Quadrant Pain In Patients Research Articles

Stump appendicitis: challenging diagnosis with serious complication: a case report

Stump appendicitis is a rare complication of appendectomy because of recurrent inflammation of the residual appendix. The diagnosis is often delayed because of low index of suspicious, which may result in serious complications. Twenty-three-year-old male patient presented with right lower quadrant abdominal pain after 7month of appendectomy done at a hospital. On physical examination, he has right lower quadrant tenderness and rebound tenderness. Abdominal ultrasound was done with finding of blind-ended tubular noncompressible 2cm long part of appendix with wall-to-wall diameter of 10mm. There is also focal defect with surrounding fluid collection. With this finding, perforated stump appendicitis was diagnosed. He was operated with similar intra operative finding. The patient discharged improved after 5days of hospital. This is first reported case in Ethiopia as far as our search is concerned. Despite past medical history of appendectomy, the diagnosis was made by means of ultrasound scan. Stump appendicitis is a rare but important complication of appendectomy, often misdiagnosed. Prompt recognition is important to avoid serious complications. This pathologic entity should always be kept in mind in case of right lower quadrant pain in patient with previous history of appendectomy.

Complications of cholecystitis: a comprehensive contemporary imaging review.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Role of laparoscopic cholecystectomy in the management of chronic right upper quadrant pain due to biliary dyskinesia: a systematic review and meta-analysis.

The objective of this study was to evaluate the surgical outcomes and feasibility of performing laparoscopic cholecystectomy (LC) in patients with longstanding right upper quadrant pain secondary to biliary dyskinesia. A systematic review of the literature including published randomized, controlled trials, non-randomized trials and comparative trials of any type, reporting outcomes of LC in the management of chronic right upper quadrant pain in patients with biliary dyskinesia, using the principles of meta-analysis on RevMan 5.3 statistical software, was undertaken. Thirteen studies including 740 patients evaluating the symptomatic improvement following LC in patients with biliary dyskinesia presenting as chronic right upper quadrant pain were included. There were 542 patients in LC group and 198 patients in Non-LC group. Successful complete resolution of symptoms was more likely to be achieved in LC group [risk ratio (RR), 0.21; 95% confidence interval (CI), 0.09-0.50, P=0.00001]. In addition, the risk of failure to resolve symptoms (risk ratio, 0.15; 95% CI, 0.05-0.39, P=0.00001) was lower in LC group. LC may be considered as an acceptable surgical intervention in patients with biliary dyskinesia presenting with chronic right upper quadrant pain. Currently there is insufficient evidence to recommend the routine use of LC in every patient with biliary dyskinesia. Paucity of high power randomised, controlled trials is the major reason for this lack of evidence which should be addressed soon and until then current study may be used to provide the basis for offering LC in selected group of patients.

Acute Cholecystitis Detected by Serial Emergency Department Focused Right Upper Quadrant Ultrasound

Acute cholecystitis is a common etiology of acute right upper quadrant pain in patients presenting to the emergency department (ED). The use of ED-focused right upper quadrant ultrasound (RUQ US) is becoming more widely utilized to evaluate abdominal pain thought to be hepatobiliary in nature. We describe a case series of two patients with acute cholecystitis detected by serial ED-focused RUQ US. Case 1: A woman presented to the ED with epigastric pain of acute onset. She was initially found to have a mild leukocytosis and cholelithiasis detected by ED-focused RUQ US. Seventy-five minutes later, the patient had a repeat bedside ultrasound by the same sonographer that showed visual evidence of acute cholecystitis that was later confirmed by surgical pathology. She was treated operatively. Case 2: A man with known cholelithiasis presents to the ED with acute-onset RUQ pain. Initial RUQ ultrasound performed by the Department of Radiology (University of Colorado Hospital) was equivocal, showing cholelithiasis with a mildly thickened wall and no pericholecystic fluid. A repeat ED-focused RUQ ultrasound 5 hours later showed increased wall thickness and pericholecystic fluid. The patient was subsequently taken for same-day cholecystectomy. This case series demonstrates the dynamic and progressive nature of acute cholecystitis detected by ED-focused RUQ US. It also highlights how serial bedside ultrasonography can reduce harm, appropriately triage patients with hepatobiliary disease and lead to reductions in overall morbidity.

Imaging of common bile duct stones

The gallbladder serves as the repository for bile produced in the liver. However, bile within the gallbladder may become supersaturated with cholesterol, leading to crystal precipitation and subsequent gallstone formation. Gallstone is one of the most common gastrointestinal diseases in clinical practice. Common bile duct stone may be silent and symptomless; alternatively the stone can cause acute cholangitis with jaundice, pain and fever and acute pancreatitis. Imaging of the gallbladder is typically requested for evaluation of right upper quadrant pain in patients with or without fever and jaundice. Hence,imaging is central to the investigation and diagnoses of choledocholithiasis. There are many options in the field of imaging of choledocholithiasis from a simple to more sophisticated examinations. Ultrasonography (US) has been the traditional modality for evaluating gallbladder disease, primarily owing to its high sensitivity and specificity for both stone disease and gallbladder inflammation. However, US is limited by patient body habitus, with degradation of image quality and anatomic detail in obese individuals. With the advent of faster and more efficient imaging techniques, magnetic resonance (MR) imaging has assumed an increasing role as an adjunct modality for gallbladder imaging. MR imaging allows simultaneous anatomic and physiologic assessment of the gallbladder and biliary tract. Magnetic resonance cholangiopancreatography is excellent for identifying the presence and the level of biliary obstruction. With newer diagnostic imaging technologies emerging, endoscopic retrograde cholangiopancreatography is evolving into a predominantly therapeutic procedure.

Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting at the emergency department. Early diagnosis and recognition of associated complications, though challenging, are essential for timely management. Imaging studies, including ultrasonography, computed tomography and magnetic resonance imaging, are increasingly utilised for the evaluation of suspected cases of cholecystitis. These investigations help in diagnosis, identification of complications and surgical planning. Imaging features of acute cholecystitis have been described in the literature and are variable, depending on the stage of inflammation. This article discusses the spectrum of cholecystitis-associated complications and their imaging manifestations. We also suggest a checklist for the prompt and accurate identification of complications in acute cholecystitis.

Acute appendicitis secondary to metastatic carcinoma of the breast: Case report and review of the literature

Abstract A 39-year-old woman presented with abdominal pain 6 years after her diagnosis of HER2 positive breast cancer. Imaging revealed an enlarged appendix likely representing acute appendicitis. Surgery was performed, and pathological analysis of the appendix indicated metastatic carcinoma. On reviewing the literature, we found a few reported cases of appendicitis caused by metastatic carcinoma of the breast. The possibility of metastasis to the appendix must be considered in the diagnosis of right lower quadrant pain in patients with breast cancer.

Chronic appendicitis “syndrome” manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults

In this short report, we describe a small series of adult patients with chronic appendicitis presenting with chronic right lower quadrant abdominal pain. The clinical presentation was unusual and atypical for classic appendicitis because of the absence of fever, peritoneal tenderness on focused graded compression of the abdomen, and leukocytosis. Computed tomography (CT) findings included the presence of an appendicolith and appendiceal thickening, without mesenteric infiltration, abscess, or collection. In this series, the appendicolith appeared to represent a marker rather than an actual cause of appendicitis. Focused CT scans with additional lung and bone windows proved optimal in detecting appendicoliths, which were not visible on the scout localizer scans, despite windowing modifications. Our findings suggest that chronic appendicitis may be a phenomenon unique to adults and should be included in the differential diagnosis of chronic right lower quadrant pain in patients seen in the emergency room setting. Surgery is curative in such patients, although expectant management is an alternative when tolerated by the patient.

Toxicity With Selective Serotonin Reuptake Inhibitors

Back to table of contents Previous article Next article Letter to the EditorFull AccessToxicity With Selective Serotonin Reuptake InhibitorsKEVIN SOLOMONS, M.D., SAMANTHA GOOCH, B.Sc., and ALLAN WONG, M.D., KEVIN SOLOMONSSearch for more papers by this author, M.D., SAMANTHA GOOCHSearch for more papers by this author, B.Sc., and ALLAN WONGSearch for more papers by this author, M.D., Vancouver, B.C., CanadaPublished Online:1 Jun 2005https://doi.org/10.1176/appi.ajp.162.6.1225AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Selective serotonin reuptake inhibitors (SSRIs) can have rare but serious adverse effects. This case report illustrates hepatotoxicity with citalopram and hepatorenal toxicity with fluvoxamine and citalopram.Ms. A, a 39-year-old Asian woman with longstanding posttraumatic stress disorder and psychotic depression, was admitted to the hospital after 3 days of catatonia, mutism, anorexia, and medication noncompliance. She had been admitted with similar presentations in the previous year. Her medical history was negative for these most recent symptoms. Her medications at admission included fluvoxamine, 50 mg/day, and clonazepam, 1 mg/day. Her fluvoxamine dosage was increased gradually to 150 mg/day. She had periumbilical and left upper quadrant pain with vomiting by day 9. Investigations demonstrated elevated levels of liver enzymes: alanine transaminase, 378 μmol/liter (her level at admission was 26 μmol/liter); aspartate transaminase, 609 μmol/liter (her level at admission was 11 μmol/liter); lactic hydrogenase, 850 μmol/liter (her level at admission was 101 μmol/liter); and serum creatinine, 763 μmol/liter (her level at admission was 66 μmol/liter). The results of tests for hepatitis and HIV were negative. Hepatic biopsies revealed cholestasis and hepatocytolysis with possible duct damage. Renal biopsies showed acute tubular necrosis requiring dialysis. Liver enzyme levels decreased with fluvoxamine discontinuation but increased within 4 days of rechallenge, from an alanine transaminase level of 208 to 379 μmol/liter and an aspartate transaminase level of 121 to 181 μmol/liter. Fluvoxamine was switched to citalopram, 10 mg/day. Her level of aspartate transaminase continued to rise to 239 μmol/liter. The citalopram was stopped, and Ms. A returned to baseline enzyme levels 3 weeks later. She responded to bilateral ECT and was discharged much improved to outpatient follow-up with normal hepatic and renal functions.Ms. A was readmitted 10 months later, frantic with anxiety, paranoid, and profoundly depressed while taking bupropion, 200 mg/day, and clonazepam, 0.5 mg/day. Bupropion was discontinued, and olanzapine, 10 mg, was added at night. Citalopram, 10 mg/day, was initiated after 7 days to target the persisting depression and distress. Epigastric and right upper quadrant pain developed after 4 days of citalopram use, with the liver enzyme aspartate transaminase rising from 34 to 251 μmol/liter and alanine transaminase from 94 to 282 μmol/liter. Results of an abdominal ultrasound, hepatitis serology, and serum creatinine were normal. Citalopram was discontinued with normalization of liver enzymes after 3 weeks. Ms. A responded well to olanzapine alone and was discharged taking 10 mg/day.To our knowledge, this is the first report in the literature documenting hepatorenal and/or hepatotoxicity in humans associated with either fluvoxamine or citalopram. Paroxetine (1), sertraline, and nefazadone (2) have been implicated in human hepatotoxicity. Health Canada reports hepatotoxicity in nine patients with fluvoxamine and one instance with citalopram but no clinical details (3). Other antidepressants involving serotonin pathways (fluoxetine, mirtazapine, trazodone, and venlafaxine) have been linked with hepatotoxicity (3). A higher index of suspicion to hepatic or hepatorenal complications may be required with new-onset upper quadrant pain in patients receiving SSRIs.