Nonspecific Abdominal Pain Research Articles

CT Findings of Undifferentiated Pancreatic Cancer With Osteoclast-Like Giant Cells: A Case Series from a Single Center's Experience With 10 Cases.

Little is known about the imaging features of undifferentiated carcinoma with osteoclast-like giant cells of the pancreas (UCOGCP) because of its extremely low incidence. To improve the diagnostic accuracy of this tumor, 10 UCOGCP cases with confirmed histopathology were collected and their clinical and image data features were analyzed. We found that the median age of our study was 61 years (50-76 years in range) and the main clinical manifestations were nonspecific abdominal pain. There were some differences in the degree of enhancement and computed tomography (CT) features between the tumor located at the head and body or tail of the pancreas. Perhaps these subtle imaging findings can provide valuable diagnostic information.

Crepitus: A rare benign case of subcutaneous emphysema after abdominal myomectomy

Introduction: Postoperative crepitus is a rare finding following laparotomy cases. The potential diagnoses for this condition can vary from benign to high morbidity and mortality findings. Case Report: In this case report, we discuss a case of a patient who developed non-specific abdominal pain who ultimately found to have crepitus on physical examination postoperative day 1. Subsequent computed tomography (CT) scan revealed a rare postoperative subcutaneous emphysema. Although these findings are infrequent after laparotomy, it is important to note that abdominal and incisional pain are commonly experienced symptoms after surgery. Conclusion: This report aims to enhance postoperative care for patients who have undergone laparotomy.

Appendiceal Neuroendocrine Neoplasms: A Comprehensive Review.

Appendiceal neuroendocrine neoplasm (NEN) is the most common adult appendiceal malignant tumor, constituting 16% of gastrointestinal NENs. They are versatile tumors with varying morphology, immunohistochemistry, secretory properties, and cancer genomics. They are slow growing and clinically silent, to begin with, or present with features of nonspecific vague abdominal pain. Most acute presentations are attributed clinically to appendicitis, with most cases detected incidentally on pathology after an appendectomy. Approximately 40% of them present clinically with features of hormonal excess, which is likened to the functional secretory nature of their parent cell of origin. The symptoms of carcinoid syndrome render their presence clinically evident. However, slow growing and symptomatically silent in its initial stages, high-grade neuroendocrine tumors and neuroendocrine carcinomas of the appendix are aggressive and usually have hepatic and lymph node metastasis at presentation. This review article focuses on imaging characteristics, World Health Organization histopathological classification and grading, American Joint Committee on Cancer/Union or International Cancer Control, European Neuroendocrine Tumor Society staging, European Neuroendocrine Tumor Society standardized guidelines for reporting, data interpretation, early-stage management protocols, and advanced-stage appendiceal NENs. Guidelines are also set for the follow-up and reassessment. The role of targeted radiotherapy, chemotherapy, and high-dose somatostatin analogs in treating advanced disease are discussed, along with types of ablative therapies and liver transplantation for tumor recurrence. The search for newer location-specific biomarkers in NEN is also summarized. Regarding the varying aggressiveness of the tumor, there is a scope for research in the field, with plenty of data yet to be discovered.

Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department.

To develop a model to discriminate non-specific abdominal pain (NSAP) from organic pain in the paediatric emergency department (PED) and evaluate the added value of laboratory markers. Prospective cohort study in an urban French PED including all patients aged ≥4 years with abdominal pain between November 2020 and May 2021. The outcome was the discrimination between NSAP (patients coded to have only "pain" or "constipation") and organic pain (all other diagnoses) using stepwise backward multivariate logistic regression method with bootstrap resampling. The study enrolled 246 patients. Overall, 163 patients (66.2%) had NSAP. Four variables associated with organic pain: pain in the epigastric region (OR 0.48 [0.23-0.99]), worsening pain (0.57 [0.32-0.99]), pain migration (0.42 [0.17-0.99]) and vomiting (0.47 [0.26-0.84]) were integrated in a clinical model. To discriminate NSAP with a probability of 65%, model sensitivity was 71.8% (64.9-78.7), specificity was 53.0% (42.3-63.7), and the Net Benefit (NB) was 15.4%. White Blood Count and C-reactive protein results improved discriminative capacity of the model (AUC 0.708 [0.643-0.773] vs. 0.654 [0.585-0.723], p = 0.01) with a supplementary NB of 12%. Patient follow-up showed 95% diagnostic accuracy. This study reveals a four-clinical predictor model with a NB of 15% in predicting NSAP. Validation studies are necessary.

Adult-onset seizures as the initial presentation of acute intermittent porphyria

Acute intermittent porphyria (AIP) is a rare metabolic disorder caused by the deficiency of enzyme porphobilinogen deaminase used in haeme biosynthesis. Nonspecific abdominal pain is the classical presentation of AIP. Patients rarely present with rapid-onset neurological manifestations such as acute peripheral neuropathy or seizures. The knowledge on the management of seizures in AIP is important as some antiepileptic drugs may exacerbate acute attack. Hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion is a recognised cause of seizures in AIP. We report a case of a 20-year-old woman presenting to a tertiary care hospital in Sri Lanka with seizures due to hyponatremia who was eventually diagnosed with AIP. Although AIP is not frequently reported in Sri Lanka, it’s important to have a strong clinical suspicion as an early diagnosis will reduce mortality and morbidity.

Inefficient Admissions for Abdominal Pain Under an Acute General Surgical Unit

BackgroundThe acute general surgical unit (AGSU) model has become a standard of efficient acute surgical care. Whilst the AGSU has been compared to the traditional surgical model, there is a lack of research auditing referrals and admissions. This study evaluates abdominal pain referrals to AGSU and the necessity of admission.MethodsA retrospective cohort study of adult abdominal pain admissions was conducted over a two-year period at a single centre in metropolitan Victoria, Australia. The data were extracted from electronic medical records and key endpoints of data included the diagnosis, length of stay, investigations and subjective pain outcomes.ResultsA total of 1587 patients met the study criteria of which 1116 (70.3%) had a non-surgical diagnosis with the majority having non-specific abdominal pain. The non-surgical patients had a lower median length of stay (25.3 h) compared to surgical patients (44.2 h, p < 0.001). They were less likely to have an abnormal haemoglobin (p = 0.004), elevated white cell count (p = 0.02) or elevated C-reactive protein > 50 mg/L (p < 0.001). On multivariable analysis, surgical patients had higher odds of having a CRP > 50 mg/L (p = 0.024) and a positive imaging result (p < 0.001). The patient’s pain control also correlated with length of stay.ConclusionA large population of patients with non-specific abdominal pain are admitted to AGSU. These patients do not require surgery and have a short length of stay. Incorporating a negative CRP result and negative imaging result may be utilised in conjunction with optimised analgesia to help avoid these unnecessary admissions, thereby improving AGSU efficiency and workload.

Rare causes of abdominal pain: a primer for the admitting general surgeon.

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.

Neuroendocrin Tumor of the Gallbladder: A Case Report

Background: Neuroendocrine tumors (NETs) of the gallbladder are rare and account for less than 1% of all gallbladder tumors. These tumors are typically asymptomatic and are often discovered incidentally during imaging for other reasons. The majority of NETs of the gallbladder are non-functioning, meaning that they do not produce hormones or cause hormonal symptoms. Case Presentation: A 32-years old woman presented with a six-month history of non-specific abdominal pain without a remarkable prior history. Ultrasonographic examination of the abdomen revealed the gallbladder containing multiple stones, with wall thickening. A laparoscopic cholecystectomy was performed, and histopathological examination of the resected gallbladder confirmed the presence of a neuroendocrine tumor. Conclusion: This case report highlights the importance of considering neuroendocrine tumors as a differential diagnosis for gallbladder masses. The patient underwent a successful laparoscopic cholecystectomy and had a good outcome. Close follow-up is necessary to detect any recurrence as these tumors have a tendency to recur locally.

A Prospective Study of Prevalence and Impact of Sarcopenia on Short-term Mortality in Hospitalized Patients with Liver Cirrhosis

Sarcopenia is common in chronic advanced liver disease and is associated with poor prognosis. There is paucity of Indian data regarding sarcopenia in chronic advanced liver disease & its impact on prognosis. The aim of this study was to study the prevalence of sarcopenia in Indian patients with chronic advanced liver disease and its impact on morbidity and short-term mortality. Patients with chronic advanced liver disease were prospectively evaluated for the presence of sarcopenia using computerized tomography (CT) abdomen. The cross-sectional area of the right psoas muscle was measured at the third lumbar vertebra (L3) and the Psoas muscle index (PMI) was calculated. Sarcopenia was defined as PMI <295mm2/m2 for females and <356mm2/m2 for males. The normative values of PMI were obtained from patients undergoing CT scan for non-specific abdominal pain who had no confounding factor which could result in sarcopenia. All patients were followed up for 6 months or until death, whichever was earlier. The impact of sarcopenia on mortality and rate of readmission has been assessed at the end of 6 months. Of the 156 patients with chronic advanced liver disease, 74 (47.4%) patients had sarcopenia. Sarcopenia was more commonly seen in males (M: F= 61:13) and in patients with alcohol-related liver disease. There was a linear correlation (negative) between the PMI and severity of liver disease as assessed by Child-Pugh and model for end-stage liver disease (MELD) scores (r=-0.591 and -0.465, respectively). Patients with encephalopathy, ascites, and coagulopathy had higher prevalence of sarcopenia. On six months follow-up, sarcopenic patients had higher readmission rates (74.3% vs. 22%; P= 0.0001) and higher mortality (24.3% vs. 3.7%; P= 0.002). MELD score and PMI were independent predictors of mortality. The cut-off value of PMI 305.9mm2/m2 predicted mortality with a sensitivity of 76.2% and a false positivity of 22.2% (area under curve was 0.805; 95% confidence interval: 0.69-0.91, P= 0.001). Sarcopenia is seen in about half of the patients with chronic advanced liver disease. It is commoner in males, patients with alcoholic liver disease, and those with advanced liver disease. Patients with sarcopenia have worse prognosis, require more frequent hospitalization and it negatively impacts short-term survival.

P-061 Bowel obstruction due to intraluminal migration of intraperitoneal mesh

Abstract Aim Report an unusual late complication after laparoscopic IPOM Material &amp; Methods Description of a clinical case Results An 84 years old patient who had previously undergone laparoscopic IPOM with ePTFE mesh in 2012 for supraumbilical primary hernia, arrived to the emergency room in March 2022 with a small bowel obstruction due to an intraluminal foreign body impacted at the distal jejunum. In the computerized tomography scan (CT) there was no evidence in the abdominal wall of the intraperitoneal mesh present in a previous CT from 2019. An exploratory laparotomy was warranted. A resection the affected jejunal loops was performed, without evident perforation and clear palpation of an intraluminal foreign body. When the piece was opened, the mesh was found intraluminally, causing the patient's bowel obstruction. Conclusions Intra-abdominal foreign bodies usually cause a chronic inflammatory process that isolate them from neighboring structures by a fibrous capsule. In this case, however, after detaching it from the abdominal wall, the mesh migrated into the intestinal lumen, probably through slow erosion by decubitus. Despite it being an unusual complication, its incidence could increase as the use of intra-abdominal mesh has multiplied in recent years. Given the appearance of non-specific abdominal pain in patients with intra-abdominal mesh, it may be advisable to perform a CT scan to rule out this or other complications associated with the mesh, even many years after the initial surgery.

Hyperreactio Luteinalis and an Incidentally Detected FIGO IIIB Borderline Tumor of the Ovary in Pregnancy - Diagnostic, Therapy and Review of Literature

Adnexal masses affect 2-10% of all pregnancies. The highest incidence of 1-6% can be seen in the first trimester, with a high rate of spontaneous remission. Two percent of these masses are malignant neoplasms or borderline tumors. A rare benign mass of the adnexa in pregnancy is hyperreactio luteinalis characterised by bilateral, multicystic ovaries with a frequent occurrence in the 3rd trimester. Clinical signs include maternal hyperandrogenaemia with virilisation, hyperemesis, nonspecific abdominal pain or laboratory findings of hyperthyroidism and elevated ß-HCG. Hyperreactio luteinalis does not require therapy due to complete spontaneous remission postpartum, but is often treated surgically in graviditate. In our case we report a first-time gravida in the 31st week of pregnancy with a symptomatic 25-cm multicystic, partly solid mass. After antenatal corticosteroid therapy, an exploratory laparotomy with right adnexectomy was performed on suspicion of malignancy. Histology revealed a hyperreactio luteinalis with an incidental finding of a serous borderline tumor of the ovary (FIGO IIIB). At 33 weeks of gestation, a pathological CTG was observed, and an urgent secondary caesarean section by re-longitudinal laparotomy was performed. Postpartum completion surgery revealed no further neoplastic cells.

Giant lipoma of the colon presenting as a case of adult intussusception: A case series

Introduction and importanceLipoma of the intestine is one of the uncommon benign tumors of the alimentary tract first reported by Bauer in 1957. The peak incidence is usually seen between 50 and 60 years of age and more commonly in females. They are usually either asymptomatic or mildly symptomatic. The occurrence of symptoms is mostly related to the diameter of the lesion. Presentation of caseWe present a single center consecutive case of three patients who had giant colonic lipomas presented with colonic intussusception. Two of the cases presented for the first time with an emergency condition: acute intestinal obstruction. The mode of presentation, diagnosis, and management outcome of colonic lipoma was assessed. DiscussionSymptomatic lipoma may present with non-specific abdominal pain, change in bowel habits, intussusception, and hemorrhage. The clinical diagnosis is usually challenging, given the non-specificity of symptoms of the disease. Computed tomography is considered to be a diagnostic modality of choice in recognizing the presence of lipoma. However, a definitive diagnosis of lipoma is usually obtained after a histopathologic examination of the resected specimen. The management of colonic lipoma depends on the size of the lesion and the presence or absence of symptoms. ConclusionColonic lipoma is a rare benign tumor that occurs in the elderly, frequently misdiagnosed as a malignant tumor. Despite the rarity of the disease, lipoma should be considered in the differential diagnosis of large bowel tumors and adult intussusception.

POSTPARTUM OVARIAN VEIN THROMBOSIS: A CASE REPORT

Ovarian vein thrombosis is a rare pathology that occurs most often in the postpartum period. It usually manifests by a non-specific abdominal pain with or without fever. It can clinically resemble acute appendicitis if the pain is located in the right iliac fossa. We report the case of a 19-year-old female patient who presented with febrile inflammatory pain of the right iliac fossa at 48 hours postpartum of an eutocic delivery, in whom a computed tomography (CT) scan showed an extensive thrombosis of the right ovarian vein with a normal-looking appendix. The treatment was based on broad-spectrum antibiotics and anticoagulant therapy, with a good clinical and biological evolution.

E001 Retroperitoneal fibrosis patients need a dedicated multidisciplinary team

Abstract Background/Aims Retroperitoneal fibrosis is a rare chronic inflammatory fibrosing condition of the retroperitoneal tissues. Inflammation can cause tethering and occlusion of nearby structures, especially the ureters, leading to acute obstruction as well as long-term renal impairment. This condition usually either presents with nonspecific abdominal pain or when the patient is in crisis due to urological obstruction. There is little known about its treatment beyond steroids. A significant proportion of patients are at risk of relapse. We characterised patients with retroperitoneal fibrosis in our heath board to better understand how these patients present and what the unmet needs in their management are. Methods Patients were identified by contacting rheumatologists and by searching the urological stent registry from 2019 to 2022. The records were searched for demographics, events around diagnosis, initial treatment, investigations, including imaging reports and pathology, as well as follow up clinic letters detailing any relapses and complications. Results We found 22 patients in the health board with idiopathic retroperitoneal fibrosis. Half had sole care under urology. Only 6 received joint care from urology and rheumatology. Demographics of these patients were comparable to literature (mean age 60 (range 43-81 years), female to male ratio (1:2.6), compared to the reported mean age of 55-60 and female to male ratio of 1:2). Diagnosis was usually made by CT scan. The mean incidence of new diagnosis was 2 per year over the last 10 years in a catchment population of 850,000. In 19 patients with treatment information available, 4 never received steroids or immunomodulation therapy. For those that received steroid therapy, doses ranged from 0.2mg/kg to 0.8mg/kg over a range of 1 week to 6 months of maximum dose duration. 73% of patients now have chronic renal dysfunction with eGFR &amp;lt;60ml/min/1.73m2, and 27% with stage 4 renal failure with eGFR &amp;lt;30 ml/min/1.73m2. One of these patients had end stage renal disease and is deceased. Conclusion This characterisation study has shown that patients have had heterogenous journeys with their RPF diagnosis and treatment. 73% of these patients have developed chronic renal dysfunction which is dramatically higher than that of the published literature figure of 32%. In order to improve outcomes, there is a need for a standardized approach to diagnosis, treatment and follow up, involving a dedicated multidisciplinary team. Disclosure E. Qian: None. H. Harris: None.

A retrospective study of patients complaining of nontraumatic acute abdominal pain, admitted in the emergency department of an urban hospital in China

Abstract Background Nontraumatic acute abdominal pain (AAP) accounts for a large proportion of emergency department (ED) admissions. This study aimed to explore the underlying correlations among basic information, imaging examinations, and diagnoses. Methods A total of 7453 patients complaining of AAP, admitted to the ED of Zhongnan Hospital of Wuhan University, were enrolled in this retrospective study from January 1 to December 30, 2019. We collected the following information from the patients: sex, age, date of visit, pain location, nature of pain, level of severity, imaging (computed tomography, x-ray, and ultrasound), diagnosis, and outcomes (release from the hospital, transfer to another hospital, transfer to another department, observation room, hospitalization, or death). Results According to this study, AAP was more common in female than male. A total of 82.11% patients of AAP were in level 3 of severity, while 0.19% patients were in level 1. A total of 77.20% of the patients had undergone imaging. Swelling pain and colic are the 2 most common types of AAP. Nonspecific abdominal pain (NSAP) is the most common diagnosis. In the diagnosis of NSAP and gastroenteritis, female patients were more prevalent than male patients, but for renal colic, male patients were 3 times as many as female patients. Nonspecific abdominal pain, biliary colic, and cholecystitis are the 3 leading causes in patients 65 years or older. Nonspecific abdominal pain, renal colic, and gastroenteritis are the 3 leading causes of AAP in patients younger than 65 years. Conclusion With the help of imaging, clinicians can specify a diagnosis and perform corresponding treatment in most cases. However, making a precise diagnosis of AAP within a short period is still challenging. Further research should be conducted to seek safer and more effective techniques to streamline clinicians’ work.

Utility of Hook Sign in the Diagnosis of Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS) is a clinical syndrome caused by compression of the celiac artery by the median arcuate ligament that often manifests with nonspecific abdominal pain. Identification of this syndrome is often dependent on imaging of compression and upward bending of the celiac artery by lateral computed tomography angiography, the so-called "hook sign." The purpose of this study was to assess the relationship of radiologic characteristics of the celiac artery to clinically relevant MALS. An institutional review board-approved retrospective chart review from 2,000 to 2,021 of 293 patients at a tertiary academic center diagnosed with celiac artery compression (CAC) was performed. Patient demographics and symptoms of 69 patients who were diagnosed with symptomatic MALS were compared to 224 patients without MALS (but with CAC) per electronic medical record review. Computed tomography angiography images were reviewed and the fold angle (FA) was measured. The presence of a hook sign (defined as a visual FA < 135°), as well as stenosis (defined as >50% of luminal narrowing on imaging) were recorded. Wilcoxon rank-sum test and Chi-squared test were used for comparative analysis. Logistic model was run to relate the presence of MALS with comorbidities and radiographic findings. Imaging was available in 59 patients (25 males, 34 females) and 157 patients (60 males, 97 females) with and without MALS, respectively. Patients with MALS were more likely to have a more severe FA (120.7±33.6 vs. 134.8±27.9, P=0.002). Males with MALS were also more likely to have a more severe FA compared with males without MALS (111.1±33.7 vs. 130.4±30.4, P=0.015). In patients with body mass index (BMI) >25, MALS patients also had narrower FA compared with patients without MALS (112.6±30.5 vs. 131.7±30.3, P=0.001). The FA was negatively correlated with BMI in patients with CAC. The hook sign and stenosis were associated with diagnosis of MALS (59.3% vs. 28.7%, P<0.001, and 75.7% vs. 45.2%, P<0.001, respectively). In logistic regression, pain, stenosis, and a narrow FA were statistically significant predictors of the presence of MALS. The upward deflection of the celiac artery in patients with MALS is more severe compared with patients without MALS. Consistent with prior literature, this bending of the celiac artery is negatively correlated with BMI in patients with and without MALS. When demographic variables and comorbidities are considered, a narrow FA is a statistically significant predictor of MALS. Regardless of MALS diagnosis, a hook sign was associated with narrower FA. While demographics and imaging findings may inform MALS diagnosis, clinicians should not rely ona visual assessment of a hook sign but should quantitatively measure the anatomic bendingangle of the celiac artery to assist with the diagnosis and understand the outcomes.

V10-10 NOVEL TECHNIQUE: PERIVESICAL FAT ROTATIONAL FLAP FOR RECTAL INTERPOSITION COVERAGE IN SALVAGE ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023V10-10 NOVEL TECHNIQUE: PERIVESICAL FAT ROTATIONAL FLAP FOR RECTAL INTERPOSITION COVERAGE IN SALVAGE ROBOTIC RADICAL PROSTATECTOMY Alexander Hwang, Matthew Watson, Michael Tonzi, and Amar Singh Alexander HwangAlexander Hwang More articles by this author , Matthew WatsonMatthew Watson More articles by this author , Michael TonziMichael Tonzi More articles by this author , and Amar SinghAmar Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 21st-century urologic oncologist has a spectrum of treatment modalities for localized prostate cancer that can be tailored to patients. For patients with low-risk prostate adenocarcinoma, multiple non-prostatectomy treatment options include whole-gland radiotherapy, brachytherapy, proton therapy, cryotherapy, and high-intensity focused ultrasound (HIFU) therapy. Salvage therapies for recurrent localized prostate cancer include surgical (e.g. radical prostatectomy and cystoprostatectomy) and non-surgical (e.g. whole-gland brachytherapy, whole-gland cryotherapy, and whole-gland HIFU). Surgical salvage therapies are plagued with significant morbidity carrying the increased risk for urinary incontinence (>50% requiring use of pads) rectal injuries (3.3-50% requiring diversion in setting of radiation), and anastomotic stricture (17-32%) (1). METHODS: We describe a 67-year-old male who initially presented to our practice after undergoing whole-gland HIFU due to biopsy proven grade group 1 prostate cancer. Unfortunately, he developed biochemical recurrence with a PSA of 2.0 and biopsy discovered grade group 3 localized prostate cancer. After discussing the associated risks, the patient elected to undergo a salvage robotic radical prostatectomy (sRRP). We modified our sPPP approach by performing a posterior dissection to free the seminal vesicles prior to dropping the bladder which allowed us to mobilize our flap through the posterior defect and interpose the flap over the anterior rectal wall and tether it to periurethral tissue with absorbable suture. Please see accompanying video for procedural details. RESULTS: The patient had a negative cystogram and denied bowel or urinary symptoms. He presented to the emergency department 3 months post-operatively complaining of nonspecific abdominal pain and computed tomography demonstrated the perivesical flap appropriately interposed in its new heterotopic location. CONCLUSIONS: The perivesical tissue flap is an anatomically accessible and vascularized tissue that can be mobilized to interpose between a radiated, tenuous anterior rectal wall and vesicourethral anastomosis to reinforce perfusion and prevent fistulas. This technique allows expansion to the armamentarium of reconstructive urology. Source of Funding: No sources of funding to disclose. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e929 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Hwang More articles by this author Matthew Watson More articles by this author Michael Tonzi More articles by this author Amar Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

Lemmel syndrome: a rare cause of obstructive jaundice (case report)

Obstructive jaundice through periampullary duodenal diverticulum (PAD), without gallstones or neoplasms, was first described by Lemmel in 1934 as Lemmel syndrome. PAD can be diagnosed incidentally or suspected in patients with obstructive jaundice and nonspecific abdominal pain. It is a rare and benign condition that can be misdiagnosed as malignancy. Ignoring this, can cause morbidity and mortality. Definite diagnosis is made by Endoscopic Retrograde Cholangiopancreatography (ERCP). An accurate diagnosis is very important to ensure patient management and to avoid complications of delayed care. We present a case who coincidentally was diagnosed with PAD and thus obstructive jaundice.

Median Arcuate Ligament Compression Associated with Flow-Related Visceral Aneurysms

PurposeTo identify risk factors for rupture, and to determine outcomes of endovascular treatment of median arcuate ligament (MAL) compression–related visceral artery aneurysms (VAAs). Methods and MaterialsA retrospective review of patients who presented with MALC-related VAAs was performed from 1999 to 2021. A total of 21 patients (12 men) and 39 VAAs associated with MAL compression were encountered (mean age, 59 years). Imaging studies were reviewed for the number, morphology/size, and recurrence of aneurysms. Statistical analysis was performed to identify risk factors for rupture. ResultsTen patients presented with acute rupture, and 12 patients were symptomatic with nonspecific abdominal pain. Twenty-two aneurysms were fusiform in morphology and 17 aneurysms were saccular in morphology. Of the 14 aneurysms that presented with acute hemorrhage, 12 (86%) were fusiform in morphology (odds ratio, 9.0; P < .01). The mean aneurysm size was 1.3 cm, and the mean ruptured size was 0.6 cm. Thirty-one aneurysms were treated by endovascular techniques, and technical success was achieved in all cases. Fourteen patients were found to have an Arc of Buhler. No procedure-related adverse events occurred. No patient underwent surgical ligament release. The mean time of follow-up was 3.2 years, and no aneurysms recurred after endovascular treatment. ConclusionsMAL compression-associated VAAs are an important clinical entity that should be treated even at small sizes, particularly if they are fusiform in morphology. Endovascular therapy is safe and feasible and results in durable aneurysm exclusion.

Diagnostic Utility of Serum Leucine-Rich α-2-Glycoprotein 1 for Acute Appendicitis in Children.

The aim of this study is to assess the diagnostic utility of serum leucine-rich α-2-glycoprotein 1 (LRG1) in pediatric patients with acute abdominal pain, admitted to the emergency surgical unit, in order to make a prompt and accurate diagnosis of acute appendicitis. Pediatric patients older than 5 years of age who presented to the emergency department from 15 October 2021 to 30 June 2022 with acute abdominal pain and suspected acute appendicitis were prospectively recruited in the study. Demographic and clinical data, as well as operative and postoperative data, were recorded. A total of 92 patients were equally distributed into two groups: children with acute appendicitis who underwent laparoscopic appendectomy and non-appendicitis patients, presenting with non-specific abdominal pain. LRG1 levels were determined using a commercially available LRG1 enzyme-linked immunosorbent assay (ELISA) kit. Serum LRG1 levels, as well as other inflammatory markers (white blood cell count (WBC), C-reactive protein (CRP) and absolute neutrophil count) were compared between groups. The median level of LRG1 in serum was significantly higher in the group of children with pathohistologically confirmed acute appendicitis than in the control group, at 350.3 µg/mL (interquartile range (IQR) 165.2-560.3) and 25.7 µg/mL (IQR 14.7-36.8) (p < 0.001), respectively. Receiver operating characteristic area under the curve for LRG1 from serum was 1.0 (95% CI 0.96-1.00; p < 0.001) and the value of >69.1 µg/mL was found to perfectly separate acute appendicitis cases from controls. Additionally, as expected, each of the examined laboratory inflammatory markers provided a significantly higher values in the acute appendicitis group compared to the control group: WBC 14.6 × 109/L (IQR 12.7, 18.7) vs. 7.0 × 109/L (IQR 5.4, 9.0) (p < 0.001), CRP 16.3 mg/dL (IQR 6.9, 50.4) vs. 2.2 mg/dL (IQR 2, 2) (p < 0.001) and absolute neutrophil count 84.6% (IQR 79.5, 89.0) vs. 59.5% (IQR 51.5, 68.6) (p < 0.001). LRG1 in the serum was found to be a promising novel biomarker, with excellent differentiation of acute appendicitis from non-appendicitis cases in children presenting with non-specific abdominal pain.