Peritoneal Irritation Research Articles

Outcomes of acute appendicitis in patients younger than age 4: a descriptive study

BackgroundAcute appendicitis is an infrequent pathology in children under 4 years of age, and its diagnosis is a clinical challenge that can lead to late detection. The intention of this study is to describe the clinical and surgical findings and to explore factors and outcomes associated with appendiceal perforation in patients under 4 years of age with histologically confirmed acute appendicitis. Cross-sectional study of historical data is on patients with a pathologic diagnosis of appendicitis. Clinical, surgical, and pathological variables were described. The relationship between the presence of perforation and associated factors and outcomes was explored using odds ratios (OR) and 95% confidence intervals.ResultsSeventy-five patients were found between 2013 and 2019. Seventy-four cases presented with pain on palpation, 56 (75%) with signs of peritoneal irritation, and 70 (93%) with sepsis on admission to the emergency room. An ultrasound was done on 57 patients (76%), and only 26 (45%) were suggestive of appendicitis. Forty-one (55%) cases were operated on by open surgery and 34 (45%) by laparoscopy. In 61 (81%), they were perforated, and 48 (64%) presented peritonitis. Perforation was associated with increased hospital days (OR = 2.54 [1.60−4.03]), days of antibiotics (OR = 4.40 [2.09−9.25]), and admission to intensive care (OR = 9.65 [1.18−78.57]).ConclusionsAbdominal pain reported by parents, pain on abdominal palpation, and clinical criteria of sepsis on admission to the emergency room are common features. Acute appendicitis complicated by perforation leads to high morbidity due to longer antibiotic treatment, hospitalization days, admission to PICU, and postoperative ileus.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis. Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection. Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

Point-of-Care Ultrasound in Diagnosing Emphysematous Pyelonephritis

A 57-year-old woman with no known systemic disease presented to the emergency department with abdominal pain and vomiting for 3 days. She was well-oriented, with a body temperature of 36.5°C, blood pressure of 133/80 mm Hg, and tachycardia of 118 beats/min. On abdominal palpation, she had tenderness, with no signs of peritoneal irritation. Right-sided costovertebral angle tenderness was elicited. Laboratory data revealed neutrophil-predominant leukocytosis (13,140/μL), thrombocytopenia (10,000/μL), and hyperglycemia (460 mg/dL), representing a new diagnosis of diabetes at the emergency department.

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

Ectopic Schistosomiasis Presenting as Ruptured Appendicitis with Periappendiceal Abscess Formation: An Alternative Pathogenetic Perspective

Schistosomiasis is still a public health burden in the Philippines. Chronic infection with Schistosoma japonicum, the only species endemic in the Philippines, clinically manifests itself in a wide variety of pathologies usually correlated with the anatomical site of adult worm activity and deposition of eggs. One of the documented ectopic sites for Schistosoma ova is the appendix. A rare sequela of this is acute appendicitis and an even rarer consequence is progression to appendiceal rupture leading to acute peritonitis. We present a case of a 27-year-old Filipino residing in Davao City but born in Agusan Province who initially complained of right lower quadrant abdominal pain but presented at the emergency room with generalized abdominal tenderness with signs of peritoneal irritation. Exploratory laparotomy with an infraumbilical incision revealed ruptured appendicitis with periappendiceal abscess formation and appendectomy was subsequently done. Schistosoma infection of the appendix was subsequently established by histopathological analysis. Furthermore, features observed suggest an atypical pathogenetic process contrary to the putative pathogenesis of most cases of acute appendicitis.

Omental infarction, unusual cause of abdominal pain

Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain. An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours. Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

Primary Follicular Lymphoma in the Small Intestine: A Rare Cause of Bowel Obstruction

A woman between 60 and 70 years of age experienced nausea, vomiting, and epigastric pain radiating throughout the abdomen for several days. Physical examination revealed abdominal tenderness with epigastric prominence, without peritoneal irritation. Dynamic computed tomography (CT) showed dilatation of the small intestine and two points of bowel obstruction due to intestinal wall thickening (Figure 1A, arrow), increased mesenteric fatty tissue (Figure 1B), and enlarged mesenteric lymph nodes (Figure 1B, arrowhead).

Splenic trauma after colonoscopy: Management and treatment

Colonoscopy is an increasingly used diagnostic-therapeutic technique. Although it is a safe procedure, it is not exempt from complications, which are rare but potentially serious. We present the case of a 54-year-old woman who came to the emergency room for abdominal pain after a diagnostic colonoscopy, with anemia in blood test. In CT angiography, was detected a grade III splenic injury according to the classification of the American Association for Surgery of Trauma (AAST), without active bleeding. Due to clinical stability, a non-operative management was decided, with good evolution. Possible causes of splenic rupture are direct trauma to the spleen or excessive traction on the colonic mucosa during biopsy. Symptoms usually appear in the first 24-72 hours after the procedure and are usually abdominal pain and peritoneal irritation, as well as anemia. Abdominal CT is recommended as the imaging test of choice (Figure 1). Treatment of these patients can be extrapolated to management for traumatic splenic injuries. Based on the AAST classification, hemodynamically stable patients may benefit from non-operative management, although in grades IV and V an angiography would be recommended to rule out active bleeding and perform prophylactic angioembolization. Therapeutic angioembolization would be indicated in stable patients with active bleeding. In the case of instability or signs of peritonism, urgent laparotomy is the treatment of choice. Some authors recommend performing control CT for the diagnosis of associated non-hemorrhagic vascular lesions, such as pseudoaneurysms. In conclusion, post-colonoscopy splenic rupture is a serious but infrequent complication, whose treatment will be determined by the stability of the patient and the presence of active bleeding in an imaging test.

Acute necrotizing calculous cholecystitis after treatment with ceftriaxone in an elderly patient: a case report

BackgroundCeftriaxone, a third-generation cephalosporin antibiotic with a long plasma half-life, is widely used to treat various infections. The use of ceftriaxone can sometimes induce biliary sludge or stone formation. Although most cases of ceftriaxone-induced pseudolithiasis are asymptomatic or mild and resolve with discontinuation of the drug, we experienced an elderly case of severe acute necrotizing calculous cholecystitis after administration of ceftriaxone.Case presentationA 72-year-old male patient was admitted to our hospital because of acute diverticulitis in ascending colon. Ceftriaxone was administered at a dose of 2 g/day for 6 days. Although he recovered after therapy, he was readmitted about 2 weeks later because of severe pain with rebound tenderness in the right upper quadrant. An abdominal imaging study revealed stones and sludge in the gallbladder that were not observed before starting ceftriaxone therapy. Therefore, antibiotic treatment with flomoxef 2 g/day was indicated. However, on the fifth day of readmission, the peritoneal irritation symptoms in the right upper quadrant worsened, and elevated inflammatory response and liver dysfunction were observed. Cholecystectomy was performed based on these findings. The resected inflamed gallbladder showed acute necrotizing cholecystitis with sand granular gallstones. A comparative analysis of the infrared spectroscopic pattern of the composition of gallstones collected during surgery with that of the ceftriaxone powder revealed that both have very similar infrared spectroscopic patterns.ConclusionsCeftriaxone-related pseudolithiasis is generally reversible and mainly observed in children. Here, we report a rare case of ceftriaxone-related acute necrotizing cholecystitis in an elderly patient. We confirmed that the stones in the gallbladder are composed of ceftriaxone. The older age, dehydration, fasting, and long-time bed rest during the administration of high-dose ceftriaxone were the potential risk factors for gallstone formation.

Ectopic Pregnancy Following Levonorgestrel Emergency Contraception: Report of Two Cases

Abstract&#x0D; Ectopic pregnancy (EP) is likely to occur as an unwanted complication after unprotected intercourse in spite of levonorgestrel emergency contraception (LNG-EC). Its incidence has been increasing recently.&#x0D; We present 2 cases of tubal EP after the oral use of levonorgestrel, treated by laparoscopy.The first unruptured EP with unclear ultrasound findings, because of uterine ventrofixation after the caesarean section (CS) . The second case is a ruptured EP after LNG –EC on day 24 of the period with mild haemoperitoneum with severe peritoneal irritation.&#x0D; The fundamental question is whether levonorgestrel participates in the etiology of EP.&#x0D; The etiology of EP involves many factors. Levonorgestrel mechanisms of action give us grounds to believe theoretically that it increases the risk of EP and participates as an etiological factor.&#x0D;

A CASE REPORT OF CHYLOUS ASCITES AND TRANSIENT MIDGUT VOLVULUS THROUGH PETERSENS DEFECT THREE YEARS POST ONE-ANASTOMOSIS GASTRIC BYPASS- MINIGASTRIC BYPASS

One-anastomosis gastric bypass- Minigastric bypass (OAGB-MGB) is an emerging bariatric surgery technique replacing the RYGP with reasonable short- and long-term side effects. Here we would like to present a late complication of OAGB-MGB associated with signs of peritoneal irritation and severe pain due to transient midgut volvulus associated with chylous ascites.. We observed peritoneal lymphatic collection in association with features suggestive for small bowel obstruction 3 years followingOAGB-MGB. So, we believe that such complication should be considered as a potential side effect during short and long term follow up after gastric bypass.A strong recommendation should be provided.

Pain management in the right iliac fossa during the Covid-19 pandemic

Abdominal pain in the right iliac fossa in women may be caused by a complicated ovarian cyst, adnexitis, and appendicitis. The paper analyses the characteristics of patients with right iliac fossa pain admitted during the Covid-19 pandemic. A retrospective analysis on 25 cases with abdominal pain in the right iliac fossa admitted to “St. Apostol Andrei” Emergency County Clinical Hospital Constanta, Romania between March 2020 and March 2021 was performed. In 52% of the cases, the symptomatology remitted with antispasmodics, 4 (16%) patients had cystic torsion and right adnexectomy (group A, without adnexa), 6 (24%) patients had ruptured cysts and right cystectomy, and 2 (8%) had immediate cystectomy together with appendectomy due to signs of peritoneal irritation (group B, adnexa retained). The age, the signs and the symptoms, as well as the inpatient diagnosis in group A were lower compared to patients in group B. The ovarian cyst can become a major surgical emergency if twisted or ruptured and it reaches an important vascular source, especially if it is associated with acute appendicitis, which often poses problems of differential diagnosis. The collaboration between gynecologists and surgeons is essential in the optimal therapeutic solution of these cases.

DEPENDENCE OF THE PAIN SYNDROME INTENSITY AFTER LAPAROSCOPIC SURGERY ON THE RESIDUAL VOLUME OF WORKING GAS IN THE ABDOMINAL CAVITY

Induction of pneumoperitoneum is a mandatory step in laparoscopic surgery in order to create a workspace for the surgeon. The cause of omalgia (pain in shoulder area) after such interventions is the accumulation of residual gas in the abdominal cavity.There are still no proven methods of quantitative assessment of the residual pneumoperitoneum. Thus, the patterns of relationship between the amount of residual gas and the intensity of pain syndrome have not been studied yet. Considering the fact that the residual gas exerts mechanical distention of anatomical structures and apparently causes local irritation in the peritoneum, it is necessary to develop preventive measures for omalgia which may involve not only the approaches to reduce the amount of residual gas but also the use of alternative gas sources, particularly argon. As inert gas argon possesses many positive qualities, it does not affect the peritoneum, and has no resorptive metabolic effects.&#x0D; The goal of our research is to work out an X-ray planimetric method for determining the amount of residual gas after laparoscopic surgery and to assess the dependence of the pain intensity on both, the amount of residual gas and the type of working gas used.&#x0D; Material and methods of research. Two experimental groups of patients with uncomplicated cholelithiasis were formed, and carboxyperitoneum and argonperitoneum were used to create the space during laparoscopic cholecystectomy. The groups of examined patients are equivalent by age and sex and are randomized for consecutive admission to the hospital. Both groups include patients who underwent surgery without the use of any drainage means. 24 hours after the operation, a chest plain radiography was performed in order to identify the area of gas crescent sign under the right hemidiaphragm using personally-developed original approach. The technique is based on the use of a mobile application to measure the area of complex geometric shapes. At the same time, the intensity of pain syndrome in the shoulder area was assessed in all the patients by means of NRS (Numeric Rating Scale) in combination with Rotterdam Elderly Pain Observation Scale (REPOS). The technique is aimed to objectify the subjective assessment of pain. Statistical software for Microsoft Excel 2010 was used for processing the study results and calculating Pearson’s correlation coefficient.&#x0D; Results of research and their discussion. The obtained results revealed moderate correlation relationship between the area of gas crescent sign under the right hemidiaphragm and pain syndrome intensity. This relationship was confirmed both in the group with carboxyperitoneum and in the group with argon as the working gas. However, it was observed that the proportion of patients with postoperative omalgia in the group with argonoperitoneum is significantly lower. Thus, both hypotheses, concerning the role of mechanical factors in the development of omalgic syndrome and the significance of chemical local peritoneal irritation have been confirmed.&#x0D; Conclusions:&#x0D; &#x0D; The suggested method of radiological planimetry allows to obtaine the digital indicators suitable for statistical analysis which characterize the amount of residual gas after laparoscopic surgery.&#x0D; The intensity of pain syndrome exhibits correlation with the amount of residual gas after the surgery.&#x0D; The severity of omalgia depends primarily on the amount of residual gas. However, the incidence of omalgic syndrome with the use of carbon dioxide is higher than with argon use.&#x0D;

Damage control surgery for perforated retroperitoneal diverticulitis causing a pyomyositis

Damage Control Surgery (DCS) is an appropriate approach to the treatment of critically ill patients with severe intraabdominal sepsis. DCS is not a surgical manoeuvre but an alternative treatment mode to primary definitive surgical care. Diverticular perforation is a common complication of diverticulitis and can lead to the creation of abscesses. A retroperitoneal abscess from colonic perforation is an unusual event, that can lead to misdiagnosis due to absence of peritoneal irritation. It requires a high index of clinical suspicion and radiological studies are needed. We present the case of a septic shock due to a perforated retroperitoneal diverticulitis also causing a pyomyositis. A DCS was performed, consisting in a sigmoidectomy, drainage of retroperitoneal infection, necrotizing pyomyositis debridement and leaving a temporary abdominal closure with the assistance of negativepressure therapy, to control the focus of the infection and in a second stage by performing a definitive surgery.

Abdomen agudo pediátrico

A 5-year-old male presented with clinical symptoms of three weeks of evolution, characterized by colicky abdominal pain, predominantly periumbilical and in the right flank, associated with occasional vomiting during the period of evolution. He consulted the health care center, where at the time of physical assessment, a soft abdomen was observed, painful to deep palpation, associated with a palpable mass in the right hemiabdomen, with no clear signs of peritoneal irritation. An abdominal ultrasound was performed, which revealed a rounded image in the hypochondrium and right flank, with the echogenic center, and two peripheral hypoechogenic and hyperechogenic rings (Figures 1 and 2). Subsequently, an abdominal multidetector computed tomography without contrast was indicated, which showed, at the level of the right hemiabdomen, a mass with soft tissue density of target aspect, associated with a small amount of adjacent fluid and ingurgitation of mesenteric vessels (Figures 3 and 4). The patient was evaluated by pediatric surgery, and a surgical procedure by exploratory laparoscopy and intestinal resection were considered.

Splenic abscess as a complication of HIV-AIDS: clinical case

Introduction: Splenic abscess is a rare entity but it occurs in up to 72% of immunologically compromised patients such as type 2 diabetes mellitus, immunohematological disorders, acquired immunodeficiency syndrome. To date, around 1000 cases have been described in the world medical literature. Clinical case: A 27-year-old male with a history of multiple hospitalizations and transfusions for dengue hemorrhagic fever, HIV (+) seven years ago with self-suspended treatment five months ago. She went to the emergency room due to abdominal pain in the epigastrium of three weeks' evolution accompanied by hyporexia, asthenia, and adynamia with hematochezia on one occasion, vomiting coffee grounds on one occasion with respiratory difficulty and dyspnea, denying fever or cough. Physical examination revealed moderate dehydration, pale integuments, tachypnea, and wheezing in the left hemithorax with wheezing in the right hemithorax, abdomen with signs of peritoneal irritation, vital signs: Blood pressure 100/60mmHg, heart rate 154/min, breaths 28/min, temp. 36.8oC. Diagnosis of probable community-acquired pneumonia plus upper gastrointestinal bleeding, severe dehydration and HIV, hypovolemic shock, and septic are included. Laboratories: hemoglobin 5.5g/dL, leukocytosis (31000/103/µl). The patient was admitted to the operating room for an exploratory laparotomy, a splenic abscess was identified on the diaphragmatic side and a splenectomy was performed. Discussion: The abscess splenic can present unique (60-70%), as it was in our case, or multiple (30-40%), the mortality can be 13% when it is unique and 22% when it is multiple. Conclusions: This case associated with HIV-AIDS is the first in our hospital.

CURRENT MODE OF TREATMENT IN ACUTE DIVERTICULITIS

Purpose: The purpose of our study is to determine whether patients with acute uncomplicated diverticulitis with micro-perforation should really be treated as patients without perforation and to identify differences in recurrence rates, complications and mode of treatment Material and Methods: A total of 47 patients with a diagnosis of acute diverticulitis were admitted to the hospital for a three-year period from 01.01.2018 to 01.01.2020 in the Department of General, Visceral and Emergency Surgery at UMHATEM "Pirogov". Of those hospitalized, women were 21 (44.68%), men 26 (55.32%). The age in this retrospective analysis varied from 27 to 81 years (average 51.3 years). Results: All patients had leukocytosis, abdominal pain, and tenderness. From the group of 47 patients hospitalized with acute diverticulitis, twenty-five (53.19%) were diagnosed with micro-perforation by pneumoperitoneum data from X-ray and CT or free intraperitoneal fluid from ultrasound. The other three (6.38%) were identified intraoperatively (by laparoscopy or laparotomy) based on an indication of peritoneal irritation. The remaining 19 (40.43%) with mild symptoms for conservative management (38.89%) - through physical examination, laboratory data and imaging diagnostic methods (X-ray, ultrasound and CT). Of the 28 operated, 13 patients had laparoscopy performed lavage and drainage, with the remaining 15 (with laparotomy) - had Hartmann's procedure. Conclusion: Acute diverticulitis with micro-perforation showed no significant differences in the complications and course of antibiotic therapy compared to the group of acute diverticulitis without micro-perforation. Neither group required surgery after one-month discharge. Accordingly, to these outcomes, the mode of treatment should be identical.

SPONTANEOUS PNEUMOPERITONEUM AND FECALOID PERITONITIS SECONDARY TO PERFORATION OF MECKEL'S DIVERTICULUM

PNEUMOPERITONEUM AND FECALOID PERITONITIS SECONDARY TO MECKEL’S DIVERTICAL PERFORATION NEUMOPERITONEO Y PERITONITIS FECALOIDEA SECUNDARIO A PERFORACIÓN DE DIVERTICULO DE MECKEL A 20-year-old man presents abdominal pain and diffuse peritoneal irritation. The computed tomography reported pneumoperitoneum and peritonitis secondary to hollow viscus perforation. An urgent intervention was performed, showing Meckel's diverticulum with a perforation on its vertex. It was decided the resection of the ileum including the diverticulum, finishing with a manual end-to-end anastomosis. Meckel's diverticulum is caused by the failure of the involution of the omphalomestheric duct. In 4-6% of cases it can cause complications. The preoperative diagnosis is difficult because the radiological and clinical findings can resemble other acute abdominal disorders.

Similar but different: A comparison of rare site ectopic pregnancies.

A comparative examination of the clinical, laboratory, ultrasound findings, and operative characteristics of rare site located ectopic pregnancies. Retrospective analysis of all department cases of rare site located ectopic pregnancies diagnosed and treated from December 2006 to December 2019. Thirty rare ectopic pregnancies were identified. Of these, 11 were ovarian, 10 were interstitial and 9 were tubal stump. The patients treated for ovarian pregnancy had significantly lower human chorionic gonadotropin (hCG) levels than patients treated for interstitial or stump pregnancies (2025±1105 mIU/ml, 18,424±2579 mIU/ml and 11,204±9221 mIU/ml, respectively, p=0.003). The main presenting symptom in patients with an ovarian pregnancy was abdominal pain (90.9%, 60.0% and 44.4%, respectively, p=0.031). Signs of abdominal peritoneal irritation (i.e., rebound tenderness and guarding) were more frequent upon physical examination in patients with an ovarian pregnancy (72.2%, 30.0% and 22.2%, respectively, p=0.044) who also exhibited the highest rates of syncope and hypovolemic shock upon admission compared to patients with an interstitial or stump pregnancy (54.5%, 10.0% and 11.1%, respectively, p=0.031). Ovarian pregnancies were associated with the lowest sonographic detection rates (9.1%, 80.0% and 100%, respectively, p=0.0001) and with free fluid in the pouch of Douglas (72.7%, 20.0% and 22.2%, respectively, p=0.02). Ovarian pregnancies experienced the highest rupture rate during surgery compared to interstitial or stump pregnancies (66.9%, 16.7% and 44.4%, respectively, p=0.028), had a significantly higher estimated blood loss (1081±647ml, 760±597ml and 343±318ml, respectively, p=0.003) and required blood transfusions in the perioperative period (63.6%, 20.0% and 11.1%, respectively, p=0.025) significantly more often. Ovarian pregnancy remains the most challenging diagnosis compared to interstitial and tubal stump ectopic's. Health care providers should recognize these rare site ectopic pregnancies and to handle these gynecological emergencies promptly.

CHILAIDITI SYNDROME IN A 49-YEAR-OLD MALE WITH COVID-19 INFECTION – CASE REPORT

The authors illustrate a case of a 49-year-old male patient admitted to our Emergency Department with dry persistent cough, fever, chills, vague abdominal discomfort and a recent history of dyspnoea and fatigability, symptoms suggestive of COVID-19 infection. Physical examination showed mild abdominal distension and no signs of peritoneal irritation. The patient was tested positive for COVID-19 and d-dimers were also found positive, raising a strong suspicion diagnosis of pulmonary thromboembolism as a complication of SARS-COV-2 infection, which required an immediate CT scan. No signs of pulmonary thromboembolism were present on the CT scan. Apart from bilateral pulmonary condensation areas having a ground glass pattern with a peripheral distribution, which are the characteristic radiologic feature of SARS-COV-2 infection, the CT scan also revealed the anterior interposition of the colon between the liver and diaphragm, this being highly suggestive for Chilaiditi Syndrome.