Rebound Tenderness Research Articles

Ripasa versus Alvarado as a Scoring System in Diagnosis of Acute Appendicitis in Al-Yarmouk Teaching Hospital

Background: Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization. A number of scoring systems have been developed to try to identify people who are likely to have appendicitis and are eligible for surgery. Aim of study: is to compare the accuracy of RIPASA to Alvarado score in the diagnosis of acute appendicitis. Methods: A prospective comparative study that was conducted at Al-Yarmouk Teaching Hospital / Baghdad during the period of one year from 1st of Feb. 2019 till 1st of Feb. 2020. It included 200 patients attended the outpatient clinic or the emergency department in Al-Yarmouk Teaching Hospital complaining from lower abdominal and/or right iliac fossa pain suggestive of acute appendicitis. Scoring was done to diagnose appendicitis by two scoring systems (Alvarado and RIPASA) using the data for each patient. The individual scores were then compared to the final diagnosis made by the clinician and to the recommendations of each scoring system. Results: In this study, most of the patients (172 patients, 86%) underwent appendectomy. We noticed that 44.8% of the operated cases were diagnosed as catarrhal appendicitis. Incidences of rebound tenderness, leukocytosis, migratory pain, ROVSING sign, and right iliac fossa guarding were significantly higher in patients diagnosed with appendicitis than those in patients diagnosed as normal appendix. Means of ALVARADO and RIPASA scores were significantly increased with severity to reach the highest level in patients diagnosed with severe appendicitis than other findings. ALVARADO score was 69.7% sensitive, 87.5% specific, and 74% accurate. RIPASA score was 94.1% sensitive, 62.5% specific, and 86.5% accurate. Conclusion: RIPASA score is more accurate and more sensitive than Alvarado score, in spite of the lower specificity, so that it can be effectively conducted for the better evaluation of acute appendicitis. RIPASA score is simple, non-invasive, and cost effective way to be used in resource limited conditions.

Prediction and management of strangulated bowel obstruction: a multi-dimensional model analysis

BackgroundDistinguishing strangulated bowel obstruction (StBO) from simple bowel obstruction (SiBO) still poses a challenge for emergency surgeons. We aimed to construct a predictive model that could distinctly discriminate StBO from SiBO based on the degree of bowel ischemia.MethodsThe patients diagnosed with intestinal obstruction were enrolled and divided into SiBO group and StBO group. Binary logistic regression was applied to identify independent risk factors, and then predictive models based on radiological and multi-dimensional models were constructed. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were calculated to assess the accuracy of the predicted models. Via stratification analysis, we validated the multi-dimensional model in the prediction of transmural necrosis both in the training set and validation set.ResultsOf the 281 patients with SBO, 45 (16.0%) were found to have StBO, while 236(84.0%) with SiBO. The AUC of the radiological model was 0.706 (95%CI, 0.617–0.795). In the multivariate analysis, seven risk factors including pain duration ≤ 3 days (OR = 3.775), rebound tenderness (OR = 5.201), low-to-absent bowel sounds (OR = 5.006), low levels of potassium (OR = 3.696) and sodium (OR = 3.753), high levels of BUN (OR = 4.349), high radiological score (OR = 11.264) were identified. The AUC of the multi-dimensional model was 0.857(95%CI, 0.793–0.920). In the stratification analysis, the proportion of patients with transmural necrosis was significantly greater in the high-risk group (24%) than in the medium-risk group (3%). No transmural necrosis was found in the low-risk group. The AUC of the validation set was 0.910 (95%CI, 0.843–0.976). None of patients in the low-risk and medium-risk score group suffered with StBO. However, all patients with bowel ischemia (12%) and necrosis (24%) were resorted into high-risk score group.ConclusionThe novel multi-dimensional model offers a useful tool for predicting StBO. Clinical management could be performed according to the multivariate score.

A Comparative Analysis of Pre Operative and Operative Findings in Non Traumatic Acute Abdomen: A Prospective Observational Study

Acute abdomen remains the important cause of morbidity and mortality in emergency. It requires careful history taking and thorough evaluation of symptoms, clinical examination and judicious use of radiological investigation which simplify the evaluation of disease. Aim and Objectives: To assess the accuracy of radiological diagnosis in comparison to postoperative diagnosis in non-traumatic cases of acute abdomen. Materials and Method: A prospective observational study of non-traumatic acute abdomen was carried out at Sahyadri Narayana Multispeciality Hospital, Shimoga, Karnataka. Total of 78 cases of acute abdomen patients were evaluated and operated over a period from December 2018 to February 2020 and included in the study group. Pediatric age group (12 years and below), traumatic cases (blunt and penetrating), acute abdomen in pregnancy and gynecological causes of acute abdomen, urological cases, and conservatively managed cases were excluded from the study. Detailed history was taken and relevant physical examination performed. All patients underwent hematological and biochemical investigations, appropriate radiological investigation (USG, AXR and CT-scan) were performed based on clinical suspicion. Clinical and radiological diagnosis based on clinical examinations and radiological investigations was compared with post-operative diagnosis based on operative findings. Result: The most common age group was 20-60 years with male preponderance. Pain in abdomen was commonest symptom followed by vomiting, anorexia and fever. Tenderness was commonest clinical sign observed followed by rebound tenderness, tachycardia and guarding/rigidity. Acute appendicitis was the most common cause of acute abdomen followed by perforation peritonitis and intestinal obstruction. The overall diagnostic accuracy of clinical examination in acute abdomen was 81.8% and if radiological imaging techniques combined with this, the accuracy raised up to 94%. Conclusion: The study strongly suggested that with thorough history taking and proper clinical examination, clinical diagnosis was successfully achieved in 82% of patients. Radiological investigations help in confirming clinical suspicions and giving added information of underlying pathology with accuracy of 94%. Keywords: Abdomen Injury; Radiological Investigations; Trauma; Diagnostic Test; Perforation.

Shabir's "SMART-LAB" score for predicting complicated appendicitis-a prospective study.

Complicated appendicitis needs an aggressive and urgent management, hence there is need of an efficient scoring system for predicting complicated appendicitis. With this in mind, the author developed the present scoring system for predicting complicated acute appendicitis. The study aimed to assess the suitability of this novel (Shabir's SMART-LAB) score for predicting diagnosis of complicated appendicitis. In this prospective study, a novel score designated as "SMART-LAB" SCORE, proposed by the author (Shabir) based on his previous observations was calculated in all patients. This score includes sonography (S), migratory right iliac fossa pain (M), anorexia (A), rebound tenderness (R), tenderness (T), leukocytosis (L), Acute phase protein-CRP (A), and serum bilirubin (B). Of a total of 150 patients included in this study, 52 cases turned out to be perforated and/or gangrenous appendicitis on intraoperative/histopathologic examination. The most commonly affected age group was 10-19 years. SMART-LAB score of >9 was present in significantly higher number of patients in complicated (perforated and gangrenous) appendicitis than uncomplicated appendicitis (p value<0.001 i.e., highly significant). Hence, high likelihood of complicated appendicitis is reflected by a score >9 (with a sensitivity= 80.7%, specificity= 92.9%, PPV= 85.7%, NPV= 90.1%, and accuracy= 88.7%), while a score 7-9 needs further confirmation to reach a conclusion, and for a score of <7, there is low likelihood of complicated appendicitis. It seems that this novel score (Shabir's SMART-LAB score) is a reasonably good tool to predict the diagnosis of complicated appendicitis. Early diagnosis of appendiceal perforation is important to limit the associated abdominal sepsis.

Subhepatic perforated acute appendicitis in a patient with midgut malrotation: A case report and review of the literature.

Introduction and importanceSubhepatic acute appendicitis (SHAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as midgut malrotation (MM) and maldescent of the caecum. Preoperative diagnosis of SHAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of SHAA.Case presentationA 25-year-old Caucasian male presented to the Emergency Department with a one-day history of right lower quadrant (RLQ) abdominal pain, nausea and vomiting. Physical examination revealed RLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a SHAA with intraluminal appendicolith, fat infiltration and pelvic fluid collection in a patient with MM. The patient underwent laparoscopic appendectomy: a retrocaecal subhepatic phlegmonous and perforated appendicitis was sectioned and removed with drainage of pelvic abscess. The postoperative course of the patient was uneventful.Clinical discussionSHAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of SHAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming MM or maldescent of the caecum. Laparoscopic appendectomy represents the correct treatment of SHAA.ConclusionSHAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with RLQ abdominal pain. Preoperative diagnosis needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of SHAA.

Acute necrotizing calculous cholecystitis after treatment with ceftriaxone in an elderly patient: a case report

BackgroundCeftriaxone, a third-generation cephalosporin antibiotic with a long plasma half-life, is widely used to treat various infections. The use of ceftriaxone can sometimes induce biliary sludge or stone formation. Although most cases of ceftriaxone-induced pseudolithiasis are asymptomatic or mild and resolve with discontinuation of the drug, we experienced an elderly case of severe acute necrotizing calculous cholecystitis after administration of ceftriaxone.Case presentationA 72-year-old male patient was admitted to our hospital because of acute diverticulitis in ascending colon. Ceftriaxone was administered at a dose of 2 g/day for 6 days. Although he recovered after therapy, he was readmitted about 2 weeks later because of severe pain with rebound tenderness in the right upper quadrant. An abdominal imaging study revealed stones and sludge in the gallbladder that were not observed before starting ceftriaxone therapy. Therefore, antibiotic treatment with flomoxef 2 g/day was indicated. However, on the fifth day of readmission, the peritoneal irritation symptoms in the right upper quadrant worsened, and elevated inflammatory response and liver dysfunction were observed. Cholecystectomy was performed based on these findings. The resected inflamed gallbladder showed acute necrotizing cholecystitis with sand granular gallstones. A comparative analysis of the infrared spectroscopic pattern of the composition of gallstones collected during surgery with that of the ceftriaxone powder revealed that both have very similar infrared spectroscopic patterns.ConclusionsCeftriaxone-related pseudolithiasis is generally reversible and mainly observed in children. Here, we report a rare case of ceftriaxone-related acute necrotizing cholecystitis in an elderly patient. We confirmed that the stones in the gallbladder are composed of ceftriaxone. The older age, dehydration, fasting, and long-time bed rest during the administration of high-dose ceftriaxone were the potential risk factors for gallstone formation.

Adolescent Female with Lower Abdominal Pain and Rebound Tenderness

A healthy 16-year-old girl presented with a 2-day history of nontraumatic abdominal pain but no fever, vomiting, or diarrhea. Her blood pressure was 109/70 mm Hg, and her pulse rate was 125 beats/min. She had severe tenderness and rebound in the left lower quadrant. Her hemoglobin level was 10.4 g/dL, and her pregnancy test result was negative. The emergency physician performed bedside ultrasound (Figure), and the patient underwent emergency laparotomy.

Acute Appendicitis: A prospective study comparing clinical appendicitis with histopathological appendicitis.

Objective: To compare clinical appendicitis with histopathological appendicitis. Study Design: Prospective Cross-sectional study. Setting: Department of Surgery, Lady Reading Hospital, MTI, Peshawar. Period: December 2019 to March 2020. Material &amp; Methods: Out 106 patients with signs and symptoms of acute appendicitis 100 patients were included in the study. 6 patients were excluded because of incomplete data. Patients were examined, ALVARADO score was calculated and routine investigations were done. After open appendectomies all specimens were sent for histopathology. Results: Male to female ratio was 1.7:1, with a mean age of 25 ± 11 year. The most common presenting complain was right iliac fossa pain (98%), followed by nausea/vomiting (86%). The commonest signs elicited were right iliac fossa tenderness (100%), rebound tenderness (100%). Mean ALAVARADO score is 7.39 ± 1.03. Intraoperative findings showed acutely inflamed appendix (90%), perforated appendix (7%) and normal (1%). The histopathology specimens showed acute appendicitis (88%), acute appendicitis with periappendicitis (8%) and normal histology (1%). Conclusion: Our study comparing clinical appendicitis with histological appendicitis with a negative appendectomy rate of only 1% suggests that acute appendicitis remains a clinical diagnosis and that timely accurate clinical diagnosis can prevent many complications associated with delayed/misdiagnosis of acute appendicitis. Laboratory evaluation and imaging especially CT may help in establishing diagnosis in equivocal cases but often leads to delay in diagnosis and also puts extra burden on the health care system.

Role of Rebound Tenderness and Other Parameters in the Evaluation of Acute Appendicitis Using Alvarado Score

Objective: To determine the role of rebound tenderness in Alvarado score compared to other parameters in evaluating acute appendicitis.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of the Study: Surgical Emergency Unit, Combined Military Hospital, Rawalpindi, Pakistan, from Jul 2021 to Jan 2022.&#x0D; Methodology: All the patients aged 18 to 70 years suspected of acute appendicitis were consecutively enrolled. An appendectomy was conducted, and an appendix specimen was sent to confirm the histopathology diagnosis. Rebound tenderness and other Alvarado score parameters were noted. Alvarado score≥7 was labelled as acute appendicitis.&#x0D; Results: Of 165 patients, the mean age of the patients was 29.09 ±6.63 years. The majority of the patients were males (119, 72.1%). Rebound tenderness was observed in 93 (56.4%) patients, migration of pain in 158 (95.8%), anorexia in 140 (84.8%), nausea/vomiting in 97 (58.8%), right lower quadrant tenderness in 54 (32.7%) cases, elevated temperature in 95 (57.6%), leukocytosis count ≥10 x 103/mm3 in 105 (63.6%), and neutrophil count &gt;75% in 67 (40.6%) patients. A significantly higher association of rebound tenderness was observed with histo pathological findings (p-value &lt;0.001), Alvarado score of &gt;7 (pvalue &lt;0.001), and its other parameters (p-value &lt;0.05). The diagnostic accuracy of rebound tenderness and Alvarado score, taking histopathology as the gold standard, showed a sensitivity of 98.92%.&#x0D; Conclusion: The study findings have shown that rebound tenderness is the most important sign of acute appendicitis compared with other Alvarado score parameters.

Young Female with Lower Abdominal Pain

A 19-year-old woman with a prior induced abortion presented to the emergency department with a 3-day history of vaginal bleeding and lower abdominal pain. Her last menstrual period was 6 weeks ago. Her blood pressure was 115/67 mm Hg and pulse rate was 108 beats/min; furthermore, she had obvious rebound tenderness. A urine pregnancy test yielded a positive result, and therefore, the emergency physician performed transvaginal ultrasonography (Figures 1 and 2).

A Case-series on Clinical and Surgical Findings of Ovarian Torsion

Background: Ovarian Torsion (OT) is a common gynecological emergency. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Current recommendations strongly are based on ovarian support. Objectives: To assess clinical findings and therapeutic approach of patients diagnosed with OT. Materials &amp; Methods: In this retrospective study 104 patients with confirmed OT in surgery were investigated. Clinical symptoms, laboratory indices, ultrasonography finding, and therapeutic approach were collected from hospital records of patients from 2001 to 2021. Results: The Mean±SD age of patients was 34.7±14.1 years old. The Mean±SD duration from hospitalization to surgery was 6.4±3 hours. The most common symptom in patients was abdominal pain (100%) followed by nausea and vomiting (76.9%). Ovarian cyst (71.2%) was the most gynecologic etiology of OT. Local tenderness (92.3%) and rebound tenderness (46.2%) were the most prevalent sign in physical examination. Necrotic ovary was found in 60 patients (57.7%) at surgery. Detorsion was possible in only 26 patients (25%). Conclusion: This study revealed that most objective findings in patients were nondifferential. The majority of patients with OT were in the reproductive ages, but just one fourth of them treated with conservative management.

A Rare Case of ACE Inhibitor-Induced Intestinal Angioedema Presenting as a Delayed Complication in a Heart Transplant Recipient

<h3>Introduction</h3> ACE inhibitor-induced intestinal angioedema is a rare side effect of ACEi that presents with nonspecific signs and symptoms. Although the risk of occurrence is greater early in therapy, angioedema can present at any time and thus a high index of suspicion is needed to avoid delays in diagnosis, unnecessary testing, and considerable morbidity. <h3>Case Report</h3> Our patient is a 54-year-old male with past medical history of orthotopic heart transplantation 3 years prior for history of end-stage ischemic cardiomyopathy, heparin-induced thrombocytopenia, and hypertension who presented with 3 days of crampy abdominal pain rated 4 out of 10. He also had bloating and watery diarrhea. He had no fever, nausea or vomiting. The patient had rebound tenderness on physical examination. Labs were unremarkable. GI pathogen panel was negative including C. difficile. CT showed a moderate segment of distal ileum which demonstrated acute inflammatory changes including mucosal hyperemia and mural edema on a background of moderate ascites. GI were consulted and performed colonoscopy that revealed no significant abnormalities. The patient had been on lisinopril for 3 years to treat hypertension. This was subsequently stopped due to suspicion of intestinal angioedema. His symptoms resolved within 72 hours of discontinuation. <h3>Summary</h3> Isolated intestinal angioedema secondary to ACEi is a diagnosis of exclusion that necessitates awareness among physicians, particularly in vulnerable subgroups such as heart transplant patients. Symptoms classically subside within 24 to 48 hours after discontinuation of the ACEi.

Determine the Accuracy &amp; Use of Ultrasound Guidance and Alvarado Score for Diagnosing Acute Appendicitis

Background: Appendicitis is one of the most common and frequently encountered operations in surgical emergencies. It is the most frequent cause of acute abdominal pain. Early and accurate diagnosis can reduce the rate of negative appendectomy (surgical removal of appendix) and helps to provide better treatment with no extra cost and complications. Aim: The objective of this study was to examine the accuracy and use of ultrasonography and Alvarado score system for diagnosing Acute Appendicitis. Place and Duration of Study: Radiology Department Hayatabad Medical Complex, Peshawarfor duration of six months from January 2021 to June 2021. Methods: In this cross-sectional observational study, 130 patients of abdominal pain having ages of 10 years to 70 years were included. All patients had diagnosis with Alvarado scoring system and ultrasound for identifying Acute Appendicitis. Patients’ detailed history including age, sex and histopathology and ultrasonographic results were recorded. All statistically data was analyzed by SPSS version 17. P-value &lt;0.05 was considered as significant. Results: Out of 130 patients, 95 (73.08%) patients were men and 35 (26.92%) patients were women. 15 (11.54%) patients were ages less than 20 years, 75 (57.70%) patients having ages between 20 to 39 years, 32 (24.62%) patients were aged between 40 to 59 years and 8 (6.15%) patients were ages of &gt;59 years. Symptoms observed in all patients such as anorexia, nausea and vomiting, tenderness in right iliac fossa, rebound tenderness, elevated temperature as 71.54%, 53.85%, 100%, 95.39% and 84.62% respectively. In all 130 patients 122 (93.85%) had found acute appendicitis by using ultrasound. As per histopathology results 95 % had acute appendicitis and 5 % had chronic or normal appendicitis. Conclusion: It is concluded that Alvarado Score system along with noninvasive ultrasound guidance resulted accurately and helps to reduce the rate of negative appendectomy, complications and infections with no extra cost. The combine role of Alvarado score and ultrasonography can helps to provide better treatment in acute appendicitis. Keywords: Alvarado score system, Histopathology findings, ultrasound results, Appendicitis.

Double-Expressor Appendiceal Burkitt’s Lymphoma: A Case Report and Literature Review

Background Appendiceal lymphoma is a very rare entity accounting for 0.015% of all gastrointestinal lymphoma cases. Acute appendicitis is the most common presentation of primary appendix neoplasms. Burkitt's lymphoma presenting as an acute appendicitis is a rare entity with around 21% of the cases presenting as a lower iliac fossa mass. Case Presentation. A 23-year-old male was admitted to the surgical ward as a case of acute appendicitis with localized tenderness in the right iliac fossa, positive rebound tenderness, a positive Rovsing's sign, and ultrasound findings of suspected complicated appendicitis. Appendectomy was performed. Histopathological examination of the appendectomy specimen revealed a double-expressor non-Hodgkin diffuse large cell lymphoma with Burkitt's-like morphology. He was sent for chemotherapy treatment. Conclusion Only 34 cases of Burkitt's lymphoma have been reported to present as acute appendicitis. Histological examination following appendectomy for an apparent appendicitis is essential. Furthermore, complete blood count and a computed tomography scan aid the diagnosis of lymphoma. Double-expressor lymphoma has been shown to have poor outcomes. Therefore, prompt and aggressive treatment is vital.

Fever, Rash, Cytopenia, and Disseminated Intravascular Coagulation in a 6-year-old.

Fever, Rash, Cytopenia, and Disseminated Intravascular Coagulation in a 6-year-old.

Role of Conservative Management in the Treatment of Acute Non-Complicated Appendicitis

Objective: The purpose of this study was to assess the efficiency of non-operative management of acute non-complicated appendicitis in terms of cost effectiveness, as well as related morbidity and mortality. Study Design: A prospective observational research. Place and duration: In the Surgical Unit of Islam Medical College and Teaching Hospital Sialkot for one-year duration from January 2021 to December 2021. Methodology: The study included 110 patients with early acute non-complicated appendicitis who were identified by clinical history, physical, and laboratory testing. 110 patients were given intravenous antibiotics for two days, followed by oral antibiotics for seven days. A proforma was used to collect the data. Several morbidities were recognized and tracked in patients. Results: There were 72 men and 38 women, with an average age of 20 years. Right iliac fossa pain, nausea, vomiting, and anorexia were the most frequent symptoms, whereas fever, tachycardia, and rebound tenderness in the right iliac fossa were the most common signs. Patients were randomly assigned to one of two groups. After an uneventful stay of 2 to 4 days. Patients in Group 1 (36.4 percent) who were treated conservatively had no problems and were discharged after a hospital stay of 2 to 4 days. Within four months, 5 patients (12.5%) and three patients (3%) experienced recurrence within six months. They had appendicectomies done in the traditional way. Wound infection was the sole postoperative complication in one patient (5%). Their hospital stay lasted anywhere from three to six days. Two (2.9%) patients with perforated/gangrenous appendix with appendicolith was found in Group-2 patients who had standard appendicectomy. Wound infection occurred in 4 individuals (5.7 percent), pelvic collection in 3 (4.3 percent), and subsequently small intestinal obstruction (adhesive) in two patients (2.8 percent). Their hospital stay lasted anywhere from four to nine days. Conclusion: Patients who were treated conservatively with antibiotics had minor discomfort and required fewer analgesics. Although surgery-related morbidity, death, and costs were averted, the recurrence rate was not insignificant. Keywords: Acute appendicitis, Conservative management, Recurrence

Post-operative gastric outlet obstruction of giant hiatal hernia repair: a case report

BackgroundGiant hiatal hernia is defined as those with more than 30% of the stomach herniating into the chest cavity. The transabdominal laparoscopic approach is the well-established repair form for giant hiatal hernia. To our best knowledge, reports on post-operative gastric outlet obstruction of giant hiatal hernia repair have been scanty up till now.Case presentationA 45-year-old female patient was referred to the Emergency Department of our hospital with a chief complaint of acute right epigastric pain for 2 days. Physical examination revealed mild tenderness in the right epigastrium, without rebound tenderness or guarding. The abdominal computed tomography scan revealed a large low-density gastric artifact in the lower mediastinum—giant hiatal hernia. The barium swallow esophagogram and gastroscopy also confirmed the presence of a giant hiatal hernia. A transabdominal laparoscopic operation for reduction of the hernia contents and repair of the hiatal defect was performed. Her right epigastric pain alleviated obviously on the first postoperative day. On post-operative day five, however, she was presented with nausea and vomiting independent of meals. The nasogastric tube was inserted and kept in the stomach for 7 days. After removing the nasogastric tube, severe nausea and vomiting of the patient occurred again. Barium swallow revealed gastroptosis and enfoldment in the duodenal bulb, which indicated the presence of gastric outlet obstruction. Gastrojejunostomy was performed for her to relieve the gastric outlet obstruction. The patient was discharged on the tenth day after the second operation without any discomfort. During the regular follow-up period, she felt well and was satisfied with her status.ConclusionsFacing the giant hiatal hernia repair, the reduction of the hernia contents and repair of the hiatal defect being well operated on are insufficient, and we must watch out the anatomical variation, like the deviation of partial intra-abdominal organs from their normal positions, as well as paying attention to the protection of abdominal vagal nerve during the operation. Post-operative gastric outlet obstruction of giant hiatal hernia repair is rare, while gastrojejunostomy can successfully relieve the gastric outlet obstruction.

Similar but different: A comparison of rare site ectopic pregnancies.

A comparative examination of the clinical, laboratory, ultrasound findings, and operative characteristics of rare site located ectopic pregnancies. Retrospective analysis of all department cases of rare site located ectopic pregnancies diagnosed and treated from December 2006 to December 2019. Thirty rare ectopic pregnancies were identified. Of these, 11 were ovarian, 10 were interstitial and 9 were tubal stump. The patients treated for ovarian pregnancy had significantly lower human chorionic gonadotropin (hCG) levels than patients treated for interstitial or stump pregnancies (2025±1105 mIU/ml, 18,424±2579 mIU/ml and 11,204±9221 mIU/ml, respectively, p=0.003). The main presenting symptom in patients with an ovarian pregnancy was abdominal pain (90.9%, 60.0% and 44.4%, respectively, p=0.031). Signs of abdominal peritoneal irritation (i.e., rebound tenderness and guarding) were more frequent upon physical examination in patients with an ovarian pregnancy (72.2%, 30.0% and 22.2%, respectively, p=0.044) who also exhibited the highest rates of syncope and hypovolemic shock upon admission compared to patients with an interstitial or stump pregnancy (54.5%, 10.0% and 11.1%, respectively, p=0.031). Ovarian pregnancies were associated with the lowest sonographic detection rates (9.1%, 80.0% and 100%, respectively, p=0.0001) and with free fluid in the pouch of Douglas (72.7%, 20.0% and 22.2%, respectively, p=0.02). Ovarian pregnancies experienced the highest rupture rate during surgery compared to interstitial or stump pregnancies (66.9%, 16.7% and 44.4%, respectively, p=0.028), had a significantly higher estimated blood loss (1081±647ml, 760±597ml and 343±318ml, respectively, p=0.003) and required blood transfusions in the perioperative period (63.6%, 20.0% and 11.1%, respectively, p=0.025) significantly more often. Ovarian pregnancy remains the most challenging diagnosis compared to interstitial and tubal stump ectopic's. Health care providers should recognize these rare site ectopic pregnancies and to handle these gynecological emergencies promptly.

Jejunal volvulus within an inguinal hernia sac like as an extremely rare cause of acute mechanical gastrointestinal obstruction in adults: First literature report.

Introduction and importanceSmall bowel volvulus (SBV) represents a rare and life-threatening cause of gastrointestinal obstruction among adults. SBV can be classified as primary and secondary subtypes. Preoperative diagnosis of SBV is a challenge because of the absence of pathognomonic clinical, radiographic and laboratory findings. Surgery represents the correct treatment of SBV.Case presentationA 69-year-old Caucasian male presented to the Emergency Department with a two-day history of abdominal pain, inability to pass gas or stool, nausea, vomiting. Physical examination revealed abdominal distension, generalized abdominal pain without guarding or rebound tenderness, a partially reducible and painless right inguinal hernia. Laboratory tests reported neutrophilic leukocytosis. Abdominal computed tomography revealed massive gastroduodenal dilatation with pneumoperitoneum and small bowel loops in the right inguinal sac. The patient underwent exploratory laparotomy: a jejunal volvulus (JV) located within the right inguinal hernia sac, causing gastrointestinal obstruction, was devolvulated and a right prosthetic inguinal hernia repair was also performed. The patient was discharged on the 10th postoperative day.Clinical discussionSecondary SBV is due to any congenital or acquired lesions and rarely occurs among adults in Western countries. This is the first literature report of a JV located within an inguinal hernia sac causing gastrointestinal obstruction.ConclusionSecondary JV represents an extremely rare abdominal emergency necessitating early diagnosis to prevent the development of intestinal ischemia, bowel necrosis and peritonitis. Diagnosis of JV needs a high index of suspicion and may be facilitated by imaging, often it is made intraoperatively. Surgery represents the appropriate treatment of JV.

An Unusual Case of Right Lower Quadrant Pain: A Case Report.

IntroductionThe perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician.Case ReportA 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day.ConclusionThis case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated.