Presence Of Intraperitoneal Fluid Research Articles

Sonographic assessment of inflammatory bowel disease in the emergency department: A case series and review of the literature.

The use of sonography for diagnosing inflammatory bowel disease (IBD) has been reported in the radiology literature but is not common practice in the hands of emergency physicians (EPs). We present a series of three cases where IBD was managed by an EP using point-of-care ultrasonography (POCUS), and discuss the sonographic features of IBD including bowel wall thickening, increased blood flow on color Doppler, infiltration of surrounding fatty tissue, and presence of intraperitoneal fluid. Complications such as bowel strictures and peri-colic abscess are also described. We suggest that the use of POCUS for the assessment of IBD patients in the ED may expedite both diagnosis and treatment, as well as minimize the use of additional imaging.

Fluid deficit calculation at hysteroscopy: could consideration of intraperitoneal fluid accumulation add insight to safety limits?

The current literature and guidelines are largely silent regarding the contribution of the fallopian tubes to the fluid deficit (FD) during hysteroscopy. We explored whether the FD could be in part due to transtubal passage. This was a prospective cohort study. Patients who underwent hysteroscopy because of benign gynecologic pathology with, or without, laparoscopy were enrolled. The fluid deficit and, in laparoscopic cases, the amount of fluid found in the pelvis were prospectively reported. Comparisons between FD and intraperitoneal fluid were performed. Sixty-five patients were included in the study. Forty-five underwent hysteroscopy prior to laparoscopy and 20 patients underwent hysteroscopy-only. These were further divided into operative hysteroscopy and diagnostic hysteroscopy subgroups. In the laparoscopy group, the average FD was 525.9 mL (95% CI: 482.1-569.7) and the calculated FD due to intravasation was 286.6 mL (95%CI: 253.0-320.3). In the hysteroscopy without laparoscopy group, the average FD was 303.0 mL (95% CI: 85.2-520.8). There was no correlation between the intrauterine fluid pressure and the amount of FD, or the presence of intraperitoneal fluid. Most women with patent tubes undergoing hysteroscopy have accumulation of distention fluid in the pelvis and that the passage was not correlated with the intrauterine fluid pressure. These findings add new insight to the current guidelines, suggesting more accurate and patient-centered safety protocols.

Ascitis fetal: a propósito de un caso y revisión de la literatura

La ascitis fetal se define como la presencia de líquido intraperitoneal que puede ser parte de un hidrops generalizado o aislado. La mortalidad de la ascitis no inmune, tanto fetal como neonatal, es aproximadamente 60%. Se presenta un caso de ascitis fetal no asociada a hidrops y se revisa la patogenia, clínica y el enfoque diagnóstico y tratamiento de esta condición fetal y neonatal.

On table POCUS assessment for the IVC following abdominal packing: how I do it.

BackgroundSome surgeons may lack proper experience in abdominal packing. Overpacking may directly compress the inferior vena cava (IVC). This reduces the venous return and possibly causes hypotension. Here, a new on table Point-of-Care Ultrasound application that has been recently used to assess the effect of abdominal packing on the IVC diameter is described. Following abdominal packing, a small print convex array probe with low frequency (2–5 MHz) is used to visualize the IVC. Using the B mode, the IVC can be directly evaluated through a hepatic window between the ribs. The ultrasound beam should be vertical to the IVC longitudinal section at its midpoint. The abdominal towels will be in front of the IVC. This will enable us to judge whether there was overpacking on the IVC.ResultsOur method demonstrates that overpacking does not compress the IVC in a patient whose blood pressure has improved. The IVC diameter progressively increases on table and in the ICU with active resuscitation implying that bleeding stopped and the resuscitation was successful. Furthermore, presence of intra-peritoneal fluid can be excluded.ConclusionsThis new application of ultrasound evaluation of IVC patency after abdominal packing is simple, practical, easily reproducible, and can guide a less experienced surgeon in determining if overpacking of the abdomen is the cause of hypotension. Ultrasound findings should be correlated with the clinical picture to be useful.

CT imaging signs of surgically proven bowel trauma

The objective of this study was to determine the incidence and interobserver agreement of individual CT findings as well as the bowel injury prediction score (BIPS) in surgically proven bowel injury after blunt abdominal trauma. This HIPAA-compliant retrospective study was IRB approved and consent was waived. All patients 14years or older who sustained surgically proven bowel injury after blunt abdominal trauma between 1/1/2004 and 6/30/2015 were included. Admission trauma MDCT scans were independently interpreted by two abdominal fellowship-trained radiologists who recorded the following CT findings: intraperitoneal fluid, mesenteric hematoma/fat stranding, bowel wall thickening/hematoma, active intravenous contrast extravasation, free intraperitoneal air, bowel wall discontinuity, and focal bowel hypoenhancement. Subsequently, the electronic medical records of the included patients, admission abdominal physical exam results, admission white blood cell count, and findings at exploratory laparotomy of the included patients were recorded. Thirty-three patients met the inclusion criteria. The incidence and interobserver agreement of the CT findings were as follows: intraperitoneal fluid 93.9%, kappa = 0.784 (good); mesenteric hematoma/fat stranding 84.8%, kappa = 0.718 (good); bowel wall thickening/hematoma 42.4%, kappa = 0.491 (moderate); active IV contrast extravasation 36.3%, kappa = 1.00 (perfect); free intraperitoneal air 21.2%, kappa = 0.904 (very good), bowel wall discontinuity 6.1%, kappa = 1.00 (perfect); and focal bowel hypoenhancement 6.1%, kappa = 0.468 (moderate). An absence of the specified CT findings was encountered in 9.1% with surgically proven bowel injuries (kappa = 1.00, perfect). In our study, 9/16 patients or 56.3% had a bowel injury prediction score (BIPS) of 2 or more as defined by McNutt et al. (J Trauma Acute Care Surg 78(1):105-111, 2014). The presence of intraperitoneal fluid and mesenteric hematoma/fat stranding are the most common CT findings in bowel injuries proven at laparotomy. A small percentage of patients have no abnormal CT findings. This grading system did not prove to be useful in our study likely due to our inherently small patient population; however, the use of BIPS deserves further investigation as it may help in identifying blunt bowel and mesenteric injury patients with often subtle or nonspecific CT findings.

Hemoperitoneum from corpus luteal cyst rupture: a practical approach in emergency room.

Corpus luteum cyst rupture with consequent hemoperitoneum is a common disorder in women in their reproductive age. This condition should be promptly recognized and treated because a delayed diagnosis may significantly reduce women's fertility and intra-abdominal bleeding may be life-threatening. Many imaging modalities play a key role in the diagnosis of acute pelvic pain from gynecological causes. Ultrasound study (USS) is usually the first imaging technique for initial evaluation. USS is used to confirm or to exclude the presence of intraperitoneal fluid but it has some limitations in the identification of the bleeding source. Contrast-enhanced computed tomography (CT) is the imaging modality which could be used in the acute setting in order to recognize gynecological emergencies and to establish a correct management. Magnetic resonance imaging (MRI) nowadays is the most useful technique for studying the pelvis but its low availability and the long acquisition time of the images limit its usefulness in characterization of acute gynecological complications. We report a case of a young patient with hemoperitoneum from hemorrhagic corpus luteum correctly identified by transabdominal USS and contrast-enhanced CT.

Does This Adult Patient Have a Blunt Intra-abdominal Injury?

Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography. We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction. Critical appraisal and data extraction were independently performed by 2 authors. The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup. Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.

The fast is positive, now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

Introduction: The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination. Methods: We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention (“therapeutic laparotomy”). We analyzed the variables using binary recursive partitioning analysis to create a decision rule. Results: There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%–80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%–46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%–22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy. Conclusion: In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.