Rebound Tenderness Research Articles

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.

Ileoileal Intussusception Secondary to Meckel's Diverticulum: A Case Report

Background: The most frequently documented aetiology of Meckel's related obstructions is volvulus or intussusception of the small bowel with the presence of Meckel's diverticulum as the lead point. This study presents a case of small bowel obstruction caused by intussusception due to Meckel's diverticulum, which led to an obstruction of the small intestine.
 Case presentation: A 17-year-old male patient visited the hospital's emergency room complaining of worsening abdomen pain for two days. It was associated with abdominal distention, fever, nausea, and vomiting. There was no roving's sign or psoas sign and no rebound tenderness. There is no history of gastrointestinal cancer in his family or previous abdominal surgery. The white blood cell count was 18,400 c/mm, and the electrolytes, liver function tests (LFTs), and urinalysis were all within normal ranges. Ultrasonography imaging of right lower quadrant (RLQ): thickening tubular structure with target sign view and enteric intussusception with the possibility of appendix component.
 Conclusion: A 17-year-old male went to the emergency room complaining of acute abdominal pain and was diagnosed with ileoileal intussusception intraoperatively.

THU371 Empagliflozin Associated Pancreatitis: A Case Report

Abstract Disclosure: A. Poloju: None. P. Majety: None. A.Y. Groysman: None. Background/Objective: Sodium glucose cotransporter 2 (SGLT2) inhibitors are increasingly being used in the treatment of type 2diabetes mellitus (T2DM). With the recent FDA approval of these medications for treatment of heart failure, their use is expected to increase further. Common adverse events associated with SGLT2 inhibitors are genitourinary infections, hypotension, acute kidney injury and euglycemic diabetic ketoacidosis. Recently, SGLT2 inhibitors are increasingly associated with drug induced acute pancreatitis (DIAP). We present a case of empagliflozin associated DIAP, with the intent to add to the limited data on this possible adverse effect. Clinical Case: A 57-year-old woman with a history of T2DM presented to the hospital with severe abdominal pain. She had no recent alcohol use or prior episodes of pancreatitis. There was no history of trauma. Home medications include metformin, glipizide, empagliflozin, and lisinopril. Exam showed epigastric tenderness to palpation without guarding or rebound tenderness. Labs were notable for elevated white blood cell count, normal lipase, calcium, triglycerides, and liver function tests. CT abdomen showed induration of the peri-pancreatic fat, suggestive of pancreatitis. After ruling out common causes of pancreatitis, DIAP and idiopathic pancreatitis were considered possible etiologies. Obtaining further history revealed that patient was started on empagliflozin two weeks prior to this presentation. The only other medication that is known to cause pancreatitis is lisinopril but our patient was on this medication for several years. The Naranjo probability scale for empagliflozin showed a possible association between the drug and side effect. Empagliflozin was discontinued and the patient was discharged on metformin and glipizide. Conclusions: Pancreatitis is a common diagnosis requiring hospital admission and is associated with significant costs to the healthcare system. Although pancreatitis is a known side-effect with other medications used in treatment of T2DM, such as GLP1RAs and DPP-4inhibitors, it has not been well described with SGLT2 inhibitors. The prevalence of DIAP is difficult to assess since most of the existing data comes from individual case reports. Our patient had no known risk factors for pancreatitis. It is yet to be studied if genetic predisposition has a role in the development of pancreatitis with SGLT-2 inhibitors. With the increasing use of these medications in the treatment of type 2diabetes mellitus and heart failure, more cases of DIAP are being reported. It is important for physicians to consider SGLT2 inhibitors as a cause of pancreatitis after excluding other common etiologies. This may reduce episodes of recurrent pancreatitis and the burden of extensive workup for idiopathic pancreatitis. Presentation: Thursday, June 15, 2023

Diagnostic tools in diagnosing acute appendicitis - Alvarado Score, CRP, USG, and CT (Abdomen)

Aims. To evaluate scope of diagnosing tools-Alvarado score, CRP, USG, and CT in acute appendicitis. Method. Conducted observational study of 152 patients in Department of Emergency Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India between January to December 2022. The diagnostic tool’s (Alvarado score, CRP, USG, CT (abdomen), sensitivity, specificity, accuracy, and ROC were analyzed to diagnose acute appendicitis. Results. Among 152 study patients, males - 86, females - 66, higher number of age group was <30 years, abnormal variables in study patients are BP - 79%, HR - 80%, RFP pain - 57%, anoxia - 78%, nausea/vomiting - 68%, RIF tenderness - 69%, rebound tenderness - 63.8%, elevated temperature - 62%, pain - 44.7%, leukocytosis - 70.7%, and left shift - 38.2%. In comparison, Alvarado scores-identified 98% patients, (<5 score - 8.2%, 5-6 score - 30.6%, >7-61.2%) (0.0271), CRP - identified 95.1% (<0.001), USG identified (group 1-33%, group 2-12.2%, group 3-11.3%, and group 4-43.5%, and CT identified 152/152 (100%) patients with acute appendicitis. The odds ratio/95% CI of diagnostic tools (USG - 0.878, 0.66, CRP - 7.337, 2.623, Alvarado score - 0.81, 0.687). Sensitivity (Alvarado's score - 84.74%, USG - 83.33%, CRP - 76.43%), and specificity was (Alvarado's score - 84.32, USG - 72.97%, CRP-83.86%. The PPV (Alvarado's score - 74.56%, USG - 75.5%, CRP - 33.16%), NPV (Alvarado's score - 32.5%, USG - 79.1%, CRP - 81.03%), and diagnostic accuracy (Alvarado's score - 72.01%, USG - 73.05%, CRP - 68.81%). ROC in individual tools-Alvarado score was specific than USG, and CRP. ROC in combination tools-Alvarado score and USG was specific than USG, and CRP. Conclusion. Among the diagnostic tools tested, as individual tool-Alvarado score was specific, in combination, and Alvarado score and USG were accurate, specific, sensitive, hence combination of tools will identify acute appendicitis early to reduce mortality by undiagnosed or late diagnosed.

Clinicopathological Profile of Appendicular Disease in Children: A Tertiary Health Care Center Study.

Background Acute appendicitis (AA) is the most common surgical emergency worldwide. Delay in diagnosis of disease often leads to serious complications such as perforation appendicitis (PA) and gangrenous appendicitis (GA). Aims and objectives The purpose of the study is to document clinicopathological outcomes in pediatric age group patients in a tertiary health care center. Material and method This study was a prospective observation study of 50 patients with pediatric appendicitis who had undergone emergency appendectomy from January 2022 to December 2022. All pediatric patients below 15 years of age with a diagnosis of AA were included. Institute ethical permission was granted before the study, and parent consent was taken for the surgery and also for inclusion in the study. After proper resuscitation, all patients underwent appendectomy, and necessary specimens were sent for histological examination. Based on histopathology reports, all patients were classified into four groups: AA, PA, GA, and normal appendix (NA). Results Out of 50 patients, 33 (66%) patients were males and 17 (34%) patients were females. The mean age of the patients was 10.22 ± 2.73 years. The mean age of AA, PA, GA, and NA patients were 10.25 ± 2.6 years, 9.78 ± 2.99 years, 10.00 ± 4.6 years, and 12.00 ± 2.8 years, respectively. The mean duration of symptoms at the time of hospital admission was 2.42 ± 0.97 days forhistopathologically proven AA patients, 4.67 ± 2.1 days for GA patients, 2.8 ± 0.83 for PA patients, and one day for NA patients. Overall clinical presentation was right iliac fossa (RIF) pain in 36 (72%) patients, migration of pain in 31 (62%) patients, anorexia in 37 (74%) patients, nausea and vomiting in 43 (86%) patients fever in 26 (52%) patients, RIF tenderness in 50 (100%) patients, rebound tenderness in 39 (78%) patients, guarding in 19 (38%) patients, Psoas's sign in nine (18% patients), and Rovsing's sign in 19 (38%) patients. On histopathological examination of the sent specimen, AA was found in 36 (72%) patients, PA was found in nine (18%) patients, GA was found in three (6%) patients, and NA was found in two (4%) patients. Wound infection was the most common complication and was found in five (10%) patients. The average duration of hospital stay for AA, PA, GA, and NA was 4.33 ± 1.04 days, 9.56 ± 4.2 days, 12.33 ± 8.5 days, and 3.50 ± 0.71 days, respectively. Conclusion The appendicular disease is common in teenage male children. Fever, dehydration, and rebound tenderness at the RIF are clinically significant findings. Duration of symptoms at the time of diagnosis, post-appendectomy complication, and duration of hospital stay significantly correlated with histopathological findings.

Epidemiological Study of Adult Patients with Acute Abdomen Referred to Fatemi Ardabil Hospital from 2020 to 2021

Introduction: The prevalence and causes of acute abdomen can be different in various regions and races. Knowing the epidemiology of the disease can prevent unnecessary surgeries and unwanted complications caused by surgery. The present study was conducted with the aim of epidemiological investigation of adult patients with acute abdomen referred to Fatemi Ardabil Hospital from 2020 to 2021.
 Methods: A cross-sectional descriptive study was conducted during a year with a statistical population of 1031 patients referred to the Emergency Department of Fatemi Ardabil Hospital with abdominal pain. The sampling method was easy non-probability sampling. The information of these patients was collected through a preliminary questionnaire and analyzed using SPSS 16 software.
 Results: In this study, the number of 535 participants were male and 496 were female. 53.5% of patients had non-bilious vomiting، 67.6% had normal abdominal function، 53% had anorexia، 16.2% had abdominal distension and 14.3% had fever. 20.1% had pain in the right lower quadrant، 16.1% no tenderness، 15.6% rebound tenderness، 5.4% guarding، 5.8% psoas sign and 16.3% Murphy sign. 27% of abdominal pain was related to appendicitis، 20% to cholecystitis، 15.3% to intestinal obstruction and the lowest number of cases were related to metastasis and ectopic pregnancy with 0.3%.
 Conclusion: The best tools available for examining and managing abdominal pain are clinical examination and a comprehensive history.

Clinical, Diagnostic and Therapeutic Aspects of Acute Appendicitis at the Reference Health Center of Commune I-Bamako

Acute appendicitis is the most frequent abdominal surgical emergency in the world. The aim of this study was to analyse the results of surgical management of acute appendicitis. Methodology: This was a prospective study from January 2020 to December 2020 in the reference health centre in Commune I of Bamako. Results: During this period, we operated on 108 patients for acute appendicitis, including 78 men and 30 women, for a sex ratio of 2.5. The mean age was 26.92 years, ranging from 5 to 70 years. Abdominal pain was the main reason for consultation. Physical signs were dominated by a positive Blumberg's sign in 99.1% of cases, right iliac fossa defensiveness in 97.2% of cases, Rovsing's sign in 50% of cases, psoitus (Psoitis) in 18.5% and pain on the right in the cul de sac of Douglas in 69.4%. This physical examination enabled the diagnosis to be made in the majority of cases. In some doubtful cases, we requested an abdominal ultrasound scan. Locoregional anaesthesia was the most commonly used anaesthetic technique (63.9%). Classic Mac Burney appendectomy with burial of the stump was the surgical technique most frequently used. Postoperative recovery was straightforward in 97.2% of cases. However, we recorded one case of death. Conclusion: Acute appendicitis remains the most frequent abdominal surgical emergency in the community. Early diagnosis and rapid management improve prognosis. Treatment is essentially surgical.

Strangulated bowel obstruction caused by an ileo-ileal knot: a rare case report

BackgroundIntestinal knot formation is a condition wherein two segments of the intestine are knotted together; however, reports of small-intestinal ileo-ileal knot formation are rare.Case presentationThe patient was a 62-year-old Asian male with a history of endoscopic colorectal adenoma resection and a spontaneous pneumothorax. The patient had no history of a laparotomy. He consulted his local doctor with the chief complaint of abdominal pain and was admitted to our hospital with suspicion of an acute abdomen. The abdomen had muscular guarding with tenderness and rebound tenderness. Contrast-enhanced computed tomography (CT) showed torsion of the mesentery of the small intestine with poor contrast filling. The patient was referred to our department with strangulated bowel obstruction and underwent an emergency laparotomy. Intraoperative findings revealed that two segments of the ileum were wrapped around each other to form a knot, and the strangulated small bowel was necrotic. After the release of the knot, partial resection of the small intestine was performed from 220 cm distal to the ligament of Treitz to 80 cm proximal to the cecum. The patient had a good postoperative course and was discharged on the 11th postoperative day.ConclusionIleo-ileal knots should be considered as part of the differential diagnosis when treating strangulated bowel obstruction.

Fortuitously detected primary ovarian carcinoid tumor: A case report.

Carcinoid tumors, derived from the cells of the disseminated neuroendocrine system, are rare, slow-growing neuroendocrine neoplasms that display a relatively indolent disease course. The majority of carcinoids are found within the gastrointestinal tract and bronchopulmonary system. Primary ovarian carcinoids are rare and account for merely 1% of all carcinoid tumors. We describe our experience of a rare case of primary ovarian carcinoid, presenting as chronic constipation, with no other carcinoid symptoms such as flushing, diarrhea, and wheezing. A 51-year-old postmenopausal woman with chronic constipation visited the clinic for routine check-up of her preexisting uterine fibroids. She had undergone hemorrhoidectomy 3 years ago. Physical examination revealed a soft abdomen without direct or rebound tenderness. Transvaginal ultrasonography revealed two subserosal fibroids, which had increased in size compared with previous ultrasonographic findings. A 3 cm hyperechoic mass was also detected in the right ovary. Her blood and urine tests were unremarkable, with no ascites in the pelvic cavity. She had a normal CA-125 level of 5.5 units/mL. The patient underwent a robot-assisted hysterectomy and right salpingo-oophorectomy because of enlarging fibroids and the right ovarian mass. Subsequently, based on the pathological and immunohistochemical findings, she was diagnosed with a primary ovarian carcinoid. The mass consisted of the insular and trabecular types of tumor cells. It was positive for pan-cytokeratin and synaptophysin, and the Ki-67 proliferation index was less than 1%. A follow-up positron emission tomography-computed tomography revealed no distant metastasis. Six months postoperatively, the patient was doing well without any signs of recurrence. Primary ovarian carcinoids without teratoma components are rare. It is crucial to make an accurate diagnosis based on the immunohistochemical staining results. Diagnosis in the early stages of the disease are associated with a favorable prognosis, but regular follow-up is mandatory.

Ileo-sigmoid knotting: A case series of 25 patients

Introductionand importance: Ileosigmoid knotting (ISK), also known as double volvulus or compound volvulus is a rare cause of intestinal obstruction in which small bowel or sigmoid colon wrap around each other, causing double loop obstruction and frequently leading to bowel strangulation. This study aimed to determine the characteristics, presentation, morbidity, and mortality associated with ISK at University Hospital. MethodsA retrospective medical record review of all patients operated for ISK between January 2018 and January 2023. A data collection format that was tested on five patients was used to collect data on sociodemographic characteristics, clinical presentation, preoperative investigations, preoperative stabilization, intraoperative findings, type of surgical procedure performed, and patients’ treatment outcomes. OutcomesA total of 29 patients were operated on for ISK during the study period. Of these, the medical records of 25 patients were retrieved, reviewed, and analyzed. Males were commonly affected with a male-to-female ratio of 2:1(16:9). The peak age for ISK was between 30 and 50 years. The mean age of the patients was 42.6 years (SD ± 15.9) and ranged from 20 to 70 years. Only one of the patients had comorbidity (retroviral infection). The average duration of illness was 1.6 days (SD ± 0.65), and the majority (23, 92%) presented within 48 h. Four-fifth (20, 80%) of patients are from the rural areas and the majority of them (15 (75%)) presented later than 24 h, while 3 (25%) of patients from urban settings presented within 24 h. Abdominal pain was present in all patients followed by vomiting (24, 96%), abdominal distention (22, 88%), and failure to pass feces or flatus (15, 52%). Four (16%) of the patients were in shock at the presentation. The leading abdominal findings were guarding (25, 100%), tenderness (24, 96%), rebound tenderness (21, 84%), and hyper-tympanic abdomen (11, 44%). On digital rectal examination, a stool was found in more than half (17, 68%), followed by an empty rectum (7, 28%) and blood in 2 (8%) of the patients. Preoperative imaging (plain abdominal x-ray) was done in 13 patients with symptoms of obstruction and with no features of diffuse peritonitis. ConclusionThe performance of prompt, individualized surgical treatment in conjunction with the use of advanced measures of critical care to combat the disastrous consequences of multiple organ failures may contribute greatly to improving the survival rate of victims of this dreadful entity.

Parsimonious clinical prediction model for the diagnosis of complicated appendicitis

ObjectiveTo develop a logistic regression model that combines clinical and radiological parameters for prediction of complicated appendicitis. Methods248 patients with histologically proven uncomplicated (n = 214) and complicated (n = 34) acute appendicitis were analyzed retrospectively. All patients had undergone a presurgical abdominal and/or pelvic computed tomography (CT) scan, assessed by two radiologists. A model using univariate and multivariate logistic regression analyses was developed, and the strength of association between independent predictors and complicated acute appendicitis was evaluated by adjusted odds radio. Clinical parameters were gender, age, anorexia, vomiting, duration of symptoms, right lower abdominal quadrant (RLQ) tenderness, rebound tenderness, body temperature, white blood cell (WBC) count, and neutrophil ratio. Radiological parameters were appendix diameter, appendicolith, caecal wall thickening, mesenteric lymphadenopathy, extraluminal air, abscess, fat stranding, and periappendicular fluid. ResultsFour features (body temperature＞37.2 °C, vomiting, appendicolith, and periappendiceal fluid) were included in the logistic regression model, and yielded an area under the curve (AUC) of 0.87 (95% confidence interval (CI), 0.80–0.93), sensitive of 88%, and specificity of 74%. ConclusionThe logistic regression model makes an accurate and simple prediction of complicated appendicitis possible.

Clinical characteristics and risk factors of hepatitis B virus-related cirrhosis/hepatocellular carcinoma: A single-center retrospective study

Background and aimsHepatitis B virus (HBV) infection is a major global health problem which progresses to liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Early prediction of disease changes and intervention are essential to slow disease progression and protect liver function. This study aimed to analyze the clinical characteristics of patients with HBV-related LC and HCC at different serum alanine aminotransferase (ALT) levels and explore the risk factors of HBV infection progressing to LC/HCC. MethodsA total of 379 patients with HBV infection treated in The Third People's Hospital of Shenzhen between January 2014 and December 2016 without any antiviral drug therapy were enrolled. Patients were divided into the LC/HCC and non-LC/HCC groups based on clinical diagnosis, which was determined through imaging and expressions of pathological and laboratory test markers, and patients with LC/HCC were further divided into three groups according to the serum ALT levels. Differences in general information, clinical symptoms, and expression levels of serological indices of the above groups were compared and analyzed, logistic regression was used to analyze the risk factors for LC/HCC development, and the clinical diagnostic efficacy of indicators was judged by the receiver operator characteristic (ROC). ResultsLC/HCC mainly occurred in the ALT normal and mildly elevated groups, with 70.83% of patients with HCC having an LC background. In the comparison of different ALT level groups, the moderately–severely elevated group had the highest proportion of patients with skin jaundice, abdominal varices, rebound tenderness, higher white blood cell and neutrophil (NEUT) counts; and higher levels of aspartate aminotransferase, glutamyl transpeptidase, total bilirubin, and direct bilirubin. The LC/HCC group was older and had significantly higher proportions of male patients, alcohol consumption, and combined hypertension than the non-LC/HCC group (all P < 0.05). Logistic regression analysis showed that age, combined hypertension, abdominal varicose veins, subcostal palpation, and NEUT count were risk factors for LC/HCC development; and the area under the curve for this model on the ROC analysis was 0.935 (95% confidence interval 0.899–0.972) with specificity and sensitivity of 97.4% and 70.7%, respectively. ConclusionsAdvanced age, combined hypertension, abdominal varicose veins, subcostal palpation, and high NEUT count are risk factors for LC/HCC development in patients with untreated HBV infection.

Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital.

This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities. We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient. Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis. Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.

Appendicitis predictive score for children younger than 4 years

The clinical presentation of acute appendicitis in infants and young children is nonspecific. The diagnosis is often delayed and is accompanied by high rates of appendiceal perforation. The aim of the present study was to develop an early diagnostic scale for acute appendicitis in children less than 4 years of age. Results: The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). Conclusions: In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis. 100 children less than 4 years of age with a presumptive diagnosis of acute appendicitis were retrospectively evaluated in 4 hospitals. The case group comprised 90 patients with histopathological diagnosis of positive appendicitis (with inflammation in the appendiceal wall) while the control group comprised 10 patients with a histopathological diagnosis of negative appendicitis (without inflammation). Epidemiological, clinical, laboratory, and ultrasound variables were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score. Accuracy of the score was measured by the area under the receiver operating characteristic curve. Final model comprised 4 variables (Blumberg's sign, C-reactive protein, neutrophil-lymphocyte index and positive ultrasound). The scale had a high discrimination index area under the ROC curve of 0.96 (95%CI 0.88-0.99), sensitivity of 95.1% (95%CI 86.3-99.0%), specificity of 90.0% (95%CI 55.7-89.5%), positive predictive value of 98.3% (95%CI 90.0-99.7%) and negative predictive value of 75.0% (95%CI 49.4-90.2). In this study, a risk score based on characteristics of children less than 4 years with abdominal pain was developed that may help predict a patient’s risk of developing acute appendicitis.

GASTROINTESTINAL ANGIONEUROTIC EDEMA AS A CONSEQUENCE OF ANGIOTENSIN – CONVERTING ENZYME INHIBITOR TREATMENT

Objective: To report a case of unusual severe adverse reaction to an angiotensin-converting enzyme inhibitor (ACEI). Design and method: A 33-year-old male with a history of hypertension for 10 years, asthma, and atopy was admitted to a local emergency department due to diffuse abdominal pain with vomiting and diarrhea for about 3 days. A few days earlier, the patient had blood pressure (BP) lowering treatment modified due to suboptimal BP control, with introduction of perindopril. The first ACEI dose was followed by lower abdominal pain, urge to have bowel movement, and difficulty passing stool. 24 hours later, the next dose was followed by severe, gradually increasing, diffuse abdominal pain, nausea, vomiting, and diar-rhea. With signs of peritonitis present on admission, a surgeon suspected an acute abdomen and or-dered abdominal computed tomography (CT) due to unclear etiology. CT showed diffuse infiltrates within the small intestine and its mesentery, with free abdominal fluid but no perforation. The patient was not operated and seen by an internist who suspected gastrointestinal angioneurotic edema related to ACEI. On admission to the medical unit, the patient was moderately unwell, conscious, with BP 185/110 mmHg, HR 128 bpm, SaO2 99% on room air, and no fever. Abdomen examination showed reduced bowel sounds, abdominal guarding, tenderness on palpation, especially in the mid-abdomen, and rebound tenderness. Laboratory tests showed elevated WBC (16,800/mm3) and CRP (19 mg/L). Results: Perindopril was withdrawn, the patient received antihistamines, analgesics, and intravenous fluids, with improvement of the patient's condition and reduction of pain and inflammation markers. Follow-up abdominal CT after 5 days showed resolution of small intestinal edematous lesions. The patient was discharged home in good condition, without abdominal pain, and with good BP control. The final diag-nosis was gastrointestinal angioneurotic edema associated with ACEI treatment. Conclusions: One condition may mimic another and thus unclear clinical presentations require cautious diagnostic and therapeutic decisions. In the presented case, angioneurotic edema following introduction of perin-dopril was unusually located in the gastrointestinal tract and its manifestations imitated an acute abdo-men.

P-012 GARENGEOT'S HERNIA WITH ACUTE APPENDICITIS: A RARE CASE

Abstract Garengeot's hernia is a rare entity that refers to the herniation of the vermiform appendix through the femoral canal, being even rarer the presence of acute appendicitis in a Garengeot hernia as presented in the clinical case, with an overall incidence of 0,08%-0,13%. A 52 years old female patient, attended the Emergency Service complaining of abdominal pain in the right lower quadrant and fever for the last 2 days. As pathological background, she had bilateral tubal ligation, right crural hernioplasty and iatrogenic uterine perforation after placement of a intrauterine device (IUD). On physical examination, she complained of pain in iliac fossa/right inguinal region showing a positive Blumberg sign. Abdominal ultrasonography revealed acute appendicitis. In the laparoscopic approach, we identified the ileocecal appendix contained in a right crural hernia with abscessed acute appendicitis. We proceeded with appendectomy and, given the soiling of operative field, we chose not to correct the hernia at that moment. Empirical antibiotic therapy with Amoxicillin/Clavulanic acid was performed and patient was discharged after 3 days. Diagnosis of Garengeot hernia with acute appendicitis is difficult, being more frequently diagnosed intraoperatively. There's no standard therapeutic approach regarding hernia repair simultaneously, being licit not to do it due to the risk of postoperative infection.

Acute Appendicitis in Duplicated Appendix: Images in Medicine

A 26-year-old male patient, with a 3-days history of peri-umbilical pain which had localized to the right iliac fossa by the time he attended the hospital, was admitted to the emergency department of our hospital. The abdominal examination revealed a soft abdomen, rebound tenderness in the right iliacfossa, and a positive psoas sign. He was not peritonitic and had a negative Rosving's sign and absenthernias. Blood tests showed a mild leucocytosis of 12.5×109/l (range, 4.0–11.0×109/l) with a neutrophilia of 10.5×109/l (range. 2.0–7.5×109/l) and a CRP of 90mg/l. Ultrasonography confirmed a diagnosis of appendicitis by the presence of free fluid within the RIF and within the 10mm appendix which was incompressible. Under general anesthesia, the surgical exploration by laparotomy revealed the presence of acute appendicitis, but the meticulous investigation of the area around the cecum detected a second appendix with a definite mesoappendix and obvious signs of inflammation (Figure 1). Formal appendectomy was then performed for both processes (Figure 2).

Diagnosis and Management of Choledochal Cyst in One Year-Old Baby: A Case Report

Background: Choledochal cysts (CC) are rare congenital anomalies of the biliary tract. The classic triad of jaundice, abdominal pain, and right upper quadrant mass are rare symptoms, mainly in children and adolescents. This study aimed to present the diagnosis and management of choledochal cyst cases in a baby girl.&#x0D; Case presentation: A 1-year-old girl, domiciled outside the city of Padang, was brought to the hospital by her parents with complaints of repeated vomiting for 1 day before being admitted to the hospital. This complaint has been accompanied by yellowish eyes and body, pale bowel movements, and dark brown urine since 3 months ago. The patient was never brought to the doctor for treatment. Since 1 month ago, the patient often feels pain in the abdomen and has a lump in the upper right abdomen. On the abdomen area, there was no distention, hepar was ¼-1/4 sharp edge, tenderness at the epicondrium area, no rebound tenderness, turgor was decreased, and no palpable mass. Abdominal ultrasonography presented a choledochal duct cyst with biliary obstruction. Abdominal CT scan with contrast revealed intrahepatic and extrahepatic biliaryectasis et causa suggestive of the choledochal cyst (Todani IVA) and hepatomegaly. The patient was consulted by the pediatric surgery division for further management and was advised to undergo surgery with the Roux En-y procedure. Follow-up after the patient underwent surgery showed clinical improvement. Symptoms of jaundice in the eyes and skin begin to decrease, as brownish stools and light brown urine.&#x0D; Conclusion: Surgical treatment with the Roux-en-Y procedure is the definitive treatment for choledochal cysts in this patient.

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.

Single-Photon Emission Computed Tomography Assessment of Sepsis-Related Myocardial Calcification.

A 63-year-old man was admitted to the emergency department with tachypnoea, abdominal pain, hypotension, and altered mental status. Upon examination, the patient had involuntary guarding and localised rebound tenderness in the right lower quadrant, suggestive of peritonitis. The patient had no history of arterial hypertension, diabetes mellitus, or ischaemic heart disease. Arterial blood gas showed elevated lactate (4.1 mmol/L), and laboratory tests were notable for leucocytosis (14.7 × 103/mm3), elevated C-reactive protein (31.4 mg/L), and elevated procalcitonin (1.7 ng/mL), with normal calcium (8.9 mg/dL), phosphorus (4.1 mg/dL), and creatinine (1.27 mg/dL). Abdominal computed tomography (CT) revealed induration of the omentum of the right lower quadrant with bubbles of free air in the subumbilical region, suggesting a ruptured Meckel’s diverticulum. The patient received initial fluid resuscitation, antibiotics (vancomycin and piperacillin–tazobactam), and analgesia. Norepinephrine and vasopressin were initiated as the patient’s blood pressure did not increase with initial fluid resuscitation. The patient underwent an exploratory laparotomy and was hospitalised for sepsis. On the first day of hospitalisation, the patient had elevated troponin I (11.2 ng/mL; laboratory reference range ≤0.04 ng/mL) and N-terminal probrain natriuretic peptide (2,386 pg/mL), with repeated 12-lead electrocardiography showing normal sinus rhythm without ST segmental change throughout hospitalisation. He denied chest pain, tightness, palpitations, or dyspnoea, and his cardiac function remained stable. Three sets of blood cultures with one anaerobic bottle and one aerobic bottle each were collected before initiating empiric antibiotics, with two of the anaerobic bottles growing Escherichia coli 48 hours after incubation. As the patient’s troponin I normalised 4 days later (0.02 ng/mL), without ST segmental changes or wall abnormalities on point-of-care ultrasonography, coronary angiography was not performed. Upon recovery, the patient was referred to our department for further evaluation to clarify the aetiology of cardiac injury. Single-photon emission computed tomography (CT) revealed perfusion defects in the inferior and inferolateral walls, reverse redistribution, and transient dilatation (Figure 1A). The coronary artery calcium score was calculated as low risk, but a hyperdense linear image at the level of the left ventricular (LV) lateral wall was observed (Figure 1B). Cardiac CT angiography (CCTA) was performed, in which Coronary Artery Disease Reporting and Data System 1 was observed (Figure 1C), with LV lateral wall calcification in axial slices (Figure 1D). Three-dimensional reconstruction showed a partial absence of thickness of the LV lateral wall in relation to the calcified tissue (Figure 1E).