Moderate Amount Of Free Fluid Research Articles

S2548 An Unusual Case of Abdominal Hematoma Presenting After Long Quiescence Period

Introduction: Incidental abdominal masses are often detected during routine imaging for abdominal pain. Abdominal hematomas usually present a few days after recent trauma and are associated with peritonitis requiring surgical intervention. We report a case of symptomatic abdominal hematoma, presenting as an abdominal mass, 1 year after motor vehicle accident (MVA). Case Description/Methods: 24-year-old female presented with sudden onset sharp epigastric and left upper quadrant (LUQ) abdominal pain, radiating to bilateral shoulders, along with decreased oral intake, nausea, and bilious vomiting. On physical exam, she was hemodynamically stable, abdomen was soft, non-distended, with epigastric and LUQ tenderness, bowel sounds normal, otherwise unremarkable exam. Initial blood work was unremarkable. Computed tomography of abdomen and pelvis (CTAP) revealed a 5.6x 2.1x 5.4 cm mass located between stomach and spleen without associated adenopathy, suspicious for gastrointestinal stromal tumor (Figure). On EUS, the lesion appeared poorly defined, multicystic and likely originating outside the gastric wall. There was also a moderate amount of free fluid in the abdomen. A fine needle biopsy was obtained, but the sample was largely blood clot. The next day, the patient developed sharp abdominal pain with guarding, blood work revealed hemoglobin levels drop from 12.9 to 7.6 g/dl. CTAP angiography showed development of large amount of intraperitoneal free fluid, without active extravasation, and grade 1 splenic laceration, likely chronic. The non-enhancing hyperdense mass was again noted, unchanged in size and location. Laparoscopy revealed a ∼6cm hematoma and evacuated 2L old blood. Postoperative diagnosis was spontaneous hemoperitoneum secondary to trauma of short gastric vessel. Pathology result showed blood, inflammation, and rare degenerated epithelial cells. Upon further interrogation, patient endorsed MVA 1 year ago but did not seek medical care due to no symptoms. Patient was monitored after surgery and upon significant improvement in her symptoms and blood work, she was discharged. Discussion: It is rare for abdominal hematomas to be quiescent for one year and then suddenly present as peritonitis without any further inciting event. Our patient could have suffered from major morbidity, given the drastic drop in hemoglobin level, without urgent intervention. Physicians should have high clinical suspicion and investigate for possible trauma, in acute abdominal pain cases with an incidental abdominal mass on imaging.Figure 1.: Computed tomography of abdomen and pelvis revealing a hypo-echoic mass located medially adjacent to the spleen and laterally adjacent to the stomach. No surrounding fat stranding or lymphadenopathy noted.

Ruptured Spontaneous Heterotopic Pregnancy Presenting with Hemoperitoneum: a case report

Heterotopic pregnancy (HP) is the coexistence of intrauterine (IU) and extrauterine (EU) gestation. It is rare and potentially fatal condition if not correctly treated or diagnosed. In this case report, we present a 33-year-old woman with a 16-week topical pregnancy with spontaneous rupture of an ectopic pregnancy (EP) in the uterine tube. At first, the patient had diffused abdominal pain, specifically in the lower abdominal level and tachycardia. The evaluation of the fetus showed no signs of distress. Abdominal and transvaginal ultrasound (US) show free intraperitoneal fluid, a normal-looking IU gestation with a positive fetal heart rate consistent with a fetal age of approximately 16 weeks, signs of parenchymal vascular hypoflux of the spleen on the color doppler study, associated with a splenic vein with low vascular amplitude flow. General surgery team were requested and to rule out aneurysm of splenic vessels as a source of bleeding she had an abdominal angiotomography that showed a moderate amount of free fluid, ectasia of gonadal and uterine vessels, with no signals of active bleeding and no spleen changes. No signs of EP were identified in this exam. The patient had hemodynamic deterioration with maintenance of abdominal girth. An emergency exploratory laparotomy was performed under general anesthesia through a supra and subumbilical incision, leading to a finding of a ruptured EP. There was a 3 cm right tubal ruptured ectopic pregnancy. A total right salpingectomy was performed with removal of the hemoperitoneum and peritoneal lavage. The patient recovered uneventfully and was discharged from the hospital within 5 days.

Rupture of Spleen During Pregnancy with Intrauterine Fetal Death Mimicking Rupture Uterus: A Case Report

Background: Splenic rupture in pregnancy or postpartum is a rare and frequently misdiagnosed event. The splenic rupture during pregnancy is difficult to diagnose because it shares signs and symptoms with other conditions such as uterine rupture and abruptio placentae. Case report: We report a case of a 26 years G3P2L2 who had splenic rupture following accidental fall from the stairs. She presented with acute abdominal pain with hemoperitoneum and intrauterine fetal death. Ultrasonography confirmed moderate amount of free fluid and fetal demise without any evidence of retroplacental clots. She was taken up for emergency laparotomy with a provisional diagnosis of rupture uterus. On laparotomy, massive hemoperitoneum due to splenic injury was noted. Hence, Splenectomy was done and she recovered without further complication. Splenic rupture should be considered in cases of trauma to the abdomen during pregnancy because of the risk of severe haemorrhage, shock, and possibility of pregnancy loss. The aim of the article is to highlight the fact that rupture of the spleen is an unusual but serious cause of acute abdominal pain in pregnancy and is associated with both maternal and fetal complications. Conclusion: Sudden abdominal pain, pallor, and hypotension following any trauma may be a sign of splenic rupture. Resuscita-tion of patients with immediate laparotomy should be done in these patients to avoid fetal and maternal morbidity and mortality. Hence, it should be one of the differential diagnoses in addition to abruptio placentae and uterine rupture in suspected cases of haemorrhagic shock.

Ruptured Ectopic Pregnancy with Negative Urine Pregnancy Test

<h3>Study Objective</h3> To report a case of a ruptured ectopic pregnancy in a patient with a negative urine pregnancy test. <h3>Design</h3> Case report. <h3>Setting</h3> Academic center. <h3>Patients or Participants</h3> The patient is a 23yo sexually active G1P0 at approximately 7 weeks gestational age who presented to the Emergency Department (ED) with abdominal pain and vaginal bleeding. She reported having a positive urine pregnancy test at home 6 days prior to presenting to the ED. However, in the ED her urine pregnancy test was negative. Transvaginal ultrasound demonstrated no intrauterine pregnancy and a complex mass with heterogeneous echotexture in the left adnexa measuring 1.7 × 2.3 × 2.6 cm with surrounding hyperemia. No clear gestational sac seen in the left adnexa. There was also noted to be a moderate amount of free fluid in the posterior cul-de-sac. <h3>Interventions</h3> Diagnostic laparoscopy with left salpingectomy. <h3>Measurements and Main Results</h3> The patient's urine pregnancy test was negative and serum b-hCG level was 19.8. Her hemoglobin dropped from 15.3 to 13.5 over the course of two hours. Diagnostic laparoscopy revealed approximately 200cc of clotted blood in the pelvis, but no evidence of active bleeding. Her left fallopian tube was minimally adherent to the pelvic sidewall and an ectopic pregnancy was noted within the left fallopian tube. Right fallopian tube bilateral ovaries appeared normal. Final pathology was consistent with chorionic villi. <h3>Conclusion</h3> The diagnosis of an ectopic pregnancy can be challenging. It is important to maintain a high clinical index of suspicion for an ectopic pregnancy even in the case of a negative urine pregnancy test.

Recurrent hydronephrosis and spontaneous renal rupture caused by lymphoplasmacytic inflammation in a cat

A seven-year-old male cat that was previously diagnosed with – and treated for – left hydronephrosis due to suspected idiopathic proteinaceous materials in the renal pelvis, presented with a short history of anorexia and vomiting. The abdominal ultrasound revealed bilateral hydronephrosis, and the intravenous pyelography showed a moderate amount of free fluid in the retroperitoneal space at 48 hours. After the nephrectomy, the gross examination of the right kidney revealed a very thin capsule with urine leakage, and the right renal pelvis showed small, black deposits. The histopathology of the right kidney revealed hydronephrosis with compression atrophy, necrosis of the renal cortex/medulla, and a moderate lymphoplasmacytic inflammation. The crystallographic analysis revealed that the black deposits were composed of 100% protein and no minerals. The cat was diagnosed with hydronephrosis and spontaneous renal rupture caused by proteinaceous pelvic materials, secondary to the idiopathic renal lymphoplasmacytic inflammation. In addition to revealing the possibility that immune-mediated renal disease can induce spontaneous renal rupture in cats, this case report demonstrates the utility of imaging for diagnosing and monitoring hydronephrosis, detecting urine leakage, and planning surgery.

Clinical pathology and ultrasonographic findings from a Warmblood gelding with primary, severe, acute pancreatitis

SummaryA 24‐year‐old Warmblood gelding presented with a 6‐hour history of recurrent colic signs of increasing severity. Upon presentation, he was mildly painful, tachycardic and tachypnoeic and had decreased borborygmi. Nasogastric intubation resulted in no net reflux and rectal palpation revealed an ascending colon impaction. Percutaneous abdominal ultrasonography revealed dilated, thickened and hypomotile loops of small intestine. Complete blood count revealed leucopenia with neutropenia and an increased packed cell volume. Serum biochemistry revealed hyperproteinaemia, hyperglycaemia, hypocalcaemia, hyperbilirubinaemia, hypercholesterolaemia and elevated liver enzymes. Despite sedation and fluid resuscitation, the gelding became severely colicky. A repeat ultrasound was performed, revealing a moderate amount of free fluid and a mass effect between the liver and right dorsal colon. Abdominocentesis yielded a yellow, turbid fluid containing free‐floating white debris with an increased total protein and lactate concentration. Cytology of the fluid revealed necrotic mesothelial cells. The gelding was humanely euthanised due to poor prognosis. Necropsy revealed acute, severe pancreatitis and duodenitis. The mass effect on ultrasonography was retrospectively identified as the pancreas exhibiting a similar architecture to that seen in cases of acute pancreatitis in small animals.

Moderate Intra‐abdominal Free Fluid on Computed Tomogram in Patients with Blunt Trauma Abdomen: Time to Shun Non‐operative Approach

We have read with interest the article by Mahmood et al. [1] on the significance of detection of intra-abdominal free fluid sans solid organ injury on computed tomogram (CT) in hemodynamically stable patients with blunt trauma abdomen (BTA). Their retrospective analysis of 122 cases reaffirms the importance of thorough and repeated clinical examination in the decision-making process for laparotomy in patients with mesenteric and bowel injury. The authors applied multivariate logistic regression analysis for identifying the predictors associated with therapeutic laparotomy. Odds ratio (OR) was calculated for the risk factors to ascertain their relationship with therapeutic laparotomy. The OR is a measure of association between an exposure of interest and a certain outcome. In other words, it is a ratio between the odds that a particular exposure will result in an outcome to the odds that the same outcome will result in absence of that exposure. Apart from identifying the exposure as a potential risk factor for a defined outcome, the OR also determines the magnitude of effect of that particular exposure on the outcome. The exposure is said to have no effect on the outcome when the OR is one. A value greater than one suggests a positive association between the exposure and the outcome, whereas a value less than one suggests a negative association between them. In the study by Mahmood et al. age, mechanism of injury, and presence of seat belt sign were found to have statistically significant positive association with therapeutic laparotomy following calculation of OR; however, two of these predictors had very wide confidence intervals, implying very low precision of the results. The logistic regression table outlining the predictors for therapeutic laparotomy depicts significant p value with a high OR and a wide confidence interval for the mild amount of abdominal fluid evident on CT scan. We think the presented data points show otherwise, in that a moderate rather than a mild amount of free fluid on CT scan has a stronger association with therapeutic laparotomy. The logistic regression analysis for a moderate amount of free fluid on CT scan as a predictor for therapeutic laparotomy revealed an OR of 8.66 (p = 0.0001) and a CI at 3.03–24.7 (statpages.org/logistic.html). In light of the above observations, a moderate amount of free fluid on CT of the abdomen should have been considered a strong predictor for therapeutic laparotomy. The authors overlooked this fact and concluded that CT scans are inaccurate for the prediction of bowel injury and the need for laparotomy. They have also advocated against immediate celiotomy in patients with abdominal injury. We think their opinion is nonspecific and not in sync with the objectives and the results of their study. While the role of clinical examination in deciding the need for laparotomy in patients with BTA is undisputed, detection of moderate free fluid on CT scan should tilt the balance in favor of laparotomy in patients with equivocal findings on clinical examination of the abdomen.

Ectopic pregnancy implanted in the liver under the diaphragm

Abdominal pregnancy has been defined as an ectopic pregnancy implanted in the peritoneal cavity but excludes pregnancies that are tubal, ovarian, or intraligamentous [1]. Abdominal pregnancy is rarely seen and accounts for approximately 1% of all ectopic pregnancies [2]. Ordinarily, the location of an abdominal pregnancy is pelvic, but very rarely it may be implanted in the upper abdomen (especially on the liver) [3]. In most cases, the attachment site of the placenta is on the lower surface of the right lobe of the liver [2]. Here we report a case of ectopic pregnancy implanted on the upper surface of the right liver lobe. A 33-year-old Chinese woman (gravida 4, para 2) was admitted to our hospital’s emergency department with severe pain in the right upper quadrant of her abdomen and right shoulder pain radiation for a duration of 1 day. She had undergone two cesarean deliveries (the first in 2003 and the second 9 months prior to her presentation) and had not used any contraceptive method afterwards. On admission, she claimed to have amenorrhoea for 5 weeks and a urinary pregnancy test was weakly positive. Her serum hCG was elevated at 186.14 mIU/mL. On examination, her pulse was 82 beats/minute and blood pressure was 108/80 mmHg. Her physical examination was normal except for right upper quadrant tenderness. On vaginal examination, the uterus was normal in size with no definite adnexal mass. There was no vaginal bleeding. Transvaginal and transabdominal ultrasound examination showed a normal-sized uterus with an endometrial thickness of 8.4 mm, normal bilateral adnexae, and a moderate amount of free fluid in the abdomen. A mixed echogenic mass of 91 mm 37 mm in size was observed attached to the superior surface of the right liver lobe (Fig. 1). Because of this unusual finding, a computed tomography scan of the abdomen and pelvis was performed. A 90-mm-long mixed hypodense mass was evident on the upper surface of the right liver lobe (Fig. 2).

Ventriculogallbladder shunt fracture: bile peritonitis

A 9-year-old girl presented with worsening lower abdominal pain and emesis of 10 hours’ duration. She had a history of a ventriculogallbladder shunt (VGBS) placed 18 months after failure of peritoneal shunting for posthemorrhagic hydrocephalus. Examination revealed a diffusely tender abdomen; she was at her neurological baseline. Serology demonstrated borderline leukocytosis without hepatobiliary abnormalities. A radiographic shunt series (Fig. 1) showed a fracture of the catheter just below the valve. The catheter below the fracture site had retracted into the lower abdomen. The distal catheter remained in place in the gallbladder dome. CT of the abdomen/pelvis (Fig. 2) revealed a moderate amount of free fluid with peritoneal thickening consistent with peritonitis. The patient was taken urgently to the operating room. Laparoscopy revealed intraperitoneal bilious fluid. The gallbladder was noted to be extensively adherent to the surrounding tissue, so the catheter was ligated just outside the gallbladder due to concern for complication with cholecystectomy or catheter removal (Fig. 3). The proximal ventricular shunt and valve were explored and noted to be working well; a distal atrial catheter was placed. The patient was discharged home on postoperative Day 4. At 3-month followup she showed no signs or symptoms of shunt malfunction. Described VGBS-specific malfunctions include bilious reflux resulting in ventriculitis 2 or meningitis 1 and cholecystic complications including atony, biliary tract infection, and cholecystitis. 3,4

Index of Suspicion * Case 1: Irritability and Signs of Peritonitis in a Neonate * Case 2: Red Eye, Excessive Tearing, Photophobia, Irritability, and Splenomegaly in an Infant * Case 3: 2-year-old Girl Who Has Cough, Right Pulmonary Abnormalities

* ALL: : acute lymphoblastic leukemia CT: : computed tomography IVC: : inferior vena cava NA: : neonatal appendicitis NEC: : necrotizing enterocolitis WBC: : white blood cell A 7-day-old boy born at term is brought to the emergency department by his foster mother for refusal to feed for ∼20 hours and increased crying, although he is intermittently consolable. When given his bottle, the infant starts to suck but then cries as though in pain. He has not vomited, and his last bowel movement was yesterday. The stool has been moderately well formed without blood or mucus, and wet diapers have continued. There is no history of respiratory symptoms, lethargy, rashes, or jaundice. The biological mother is a 27-year-old woman with a known history of previous drug abuse; she had received some prenatal care. This infant was born by scheduled cesarean delivery. Initial physical examination reveals a crying but consolable neonate. His temperature is 37.7°C, heart rate is 170 beats/minute, and respiratory rate is 56 breaths/minute; the remainder of his findings are normal. His complete blood count (white blood cell [WBC] 11.7 × 109/L, 78.5% neutrophils, 11.4% monocytes, 9.8% lymphocytes), serum concentrations of electrolytes and glucose, urinalysis, and cerebrospinal fluid studies are normal. Cultures are obtained. An abdominal radiograph is normal and abdominal ultrasonography reveals trace pelvic fluid. He is given a bolus of normal saline and is started on antibiotics to treat possible sepsis. A few hours after admission, repeat examination is concerning for inconsolability, poor suck reflex, and lethargy. His abdomen is distended, firm, and tender to palpation. Bowel sounds are normal. Further studies are performed that reveal the diagnosis. A previously healthy 10-month-old boy is seen for a 2-week history of an erythematous left eye with tearing. Earlier, he was diagnosed as having conjunctivitis at an urgent care clinic and was treated with a 10-day course of polymyxin B/trimethoprim eye drops without improvement. He has felt warm intermittently but has not had a …

Acute Dengue Fever with Computed Tomography (CT) Correlation

A 23-year-old female presented to the emergency department with vomiting and abdominal pain. She had traveled home to Canada the previous day from Indonesia and Thailand. Her symptoms had started 5 days previously in Bangkok with malaise and fever. On clinical examination she looked ill with a low-grade fever of 37.3°C. Cardiovascular, respiratory, and neurological examinations were normal. On examination, her abdomen was extremely tender with guarding of the right upper quadrant. A diffuse purpuric erythematous rash was noted over her extremities and trunk (Figure 1). Figure 1. Purpuric rash on both legs. This figure appears in color at www.ajtmh.org. Laboratory tests revealed a low platelet level at 34 with raised liver transaminases: aspartate aminotransferase 244 and alanine aminotransferase 111. Malaria smear was negative. Chest radiograph at initial presentation was negative but within 24 hours after the highest fever at 39.4°C showed moderate bilateral pleural effusions (Figure 2). Figure 2. (A) Chest radiograph at initial presentation and (B) after 24 hours showing bilateral pleural effusions (white arrows). Computed tomography (CT) of the abdomen showed a moderate amount of low-attenuation free fluid in the abdomen and pelvis with periportal edema and pericholecystic fluid (Figure 3). Figure 3. Computed tomography (CT) of the abdomen including the lung bases (A) showed bilateral pleural effusions without evidence of pulmonary edema on lung windows (B). Moderate amount of free fluid seen in the upper abdomen (C, D) with periportal edema (white ... The combination of thrombocytopenia and imaging findings consistent with plasma leakage are suggestive of dengue hemorrhagic fever1; later confirmed on serology with both single IgG and IgM positive results. Imaging in assessment of fluid in multiple body compartments becomes detectable at the time of the immune response and typically at the time of disappearance of fever and is well demonstrated on both CT and ultrasound examinations.2

Isolated angioedema of the bowel due to C1 esterase inhibitor deficiency: a case report and review of literature

IntroductionWe report a rare, classic case of isolated angioedema of the bowel due to C1-esterase inhibitor deficiency. It is a rare presentation and very few cases have been reported worldwide. Angioedema has been classified into three categories.Case presentationA 66-year-old Caucasian man presented with a ten-month history of episodic severe cramping abdominal pain, associated with loose stools. A colonoscopy performed during an acute attack revealed nonspecific colitis. Computed tomography of the abdomen performed at the same time showed a thickened small bowel and ascending colon with a moderate amount of free fluid in the abdomen. Levels of C4 (< 8 mg/dL; reference range 15 to 50 mg/dL), CH50 (< 10 U/mL; reference range 29 to 45 U/ml) and C1 inhibitor (< 4 mg/dL; reference range 14 to 30 mg/dL) were all low, supporting a diagnosis of acquired angioedema with isolated bowel involvement. Our patient's symptoms improved with antihistamine and supportive treatment.ConclusionIn addition to a detailed comprehensive medical history, laboratory data and imaging studies are required to confirm a diagnosis of angioedema due to C1 esterase inhibitor deficiency.

Index of Suspicion

Index of Suspicion

Heterotopic gestation: another possibility for the emergency bedside ultrasonographer to consider

Emergency bedside ultrasonography has become an important tool in differentiating an intrauterine from an ectopic pregnancy. As the odds of a heterotopic pregnancy were thought to be minute, some ultrasonographers and Emergency Physicians certified in bedside ultrasonography have taught that an intrauterine gestation with fetal heart tones clinches the diagnosis of intrauterine pregnancy. However, with the current rise in heterotopic gestations, this standard of care should be re-evaluated. If emergency bedside ultrasonography reveals an intrauterine gestation in the presence of either a moderate amount of free fluid in the pelvis or a co-existent ovarian cyst, one must consider and search for a heterotopic pregnancy.