Quadrant Pain Research Articles

A retrospective cohort study to examine the association between the persistence of abdominal pain after cholecystectomy and ejection fraction on HIDA scan in patients with biliary dyskinesia

Background and aimsThe persistence of pain in patients who underwent cholecystectomy primarily for biliary dyskinesia has been associated with gall bladder ejection fraction (GBEF) found on hepatobiliary iminodiacetic acid (HIDA) scan. Cholecystectomy is a definitive treatment for cholelithiasis but is questionable in biliary dyskinesia. During the postoperative follow-up, gastroenterologists and surgeons often found that some patients with biliary dyskinesia continue to experience biliary pain even after surgery. This study aims to investigate whether the value of GBEF found on the HIDA scan predicts the persistence of pain after cholecystectomy in patients with biliary dyskinesia (EF <35% on HIDA scan). MethodsIt is a retrospective cohort study conducted at Kern Medical by recruiting patients from November 2019 to October 2022 in consecutive manner. It is a single sample study consisting of post-cholecystectomy biliary dyskinesia patients with dichotomous outcomes, i.e., persistent typical recurrent epigastric or right upper quadrant pain with/without meals versus no pain. The primary outcome was the presence of pain 30 days after the cholecystectomy. Univariate analysis was performed with some of the bivariate indicators and continuous predictors, which contained fewer missing elements and had more variation. ResultsUnivariate logistic regression suggested that HIDA GBEF as a continuous variable does not suggest a relationship with pain after surgery (p = 0.3951). A ROC analysis suggested a cutoff of HIDA GBEF = 16 (AUC = 0.60, Specificity = 0.5455, Sensitivity = 0.7333). ConclusionOur study does not support the relationship between GBEF found on HIDA scan to improved outcomes after the surgery. But larger controlled trials comparing outcomes of the patients with biliary dyskinesia who did and didn't undergo cholecystectomy are needed to look for other factors.

9547 Multidisciplinary Approach to Complex Right Lower Quadrant Pain

9547 Multidisciplinary Approach to Complex Right Lower Quadrant Pain

Mucocele of the Appendix Discovered Golestan Hospital of Ahwaz: A Case Report

Introduction: One rare cause of appendicitis is mucocele, which may have a neoplastic or non-neoplastic source. Simple appendectomy or right hemicolectomy may be necessary; sometimes, medication may be prescribed to manage symptoms. In this study, we reported a rare case with mucocele of the appendix managed by antibiotic therapy and a simple appendectomy. Case Presentation: A 60-year-old female with a seven-month history of right lower quadrant pain. A physical exam showed tenderness and rebound tenderness in the McBurney’s point. Her CT-scan tubular mass, measured 105 * 37 mm in RLQ, is suggested for mucocele appendicitis. Appendectomy was performed through a McBurney incision, and the pathology was a mucocele of the appendix with mucin-secreting mucosal hyperplasia. Conclusions: Malignancy of the appendix is extremely rare. Appendiceal tumors have a low prevalence, but due to the nature of these tumors, which can also be malignant, they should be given importance, and careful follow-up is mandatory. Patients must remain informed and proactive as the surgical community continues to learn more about this condition. The mucocele appendix can be successfully managed and treated with timely diagnosis and treatment.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BackgroundRight upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. Case ReportThis case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. Why Should an Emergency Physician Be Aware of This?Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

Segmental Arterial Mediolysis and its Mimickers: A Case Report and Review of the Literature.

Segmental arterial mediolysis (SAM) is a rare and underdiagnosed vasculopathy.SAM is a challenging diagnosis and should not be confused with vasculitis.SAM has a good prognosis with spontaneous resolution in most cases.

A different way to diagnosis acute appendicitis: machine learning.

&lt;b&gt;&lt;br&gt;Indroduction:&lt;/b&gt; Machine learning is a branch of artificial intelligence based on the idea that systems can learn from data, identify patterns, and make decisions with minimal human intervention.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Aim:&lt;/b&gt; Our aim is to predict acute appendicitis, which is the most common indication for emergency surgery, using machine learning algorithms with an easy and inexpensive method.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Materials and methods:&lt;/b&gt; Patients who were treated surgically with a prediagnosis of acute appendicitis in a single center between 2011 and 2021 were analyzed. Patients with right lower quadrant pain were selected. A total of 189 positive and 156 negative appendectomies were found. Gender and hemogram were used as features. Machine learning algorithms and data analysis were made in Python (3.7) programming language.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Results:&lt;/b&gt; Negative appendectomies were found in 62% (n = 97) of the women and in 38% (n = 59) of the men. Positive appendectomies were present in 38% (n = 72) of the women and 62% (n = 117) of the men. The accuracy in the test data was 82.7% in logistic regression, 68.9% in support vector machines, 78.1% in k-nearest neighbors, and 83.9% in neural networks. The accuracy in the voting classifier created with logistic regression, k-nearest neighbor, support vector machines, and artificial neural networks was 86.2%. In the voting classifier, the sensitivity was 83.7% and the specificity was 88.6%.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Conclusions:&lt;/b&gt; The results of our study show that machine learning is an effective method for diagnosing acute appendicitis. This study presents a practical, easy, fast, and inexpensive method to predict the diagnosis of acute appendicitis.&lt;/br&gt.

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

FRI229 Bilateral Adrenal Hemorrhage Following Deep Tissue Body Massage

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. P. Russell: None. S. Storm: None. S. Patel: None. V. Verma: None. R. Kant: None. Introduction: Adrenal hemorrhages have been reported in patients undergoing ACTH stimulation test using bovine- source ACTH. It can also be seen in severe stressful situations such as septicemia and extensive thermal burns due to sudden and profound adrenocortical stimulation by endogenous ACTH. Idiopathic spontaneous adrenal hemorrhage and motor vehicle accident induced adrenal hemorrhage have also been rarely reported. Coagulopathy, thromboembolic disease, and postoperative state are 3 major risk factors associated with bilateral adrenal hemorrhage. We present a unique case of a patient who presented with bilateral adrenal hemorrhage following deep tissue body massage. Clinical Case: A 44-year-old male with a past medical history of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to lupus anticoagulant disorder status-post inferior vena cava (IVC) filter and recent change from Coumadin to Xarelto presented to the ED with a chief complaint of right upper quadrant (RUQ) pain extending to the right flank. Patient experienced unrelenting pain after a deep-tissue massage one week prior to presentation. Patient was seen two days prior to admission for similar complaints, but was discharged after reassuring CT abdomen/pelvis, ultrasound, and labs. He returned after pain worsened, and a repeat CT showed right adrenal hemorrhage and enlargement. Patient denied all other symptoms except pain. Vitals included BP of 144/84 mmhg, RR 20/min, HR 89/min, temp of 98.1°F, and SpO2 of 99%. Physical exam was notable only for RUQ pain and right CVA tenderness. Initial labs showed normal CBC including HGB 13.6g/dL (13-17 g/dL), HCT 37.5% (38.5-52%), and PLT 181K/microL (150-450 K/microL). Glucose 120mg/dL (70-99mg/dL), Na 129mmol/L (135-146 mmol/L), K 3.3mmol/L (3.5-5.2 mmol/L), Cl 87mmol/L (98-107 mmol/L), anion gap 17mmol/L (4-15mmol/L). LFT, serum lipase and CPK were non-contributory. PT was elevated at 24.7s (10-13s) and INR was 2.1 (0.9-1.2). Anticoagulation was stopped for three to four weeks, and nonsurgical management was recommended. Potassium supplementation was given, and the patient was continued on his hypertension medications. On further investigation, origin of the hemorrhage was determined to be traumatic secondary to the massage during which the masseuse walked on the patient. The patient was discharged after three days but was readmitted after continued abdominal pain and hyponatremia. He was diagnosed with a left-sided adrenal hemorrhage on repeat CT scan twelve days after identification of the first. Medical management was successful. Conclusion: Adrenal hemorrhage is a potentially life-threatening condition often caused by trauma, severe burns, or septicemia. Anticoagulant therapy and thromboembolic disease, as seen in our patient, are also risk factors. The atypical trauma induced by the patient's massage likely initiated the hemorrhagic event. Presentation: Friday, June 16, 2023

FRI205 Splenic Infarct: A Rare Presentation Of Cushing Syndrome

Abstract Disclosure: G. Virella: None. Splenic Infarct: A Rare Presentation of Cushing Syndrome Geover, Virella M.D. 1,2, Carlos Santiago Botero Suarez, M.D.1,2, Alfredo Palomino Abella, M.D. 1,2, Mustafa Kinaan, M.D. 1,2 1) University of Central Florida HCA Healthcare GME, Greater Orlando, Florida2) Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.Introduction Cushing’s syndrome (CS) is associated with a hypercoagulable state leading to increased incidence of thromboembolic events. The mechanism behind this phenomenon is due to an imbalance between activity of pro- and anticoagulant pathways. We report a case of newly diagnosed CS in a patient presenting with acute splenic and inferior vena cava (IVC) infarcts. Case Description A 59-year-old woman with no significant medical history presents with acute left upper quadrant pain. She denied other symptoms. Physical examination was remarkable for tachycardia, left upper quadrant tenderness, and centripetal adiposity with BMI of 19. Labs showed marked leukocytosis (WBC 26 x 109/L) and thrombocytopenia (platelet 96,000 cells/uL). She was also found to be diabetic (HgA1C 12.5%). Abdominal CT imaging showed a wedge-shaped 4.3 x 3.1 x 2.3 cm splenic infarction, peri-splenic abscess, and thrombosis of the left renal and gonadal veins extending into the IVC. Additionally, there was a left adrenal incidentaloma measuring 4.5 x 3.8 x 2.9 cm. MRI of the left adrenal gland was consistent with an adenoma. The right adrenal gland was unremarkable. Screening for pheochromocytoma and hyperaldosteronism was normal. A morning serum cortisol was 33.4 mcg/dL, and ACTH level of &amp;lt; 1.5 pg/mL. An overnight 1-mg dexamethasone suppression test revealed post-dexamethasone cortisol of 4.58 mcg/dL. These findings were consistent with Cushing syndrome secondary to adrenal cause. The patient was initially treated with heparin infusion and underwent a successful thrombectomy of the IVC and gonadal vein. She later underwent a successful laparoscopic left adrenalectomy and splenectomy. Pathology reports confirmed an adrenocortical adenoma. A random post-surgical cortisol was 22.8. The patient had an uneventful postoperative course and was discharged home with outpatient endocrine follow-up planned to evaluate for hypercortisolism resolution and management of diabetes. Conclusion Cushing Syndrome patients have been shown to have an almost 18-fold higher rate of venous thromboembolism (VTE). This is an often-overlooked complication of hypercortisolism. The pathogenesis is not fully understood but is believed to be related to shortening of activated partial thromboplastin time (aPTT), increased clot lysis time, and glucocorticoid-induced increase in procoagulant factors such as fibrinogen, von Willebrand factor, and factor VIII. Our case will closely demonstrate the link between hypercortisolism and hypercoagulability. Presentation: Friday, June 16, 2023

FRI198 Acute Pancreatitis And Diabetic Ketoacidosis As A Presentation Of Subclinical Cushing Syndrome

Abstract Disclosure: W.H. Alkhidady: None. N. Almefgaie: None. A. Ekhzaimy: None. Case Report: A 43-year-old Saudi woman, presented to the emergency department with two days history of right upper quadrant pain, radiating to the back. Associated with nausea and vomiting with no history of diarrhea, constipation, or constitutional symptoms. She has a 4-year history of hypertension on 5 mg amlodipine with no history of endocrine or malignant tumors. On Examination she was alert, severely dehydrated with temperature of 37 °C, pulse of 124 per minute, blood pressure of 147/61 mmHg. The abdomen was tender in the right upper quadrant area. A laboratory examination showed lipemic sample with high triglycerides level 11mmol/L (0.4-1.48), high amylase 763nu/l (25-115), lipase 5773 u/l (73-393), low potassium level 2.6 mmol/l (3.50-5.10) and low calcium level 1.25 mmol/l (2.10-2.55). The urine analysis showed 4+ glucosuria and ketonuria. Her venous blood gas showed pH of 7.18 and bicarbonate of 10 mmol/L, random blood glucose was 16 mmol/L and anion gap could not be calculated at that time. A diagnosis of DKA secondary to acute pancreatitis secondary to high triglycerides level was made and management was started along with plasmapheresis. A CT pancreatitis protocol was done which showing a 4.2 x 3.5 cm well-circumscribed left adrenal lesion. An MRCP showed 4.3 cm well defined collision tumor in left adrenal gland, its peripheral part is suggestive of adenoma. further work up showed negative 24-hours urine metanephrins, normal Aldosterone Renin ratio, High 24-hour urine cortisol level 644 nmol/l, low ACTH 0.6 pmol/l and morning cortisol level post 1 mg DST was not suppressed on two different occasions. Since the patient had no phenotypical presentation of Cushing’s a diagnosis of SCS was made. She underwent left robotic assisted adrenalectomy, with pathological diagnosis of adrenocortical adenoma. 2 days later, AM cortisol level reduced to 230 nmol/L. while blood pressure and serum potassium remained normal with no signs of adrenal insufficiency. Her Diabetes mellitus and Hypertriglyceridemia resolved after left adrenalectomy. Conclusion: This case report demonstrates the uncommon association of subclinical Cushing syndrome and acute pancreatitis as a first presentation therefore it highlights the significant role of endocrine evaluation of any young patient with unexplained acute metabolic presentations. Presentation: Friday, June 16, 2023

FRI196 Non-Hemorrhagic Adrenal Infarction in Pregnancy with Tuberous Sclerosis

Abstract Disclosure: A. Mahaldar: None. H. Al Jumaili: None. S.R. Campbell: None. M.Z. Baker: None. Background: Non hemorrhagic adrenal infarction is a rare diagnosis in pregnancy with less than 20 cases reported in literature so far. No cases have been reported in patients with tuberous sclerosis. Most patients present with abdominal pain. Clinical Case: 29 year old woman G2P1 presented at 35 weeks gestation with right upper quadrant pain. She reported two episodes of dizziness in first trimester but otherwise had an uneventful pregnancy prior to presentation. First pregnancy was uncomplicated. Past medical history included asymptomatic tuberous sclerosis. No previous history of blood clots. Physical examination revealed a distended abdomen appropriate for gestational age and right upper quadrant tenderness to palpation. Initial laboratory data was unremarkable except for leukocytosis with WBC 16.6 k/mm3 (4-11 k/mm3). Normal electrolytes and liver function tests. Abdominal ultrasound revealed cholelithiasis without evidence of acute cholecystitis and unremarkable renal findings. CT abdomen pelvis with contrast showed thickening with surrounding stranding of right adrenal gland suggesting acute adrenal infarction and multiple pancreatic cysts. 8 am cortisol was 4.9 mcg/dl (4.1-16.6 mcg/dl) and ACTH was 23 pg/ml (7.2-63.3 pg/ml). Patient had received 2 doses of betamethasone due to concern for preterm delivery at 48 hours and 36 hours prior to this blood draw. Hypercoagulable panel was sent prior to starting enoxaparin. Elevated Factor VIII &amp;gt;150% (50 to 150%) was noted as expected in pregnancy. Lupus anticoagulant was weakly positive with LA sensitive PTT 50.1 (0 to 51.9 sec). Anticardiolipin antibody and beta 2 glycoprotein antibody were normal. Patient was treated with hydrocortisone 15 mg by mouth daily and full dose enoxaparin for anticoagulation. At one month follow up 8 am cortisol was 24 mcg/dl. Hydrocortisone replacement was discontinued. Labor was uncomplicated with vaginal delivery at 38 weeks gestation. Day 1 postpartum at 7:30 AM cortisol was 20.94 mcg/dl. Patient was discharged home in a stable condition with continued anticoagulation with enoxaparin and no further hydrocortisone treatment. Conclusion: We present a case of non hemorrhagic adrenal infarction in a pregnant patient with tuberous sclerosis. Adrenal infarction without hemorrhage is rare. Anatomy of adrenal gland makes it prone to microvascular thrombosis and infarction in a thrombotic state because of single draining vein for venous drainage. Pregnancy as a hypercoagulable state has been previously associated with non hemorrhagic adrenal infarction in few case reports. Whether tuberous sclerosis played any role in our patient’s pathogenesis remains unclear as there are no data or case reports linking the two. In conclusion, the diagnosis of non hemorrhagic adrenal infarction needs to be considered in hypercoagulable or pregnant patients presenting with abdominal pain. Presentation: Friday, June 16, 2023

S2505 Misdiagnosis of Left Lower Quadrant Pain

S2505 Misdiagnosis of Left Lower Quadrant Pain

Tacrolimus-associated sinusoidal obstruction syndrome after living-related liver transplantation

Sinusoidal obstruction syndrome (SOS), previously known as hepatic veno-occlusive disease, is manifested by obliterating inflammation of the terminal hepatic veins, characterized by hepatomegaly, right upper quadrant pain, jaundice and ascites, and most often occurs in patients after hematopoietic stem cell transplantation and usually in those who received platinum-based drugs. Cases of SOS development in patients after transplantation of solid organs (lungs, pancreas, liver) are also reported in the world literature. These incidents are rare, and isolated and poorly studied after living-related liver lobe transplantation. The diagnosis is based on clinical signs, imaging techniques (according to ultrasound and radiological methods of examination), histological assessment of liver biopsy. Tacrolimus has been reported to be a causative agent that potentially plays a role in the pathophysiological mechanism of SOS. Aim. To study the relationship between the use of prolonged-release tacrolimus and the development of SOS in patients after living-related liver transplantation. Clinical case. In this article, we present a case of SOS after living-related liver transplantation which was associated with a toxic effect of prolonged-release tacrolimus (“Envarsus”). In a 55-year-old man, after living-related liver transplantation, high blood concentrations of tacrolimus associated with uncontrolled drug intake were detected. When performing a number of laboratory and instrumental methods of examination due to a massive ascites manifestation, the diagnosis of SOS was made. The study was carried out in accordance with the principles of the Helsinki Declaration. The informed consent was obtained from the patient for conducting the studies. Conclusions. By ruling out other possible contributing factors, including an acute rejection crisis, it was concluded that prolonged-release tacrolimus (“Envarsus”) was the cause of SOS.

Clinical characteristics of human fascioliasis in Egypt

There is a lack of epidemiological data on fascioliasis in Egypt regarding disease characteristics and treatment outcomes across different governorates. We aimed to identify the demographic, epidemiologic, clinical, laboratory, and radiological characteristics and treatment outcomes of patients diagnosed with fascioliasis in Egypt. Data on human fascioliasis were collected retrospectively from patients’ medical records in the period between January 2018 and January 2020. The study included 261 patients. More than 40% of enrolled patients were in the age group of 21–40 years old. Geographically, 247 (94.6%) were from Assiut Governorate with 69.3% were from rural areas. The most frequent symptoms were right upper quadrant pain (96.9%), and fever (80.1%). Eosinophilia was found in 250 cases (95.8%). Hepatic focal lesions were detected in 131 (50.2%); out of them 64/131 (48.9%) had a single lesion. All patients received a single dose of 10 mg/kg of triclabendazole, 79.7% responded well to a single dose, while in 20.3% a second ± a third dose of treatment was requested. After therapy, there was a reduction in leucocytes, Fasciola antibodies titer, eosinophilic count, bilirubin, and liver enzymes with an increase in hemoglobin level. According to our findings, a high index of suspicion should be raised in cases with fever, right upper abdominal pain, and peripheral eosinophilia, and further imaging workup is mandated to detect hepatic focal lesions. Prompt treatment by triclabendazole can serve as a standard-of-care regimen even for suspected cases.

INCIDENTALLY DIAGNOSED APPENDIX DIVERTICULOSIS AFTER APPENDECTOMY

Title:&#x0D; Incıdentally Diagnosed Appendix Diverticulosis After Appendectomy&#x0D; Short Title:&#x0D; Appendix Diverticulosis&#x0D; Abstract &#x0D; Appenix diverticulitis was first described by Kelynack in 1893. Appendix diverticulosis is a rare clinical manifestation of the appendix with a changing rate of 0.004 to 2.1% of all appendectomies. Generally diagnosed in males, and the mean age is 38. Appendix diverticulosis may be inflamed and result in appendix diverticulitis or can be incidentally diagnosed by acute appendicitis. Clinical presentation of appendix diverticulitis may be similar to acute appendicitis but clinical signs may occur slowly and mildly. &#x0D; The thirty-five-year-old male patient was admitted to the emergency department with right lower quadrant pain. The patient has abdominal tenderness, rebound, and defense reactions with other intraabdominal infections signs. Abdominal ultrasonography was performed and appendix diameter was measured enlarged, and inflammation signs were observed in the surrounding tissue in favor of acute appendicitis. A laparoscopic appendectomy was performed. During the operation, three small herniated tissue was observed on the anti-mesenteric surface of the appendix. Acute phlegmonous appendicitis and appendix diverticulosis diagnosis were confirmed with the histopathological examination.&#x0D; Appendix diverticulosis may occur either acquired or congenital. The congenital diverticulosis is generally located on the anti-mesenteric edge and contains all layers of the appendix wall. Diagnosed appendix diverticulosis is acquired type predominantly. Appendix diverticulosis is diagnosed more commonly in patient who has cystic fibrosis or Hrschsprung’s disease. However, no relationship between colon diverticular disease and appendix diverticula has been found. There is a high risk of appendiceal neoplasms such as carcinoid tumors and mucinous adenomas. The gold standard to diagnose appendix diverticula is histopathological examination.

Performance of Ultrasonography in the Diagnosis of Acute Colonic Diverticulitis.

Computed tomography is regarded as the reference-standard imaging modality for the assessment of acute left-sided colonic diverticulitis (ALCD). However, its utility may be impaired by cost issues, limited availability, radiation exposure, and contrast-related adverse effects. Ultrasonography is increasingly advocated as an alternative technique for evaluating ALCD, although there is variation regarding its accuracy in disease diagnosis and staging and in determining alternative diagnoses. The aim of this study was to assess the performance of ultrasonography in diagnosing ALCD, differentiating complicated from non-complicated disease and defining alternative diseases related to left lower quadrant pain. Within a 2-year period, all consecutive adult patients with clinically suspected ALCD and available abdominal computed tomography were prospectively evaluated and planned to undergo an abdominal ultrasonographic examination, tailored to the assessment of left lower quadrant. Computed tomography (CT) was regarded as the reference standard. A total of 132 patients (60 males, 72 females; mean age: 61.3 ± 11 years) were included. The sensitivity, specificity, and area under curve of ultrasonography for diagnosing ALCD were 88.6, 84.9, and 86.8%, with positive and negative predictive values of 89.7 and 83.3%, respectively. The method had sensitivity, specificity, and area under curve of 77.8, 100, and 88.9%, respectively, for defining complicated disease. The area under the curve for the identification of alternative diseases in patients with left lower quadrant pain was 90.9%. Ultrasonography has high diagnostic accuracy for diagnosing ALCD, differentiating complicated from non-complicated disease and establishing alternative diagnoses related to left lower quadrant pain. A low threshold to get a CT should be maintained as not to miss cases that may mimic ALCD.

Incidental Finding of Chronic Appendicitis

Chronic appendicitis is a rare, often overlooked condition, with minimal and vague clinical presentation, and sub-normal lab values. We report the case of a 24-year-old male who presented with intermittent right upper quadrant pain evolving for five months. Computed tomography (CT) imaging showed signs of appendicitis.

ThTP6.8 Incidence and management of non-resolution of Biliary Colic or Right Upper Quadrant pain Post Laparoscopic Cholecystectomy

Abstract Background The pathogenesis and risk of chronic pain after laparoscopic cholecystectomy are not well understood. Post-cholecystectomy syndrome describes persistence of biliary colic or right upper quadrant pain with a variety of GI symptoms, similar to features prior to cholecystectomy. It is attributed to biliary (retained stone, biliary stricture), extra-biliary (pancreatitis, gastritis, IBS) and psychiatric or neurological disorders. Aim To find out (1) the incidence of post laparoscopic cholecystectomy pain. (2) if patients were counselled on non-resolution of pain during consenting for surgery. (3) if patients were investigated for non-resolution of pain. Methodology Retrospective cohort study was performed by interviewing patients undergoing laparoscopic cholecystectomy from April2022-October2022. Direct telephone consultation to enquire about non-resolution of pain. Digital case notes were reviewed for subsequent admissions. Results A total of 50 cases met the audit inclusion criteria over the period of 7months. Mean age of the selected population was 47.98 years (SD 15.47). Male:female ratio was 11:39. 24%(n=12) patients were reported non-resolution of pain post-op. 48%(n=24) patients were counselled on non-resolution of pain while consenting for surgery. Discussion The study suggested a significant number of patients experience non-resolution of pain post-cholecystectomy. However, less than half of the study population were counselled during consenting. Limitations include low number of patients and risk factors like urgent surgery like ‘hot gallbladders’ and choledochotomy could not be assessed. To improve clinical practice, non-resolution of pain should be mentioned during consenting. Additionally, a potential follow-up system should be introduced to review non-resolution of pain and guidelines on investigation of the residual pain should be produced.

Presentation and Management of Uterine Didelphys with Unilateral Cervicovaginal Agenesis/Dysgenesis (CVAD): A Multicenter Case Series

IntroductionThere are several well-described presentations of uterine didelphys (UD): UD without vaginal septum, UD with non-obstructed longitudinal vaginal septum, or UD with duplicated vaginas and an obstructed hemivagina on one side with ipsilateral renal anomaly. Study ObjectiveTo describe another variant of UD and compare the presentation and management across different institutions MethodsThis was a retrospective case series approved by the NASPAG Fellows Research Consortium. Participating institutions obtained IRB approval. Inclusion criteria included a diagnosis of UD and unilateral cervicovaginal agenesis/dysgenesis (CVAD). Descriptive statistics were used. ResultsFive patients met the inclusion criteria, with ages ranging from 13 to 27 years. Presenting symptoms included dysmenorrhea (80%), irregular bleeding (40%), acute onset left lower quadrant pain (20%), and abdominal mass (20%). Three patients had additional known abnormalities, including solitary kidney and solitary adrenal gland. All patients underwent pelvic magnetic resonance imaging. Two cases were only suspicious for unilateral CVAD on imaging and required pathology review postoperatively to confirm diagnosis. Two cases required a 2-staged approach with an initial diagnostic surgery followed by a second definitive procedure. Three patients were noted to have endometriosis intraoperatively. Postoperative follow-up ranged from 2 months to 2 years, with 1 patient reporting chronic pelvic pain. ConclusionDiagnosis on the basis of pelvic imaging can be difficult, as this unique variant may mimic classic obstructed hemivagina with ipsilateral renal anomaly. In patients with UD with unilateral CVAD, standard management is removal of the obstructed uterine horn. This multicenter series stresses awareness about the clinical presentation, distinguishes cases of cervical agenesis from dysgenesis, and reviews approaches to management.

Role of intravascular ultrasound in endovascular management of nutcracker syndrome: A case report.

Here, we describe nutcracker syndrome management using intravascular ultrasound (IVUS) during endovascular stent placement of the renal vein. A 60-year-old woman with a known Factor V Leiden mutation, long-standing smoking history, and family history of pancreatic cancer presented with 2years of intermittent left upper quadrant pain (LUQ) and a 15lb unintentional weight loss. Work-up included abdominal ultrasound (US) and abdominal computerized tomography (CT) scan. Abdominal US and Chest CT scan were negative while the abdominal CT scan revealed severe compression of the left renal vein by the superior mesenteric artery, consistent with nutcracker syndrome. Renal venogram and endovascular stent placement performed under IVUS guidance. IVUS was used to determine stent size and measure flow and assess patency after stent placement. Post-renal vein stent placement, the patient had resolution of her symptoms with follow-up duplex renal ultrasound exam demonstrating restored blood flow in the left renal vein with improved patency.