Signs Of Acute Abdomen Research Articles

Abdominal apoplexy in late trimester of pregnancy: Case reports

Background: Abdominal apoplexy or Idiopathic Spontaneous Intraperitoneal Hemorrhage (ISIH) is rare and refers to intra-abdominal hemorrhage caused by spontaneous rupture of blood vessels in the abdominal cavity or retroperitoneum. The clinical diagnosis of abdominal apoplexy during pregnancy is rarer, and often made only after emergent exploratory laparotomy is performed for unstable vital signs and severe anemia. Affected by an enlarged uterus during pregnancy, the symptoms and signs of acute abdomen may be confused with placental abruption or other more common complications of pregnancy. Case presentation: Both cases in the study showed that the main symptoms were abdominal pain, hypotension, nausea, vomiting, and other associated blood loss symptoms of varying degrees. Due to its sudden onset, this dangerous condition with no typical symptoms and signs can be easily misdiagnosed, two cases were given urgent surgery finally. At a 12-month follow-up, no abnormalities were observed during medical examinations of both mother and child. Conclusions: The clinical diagnosis of abdominal apoplexy during pregnancy usually needs emergent exploratory laparotomy to find the hemorrhagic spot. We analyzed and summarized two cases of abdominal apoplexy in the late third trimester of pregnancy in and aims to provide certain clinical reference for surgeons when seeing the abnormal sustaining abdominal pain during pregnancy so that adverse pregnancy outcomes can be avoided.

Water-beads Ingestion with Intestinal Obstruction in Children: A Case Report

Background: Foreign body ingestion often occurs in the pediatric population and can cause no symptoms or even cause complications due to swallowing the foreign body. The aim of this case report is to increase clinician knowledge of cases of foreign body ingestion which can cause complications. Case: We report a case of foreign body ingestion water beads with complications of intestinal obstruction in a 1 year 2-month-old girl. The patient came with complaints of vomiting more than ten times containing fluid accompanied by decreased intake. The patient was suspected of swallowing water beads. The patient came to the emergency room with no signs of acute abdomen and the results of plain abdominal radiograph showed no foreign objects. The patient began to show symptoms of obstruction, not being able to defecate and not being able to pass gas. Physical examination revealed abdominal distention accompanied by inaudible bowel sounds. Abdominal CT scan results showed ileal obstruction. An exploratory laparotomy was performed, and two water beads were found intraoperative, which were the cause of the obstruction. The foreign body was removed. After surgery, the patient experienced gradual clinical improvement until he was discharged ten days after the procedure. Discussion: Foreign body ingestion in children is often not witnessed by anyone and may not cause symptoms until complications such as obstruction or peritonitis occur. Some foreign objects are radiolucent in plain radiographs. In emergency cases of foreign body ingestion, it is necessary to carry out emergency endoscopic procedures, even emergency surgical procedures in cases that cause complications. Conclusion: This case report increases clinician knowledge and awareness regarding the clinical approach in evaluating patients with suspected foreign body ingestion in children.

Adnexal Torsion in the Second Trimester of Pregnancy: A Case Report and Review of the Literature

Acute abdomen in pregnancy is one of the biggest diagnostic and therapeutic challenges today. Despite advances in medical technology, the preoperative diagnosis of acute abdominal conditions is still inaccurate. Torsion of the adnexa, which refers to complete or partial rotation of the adnexa, resulting in obstruction of venous and lymphatic reflux in the ovary, is a common gynecological emergency. Torn adnexa affect both the ovary and the fallopian tube, and rarely affect only one of them. Adnexal torsion occurs more frequently in the first and early second trimester than in the third trimester. It is difficult to diagnose in advanced pregnancy because of nonspecific symptoms and signs of acute abdomen as well as ultrasound limitations due to uterine enlargement complicate diagnosis. Late diagnosis and delayed surgical treatment result in ovarian loss and fetal endangerment. It is important to thoroughly evaluate the adnexa at the 1st ultrasound examination in pregnancy and to monitor the observed formations.

Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B.

People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.

An Unexpected Cause of Acute Abdomen Late After Heart Transplantation—A Case Report

Cytomegalovirus (CMV) infection is a frequent complication after a solid organ transplant, and in 86% of the cases, CMV disease occurred during the first 6 months after transplantation. Invasive CMV infections may be present as ulcerative infections of the upper gastrointestinal tract with esophagitis, gastritis, and ulcerations of the duodenum and the small bowel; however, CMV infections of the pancreatobiliary system, especially papillitis, are rarely observed. We present a case report of a man who underwent a heart transplant 6 years before, with a clinical picture of duodenitis and a simultaneous pseudotumor of major duodenal papilla who developed signs of acute abdomen caused by gastrointestinal CMV infection, successfully treated with medical therapy with valganciclovir. There is an urgent need for developments in CMV and solid organ transplantation to stratify the risk of late-onset CMV disease.

Self-assessment questions

A 30 year old woman in her first pregnancy at 20 weeks had an anomaly scan that demonstrated a 8 cm unilocular, left adnexal cyst with hyperechoic component and acoustic shadowing and minimal free fluid. There were some internal echoes and some solid component. The ORAD Score was 3. She has been referred for further assessment by the medical team. On review, she does not report any abdominal pain and examination demonstrates a gravid uterus with no signs of acute abdomen. What is the next step in management of this patient?A.Urgent laparoscopy and cystectomyB.Check CA 125 and calculate RMIC.Referral to gynaecology MDTD.MRI to evaluate the nature of the cystE.Urgent CT scan

Enigma of the unusual pelvic mass: Lessons learnt

Ruptured ectopic pregnancy (EP) is one of the common complications of early pregnancy. We are presenting a case of unruptured EP which presented as an ovarian mass on ultrasonography. Chronic ectopic pregnancies are very rare presentations that can present as hematosalpinx and can pose diagnostic challenges in cases with misleading clinical history and absent acute abdomen signs. In such cases, magnetic resonance imaging can be a problem-solving tool and can identify pathology, and helps in the prompt management of pathology.

Sonographic diagnosis of intramural duodenal hematoma.

A previously healthy 2-year-8-month-old boy was brought to the emergency department due to non-bilious vomiting several times in one day. Refractory vomiting persisted after fasting with intramuscular metoclopramide use. On evaluation, the patient appeared mildly anxious and showed no signs of acute abdomen. The vital signs were as follows: temperature 36.9 °C, blood pressure 122/64 mmHg, pulse 86 beats/min, respiratory rate 20 breaths/min, and oxygen saturation 100% breathing ambient air. Abdominal sonography revealed a heterogeneous mass lesion along the duodenal convexity with a size of 44.2∗12.3∗13.6 mm (Fig. 1), accompanied with several hypoechoic heterogeneous lesions at the right subphrenic area.

S2147 That's a Lot of Air! a Case of Incidental Pneumatosis Intestinalis

Introduction: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of gaseous cysts in the submucosa and subserosa of the gastrointestinal tract with an incidence of 0.03%. Common causes include pulmonary disease, chemotherapy, ileal surgeries or bowel obstruction with rare causes linked to lactulose or sorbitol-containing compounds. Management is usually conservative after excluding emergent surgical causes like bowel ischemia or bleeding. We describe a case of PCI found incidentally on imaging in a male with cerebral palsy. Case Description/Methods: A 24-year-old male with an extensive medical history notable for cerebral palsy, epilepsy, tracheostomy and gastrostomy dependence and recurrent small bowel obstructions, presented for evaluation after an outpatient computed tomography (CT) chest demonstrated extensive pneumatosis involving the imaged transverse colon. On review, the patient had a history of abdominal distention and intermittent alternating constipation and liquid stools. Physical examination revealed abdominal distention without tenderness or stool in the rectal vault. Workup revealed normal complete blood count, metabolic profile and lactic acid. CT of the abdomen showed extensive pneumatosis involving the colon (Figure). Considering that the patient had no signs of acute abdomen, he was managed conservatively with gastric decompression. Care was taken to avoid hypoxia and hypotension. Serial abdominal exams and X rays showed improvement and he was restarted on tube feeds which he tolerated well and was discharged home. A few days later, he presented with hematochezia and repeat CT abdomen redemonstrated colonic pneumatosis, however now with new free air. He was managed conservatively again with colonic decompression and slow introduction of feeds and was stable for discharge. Discussion: Pneumatosis cytoides intestinalis is an uncommon condition that can present from asymptomatic abdominal distention to diarrhea and hematochezia. In our case, the proposed mechanism could be related to recurrent bowel obstructions, pulmonary disease or the sorbitol content of his anti-seizure medications. Management is usually conservative with surgery reserved for toxic patients and hyperbaric oxygen used in select patients. Although this patient had hematochezia, he was able to be managed conservatively without surgery. Therefore, in most patients, despite concerning features, PCI may be appropriately managed without surgical intervention.Figure 1.: Diffuse Colonic Pneumatosis and Dilatation.

Idiopathic pyometra and tubo-ovarian abscess in a postmenopausal patient treated conservatively.

Background: Pyometra is a rare gynecological condition and is characterized by pus accumulation in the uterine cavity. It occurs more frequently in postmenopausal women than tubo-ovarian abscesses, which constitute a more common gynecological complication among premenopausal women.Objective: A 72-year-old woman was admitted to our emergency department with lower abdominal pain, diarrhea and fever for the last three days. The laboratory results were indicative to sepsis. The clinical examination revealed sensitivity by palpation of the lower abdomen without any signs of acute abdomen. The gynecological assessment showed pus outflow through the cervix and a pus culture was done. The ultrasound examination found an enlarged uterus, full of hypoechoic fluid, unclear borders between endometrium-myometrium, a mixed echogenicity adnexal mass and no free fluid in the pouch of Douglas. A computed tomography (CT) of the abdomen showed the presence of pyometra and a tubo-ovarian abscess of the right adnexa.Method: The patient was treated with intravenous antibiotic therapy. When the patient was hemodynamically stable and afebrile, she underwent ultrasound-guided dilatation and curettage of the cervical canal and the endometrium in order to exclude an underlying malignancy, under general anesthesia.Results: The patient responded promptly to the intravenous antibiotic therapy which was adapted to the pus culture result. The laboratory results withdrew to normal values and the patient was discharged after fifteen days of hospitalization in an afebrile and hemodynamically stable condition.Conclusion: Pyometra and tubo-ovarian abscess in postmenopausal women could be a lethal complication of pelvic inflammatory disease. The key in treatment is the dilatation of the cervix and drainage of the pyometra. The administration of intravenous antibiotics and drainage through the cervix could be a suitable method of treatment for pyometra in older patients or those with poor performance status if only the histological examination is negative for malignancy.

Atraumatic splenic rupture in a child with COVID 19

BackgroundThe majority of children with COVID-19 have only minor symptoms or none at all. COVID-19, on the other hand, can cause serious illness in some children, necessitating hospitalization, intensive care, and invasive ventilation. Many studies have revealed that SARS-CoV-2 affects not only the respiratory system, but also other vital organs in the body. We report here a child with an atraumatic splenic rupture as the initial and only manifestation of COVID-19.Case presentationA 13-year-old boy with clinical signs of acute abdomen, left-sided abdominal pain, and hemodynamic instability was admitted to the PICU in critical condition. His parents denied any trauma had occurred. In addition to imaging tests, a nasopharyngeal swab was taken for COVID-19 testing, which was positive. The thoracic CT scan was normal, whereas the abdominal CT scan revealed hemoperitoneum, splenic rupture, and free fluid in the abdomen.ConclusionsThe spleen is one of the organs targeted by the SARS-CoV-2. Splenic rupture, a potentially fatal and uncommon complication of COVID-19, can be the first and only clinical manifestation of the disease in children. All pediatricians should be aware of the possibility of atraumatic splenic rupture in children with COVID-19.

Lethal hemorrhagic necrotizing pancreatitis in a child with congenital immunodeficiency and COVID-19

PurposeVarious manifestations of coronavirus (SARS-CoV-2) have been reported since the pandemic began. Some articles have reported acute pancreatitis in adult patients due to COVID-19 infection. To our knowledge this is the first report of acute hemorrhagic necrotizing pancreatitis in children associated with SARS-CoV-2 infection.Case presentationA 7-year-old girl with congenital immunodeficiency was referred to the intensive care (ICU) unit with acute respiratory distress syndrome. She required mechanical ventilation (MV) due to pulmonary involvement of COVID-19 (chest CT with lower lung ground-glass opacities). SARS-CoV-2 infection was laboratory confirmed. Following a 49-day stay in the ICU, due to the clinical and radiological signs of acute abdomen and to the rapid deterioration in the clinical status, an indication to proceed an urgent surgerical intervention was made. Intra-operatively an adhesiolysis with blunt dissection of the of gastrocolic ligament was performed, then followed by debridement of the necrotic pancreas (more than 1⁄2 of the pancreas was damaged). Continuous lavage and drainage were placed. During the post-operative period, patient required aggressive MV and insulin therapy for persistent hyperglycemia. The CT scans reported a necrosis of the pancreas and we observed amylase and lipase elevation in the peritoneal lavage sample. Despite active intensive therapy, the patient's condition did not improve and she died 38 days after laparotomy as a result of multi-organ failure.ConclusionThe mechanism for the development of acute haemorrhagic necrotizing pancreatitis in the COVID-19 positive patients is unclear; perhaps it is due to a direct cytopathic effect from the COVID-19 virus, or due to the ACE2 expression in pancreas.

Gastric Perforation Secondary to Trichobezoar: A Surgical Emergency

Trichobezoar is a clinical condition where hair accumulates in the gastrointestinal tract. Patients with trichobezoar present with a history of nausea, pain, vomiting, and occasionally with signs of acute abdomen. We report a case of trichobezoar that presented with gastric perforation and peritonitis which required laparotomy and longitudinal gastrotomy for evacuation of the trichobezoar.

Acute abdomen due to axial torsion of Meckel's diverticulum

Meckel's diverticulum is a remnant of the omphalomesenteric duct and is the most common congenital anomalies of the gastrointestinal tract. The complications of MD include hemorrhage, perforation, intestinal obstruction, and inflammation. Torsion is one of the rarest complications of MD, and only a few reports exist that discuss this complication. We report a case of a 2.5-year-old male who presented with signs of acute abdomen. Dilated small bowel loops, gangrenous and axially torsional Meckel's diverticulum were found intraoperatively. Diverticulectomy was performed without ileal resection. The patient was discharged in good condition with no complications occurring during follow-up for 2 months. In the English literature, About 6 cases in children and less than 20 cases in adults of MD with axial torsion have been reported.

Peritonitis Caused by Morganella morganii After Elective Cesarean Section

Morganella morganii belongs to the tribe Proteeae of the Enterobacteriaceae family. This species is considered as an unusual opportunistic pathogen that mainly causes post-operative wound and urinary tract infections. In this case we report a 33 year old multigravid woman presented to the emergency with diffuse lower abdominal pain. She was on her postoperative sixth day after an elective cesarean. Physical examination showed signs of acute abdomen and laboratory findings were consistent with infection. An emergency laparatomy revealed intraabdominal purulent fluis collection and fibrin deposits on organs. Microbiologic culture resulted in M. morganii and appropriate antibiotherapy was applied. The patient was discharged with no further complications. In conclusion, M. morganii is a rare cause of cesarean section related peritonitis and our patient may be the first case of M. morganii peritonitis and the first of monobacterial infection with that organism.

Significance of Biomarkers in Early Diagnosis of Abdominal Sepsis.

Peritonitis is one of the most important sources of abdominal sepsis. Since intra-abdominal infection leads to the activation of the inflammatory response, this suggested that some of these mediators could be used as markers of the severity of newly formed sepsis, but primarily to identify or rule out new-onset sepsis. The aim of this study was to evaluate the sensitivity and specificity of serum markers of inflammation: C-reactive protein, procalcitonin and serum amyloid A in the serum of patients with diffuse secondary peritonitis. Methods: The prospective cohort study was conducted at the Clinic for Emergency Surgery of the Clinical Center of Serbia in Belgrade. The study group consisted of 100 patients aged 18 to 70 years, with signs of acute abdomen due to diffuse secondary peritonitis. Results: CRP and PCT are so far among the most valuable preoperative markers for distinguishing sepsis from SIRS. On the first postoperative day the analysis of the relationship between sensitivity and specificity at the different breakpoints used indicates a greater diagnostic accuracy and greater sensitivity of SAA compared to CRP and PCT. In the remaining postoperative period in our study, the ROC curve mostly coincided with the diagonal line, so CRP, PCT, and SAA had little diagnostic accuracy. The results of our study suggest that finding a specific marker for the diagnosis of abdominal sepsis, a marker that would differentiate between SIRS and sepsis, pre- and postoperatively, would be very useful.

Peptik Ülser Perforasyonlarında Nonoperatif Tedavi ve Literatürün Gözden Geçirilmesi

Background: Peptic ulcer perforation is a complication of peptic ulcer disease frequently encountered in the emergency departments. Although there are many treatment options ranging from nonoperative treatment to wide resections, surgery is the first treatment option in peptic ulcer perforations. In this article, we aimed to present the feasibility of nonoperative treatment in appropriate and selected cases. Materials and Methods: The data of the patients who were not operated but provided with medical treatment in our clinic between January 2016 and July 2018 were evaluated retrospectively. Results: Three of the patients were male, one of them was female, and the mean age was 58 years (range, 35-79). On physical examination, there were no signs of acute abdomen, only tenderness was observed in the right upper quadrant and epigastric region. Standing direct abdominal radiography revealed free air under the diaphragm in three patients. The diagnosis was made with tomographic findings in one patient. No contrast agent extravasation was observed in any patient. The patients were examined intermittently by a specialist surgeon, oral intake was permitted on the 4th day of hospitalization, and they were discharged on the 7th day on average. Conclusion: Peptic ulcer perforation is a condition, which is still common and requires emergency surgery in case of acute abdomen development. Although the time elapsed after perforation is a factor affecting mortality and morbidity, nonoperative treatment is a method that can be successfully applied under strict physical examination and laboratory follow-up in appropriate and selected patients without diffuse peritonitis and extravasation on CT with water-soluble contrast agent.

Duodenal perforation secondary to stent migration after ERCP for hepatobiliary tuberculosis: Case report of a lethal complication in a young patient.

IntroductionInterventional internal drainage of the biliary tract has become an established procedure for the temporary and definitive treatment of biliary obstruction due to malignant or benign disease. The complication rate is reported to be so low that when feasible, this technique is preferred over a surgical drainage procedure.Presentation of a caseA 26-year old woman was referred to the hepatopancreaticobiliary surgery service due to severe abdominal pain for 3 days after undergoing endoscopic retrograde cholangiopancreatography (ERCP). She underwent biliary dilatation and stent insertion for obstructive jaundice secondary to biliary stricture from hepatobiliary tuberculosis. The patient underwent exploratory laparotomy, peritoneal lavage, duodenorrhaphy and tube jejunostomy for bilious peritonitis and duodenal perforation from biliary stent migration. The patient died one day post-operation due to septic shock from secondary bacterial peritonitis.DiscussionERCP and other interventional endoscopic biliary interventions are increasingly being used for biliary obstruction. Despite the various complications which arise from these diagnostic and therapeutic modalities, complications are relatively uncommon. Duodenal perforation from biliary stent migration is a rare complication after undergoing ERCP and stenting. However, in patients presenting with severe pain and physical signs of acute abdomen after the procedure, it should always be a consideration.ConclusionsDespite the relative safety of interventional techniques for biliary obstruction, complications like pancreatitis, hemorrhage and perforation may occur. Early recognition and high index of suspicion allows for early intervention with good outcomes. Duodenal perforation from stent migration can occur and when intervention is delayed may lead to morbidity and mortality.

Acute brucellosis associated with isolated splenic and left gastric artery vasculitis and acute ischemic bowel infarction. A systematic review of the most recent cases

Brucellosis is a multisystem bacterial zoonosis caused by Gram-negative bacteria Brucella spp. Ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols are all ways for germs to spread from animals to humans. Intestinal vasculitis with gangrene due to brucellosis has rarely been reported. We report a 62-year-old male patient presenting with acute onset of recurrent attacks of abdominal pain, remittent fever, malaise, and weight loss, which were followed by severe left hypochondrium abdominal pain with rigidity and signs of acute abdomen. Brucellosis was clinically suspected and confirmed by an enzyme-linked immunosorbent assay against the Brucella melitensis species. An abdominal CT scan revealed isolated splenic and left gastric artery vasculitis, leading to acute bowel ischemia, bowel infarction and gangrenous jejunal bowel segment. Histopathological examination of the resected gangrenous bowel segment revealed leucocytoclastic vasculitis. The patient was successfully treated with a standardized antimicrobial therapy for brucellosis and a short course of steroids with a complete resolution of the symptoms and signs. The case is discussed and the literature is reviewed.

Abdominal disturbances in children with Covid-19

Covid-19 continues to spread at an unprecedented pace, sparing no country in the world and including almost all ages. Although at the beginning of the pandemic, it was thought that the virus did not affect children, however over time, in different countries, more and more cases of children with Covid-19 begun to appear, though rarely among them were recorded any victims. 
 However, the clinical picture of infections with this virus in children was much more challenging than in adults. 
 In this article, we will present the case of three children of ages 4 to 14 years, with signs of acute abdomen, respectively with acute abdominal pain, fever, vomiting, and in whom acute appendicitis was suspected. In all three patients, anamnestic data showed positive family members infected with covid-19. 
 All three children were sent to the surgery ward for follow-up and further treatment. 
 The laboratory analyzes in all of them resulted in increased values ​​of both erythrocyte sediment and CRP, while only in one of them the values ​​of LDH and transaminases (AST, ALT) were also increased. 
 Ultrasonographic examination of the abdomen in two children showed the presence of a small amount of free fluid in the abdomen and mesentery thickening with several packets of enlarged lymph nodes. Radiography of the lungs did not show pulmonary lesions in any of the children. Body temperature ranged from 37.2 to 38.50C, while urine was within the normal range. 
 All children were hospitalized and kept under observation for several consecutive days. At the same time, they were treated with antibiotics of the group of cephalosporins of the third generation, as well as with antipyretics (paracetamol).
 As their condition improved and the abdominal pain subsided completely, they were released from the hospital with instructions to continue the rest and taking vitamins at home in the form of ready-made preparations for children.
 Conclusion: While the Covid-19 pandemic is rapidly spreading and not sparing even children, pediatricians and surgeons must be very cautious in treating children with acute abdominal pain since infections with Covid-19, and not surgical diseases, might be the real cause of these concerns.