Serial Abdominal Examinations Research Articles

Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study.

The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting. A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure. During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05). Our findings support that some penetrating abdominal trauma patientscan benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.

Ureteroneocystostomy for treatment of struvite urolithiasis in a ferret.

To assess the clinical outcome of a ferret undergoing a ureteroneocystostomy for treatment of urolithiasis. A 10-month-old spayed female ferret. The ferret was evaluated for straining to urinate and defecate, hematochezia, and a rectal prolapse. Plain radiographs revealed large cystic and ureteral calculi. Clinicopathologic analyses indicated the ferret was anemic with an elevated creatinine concentration. Exploratory laparotomy defined bilateral ureteral calculi that were unable to be successfully moved into the bladder. A cystotomy was performed to remove a large cystic calculus. Serial abdominal ultrasonographic examinations showed progressive hydronephrosis of the left kidney and persistent pyelectasia of the right kidney secondary to bilateral ureteral calculi. This confirmed a left ureteral obstruction secondary to the distal calculus while the right ureter remained patent. A ureteroneocystostomy was performed to allow for left renal decompression. The ferret recovered well despite worsening hydronephrosis of the left kidney in the perioperative period. The ferret was discharged from the hospital 10 days after initial evaluation. At 3-week follow-up, abdominal ultrasonography confirmed resolution of hydronephrosis and ureteral dilation of the left kidney and ureter. A ureteroneocystostomy successfully allowed renal decompression and ureteral patency in a ferret with urolithiasis. To the authors' knowledge, this is the first time this procedure has been reported in a ferret for treatment of a ureteral calculus obstruction and may result in good long-term outcome.

Male with abdominal distention and abnormal chest x-ray.

A 48-year-old man receiving chemotherapy for glioblastoma multiforme presented for generalized weakness and fecal incontinence, which he described as “dribbling drops” of liquid stool. Physical examination showed dry mucous membranes, bowel sounds in the right upper quadrant, diffuse abdominal tenderness without peritoneal signs, suprapubic fullness, and a large amount of clay-like stool in the rectal vault. Dehydration was suggested by sodium of 148 mmol/L and osmolarity of 313 mOsm/kg on serum chemistries. Chest radiograph (Figures 1 and 2) was obtained, followed by computed tomography (Figure 3). Chilaiditi's sign occurs when the bowel is interposed between the right hemidiaphragm and the liver. It occurs in less than 1% of the population and is more common in elderly males and those with chronic constipation, cirrhosis, obesity, or chronic lung disease.1 When symptoms of abdominal pain, nausea, vomiting, or respiratory distress occur, it is known as Chilaiditi's syndrome. Our patient was admitted for serial abdominal examinations, and he responded to conservative management with bladder decompression with Foley catheter and enemas. Surgery may be required if obstruction, volvulus, or bowel ischemia is suspected. Chilaiditi's sign is an important mimic of pneumoperitoneum. Haustral markings may be seen on plain films. Inverting the image or changing the penetration may assist in visualizing haustra. Air will not move if the patient is repositioned for additional images. Computed tomography is diagnostic. Distinguishing factors on ultrasound have also been described.2

Accuracy of CT Scan for Detecting Hollow Viscus Injury in Penetrating Abdominal Trauma

BackgroundIn penetrating abdominal trauma, computed tomography (CT) is routinely performed to evaluate stable patients for selective non-operative management (SNOM). Triple-contrast CT (oral, rectal, and IV) has traditionally been used. However, due to its disadvantages, most trauma centres, including our unit at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), now perform single-contrast intravenous-only CT scans. We performed a retrospective review to determine the accuracy of single-contrast CT scans for detecting hollow viscus injuries (HVI) in penetrating abdominal trauma.MethodsA retrospective review of all patients who presented to CMJAH with penetrating abdominal injuries was performed between 01 August 2017 and 31 August 2019 and were evaluated for SNOM with CT (IV contrast only). Patient records were reviewed to determine pertinent demographics, mechanism, and site of injury, as well as metabolic parameters. CT findings were compared to findings at laparotomy.ResultsA total of 437 patients met the inclusion criteria. The majority were male (92.7%), with a mean age of 31.5 yrs (SD 8.7). Injuries were predominantly due to stab wounds (72,5%, n = 317). CT scan was negative in 342 patients, of which 314 completed SNOM successfully. A total of 93 patients proceeded to laparotomy. CT had a sensitivity of 95.1%, specificity of 44.2%, positive predictive value of 57.4%, and negative predictive value of 92%.ConclusionSingle-contrast CT in penetrating abdominal trauma is a valuable investigative tool in identifying patients for SNOM. Features of HVI on single-contrast CT are not very specific and should be interpreted along with other clinical factors including wound trajectory and serial abdominal examinations. Other associated injuries such as diaphragmatic and solid organ injuries should be considered in the final management plan.

Favourable outcomes of conservatively managed acute abdomen associated with multisystem inflammatory syndrome in children during the COVID-19 pandemic.

Abdominal pain is one of the most common symptoms of multisystem inflammatory syndrome in children (MIS-C). Abdominal pain can vary from mild to severe and may present as acute abdomen. Severe abdominal pain in patients with MIS-C should be differentiated from surgical causes of acute abdomen to prevent unnecessary surgery. The diagnosis of MIS-C was based on WHO and CDC recommended criteria. Records of children treated for MIS-C between September 2020 and January 2021 were reviewed retrospectively. In a short time, we encountered seven patients who were diagnosed with MIS-C and showed acute abdomen findings. There were four male and three female patients. The median age was 9 years. Fever, abdominal pain and distension were present in all. The median duration of symptoms was 4 days. Five patients had general abdominal tenderness mimicking acute abdomen. Three patients had right lower quadrant tenderness mimicking acute appendicitis. After the initiation of immunomodulatory therapy and antibiotics, the physical examination findings were improved step by step in all. The median time to initiate oral feeding was 2 days. The median length of hospitalization time was 8 days. Serial abdominal examinations performed by the same surgeon enabled us to follow these patients conservatively and thus avoid unnecessary surgical intervention.

Bleeding Duodenal Diverticulum with Iatrogenic Perforated Duodenal Diverticulum: Double Trouble

Background: Duodenal diverticulum is the second most common location following the large bowel. Only 1–5% of patients with DD are symptomatic. Complications of duodenal diverticulum includes obstruction of duodenum, biliary pancreatic duct, pancreatitis, haemorrhage, diverticulitis with or without perforation, and other biliopancreatic manifestations including fistula formation in the bile duct, choledocholithiasis and cholangitis, bezoar formation inside the diverticulum, perforation and bleeding. Surgical or non-surgical treatment are considered in selected patient in treating perforated duodenal diverticulum. Case Presentation: We present a 69 year old gentleman presented to emergency department with complaint of passing out blackish stool for 2 days duration associated with presyncopal attack. On arrival, patient appear pale with class 3 hypovolemic shock symptoms. Abdominal examination revealed mild tenderness over epigastric region without signs of peritonism. Digital rectal examination showed fresh melena. Oesophagogastroduodenoscopy (OGDS) showed a huge diverticulum at duodenum (D3) with pooling of blood and blood clots. In view of bleeding at D3 diverticulum,adrenaline was injected and haemoclipped was applied. Hemostasis from bleeding duodenal diverticulum was successfuly secured. However, patient had iatrogenic perforated duodenal diverticulum. Conclusion: We present a case of upper gastrointestinal bleeding from a D3 diverticulum with iatrogenic perforated duodenal diverticulum due to endoscopic hemostasisinjection.We treated this patient conservatively by keep nil by mouth and started on parentral nutritional support, intravenous antibiotics and serial abdominal examination. We advocate in duodenal diverticulum bleeding the application of endoscopic clips and injection should be use juridiously. In case of iatrogenic perforation of duodenum diverticulum due to endoscopic hemostasis can still be treated conservatively in stable, elderly patients with no signs of diffuse peritonitis and no clinical evidence of sepsis

Splenic Injury Following Colonoscopy: A Case Report.

IntroductionColonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur.Case ReportA 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs.ConclusionSplenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted.

310 Management of Anterior Penetrating Abdominal Injuries and the Role of Computerised Tomography

Abstract Introduction Optimal management of anterior penetrating abdominal injuries (A-PAI) is an area of ongoing debate. Randomised controlled trials are missing and guidelines are based on expert opinion. The accuracy of computerised tomography (CT) is challenged, and hence diagnostic laparoscopies are still widely used. Method We retrospectively reviewed the TARN database identifying patients presenting with A-PAI to a London Major Trauma Centre between 01/19/2015-31/03/2018 and reviewed their clinical notes. Results 143 patients were identified (79% male, mean age = 30). Non-operative management (NOM) took place without complication in 15% (n = 12) of cases, despite 38% (n = 8) showing a potential peritoneal breach on CT, and 19% (n = 4) a definitive intra-abdominal injury. Of the 37% (n = 53) of patients undergoing laparoscopy, half revealed no intra-abdominal injury. When comparing CT consultant reports to intra-operative findings, the accuracy of CT in identifying peritoneal breach was calculated to be 93% and sensitivity at 95%. Negative predictive value was 62%. Conclusions We concluded that a significant number of patients have unnecessary laparoscopies, which are not without risk. CT is an excellent resource, but negative predictive value is poor. NOM with serial abdominal examination remains a valid clinical option in the stable non-peritonitic patient and in the absence of definitive viscous perforation on CT.

Gastrointestinal Perforation in a COVID-19 Patient

To the Editor Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the virus responsible for coronavirus disease-19 or “COVID-19,” is currently implicated in a global pandemic. As of April 19, 2020, there have been 2,241,778 confirmed cases worldwide.1 Although the pathophysiology is still being elucidated, there is evidence of hyperactivation of effector T cells and excessive release of inflammatory cytokines, particularly interleukin (IL)-6, leading to cytokine release syndrome and end organ damage.2 Current proposed treatments include tocilizumab, an IL-6 receptor antagonist, and corticosteroids. We present a brief case of a patient with COVID-19 who subsequently developed a gastrointestinal (GI) perforation, which we believe was due to the underlying disease process itself, or treatment modalities given. A 73-year-old man, with a prior history of coronary artery disease, peripheral vascular disease, diabetes, chronic kidney disease, and obesity (with a body mass index of 32), presented to the hospital with fever, cough, and shortness of breath. On presentation, he was febrile and hypoxemic requiring a non-rebreather at 15 L/min. Initial blood work showed a white blood cell count of 22.0 × 103/μL, hemoglobin of 11.6 g/dL, hematocrit of 34%, platelet count of 257 × 103/μL, Na of 132 mEq/L, K of 4.6 mEq/L, Cl of 104 mEq/L, CO2 of 10 mEq/L, BUN of 92 mg/dL, and Cr of 4.0 mg/dL (with a known baseline of 1.8 mg/dL). Chest x-ray revealed diffuse, patchy, bilateral lung opacities. Nasal polymerase chain reaction swab for SARS-CoV-2 was positive. On hospital day 2, he required intubation and mechanical ventilation. Also, on hospital day 2, he received tocilizumab, 400 mg intravenously. Because of the failure of ventilator weaning, he underwent a tracheostomy on hospital day 9. He received intravenous methylprednisolone, at a total daily dose of 100 mg, between hospital days 11 and 16, given his respiratory status had not significantly improved. By hospital day 16, he was still requiring full ventilatory support via his tracheostomy. He otherwise did not appear to have any other specific complaints. That day, a routine chest x-ray showed substantial subphrenic air likely representing a GI perforation, which was confirmed on a lateral decubitus film (Fig. 1). He was evaluated by surgery, and exploratory surgery was discussed; however, due to his high-risk surgical status, a conservative approach was chosen. He was followed up with serial abdominal examinations and given intravenous antibiotics. Six weeks later, he continues to do well and has since been decannulated. On review of his case, it was felt that either his underlying viral infection or his treatments (tocilizumab and/or corticosteroids) were the likely etiology of his perforation.FIGURE 1: Lateral abdominal decubitus XR with abdominal free air.SARS-CoV-2 represents a significant and ongoing cause of morbidity and mortality worldwide. This viral infection often presents with fever, cough, and shortness of breath, though GI symptoms, such as nausea, vomiting, abdominal pain, and diarrhea, are also common.3 Angiotensin-converting enzyme-2 receptor is a major functional receptor of SARS-CoV-2 and is expressed on the surface cells of the digestive tract, likely leading to the GI symptoms seen in the disease.3 To date, there have been no reports of GI perforation specifically attributed to SARS-CoV-2, though given the widespread expression of angiotensin-converting enzyme-2 receptors in the digestive tract, it is plausible that viral binding can lead to disruption of mucosal cell integrity. However, both tocilizumab and corticosteroids have been implicated in general GI perforation. Tocilizumab is associated with a small risk of GI perforation. On review of patients taking tocilizumab for rheumatoid arthritis, a GI perforation rate of 1.55 to 1.9 per 1000 patient years was seen.4 Mesenteric adipose tissue is both maintained by and a major source of IL-6, and although IL-6 activity leads to transmural inflammation of the bowel, the local accumulation of the adipose tissue itself can be protective against perforation. Thus, the inhibition of IL-6 by tocilizumab and the resulting breakdown of mesenteric fat are possible mechanisms of perforation.5,6 The IL-6 and cytokine release syndrome may have led to mucosal breakdown in our patient, and as he had a body mass index of 32 and likely increased mesenteric fat, he could have been more susceptible to tocilizumab's actions as well. Corticosteroids are also well known to lead to GI perforation. Corticosteroids can impair the body's ability to contain microperforations via anti-inflammatory properties, and also inhibit prostaglandin production, which has an important role in maintaining colonic mucosal integrity via secretion of mucin and bicarbonate.7 Ultimately, though the etiology of our patient's GI perforation is unclear, we hypothesize that it must be related to either his underlying disease process or is a consequence of treatment. Clinicians must remain aware of this potential complication when caring for COVID-19 patients. Lydia M. Winnicka, MDMangalore A. Shenoy, MD Department of Pulmonary and Critical Care Medicine NYU Winthrop Hospital, Mineola, NY [email protected]

Operation After Radiologic Embolization for Blunt Liver Trauma

Abstract Motor vehicle accidents and other blunt high-impact traumas occur with relative frequency in children and adolescents, potentially causing severe injury or death (Martin et al., 2017). A common consequence of blunt trauma is laceration to the solid organs such as liver, kidneys, or spleen. These injuries are typically managed nonoperatively, occasionally utilizing interventional radiology (IR) embolization (Arbra et al., 2017). This case report discusses a child with Grade V+ liver laceration, who underwent IR embolization and ultimately required laparoscopic evacuation of abdominal hemorrhage with peritoneal drain placement. As a complication of IR embolization, the patient developed an occlusive thrombus in his right common femoral artery. A systematic review of nonoperative management in pediatric trauma by the American Pediatric Surgical Association concluded that there is no need to put patients through the risks of an IR embolization procedure if the patient remains stable (Gates et al., 2019). Although the guidelines are useful, clinical judgment remains the best determinant for invasive intervention. From a trauma nursing perspective, these cases require serial abdominal examinations combined with excellent communication between nurses and physicians to highlight changes in physical examination findings. In addition, research on IR procedures in the context of hepatic injury needs further study.

CT tractography in anterior abdominal stab wounds: a proposed algorithm.

This study evaluates the accuracy of IV contrast-enhanced computed tomography (CT) tractography in the detection of peritoneal violation in anterior abdominal stab wounds (AASW) and its impact on the management algorithm. This prospective study included 61 patients who presented to Kasr Alainy Hospital with AASW. According to the IV contrast-enhanced CT tractography, they were classified into penetrating, equivocal and non-penetrating injuries. The former two were subjected to diagnostic laparoscopy (DL), while the non-penetrating group was subjected to serial abdominal examination (SAE). The accuracy of CT tractography to detect peritoneal violation was assessed by correlating its findings with management outcome. CT tractography stratified the injuries into non penetrating (54.1%), equivocal (14.8%) and penetrating (31.1%). All non-penetrating stabs were managed successfully by SAE. DL proved negative for peritoneal violation in all equivocal injuries and positive in all injuries designated as penetrating. Consequently, sensitivity, specificity, positive and negative predictive values and accuracy of CT tractography in detecting peritoneal violation was 100%. No missed injuries were encountered in this study. IV contrast-enhanced CT tractography is an effective tool in the evaluation of patients with AASW. Patients with negative tractography can be safely managed by SAE. Positive tractography accurately indicates peritoneal violation which warrants further management. Patients with equivocal findings were all negative for peritoneal violation by laparoscopy, therefore, they might be reallocated for frequent SAE to reduce the rate of non-therapeutic interventions.

Presentation and postoperative outcomes of residual cavity of liver hydatid cyst

Background: Hydatid disease is endemic in the Mediterranean region, the Middle East and South America. The aim of the study was to follow up the fate of residual liver hydatid cysts cavities after surgery.Methods: From the period of April 2014 to April 2017 a prospective study was conducted on sixty patients who were admitted to Fallujah Teaching Hospital for surgery of hydatid cyst of the liver. There were 36 female and 24 male patients who were followed up by serial abdominal ultrasound examinations at three monthly intervals for a period of up to two year.Results: Complete involution of the hydatid cavities occurs more in those treated by omentoplasty and simple closure and complications are lower than those treated by external drainage.Conclusions: Characteristics of liver hydatid cyst and the type of surgical treatment can be considered as a determinant of postoperative cavity related complication.

Isolated free fluid on computed tomography for blunt abdominal trauma.

The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

Portal Vein Thrombosis (PVT) Following Laparoscopic Sleeve Gastrectomy Successfully Treated by Trans-Hepatic Catheter-Directed Tissue Plasminogen Activator (tPA)

sIntroduction Portal vein thrombosis is a potential life-threatening condition that rarely happens after bariatric sleeve gastrectomy. There is a debate regarding the best therapeutic options due to lack of large randomized trials. We present a case of Acute PVT that was successfully treated by trans-hepatic catheter-directed tissue plasminogen activator (tPA). Case Presentation A 42 year old male with history of morbid obesity presented to our hospital with peri-umbilical pain one week after he underwent an elective laparoscopic vertical sleeve gastrectomy. Other medical history includes hypertension and hyperlipidemia. Social history was negative for smoking or alcohol intake. Home medications were lisinopril and multivitamins. His abdominal pain was radiating to back, associated with nausea and vomiting. His vitals showed blood pressure of 154/100 mmHg, heart rate of 121 bpm, with no fever. Physical exam showed positive epigastric, right and left upper quadrants tenderness, with no peritoneal signs. His labs showed WBC of 28,000, hemoglobin 15.2 g/dl, platelets of 245,000 and lactate of 3.2 mg/dl. His liver and kidney function tests were normal. CT abdomen showed positive finding for portal vein thrombosis extending to the superior mesenteric vein (SMV) and mesenteric thickening of the proximal jejunum (Image 1). Initially the patient was started on heparin infusion with serial abdominal examinations. However, his clinical condition started to deteriorate, and he was admitted to intensive care unit. After discussion with the patient the option of minimally invasive trans-hepatic portal vein thrombolysis, he was agreeable to have the procedure. The patient underwent 2 sessions of interventional radiology (IR) guided trans-hepatic portal vein access using angiojet to create a channel in the clot, followed by 20 cm infusion length tPA catheter placement (Image 2). The patient tolerated the procedure well, his condition started to improve and he was discharged home after 3 day on oral warfarin.Conclusion Our case shows that trans-hepatic catheter-directed tissue plasminogen activator (tPA) is a safe and feasible therapeutic option in patient presenting with acute PVT.2389_A Figure 1. CT abdomen showed positive finding for portal vein thrombosis extending to the superior mesenteric vein (SMV) and mesenteric thickening of the proximal jejunum.2389_B Figure 2. Interventional radiology (IR) guided trans-hepatic portal vein access using angiojet to create a channel in the clot with 20 cm infusion length tPA catheter placement

Bowel injury following gynecological laparoscopic surgery.

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication. We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment. Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed. Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

Chemical Colitis From a Hydrogen Peroxide Enema

Constipation is one of the most common complaints among patients. Many resort to “natural” therapies described by complimentary and alternative medicine. Hydrogen peroxide enemas, ranging from 3-10% solutions, are one of the promoted remedies. We present a case of chemical colitis after using a hydrogen peroxide enema. A 26-year-old female with chronic constipation, presented with bright red blood per rectum for 2 days. It started immediately after using a 35% hydrogen peroxide enema for constipation. She had used herbal enemas previously, and this was the first time she had used hydrogen peroxide. She had large-volume rectal bleeding with fresh blood that quickly slowed down. She had abdominal pain with vomiting, decreased appetite, and tenesmus. Initial assessment revealed an afebrile, normotensive young woman, with diffuse abdominal tenderness most severe in the left lower quadrant, without rebound tenderness or rigidity. Laboratory evaluation was significant for leukocytosis (17.09 x 103/μL) and slightly elevated C-reactive protein (3.0 mg/dL). Her hemoglobin was normal on presentation 12.8 g/dL. Fecal calprotectin was greater than 1250 μg/g with fecal leukocytes present. Her lactic acid was within normal limits. Computed tomography of the abdomen and pelvis revealed diffuse left transverse and left colonic thickening and submucosal edema up to the mid-transverse colon, suggestive of colitis (Image 1). She was admitted and was managed conservatively with intravenous hydration, electrolytes correction, serial abdominal examinations, and hemoglobin checks. Colonoscopy was deferred due to risk of perforation. Rectal bleeding stopped after 3 days; she clinically improved with supportive care only. The patient was discharged and advised to avoid chemical enemas in the future. At a 3-month follow up, she denied any episodes of rectal bleeding. There are a few reported cases of chemical-induced colitis in patients experimenting with hydrogen peroxide enemas to self-treat chronic constipation. Hydrogen peroxide enemas are an increasing “home remedy” that are made popular on alternative medicine websites. The production of hydroxyl free radicals from hydrogen peroxide causes cell death. Macroscopically, it leads to corrosive injury of the colonic mucosa. With increasing availability of information on the Internet, it is critical to caution and inform patients of potentially dangerous therapies that are not medically approved.Figure: Diffuse submucosal edema up to mid-transverse colon, suggestive of colitis.

Pediatric Trauma

Children have unique anatomy and physiologic responses to trauma that create different challenges for their management. It is important to follow the Advanced Trauma Life Support (ATLS) algorithm for assessing and treating a pediatric trauma patient, paying close attention to the primary survey. Once the primary survey is accomplished with adequate stabilization, the secondary survey proceeds with a focus on specific injuries. Head trauma is the leading cause of morbidity and mortality (M+M) in children. Early identification and prevention of secondary injury are important to optimize outcomes. The head and neck anatomic differences in a child cause a higher fulcrum of their cervical spine, leading to higher cervical spine injuries (CSIs). CSI is rare but carries a higher M+M due to higher spinal cord injuries. The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rule (CCR) are useful decision rules to clear cervical spines in adults but have limited strength in young children. PECARN has derived a pediatric cervical spine clearance rule, but this has yet to be prospectively validated. Similar to CSIs, thoracic injuries in children are rare but carry a higher M+M due to anatomic differences in children. A child’s chest anatomy and increased compliance cause more difficulty in injury identification. Abdominal trauma is common in children and can also be difficult to identify. Unlike adults, children can compensate for blood loss much longer while maintaining their blood pressure. Serial abdominal examinations are useful when imaging is negative and a patient has persistent symptoms. This review contains 5 highly rendered figures, 18 tables, and 92 references. Key words: abdominal trauma, Advanced Trauma Life Support (ATLS), cervical spine injury, head trauma, National Emergency X-radiography Utilization Study (NEXUS), Pediatric Emergency Care Applied Research Network (PECARN), thoracic trauma, traumatic brain injury

Operative and non-operative management of children with abdominal gunshot injuries.

Non-operative management (NOM) is a standard treatment method for solid organ injuries worldwide. There is no consensus on the management of gunshot wounds (GSW) because of the higher frequency of hollow viscus injuries (HVI) and the unpredictable depth of tissue damage produced by kinetic energy transfer during retardation of the bullet. Here we aimed to reevaluate indications for surgery and NOM based on our pediatric patients with abdominal GSW. We performed a retrospective analysis of patients evaluated and treated for abdominal GSW at University of Dicle between January 2010 and October 2016. Patients with hemodynamic instability, signs of peritonitis on serial abdominal examination, and free air in the abdomen underwent laparotomy; these were included in group I (n=17). Patients managed non-operatively were included in group II (n=13). Our statistical analysis showed significantly lower Hb levels and systolic blood pressure levels (p<0.001) and higher pulse rate, higher mean injury severity score, and longer length of stay at intensive care unit in patients in group I than in those in group II (p<0.001). We further detected colon perforation (n=10) and small bowel perforation (n=7) in patients in group I; liver laceration (n=4), splenic injury (n=1), and renal injury (n=3) but no solid organ injury or HVI (n=5) were detected in patients in group II. The major drawback of NOM is the difficulty in diagnosing HVI in abdominal GSW, which may delay treatment. We suggest that patients with solid organ damage who are hemodynamically stable and exhibit no signs of peritonitis upon serial abdominal exam may be treated with NOM.

Numerous Sharp Foreign Body Ingestion and Spontaneous Expulsion Without any Complications

Clinical Image: A 37-year-old male with known case of paranoid schizophrenia presented to our emergency department after he inserted 2 pencils into his penis leading to pain and bleeding. Patient had significant history with multiple attempts of self harm by ingesting sharp objects, batteries, sleeping pills and cutting his wrist. He underwent cystoscopic removal with Foley catheter placement and his symptoms gradually resolved in few days. His hospital course was complicated on fourth day of admission as he apparently ate electric glass light bulb from the bathroom with intent of secondary gain. Initial X-ray abdomen showed numerous scattered radio- opaque foreign bodies in the entire colon (Figure 1). Computed tomography of chest and abdomen didn’t reveal perforation. Patient was kept NPO and observed clinically with serial abdominal examination. Follow-up serial X-ray abdomen was done which showed gradual clearing of radio opaque foreign bodies until day 11 when all the foreign body was completely cleared (Figure 2). Patient didn’t have any symptoms and there were no signs of peritonitis or bowel perforation during the entire hospital stay. The patient was eventually discharged from the hospital. Foreign body ingestion is encountered commonly in clinical practice [1]. Most ingested foreign bodies pass spontaneously. However few cases of foreign body ingestion require endoscopic removal or surgery to treat complications. Even though the risk of a complication caused by a sharp-pointed object is as high as 35%, but these patients could be observed clinically provided there are no symptoms or signs of perforation.

Role of elevated liver transaminase enzymes in diagnosis of liver injury in cases after abdominal trauma

Background: Major liver trauma in polytraumatic patients accounts for significant morbidity and mortality. Delayed diagnosis of patients with severe liver injuries is associated with an adverse outcome. Diagnostic modalities include serial abdominal examination, focused abdominal sonography for trauma, computed tomography scanning, diagnostic peritoneal lavage. The objective of this study was to detect relationship between raise of serum levels of hepatic transaminase enzymes and liver injury, and if the degree of the rise may also correlate with the severity of hepatic injury after abdominal trauma. Methods: cross sectional, prospective study observational study of all patients admitted emergency department in Suez Canal university hospital. Patients with abdominal trauma were subdivided (according to either surgical record after abdominal exploration or CT scans reports released by radiology department) in two groups, group with liver injury (31) cases and those without liver injuries (31) cases. Results: As regard to alanine aminotransferases (ALT) our study showed that serum ALT was raised in 28 cases from 31 cases of liver injury and only 4 patients with raised serum ALT did not have liver trauma (sensitivity: 90.3%, specificity: 87% , CI: 88.7%). Regarding aspartate aminotransferases (AST) our study showed serum AST was raised in about 21 cases from 31 cases of liver injury and only 7 patients with raised serum AST did not have liver trauma (sensitivity: 93.5%, specificity: 77.4% , CI: 87.1%). Conclusions: An abnormal ALT and AST can predict the presence of hepatic injuries in abdominal trauma patients, while the level of the abnormality can determine the severity of the insult to the liver. Also we can conclude that ALT is more specific for liver injury more than AST, Although AST show high sensitivity for liver injury than ALT.