Peritoneal Reaction Research Articles

Chemical Peritonitis Due to Ruptured Ovarian Teratoma: A Case Report and Literature Review

Introduction: Mature cystic teratomas (MCT) are the most common ovarian tumors in pediatric patients, often asymptomatic due to slow growth, when symptomatic, they can lead to abdominal pain. Spontaneous rupture can result in acute chemical peritonitis (CP), a rare but life-threatening complication. This study presents a clinical case of a patient with spontaneous rupture of an ovarian teratoma and associated acute CP. Clinical Case: 13-year-old female presented with acute abdominal pain, fever, distended and painful abdomen with peritoneal reaction in the right iliac fossa and hypogastrium. Abdominal ultrasound showed a hypoechoic rounded image with an anechoic center in the right adnexal region. Laparoscopic exploration revealed a cystic teratoma of the right ovary with torsion, but no compromise of vitality. Purulent fluid indicated CP due to ruptured and twisted ovarian teratoma. Right ovarian cystectomy was performed, drainage was offered in the Douglas pouch. The patient's condition improved, and she was discharged after recovery. Discussion: Rupture and CP are rare but require emergency surgery. Preoperative diagnosis can be challenging due to their non-specific clinical presentation and the need to rule out malignant complications. Conclusion: Early and appropriate management of MCT is essential to prevent serious complications. Sebum spillage can cause CP, the treatment of choice is teratoma removal, combined with extensive lavage to avoid chronic peritonitis. Laparoscopic surgery stands out as a safe and effective option. A high index of suspicion and comprehensive approach are emphasized in managing this uncommon condition in the pediatric population.

Identification of an Objective Cut-Off Point to Define the Clinical Stage T4a in Colon Cancer

Introduction: The current state of pathology practice and the variability in diagnosing pT4a colon cancer have been underexplored in existing studies. Our objective was to establish a specific cutoff point to distinguish between the pathological stages of pT3 and pT4a in colon cancer. Methods: We conducted a cross-sectional study involving pT3 and pT4 (pN0-2, cM0) colon cancers, measuring the distance to the serosa. Patients were categorized and analyzed based on this distance and the peritoneal reaction, with the aim being to ascertain their prognostic implications. Results: A total of 384 patients were analyzed. Patients with a distance between the invading front of cancer and the serosa ≥ 1 mm without a peritoneal reaction exhibited a median survival of 118 months, contrasting the amount of 70 months for those with <1 mm plus peritoneal reaction. Only lengths <1 mm with peritoneal reaction showed a significant correlation with mortality (p < 0.001). Conclusion: Our study revealed that patients in whom neoplastic cells were less than 1 mm from the serosal surface, accompanied by a peritoneal reaction (hemorrhage, inflammation, neovascularization, fibrin), had significantly lower survival rates compared to those with more than 1 mm distance and without peritoneal response (70 vs. 118 months, p < 0.001). Hence, such cases should be considered within the pT4a stage.

Idiopathic Ascites after Laparoscopic Appendicectomy: a review of literature and a case report

Introduction: Minimal access surgery, encompassing laparoscopy and robotic procedures, has become the preferred choice for a wide range of surgical interventions, receiving widespread acceptance from both surgeons and patients. However, as the utilization of these minimally invasive techniques continues to grow, surgeons are increasingly confronted with unforeseen and puzzling complications. One such rare and perplexing complication is the emergence of ascites following laparoscopic procedures, particularly when no accidental injury to the bowel or urinary system has occurred, posing a challenging and distressing scenario for the operating surgeon. Aims and Objective:We have encountered a case of idiopathic ascites following a laparoscopic appendicectomy in a 10-year-old boy. The primary objective of this study is to conduct a comprehensive literature review to identify similar case reports and publications. By doing so, we aim to enhance our understanding of the causes and principles for managing idiopathic ascites occurring after laparoscopic surgery. Methods: A 10-year-old boy was admitted to the hospital with typical symptoms of acute appendicitis. Following evaluation, a nearly bloodless and uneventful laparoscopic appendicectomy was performed. However, postoperatively, he developed ascites accompanied by scrotal swelling due to scrotal edema, and despite thorough evaluation, no identifiable cause was found. The patient was managed conservatively and fully recovered without any subsequent complications. Results: The occurrence of ascites stemming from an idiopathic allergic or inflammatory peritoneal reaction during a laparoscopic procedure is exceptionally rare. During the patient's evaluation, the paramount concern was to rule out potentially significant complications such as bowel or urinary tract injuries, which can commonly result in postoperative peritoneal fluid accumulation. After the procedure, the boy underwent a thorough evaluation, but no definitive cause for the ascites was identified, further highlighting the enigmatic nature of this condition. Conclusion: Postoperative ascites without a discernible cause following laparoscopic surgery is an unexpected complication. In such cases, the leading hypothesis points to a peritoneal inflammatory reaction induced by agents utilized during laparoscopy. J Bangladesh Coll Phys Surg 2024; 42: 194-198

Biliary Granulomatous Peritoneal Reaction as Consequence of Cholecystectomy: Case Report and Literature Review

Biliary Granulomatous Peritoneal Reaction as Consequence of Cholecystectomy: Case Report and Literature Review

Unusual ascites post laparoscopic cholecystectomy in old patient: Case report and review of the literature.

IntroductionAscites that precede laparoscopic cholecystectomy is an infrequent event. Its actual mechanism is not identified, but an inflammatory or allergic peritoneal reaction has been proposed. It can a life-threatening or an acute serious condition; for instance, the bile duct or other visceral injuries are eliminated.Case presentationWe present a 83 years old, medically free, who presented with fever and right upper quadrant pain. Diagnosed with severe acute calculus cholecystitis. Diagnostic laparoscopy and laparoscopic cholecystectomy were done, with copious irrigation of the abdomen. Postoperatively, patient started to had tense with moderate tenderness abdomen. Drain output showed clear ascites fluid. Postoperative ascites culture returned back as negative. Ascites treated conservatively with fluid restriction and furosemide. As per our knowledge, this is the fourth case that was reported in the literature of medicine.DiscussionThis was a particular case related to ascites which emerged without any known cause. The medical history of a powerful allergic background is can be the reason for transudative ascites that take place following an uneventful, occasional laparoscopic cholecystectomy. There was a presumed abnormal peritoneal or allergic reaction to the diathermy. No specific aetiological aspect was known irrespective of an extensive search being carried out.ConclusionIn cases of idiopathic post-laparoscopic ascites, general care and support is needed and fluid restriction and possible diuretic might be needed with no need for surgical intervention. Further studies are recommended for understanding of the pathophysiology of the disease.

Abdominal Cocoon Syndrome: A Rare Cause of Intestinal Obstruction

Abdominal cocoon syndrome, also known as Sclerosing Encapsulating Peritonitis, is characterized by a fibro-collagenous membrane that involves abdominal viscera and it’s a rare cause of intestinal obstruction.We present here two cases. Two male patients, 29 and 75 years old, were admitted to our emergency department with abdominal pain, vomiting, tender and painful abdomen but without changes in intestinal transit or peritoneal reaction. They were treated surgically and diagnosed with abdominal cocoon syndrome.Patients with abdominal cocoon syndrome usually present with recurrent episodes of intestinal obstruction, which result from the compression of the bowel within the constricting cocoon. Most of the time, this clinical picture resolves with conservative measures, delaying the diagnosis. The definitive treatment consists of excision of the membrane with lysis of adhesions, which is usually reserved for more severe cases of obstruction.This is a rare disease, where a high suspicion index is of paramount importance, especially considering that most of the diagnoses are made at the surgery.

Feasibility and safety of a new endoscopic synthetic sealant nebulizing device over gastric endoscopic submucosal dissections

BackgroundEndoscopic Submucosal Dissection (ESD) is the treatment of choice of superficial neoplastic gastrointestinal lesions. Delayed bleedings and perforations are still current clinical concerns. Glubran 2 is a synthetic cyanoacrylate-derived glue nowadays already widely used as an effective tissue adhesive. ENDONEB is a novel device thought for enabling the sealant nebulization over a specific targeted surface during laparotomy, laparoscopy, and thoracotomy. The aim of this single-center preclinical animal trial is to evaluate the feasibility and safety of the same nebulization technique during ESD in the perspective that further clinical studies would demonstrate the efficacy of Glubran 2 in preventing post-ESD adverse events.MethodsFour live Landrace pigs were enrolled. Two approximately 30-mm-wide gastric ESDs were performed in each pig (experimental ESD and control ESD). About 0.5 mL of Glubran 2 was nebulized on the experimental ESDs. Subjective perception of the feasibility of the Glubran 2 nebulization was reported. Pigs were clinically monitored at follow-up and upper GI endoscopy was performed at 24 and 48 hours, when animals were euthanized to perform a macroscopic and histological analysis of the specimens.ResultsNo peri-procedural adverse events were reported. Glubran 2 nebulization over experimental ESDs showed to be technically easy and time-effective. Clinical and endoscopic animal monitoring was negative at follow-up. At 24 hours, the Glubran 2 film was clearly visible on the eschar of the ESDs and signs of initial hydrolysis were discernable at 48 hours. No signs of peritoneal reaction were observed at the macroscopic examination. Equal transmural inflammation was described at the histological examination of both types of ESDs.ConclusionsSafety and feasibility profiles of Glubran 2 nebulizing ENDONEB device over ESD surfaces were excellent. Further evidences and human trials are needed to investigate its effectiveness in ESDs’ eschars sealing and, thus, in delayed micro-perforations and bleedings prevention and treatment.

Íleo biliar como causa poco frecuente de abdomen agudo obstructivo, presentación de caso clínico

Introducción: El íleo biliar es una complicación infrecuente de la colelitiasis y además es causa de obstrucción mecánica del intestino delgado o grueso, la cual es producida por la migración de un lito a través de una fístula bilioentérica misma que es más frecuentemente colecisto duodenal (65-77%) y, que, a pesar de poder alojarse en cualquier parte del trayecto, este muy comúnmente se aloja en el íleon terminal debido a su estrechez anatómica.
 Objetivo: Realizar una revisión bibliográfica sobre la sospecha clínica del íleo biliar, así como su manejo quirúrgico y ejemplificarlo mediante la presentación de un caso clínico.
 Material y métodos: Estudio descriptivo, retrospectivo, presentación de caso clínico en el “Hospital Básico IESS Latacunga”, caso que fue tratado en el servicio de Cirugía General del hospital.
 Resultados: Paciente que 24 horas antes de acudir a consulta presentó sin causa aparente dolor abdominal tipo cólico de moderada intensidad, localizado en epigastrio con irradiación difusa a flancos, este dolor fue acompañado por náusea que llega al vómito en más de 20 ocasiones siendo al inicio de contenido alimenticio, pero posteriormente tornándose bilioso, también se realizó tacto rectal donde se encontró esfínter tónico, ampolla rectal vacía, sin masas y dedo de guante limpio, se realiza exámenes complementarios de imagen donde se identifica la Triada de Rigler, compatible con un íleo biliar. Se decide intervención quirúrgica de emergencia.
 Conclusiones: El íleo biliar es una causa importante e infrecuente de obstrucción mecánica y su conocimiento por parte del cirujano es indispensable para un diagnóstico lo más precoz posible.

Hernia paracecal, reto diagnóstico y quirúrgico: reporte de caso y revisión de la literatura

Introducción. La hernia paracecal es una entidad rara que corresponde al 13 % de todas las hernias internas. Aunque algunas pueden ser adquiridas, la mayoría son congénitas y se originan en los recesos creados durante la adherencia y fusión de los repliegues peritoneales alrededor de la región ileocecal.
 Caso clínico. Se trata de un hombre de 42 años de edad a quien se le diagnosticó una apendicitis aguda. La intervención quirúrgica se inició con una incisión para apendicectomía localizada; no obstante, por los hallazgos intraoperatorios, se decidió la conversión a laparotomía y se produjo el hallazgo incidental de una hernia paracecal.
 Resultados. El paciente fue hospitalizado y, en el quinto día postoperatorio, presentó obstrucción intestinal por lo cual fue intervenido nuevamente; se encontró escaso líquido de reacción peritoneal y adherencias. Se le dio el egreso hospitalario cuatro días después de su último procedimiento quirúrgico y continuaba asintomático hasta su segundo control.
 Discusión. Las hernias paracecales son hernias internas que se describen como la protrusión de una víscera hueca por una apertura mesentérica o peritoneal. Sus manifestaciones clínicas son variadas y se puede presentar sin síntomas, con dolor abdominal localizado o hasta con obstrucción intestinal. El tratamiento quirúrgico se basa en liberar y examinar el segmento intestinal herniado y, de requerirse, proceder a la resección con anastomosis; se debe resecar el saco herniario cuando sea evidente, valorar los vasos mesentéricos y cerrar el defecto herniario.
 Se trata de una enfermedad poco común y es importante conocer su manejo con la finalidad de evitar complicaciones, ya que continúa siendo un reto diagnóstico para el cirujano.

Chemical peritonitis resulting from spontaneous rupture of amature ovarian cystic teratoma: acase report.

Mature cystic teratomas (dermoid cysts) are themost common germ cell tumours with 10-25% incidence of adult and 50% of paediatric ovarian tumours. Theaetiology of dermoid cysts is still unclear, although currently theparthenogenic theory is most widely accepted. Thetumour is slow-growing and in themajority of cases it is an accidental finding. Presenting symptoms are vague and nonspecific. Themain complication of adermoid cyst is cyst torsion (15%); other reported complications include malignant transformation (1-2%), infection (1%), and rupture (0.3-2%). Prolonged pressure during pregnancy, torsion with infarction, or adirect trauma are themain risk factors for a spontaneous dermoid rupture that can lead to acute or chronic peritonitis. Thediagnosis of mature cystic teratoma is often made in retrospect after surgical resection of an ovarian cyst, because such imaging modalities as ultrasound, computer tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign and malignant pathology. We present areport of aclinical case of a35-years-old female, who was referred to thehospital due to abdominal pain spreading to her feet for three successive days. She had ahistory of anormal vaginal delivery one month before. Abdominal examination revealed mild tenderness in the lower abdomen; no obvious muscle rigidity was noted. Transvaginal ultrasound showed amultiloculated cystic mass measuring 16×10cm in thepelvis. In theabsence of urgency, planned surgical treatment was recommended. Thenext day thepatient was referred to thehospital again, with acomplaint of stronger abdominal pain (7/10), nausea, and vomiting. This time abdominal examination revealed symptoms of acute peritonitis. Theultrasound scan differed from theprevious one. This time, thetransvaginal ultrasound scan revealed abnormally changed ovaries bilaterally. There was alarge amount of free fluid in theabdominal cavity. Thepatient was operated on-left laparoscopic cystectomy and right adnexectomy were performed. Postoperative antibacterial treatment, infusion of fluids, painkillers, prophylaxis of thethromboembolism were administered. Thepatient was discharged from thehospital on theseventh postoperative day and was sent for outpatient observation. Ultrasound is theimaging modality of choice for adermoid cyst because it is safe, non-invasive, and quick to perform. Leakage or spillage of dermoid cyst contents can cause chemical peritonitis, which is an aseptic inflammatory peritoneal reaction. Once arupture of an ovarian cystic teratoma is diagnosed, immediate surgical intervention with prompt removal of thespontaneously ruptured ovarian cyst and thorough peritoneal lavage are required.

Effect of Physical Exercise on Endometriosis Experimentally Induced in Rats.

Endometriosis is characterized by the growth of endometrial tissue outside the uterine cavity. The prevalence of endometriosis among women experiencing pain, infertility, or both is as high as 35% to 50%. The most common symptoms of endometriosis are dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Evidence has suggested that endometriosis symptoms result from a local inflammatory peritoneal reaction caused by ectopic endometrial implants that undergo cyclic bleeding. On the other hand, regular physical exercise seems to have protective effects against diseases that involve inflammatory processes such as type 2 diabetes and colon and breast cancer. On this basis, it is possible that the practice of physical exercise may have beneficial effects on endometriosis. Therefore, the objective of this study was to evaluate the possible anti-inflammatory effect of physical exercise on endometriosis experimentally induced in rats. Seventy female Wistar rats were divided into 7groups of 10 animals each. Animals performed light exercise (swimming once a week), moderate exercise (swimming 3 times a week), and intense exercise (swimming 5 times a week) before or after endometriosis induction. At the end of the experimental protocol, a reduction in the size of endometriotic lesions was observed after physical exercise regardless of its frequency, with a greater reduction in the groups practicing moderate and intense activity; an increase in FAS levels and a decrease in matrix metalloproteinases 9 and proliferating cell nuclear antigen (PCNA)levels was also observed. The immunohistochemistry results did not lead to conclusive results. As expected, oxidative stress was reduced in all groups. These results show that the practice of physical exercise could be beneficial, at least in part, for the treatment of endometriosis.

A rare case of accessory spleen torsion in a child diagnosed by ultrasound (US) and contrast-enhanced ultrasound (CEUS)

Accessory spleen, also known as supernumerary spleen or splenunculum, is a congenital anomaly of the spleen due to a fusion defect during the embryogenesis. Usually it is detected casually during an ultrasound (US) examination of the abdomen and it is asymptomatic. RESULTS: We present a case of a 12years old male patient, with 2-days history of left abdominal pain, without fever, gastrointestinal or genitourinary symptoms. The day before our observation, the patient had gone to another hospital, from where he had been discharged with medical analgesic therapy, without any benefit. Blood tests were normal, the Ultrasound abdominal examination showed normal aspect of abdominal organs, but the presence in the left side of a small round parenchymal structure surrounded by hyperechogenic mesenteric fat. We interpreted this image as an accessory spleen, complicated by torsion. As the torsion of accessory spleen is a quite rare occurrence, we carried out a contrast enhanced ultrasound (CEUS) to get more information. CEUS showed the absence of enhancement of the nodular formation, suggestive for a complete lack of vascularization; the spleen was normally enhanced. While the management in case of accessory spleen torsion is non-operative, in this case the patient underwent surgical exploration, due to the persistence of abdominal pain despite the medical therapy, with clinical signs of peritoneal reaction, mimicking an acute abdomen. Surgery confirmed the diagnosis of accessory spleen torsion. In conclusion, US is the first diagnostic tool in pediatric abdominal pain and allows to direct the diagnosis; the use of CEUS helps to clarify the US reports, without leaving doubts about the parenchymal vascularization of the abdominal organ involved.

Locally Advanced Colorectal Cancer: True Peritoneal Tumor Penetration is Associated with Peritoneal Metastases

BackgroundFindings show T4 colorectal cancer (CRC) to be a risk factor for the development of peritoneal metastases (PM). Heterogeneity regarding peritoneal involvement of T4 tumors might explain the wide range of reported PM incidences (8–50%). Hyperplastic and mesothelial inflammatory reactions complicate evaluation of the exact primary tumor involvement of the peritoneal layer. This retrospective cohort study aimed to assess the association between either inflammatory peritoneal reaction or peritoneal involvement of the primary tumor and the risk of PM.MethodsSince 2010, pathologists at UZ Leuven have systematically categorized peritoneal involvement in peritoneal reaction with tumor less than 1 mm from the peritoneal surface or true peritoneal penetration. All patients undergoing resection of CRC between January 2010 and July 2013 who fulfilled either of these pathologic criteria were included in this study.ResultsThe study enrolled 159 CRC patients. Peritoneal reaction with tumor less than 1 mm from the peritoneal surface was present in 43 patients and true peritoneal penetration in 116 patients. Overall, 29 patients (18%) had synchronous PM, and 30 patients (23%) had metachronous PM. In the multivariable analysis, true peritoneal penetration, in contrast to peritoneal reaction with tumor less than 1 mm from the peritoneum, was associated with greater risk of PM (odds ratio [OR], 2.518; range, 1.038–6.111; p = 0.041) and lymph node involvement (N1: OR, 1.572; range, 0.651–3.797 vs N2: OR, 4.046; range, 1.549–10.569; p = 0.014).ConclusionHistologically confirmed true peritoneal penetration by CRC, rather than inflammatory peritoneal reaction constitutes a high risk for PM. With evolving treatment strategies that aim to treat PM in an earlier phase, identification of high-risk patients becomes highly important clinically.

Peritoneal lavage with coconut water in rats with abdominal sepsis and its effects in peritoneum

Purpose: This study aims to analyze the effects of peritoneal lavage with coconut water on the peritoneal reaction in abdominal sepsis model in rats. Methods: We used 12 male Wistar rats weighing between 310±15 g. The animals were randomly distributed into 2 groups, with 6 animals each. Abdominal sepsis was induced by cecum ligation and puncture (CLP) in both groups. Group 1 was subjected to peritoneal lavage three times with 5 ml of saline each time; Group 2 submitted to peritoneal lavage with 5ml of coconut water also three times. Peritoneal lavage occurred 24 hours after CLP. Twenty four hours after, liquid from peritoneal cavity was harvested for counting of bacterial colony forming units (CFU/mL) of both groups. Euthanasia was done with overdose of anesthesia. For histopathological analysis, fragments of the peritoneum were removed, and a score was applied to the degree of inflammation. RESULTS: Group 2 had a lower histopathological score (p<0.005) and the fluid obtained in the first peritoneal lavage showed a lower amount of CFU compared to group 1 (p <0.005). CONCLUSION: The peritoneal lavage with coconut water positively influenced the inflammatory response in fragments of the peritoneum and the amount of CFU of bacteria in the peritoneal fluid in an experimental model.

The urgency of the problem of adhesions in the pelvis, its consequences and the role of undifferentiated connective tissue dysplasia in its development

This article describes the prevalence, diagnosis of chronic pelvic pain syndrome (CPPS) and negatively reflect on the quality of life of patients. Pelvic peritoneal adhesions are one of the most important causes of CPPS (17%). The mechanism of occurrence of adhesions in the abdominal cavity and peritoneal reaction to the action of various stimuli is not completely disclosed but the tendency to the formation of adhesions, is a variant form of undifferentiated connective tissue dysplasia.

Spontaneous chylous ascites after laparoscopic cholecystectomy: a case report

Cholecystitis with cholelithiasis is a very common disease in clinical practice. Now a days it is treated by laparoscopic cholecystectomy very safely with minimal trauma, discomfort and short hospital stay. Rarely, it is complicated by post-operative chyle leakage in peritoneum. We present a case of spontaneous chylous ascitis after laparoscopic cholecystectomy. Probably idiopathic or caused by trauma of pneumoperitoneum, abnormal peritoneal reaction to various chemicals released during operative procedure and diathermy used during laparoscopic cholecystectomy. We discuss its review, clinical presentation, diagnosis, treatment and management of this case. Chyle leake is rare post-operative complication can be managed by simple conservative treatment.

The Duplication of the Appendix: A Look Crossed Between the Surgeon and the Pathologist

The appendicular duplication is a rare congenital malformation. From an uncertain pathogeny, it can be a fortuitous discovery or reveal by an appendicular syndrome or an occlusive syndrome intestinal. We are carrying a particular form of appendicular duplication, siege of an acute appendicitis at uncommon elements suppurated with a peritoneal reaction to a patient aged of 14 years. We discuss then the viewpoint of the surgeon and the one of the pathologist in the assistance of that affection not well known.

Local Foreign Body Reaction of Peritoneum After Rupture of Cystic Partially Immature Teratoma

This is a pictorial report of rare sequelae after an unintended intraoperative rupture of a cystic teratoma. A 30-year-old woman was operated on for a mature cystic teratoma of the right ovary with an unintended intraoperative rupture of the ovarian tumor during the procedure. Postoperatively, the final immune histologic report showed partial neuroendocrine differentiation of an immature origin. At relaparoscopy for staging 7 weeks later, several suspicious peritoneal lesions of up to a 2.5-cm diameter were discovered and excised for which malignancy could not be excluded macroscopically. However, the final histologic report revealed a foreign body reaction related to spilling of the content of the mature teratoma. It is important to distinguish local peritoneal reaction from chemical peritonitis. The postoperative follow-up regarding symptomatic recurrence was uneventful.

Endometriosis and physical exercises: a systematic review.

Regular physical exercise seems to have protective effects against diseases that involve inflammatory processes since it induces an increase in the systemic levels of cytokines with anti-inflammatory and antioxidant properties and also acts by reducing estrogen levels. Evidence has suggested that the symptoms associated with endometriosis result from a local inflammatory peritoneal reaction caused by ectopic endometrial implants. Thus, the objective of the present review was to assess the relationship between physical exercise and the prevalence and/or improvement of the symptoms associated with endometriosis. To this end, data available in PubMed (1985–2012) were surveyed using the terms “endometriosis and physical exercises”, “endometriosis and life style and physical exercises” in the English language literature. Only 6 of the 935 articles detected were included in the study. These studies tried establish a possible relationship between the practice of physical exercise and the prevalence of endometriosis. The data available are inconclusive regarding the benefits of physical exercise as a risk factor for the disease and no data exist about the potential impact of exercise on the course of the endometriosis. In addition, randomized studies are necessary.

Beyond acute abdomen…

The authors present the case of male patient, 68years, farmer, autonomous, hypertensive, diabetic, excessive alcohol intake 200g/day for 20years, and mild hepatic steatosis documented on abdominal ultrasound 4months before this episode. Appealed to the emergency department by sudden intense pain in the right shoulder associated with vigorous physical exertion, with subsequent irradiation to the flank and right upper abdominal quadrant. Physical examination highlighted hematoma at the right upper abdominal quadrant and pain on deep palpation without peritoneal reaction.