exam, patient appeared comfortable and was hemodynamically stable, but had mild epigastric tenderness. EGD showed submucosal bulging (Image 1 and 2) in fundus/ body that prompted cross sectional imaging. The CT A/P with contrast (Image 3) showed a large mass highly concerning for a hemorrhagic pseudocyst w/ a 1.0 cm hyperdense focus within the supero-lateral portion of the hemorrhagic collection concerning for active extravasation from a suspected pseudo-aneurysm of the splenic artery. Patient was immediately taken for an angiography with IR and no extravasation was noted that afternoon; however, a repeat angiography the next day showed active extravasation of the distal branch of the splenic artery. A coil embolization was performed immediately. Patient was transferred to MICU for further monitoring and remained hemodynamically stable until discharge. While any splanchnic vessel can be source of bleeding, the splenic artery is most commonly involved in pseudo-aneurysm formation. Bleeding should be suspected in patients with a pseudocyst if a) no obvious bleeding source can be found on endoscopy b) sudden drop in hematocrit c) increase in pseudocyst size d) bruit heard on auscultation over pseudocyst. Angiography is the gold standard for examination. Current practice entails contrast enhanced CT, which guides the need for angiography and further embolization or surgery.2 As demonstrated in our case, a high index of suspicion is important in the management of pancreatic pseudocysts as our patient (with history of alcoholism) was hemodynamically stable and having only mild abdominal pain. 1. Bretagne JF, et al. Pseudo aneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contributions to diagnosis in 8 cases. Gastrointest Radiol. 1990. 2. Hsin-Hui Chiu, et al. Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage. The American Journal of Surgery. 2006.1376_A.tif Figure 1: No Caption available.1376_B.tif Figure 2: No Caption available.1376_C.tif Figure 3: No Caption available.

MASSIVE FATAL INTRAPERITONEAL BLEEDING FROM GASTROHEPATIC LIGAMENT FOLLOWING PEG TUBE PLACEMENT: AN EXTREMELY RARE COMPLICATION

SESSION TITLE: Critical Care 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Placement of a percutaneous endoscopic gastrostomy (PEG) tube is a common procedure to allow for enteral nutrition in patients with multiple indications. The incidence rates for serious and minor complication have been estimated to be 3 % and 6 %, respectively. Immediate mortality after the procedure appears is less than 1%. Intraperitoneal bleeding is extremely rare and a few cases have been reported associated with hepatic laceration and spleen avulsions. CASE PRESENTATION: 84-year-old male with a past medical history significant for paroxysmal atrial fibrillation and mechanical mitral and aortic valve replacement on Warfarin initially presented with seizure, and diagnosed with coccidioidomycosis pneumonia and started on fluconazole. His long hospital stay was complicated with dysphagia, failed swallow evaluation with sign of aspiration of videofluoroscopic swallow study. Patient family was interested in PEG tube placement for further feeding of the patient. Warfarin was stopped, and started on heparin drip that also was stopped 4 hours pre operative. PEG tube was placed in first attempt without any obvious complication. After 5 hours, the patient was found to be unresponsive and pulseless. Code Blue was called and resuscitation was started following ACLS protocols. Cardiac monitor showed pulseless electrical activity. After 4-5 minutes of chest compression, ROSC was obtained and he was transferred to MICU. Vitals: BP 53/32, HR 63, Temp 98.1. He was given IV fluid and started on levophed and vasopressin. Physical Examination showed abdominal distension with severe abdominal tenderness. Labs showed significant drop in hemoglobin to 6.3 from 10.6. Bedside abdominal ultrasound showed massive fluid in the intraperitoneal cavity. Gastroenterologist was called, and EGD was repeated at bedside with no sign of bleeding in the stomach. The patient was sent to operation room for emergent laparotomy for intraperitoneal bleed. Active bleeding from gastrohepatic ligament was found. About 1400 ml of blood was drained. The source of bleeding was controlled and was sent back to MICU. In spite of multiple blood transfusion with the high dose of norepinephrine and vasopressin infusion, his blood pressure stayed low. The patient could not sustain the acute conditions and expired. DISCUSSION: PEG tube placement is a safe procedure with minor complication. Immediate mortality after PEG placement is very rare, as low as <1%. Massive intraperitoneal bleeding is extremely rare. We report the first case of immediate massive bleeding from gastrohepatic ligament during PEG tube placement.We report the first case of immediate massive bleeding from gastrohepatic ligament during PEG tube placement. Rapid diagnosis and surgical intervention is critical and can prevent an untimely death. CONCLUSIONS: PEG tube placement is a very common procedure, but physicians should be mindful of this uncommon complication. Reference #1: Gauderer MW. Twenty years of percutaneous endoscopic gastrostomy: origin and evolution of a concept and its expanded applications. Gastrointest Endosc. 1999;50:879–883. Reference #2: Gubler C, Wildi M, Bauerfeind P (2005) Liver injury during PEG tube placement: report of two cases. Gastrointest Endosc 61:346–8 Reference #3: Lau G, Lai SH. Fatal retroperitoneal hemorrhage: an unusual complication of percutaneous gastrostomy. Forensic Sci Int 2001;116:69-75. DISCLOSURES: No relevant relationships by Abdul Aleem, source=Web Response no disclosure on file for Nabil Sultani

Complications of percutaneous liver biopsy with Klatskin needles: a 36-year single-centre experience.

Liver biopsy is the gold standard in evaluating liver diseases but is susceptible to complications. Safety data on aspiration needle biopsies remain limited. To evaluate the safety of percutaneous liver biopsy performed with Klatskin needle. Clinical and biochemical data were retrospectively retrieved from sequential subjects who underwent liver biopsy with Klatskin needle from 1978 to 2015. Subjects with complications underwent thorough chart reviews for hospital course. Of 3357 biopsies performed, complications occurred in 135 (4%) biopsies with 33 (1%) resulting in major complications. Severe pain occurred in 78 (2.3%) subjects and bleeding occurred in 21 (0.6%) subjects. Biliary injury occurred in 8 (0.2%) biopsies. Three subjects died as a result of massive intraperitoneal bleeding. Compared to viral hepatitis, biopsies performed with certain diagnosis had significantly higher odds of major complications: NRH (OR: 17), DILI (OR: 20), GVHD (OR: 32) and HCC (OR: 34). Subjects with major complications had higher pre-biopsy median AP (153 vs. 78 U/L, P < 0.001), ALT (105 vs. 64 U/L, P < 0.05), AST (62 vs. 47 U/L, P < 0.02), along with marginally lower total bilirubin (1.0 vs. 0.7 mg/dL, P < 0.01) and albumin (3.7 vs. 4.0 g/dL, P < 0.001). By multivariate backward logistic regression, platelets ≤100 K/μL and aPTT >35 were independent risk factors of post-biopsy bleeding. Klatskin needle liver biopsies are safe with rare procedural morbidity. Our data suggests certain acutely ill subjects and those with systemic illnesses may be at higher risk of major complications. Clinicians should weigh the risks and benefits of liver biopsy in these patients with other alternative approaches.

Getting the GIST: a pictorial review of the various patterns of presentation of gastrointestinal stromal tumors on imaging.

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors of the gastrointestinal tract, are a relatively recently described entity. Most exhibit a mutated tyrosine kinase receptor gene and in some capacity are treated by tyrosine kinase inhibitors. GISTs can occur across the age spectrum but are more common in patients older than 40 years. They exhibit a wide range of clinical presentations and imaging characteristics. All patterns of enhancement on contrast enhanced computed tomography (CECT) can be seen with GISTs, including hypoenhancing, isoenhancing, and hyperenhancing tumors. They can be large or small, endoluminal or exophytic. Clinical presentations include asymptomatic patients, nonspecific symptoms, obstruction, and bleeding. Bleeding can take the form of slow, intraluminal GI bleeding or massive intraperitoneal bleeding secondary to rupture and can be seen regardless of the enhancement pattern. Some can cavitate, ulcerate, rupture or cause fistulae. The radiologist's knowledge of the variety of combinations of presentations can narrow the differential diagnosis and ultimately lead to faster diagnosis and treatment.

A Rare Case of Secondary Abdominal Pregnancy continuing up to Term with a Live Baby

ABSTRACT Secondary abdominal pregnancy is a very rare condition. Outcome of secondary abdominal pregnancy with pregnancy continuing up to term and delivering a live baby by laparotomy is more rare. Management of secondary abdominal pregnancy depends on the gestational age of the fetus when diagnosed. If not diagnosed at the correct time patient may have life-threatening complications, for example, massive intraperitoneal hemorrhage, peritonitis, intestinal obstruction, intestinal perforation, fecal fistula formation, and lithopedion formation. How to cite this article Moitra B. A Rare Case of Secondary Abdominal Pregnancy continuing up to Term with a Live Baby. J South Asian Feder Obst Gynae 2016;8(2):249-251.

Considerations on Liver Injuries Caused by CPR Case Presentation

Cardiac arrest is a life-threatening condition which requires fast maneuvers for saving the victim’s life. Cardio-pulmonary resuscitation (CPR) is one of the easiest and handiest maneuver which proved many times to be savior even though sometimes it could worsen the victim’s prognosis. In this paper the authors present the case of a 75-year old male, with a significant medical history and long term thrombolytic treatment who suffered a witnessed cardiac arrest. The emergency team who arrived at the victim’s home initiated the CPR and transported him to the hospital. The electrocardiogram showed inferior-lateral acute myocardial infarction and the cardiologist in the emergency room decided to transfer him to another hospital for specialized treatment. Despite the fact that the CPR was continued in the ambulance in order to maintain the cardiac activity, the blood pressure decreased gradually and he died couple of hours later. Internal examination at the autospy revealed multiple injuries caused by the cardiac massage: rib and sternum fractures, massive intraperitoneal bleeding, liver laceration and contusion. This paper brings to the attention of the physicians the issue of the iatrogenic injuries following the CPR and the possibility for these injuries to contribute to thanatogenesis. The authors also analyze the factors influencing the quality of the life-saving procedures and the role of the pathologist in establishing the correct cause of death taking into the gravity of the CPR related injuries.Keywords: CPR, liver injury, death

Rare presentation of ruptured rudimentary horn pregnancy

It is a rare occurrence for the rudimentary horn of uterus to harbour a pregnancy and the usual outcome is devastating leading to a spontaneous rupture in second trimester with the patient presenting in shock with massive intra-peritoneal haemorrhage and if appropriate management is not instituted in time it may lead to high rate of mortality. We report an unusual case of rupture rudimentary horn pregnancy who presented as a chronic ectopic with an adnexal mass and surprisingly with no sign of shock. Diagnosis is often difficult in such a situation which puts the treating gynaecologist in dilemma. High clinical suspicion supplemented with radiological findings helped clinch the diagnosis and laparotomy was performed followed by resection of the rudimentary horn to prevent future complications.

Massive Intraperitoneal Hemorrhage Due to Perforated Cholecystitis

Massive Intraperitoneal Hemorrhage Due to Perforated Cholecystitis