Signs Of Peritoneal Irritation Research Articles

Idiopathic superior mesenteric venous thrombosis requiring bowel resection: a report of four cases

BackgroundSuperior mesenteric venous thrombosis (SMVT) is mostly treated with anticoagulation therapy; however, SMVT can lead to irreversible bowel ischemia and require bowel resection in the acute or subacute phase.Case presentationWe report four cases of SMVT that required careful observation and bowel resection. Case 1: A 71-year-old man presented with abdominal pain, diarrhea, and vomiting that showed a completely occluded SMV with thrombus and small bowel ischemia. Case 2: A 47-year-old man presented with abdominal pain, peritoneal irritation symptoms, and a completely occluded SMV with thrombus, ischemia of the small bowel, and massive ascites. Case 3: A 68-year-old man presented with abdominal pain and vomiting for several days and showed a partially occluded SMV with a thrombus, bowel ischemia, and massive ascites. Case 4: A 68-year-old man presented with acute abdominal pain and a partially occluded SMV with thrombus and bowel edema without ischemic changes. Anticoagulation therapy was administered; however, 3 days later, abdominal pain and bowel ischemia worsened. Bowel resection was performed in all cases.ConclusionsMost idiopathic SMVT cases can be treated with anticoagulation therapy or endovascular thrombectomy. However, in cases with peritoneal irritation signs, these treatments may be ineffective, and bowel resection may be required.

Inverted Meckel’s diverticulum as a cause of intestinal intussusception in a child: A case report

One of the causes of intussusception is the presence of Meckel’s diverticulum. Although Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract, isolated cases of intussusception caused by the inversion of Meckel’s diverticulum into the lumen of the ileum have been described in world literature. Description of case. The patient was a 2-year-11-month boy who was transported by an ambulance team, with complaints of paroxysmal abdominal pain and single vomiting. Palpation revealed lower abdominal pain without signs of peritoneal irritation. The child underwent an ultrasound examination of the abdominal cavity, which revealed a layered structure consisting of the wall of the large and small intestines in the right lower quadrant. Thus, a diagnosis of intussusception was established. An attempt to conservatively straighten the intussusception during pneumoirrigoscopy was ineffective. Emergency laparoscopy was performed, and ileocecal intussusception was diagnosed, which was eliminated without technical difficulties. During the inspection of the ileum, a crater-shaped depression with a dense formation extending from it into the intestinal lumen was discovered on its antimesenteric edge 30 cm from the ileocecal angle. The operation was continued with a minilaparotomy in the right iliac region. Meckel’s diverticulum was manually inverted from the ileum, tied at the base, and cut off with the stump immersed in a purse-string suture. The postoperative period was event-free. On day 5 after the operation, the child was discharged home in a satisfactory condition. For any intussusception in children aged 1 year, the anatomical causes must be excluded, except for the possibility of an inverted Meckel’s diverticulum. Therefore, after successful intestinal disinvagination, a thorough revision of the ileum is necessary.

Nonocclusive mesenteric ischemia (NOMI) on Roux limb after biliary reconstruction successfully treated by interventional radiology (IVR).

Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disorder. Early diagnosis is challenging because NOMI lacks specific symptoms. A 52-year-old man who received extended cholecystectomy with Roux-en-Y hepaticojejunostomy for gallbladder cancer (GBC) presented to our hospital with nausea and vomiting. Neither tender nor peritoneal irritation sign was present on abdominal examination. Blood test exhibited marked leukocytosis (WBC:19,800/mm3). A contrast-enhanced abdominal computed tomography (CT) scan revealed remarkable wall thickening and lower contrast enhancement effect localized to Roux limb. On hospital day 2, abdominal arterial angiography revealed angio-spasm at marginal artery and arterial recta between 2nd jejunal artery and 3rd jejunal artery, leading us to the diagnosis of NOMI. We then administered continuous catheter-directed infusion of papaverine hydrochloride until hospital day 7. Furthermore, the patient was anticoagulated with intravenous unfractionated heparin and antithrombin agents for increasing D-dimer level and decreasing antithrombin III level. On hospital day 8, diluted oral nutrition diet was initiated and gradually advanced as tolerated. On hospital day 21, the patient was confirmed of improved laboratory test data and discharged with eating a regular diet. We experienced a rare case of NOMI on Roux limb after 2years of extended cholecystectomy with hepaticojejunostomy for GBC, promptly diagnosed and successfully treated by interventional radiology (IVR).

Spontaneous heterotopic pregnancy resulting in tubal rupture and complete spontaneous abortion: a case report in Tiko, Cameroon

Introduction and importance: A heterotopic pregnancy (HP) following spontaneous conception is a rare and potentially life-threatening condition. Its diagnosis can be overlooked, hence remaining one of the challenging gyneco-obstetrical emergencies, especially in the low-resource setting. Case presentation: A 24-year-old G2P0010 at 11 weeks of gestation with a history of one induced abortion and a family history of twin pregnancies presented with an acute abdomen, associated with vaginal spotting in an afebrile context. An abdominopelvic ultrasound showed retained products of conception, and the presence of a left adnexal mass suggestive of an extrauterine gestational sac at ~6 weeks of gestation. There was spontaneous expulsion of retained products of conception. The deterioration of the hemodynamic stability of the patient prompted an emergency laparotomy to be done. The patient was transfused, postsalpingectomy counseling done and was discharged on oral analgesics, blood tonics, and antibiotics on day 6 postoperation. Clinical discussion: HP following spontaneous conception is a rare and potentially life-threatening condition. This case reports on the management of spontaneous HP resulting in a ruptured ectopic pregnancy (EP) and a complete spontaneous abortion managed in a low-resource setting. This case emphasizes the importance of a systematic ultrasound to be done for all patients with a clinically confirmed abortion to rule out an associated EP. Conclusion: A spontaneous abortion without signs of peritoneal irritation can be associated with an EP. Ultrasound can help in the early diagnosis, and laparotomy can be life-saving.

Management of Perforated Sigmoid Diverticulitis with Associated Retroperitoneal Abscess and Generalized Peritonitis

Introduction: Diverticulitis represents a relatively common pathology within the gastrointestinal tract. While diverticula can occur throughout the digestive system, their prevalence is notably higher in the left colon, particularly in the sigmoid region. This condition predominantly affects middle-aged and elderly males. The most effective diagnostic methods for this disease are colonoscopy and computed tomography (CT) with contrast. Although severe complications of diverticulitis are infrequent, the optimal classification of these complications has been described by Hinchey.
 The article aims to show the case of a young patient with complicated diverticulitis with perforation and generalized peritonitis, classified as stage III-IV, according to Hinchey.
 Case report: A 43-year-old female patient was urgently admitted to the General Surgery Clinic at Tetovo Clinical Hospital, presenting with severe generalized abdominal pain and signs of peritoneal irritation. Comprehensive diagnostic imaging revealed a large retroperitoneal abscess located above the psoas muscle, accompanied by a significant accumulation of free fluid, suspected to be pus, in the abdominal cavity. Following initial resuscitation, surgical intervention was undertaken. Intraoperative findings included advanced inflammatory changes in the sigmoid colon, characterized by thickened fibrotic walls and a partially constricted lumen. A large abscess was also identified in the retroperitoneal space between the spleen and left kidney. Given these findings, resectioning the distal descending colon and most of the sigmoid colon was considered necessary. The retroperitoneal abscess was incised, its contents aspirated, and a thorough cavity debridement was performed. Subsequently, the Hartmann procedure was executed. Postoperatively, due to the patient's deteriorating condition, she was transferred to the intensive care unit for continued treatment. The patient was discharged from the hospital in stable condition on the tenth day following the surgery.
 Conclusion: While complications from sigmoid diverticula are uncommon, they can occasionally be extremely severe and pose a significant risk to patient survival.

IDIOPATIC SCLEROSING ENCAPSULATING PERITONITIS

ABSTRACT Introduction: Sclerosing Encapsulating Peritonitis (SEP) is a rare syndrome characterized by a chronic inflammatory process that leads to the formation of a thick fibrocollagenous membrane that surrounds and entraps intra-abdominal organs. As a result, although some cases may be asymptomatic, patients commonly develop symptoms of intestinal obstruction, and the diagnosis is often made incidentally during intra-abdominal surgeries. Case report: A 37-year-old male patient, a chronic alcoholic, was admitted with severe abdominal pain for seven days associated with abdominal distension, anorexia, and fever. Abdominal examination revealed signs of peritoneal irritation. Chest X-ray and abdominal computed tomography showed pneumoperitoneum and a large fluid collection, with signs of wall thickening extending through the pelvic cavity, parietocolic gutters, anterior abdominal cavity, and hepatodiaphragmatic space, causing compression of the hepatic parenchyma and displacement of intestinal loops. Due to these findings, the patient underwent an emergency exploratory laparotomy, in which a fibrocollagenous membrane, extensive bowel obstruction, and an abscess were identified. A total of 4.5 liters of purulent secretion were drained, the fibrous membrane was excised, the abdominal cavity was copiously washed, and a drain was placed in the upper right quadrant. He had a satisfactory resolution of the condition, without postoperative complications, and was discharged 11 days after the procedure. Conclusion: Initially, conservative management should be prioritized due to the technical difficulty of surgery and possible complications. However, in case of greater the level of peritoneal involvement and tissue adhesion, there is a higher chance of failure of conservative management, and surgical intervention may become necessary. Keywords: Peritonitis. Fibrosis Peritoneal. Intestinal Obstruction.

Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study

Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.

Demographic, Clinical and Radiological Characteristics of Pediatric Cases Diagnosed As Transient Intussusception As A Result of Spontaneous Reduction

Objectives: Transient intussusception (TI) is a condition in which part of the small intestine is identified to enter the anterior part of the intestine telescopically, but this condition spontaneously reduces during follow-up. The observation of this situation has increased with the widespread use of ultrasonography among diagnostic tools. In this study, the aim was to present cases of intussusception that resulted in spontaneous reduction in our clinic. Materials and Methods: The records of cases diagnosed with intussusception between 01.01.2014 and 01.09.2022 were scanned. The files of the patients who were diagnosed with TI as a result of observation were investigated. Age, gender, clinical findings, duration of admission, ultrasonography findings, treatment options and results were analyzed retrospectively. Results: A total of 71 cases diagnosed with intussusception included 50 males and 21 females, with a mean age of 22.3 months. Intussusception was ileo-colic in 36 patients, ileo-ileal in 32 patients, and jejuno-jejunal in three patients. Clinical observation with physical examination and ultrasonography (US) was performed in 33 (21%) patients with SBI who did not have signs of peritoneal irritation and had short segment involvement. Surgical reduction was performed in four patients because intussusception persisted after observation. Control US performed on the remaining 29 patients showed that intussusception disappeared. The age range of 29 patients diagnosed with TI ranged from 10 to 122 months (mean 46.2 months). Of the cases, 19 (65.5%) were male and 10 (34.4%) were female. The length of the invaginated segment ranged from 1-2.2 cm (mean 1.8 cm). Conclusion: Spontaneous reduction of SBI, which does not have acute abdominal findings and progresses with short segment involvement on US, may occur during clinical observation. For this reason, close follow-up of suitable cases that may develop spontaneous reduction is important to avoid unnecessary surgical interventions and consequences.

#3740 AFTER ALL A TYPICAL HUS

Abstract Background and Aims Typical Hemolytic Uremic Syndrome (HUS) is a thrombotic microangiopathy (TMA) characterized by the triad of acute renal failure, hemolytic anemia and thrombocytopenia. TMAs are classified into: Inherited or primary acquired (atypical HUS), secondary or infection associated. Infection with Shiga-toxin–producing Escherichia coli (E. coli), mainly of serotype O157:H7, is the most common cause of typical HUS, but other serotypes have been rarely associated such as Enteroagregative Escherichia coli (EAEC) serotype O104:H4. Method Case Report Results We report a case of a 51-years-old male with past medical history of arterial hypertension (treated with Perindopril) and IgGk Multiple Myeloma (MM) diagnosed 10 years prior submitted to two bone marrow autotransplants (9 and 4 years prior) and multiple chemotherapy agents including Carfilzomib-Pomalidomide-Dexamethasone (last cycle 4 days before the onset of symptoms). One week after returning from a trip to Brazil, he was admitted to the emergency department with a two-day history of non-bloody diarrhea (4-5 liquid stools per day) and asthenia, with similar positive familiar epidemiology. He denied abdominal pain, fever, nausea or vomiting. At physical examination, he was hypertensive (177/90 mmHg), anuric (12,5 ml/h), dehydrated and apyretic. Abdominal palpation was painless and there were no signs of peritoneal irritation. Laboratory tests showed hemoglobin 10.5 g/dl, new onset thrombocytopenia (261 000/uL » 21 000/uL), kidney disfunction (serum creatinine (sCr) 0.74 mg/dL to 9 mg/dL and serum urea (sU) 41 mg/dL to 260 mg/dL), hyperkaliemia (6 mEq/L) and metabolic acidosis (pH 7,39 and bicarbonate 18.4 mEq/L). LDH was 1949 U/L, C-reactive protein 30.6 mg/L, procalcitonin 3.77 ng/mL, haptoglobin &amp;lt;0.07 g/L and with normal complement levels (C3 and C4). Schistocytes were present in peripheral blood smear. The diagnosis of Acute Kidney Injury related with TMA was established and the patient was transferred to the Nephrology ward and urgent hemodialysis was started. Exhaustive study was performed showing normal renal ultrasound, non-nephrotic proteinuria (1.6 g/g), urinalysis showed leukocyturia and erythrocyturia. Autoimmune study including PR3-ANCA, MPO-ANCA, anti-GBM antibody, Anti-dsDNA antibody, anti-beta 2-glycoprotein I antibodies, anticardiolipin antibodies, anti-ADAMTS13 antibodies and ADAMTS13 activity, as well as study of complement C5, C'3, C'4, factor B, H and I, anti-factor H ac, AH 50 and CH50b were unremarkable. Blood and urine culture and antistreptolysin O titers were negative. Specific stool cultures for E. coli O157, Shigella, Salmonella, Yersinia and Campylobacter were negative. Stool evaluation for parasites were also negative. Viral serology for HIV, HBV, HCV and Plasmodium tests were negative. PCR stool was required due to high suspicion of E.coli infection. The suspicion of a Carfilzomib induced TMA was also raised, while molecular techniques results were awaited. MM was stable and treatment was held until recovery of kidney function. During hospitalization the patient recovered diuresis and creatinine decreased. On the 11th day of hospitalization, he was discharged but still depended on hemodialysis. Finally, stool PCR techniques identified aatA and aggR genes associated with EAEC O104:H4 allowing the diagnosis of acquired infectious HUS rather than drug-related TMA. One week after discharge, the dialysis was stopped due to sCr 3 mg/dL. Four months later, he resumed Carfilzomib and kidney function remained stable with sCr 0.9 mg/dL, despite sustained proteinuria of 1.2 g. Conclusion The authors emphasize the importance of considering other causes of TMA when E.coli O157 infection is excluded, namely drug-related causes (as Carfilzomib) or less frequent infectious agents such as EAEC O104:H4. This case reveals the importance of requesting PCR in the stool even when the E.coli test is negative. This is of particular relevance in immunosuppressed patients. This diagnosis allowed continuing MM treatment.

Two cases of spontaneous rupture of the uterine artery in the perinatal period: A case report.

Uterine artery spontaneous rupture is a rare but potentially life-threatening complication during pregnancy and puerperium. The lack of typical symptoms makes it difficult to diagnose, which can result in serious consequences for both the mother and fetus. Case 1 presented with fainting and lower abdominal discomfort, while Case 2 developed hypotension after delivery and remained in poor condition even after rehydration. Both cases were diagnosed with uterine artery spontaneous rupture, with intraoperative findings revealing ruptures in different branches of the uterine artery. Both cases underwent surgical interventions, with laparoscopic surgery performed in Case 1 and repair of the ruptured artery in Case 2. Both cases had successful outcomes, with the ruptured arteries repaired and the patients discharged from the hospital within a week after surgery. Uterine artery spontaneous rupture is a rare but potentially life-threatening complication that may present with atypical symptoms. Early diagnosis and prompt surgical intervention are crucial in preventing serious complications for both the mother and fetus. Clinicians should maintain a high level of suspicion for this condition when evaluating patients presenting with unexplained symptoms or signs of peritoneal irritation during pregnancy and puerperium.

Risk factors analysis and the development and validation of a clinical prediction model for acute mesenteric ischemia-induced intestinal infarction

Objective: To investigate the risk factors of intestinal infarction caused by acute mesenteric ischemia (AMI), and develop and validate a clinical prediction model of Nomogram plot for intestinal infarction caused by AMI. Methods: From January 2014 to December 2020, 201 patients with AMI in the Affiliated Hospital of Yunnan University were selected as the modeling group, and 105 patients with AMI in the First Affiliated Hospital of Kunming Medical University were collected as the validation group. The age of patients in the modeling group was (62±12) years, and there were 70 males and 131 females. The age of patients in the validation group was (62±10) years old, and there were 69 males and 36 females. The clinical data including clinical manifestations, laboratory indicators and imaging indicators of patients in the two groups were retrospectively analyzed, and univariate and multivariate binary logistic regression analyses were performed to screen out risk factors for the progression of AMI to intestinal infarction. A Nomogram plot clinical prediction model for AMI causing intestinal infarction was developed using R software, and the differentiation, calibration and net clinical benefit of this Nomogram plot were evaluated by C-index, calibration curve and clinical decision analysis curve. Results: Shock (OR=13.69, 95%CI: 2.31-88.87), body temperature ≥38.0 ℃ (OR=6.39, 95%CI: 1.85-22.11), white blood cells (WBC) ≥18×109/L (OR=1.19, 95%CI: 1.03-1.37), intestinal changes on CT (OR=0.17, 95%CI: 0.04-0.66), peritoneal irritation (OR=0.06, 95%CI: 0.01-0.26), and pH≤7.34 (OR=0.00, 95%CI: 0.00-0.01) were risk factors for intestinal infarction caused by AMI. Body temperature ≥38.0 ℃ (sensitivity: 81.5%, specificity: 87.0%), WBC ≥18×109/L (sensitivity: 84.0%, specificity: 83.0%) and pH ≤7.34 (sensitivity: 70.4%, specificity: 76.7%) were cut-off values for progression to intestinal infarction in patients with AMI. The Nomogram plot prediction model of intestinal infarction induced by AMI was established by using the above parameters and validated internally and externally. The C index of validation group and modeling group were 0.96 (95%CI: 0.921-0.999) and 0.98 (95%CI: 0.962-0.996), respectively. The calibration curves of the validation group and the modeling group were shaped near the reference line, and the deviation from the reference line was low. The clinical decision analysis curves of validation group and modeling group showed that the clinical prediction model of Nomogram could bring better clinical net benefit for AMI patients. Conclusions: Shock, temperature, white blood cells, intestinal changes on CT, peritoneal irritation sign, and PH are independent risk factors for AMI-induced intestinal infarction. The Nomogram plot established by these factors can effectively predict the probability of AMI patients progressing to intestinal infarction.

Abdominal Compartment Syndrome After Binge Eating

Question: A 41-year-old woman with a history of eating disorder was admitted to the hospital with progressively worsening abdominal pain. Apart from the eating disorder, there were no previous illnesses in the patient’s medical history. On physical examination her abdomen was significantly distended, painful, and with signs of peritoneal irritation. Bowel sounds were absent. Laboratory examination showed a severe lactic acidosis, an elevated C-reactive protein (CRP) at 20 mg/L (<5.0), as well as massive leukocytosis. The patient became hemodynamically unstable and soon needed catecholamine resuscitation. The abdominal ultrasound was limited owing to the pain and hemodynamic instability.

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

Gonococcal Pelvic Inflammatory Disease with Sepsis Criteria: Review of 2 Cases

Background: Infection caused by Neisseria Gonorrhoeae increases the risk of pelvic inflammatory disease (PID). Gonococcal PID tends to be clinically more severe than non-gonococcal ones. The main is to present two cases of gonococcal PID, with rapid clinical and analytic progression, leading to severe sepsis, but without imaging manifestations. Clinical presentation: 1. 41-year-old patient with replacement of intrauterine releasing levonorgestrel device (IUD), presented abdominal pain and green vaginal discharge. Abdominal examination revealed signs of peritoneal irritation and blood test showed leukocytosis, increased C Reactive Protein and procalcitonin, as well as coagulation abnormalities. Imaging tests (vaginal ultrasound/tomography) revealed no structural pathology, without collections. Given the criteria of severe sepsis, broadspectrum intravenous (iv) antibiotic therapy was started and laparoscopy and IUD removal were performed. Cervical and IUD cultures were positive for Neisseria gonorrhoeae. 2. 20-year-old woman, with an IUD, consulted for abdominal pain, low-grade fever and green vaginal discharge. Abdominal examination suggested peritoneal sensitivity and laboratory tests leukocytosis, increased C Reactive Protein and procalcitonin with coagulation abnormalities. Imaging tests (vaginal ultrasound/tomography) showed no structural pathology, without collections. Despite analgesia and broad-spectrum iv antibiotics, the patient worsened, proceeding to remove the IUD. Given the criteria compatible with severe sepsis, laparoscopy was decided. Endocervical and IUD cultures revealed Neisseria gonorrhoeae. Conclusions: Facing the situation of an acute PID with severe and fast clinical worsening even without findings in imaging tests, we should consider gonococcal ethiology as a possible cause. Surgical approach shouldn’t be delayed in order to control the infection and rule out other possible diagnosis.

Outcomes of acute appendicitis in patients younger than age 4: a descriptive study

BackgroundAcute appendicitis is an infrequent pathology in children under 4 years of age, and its diagnosis is a clinical challenge that can lead to late detection. The intention of this study is to describe the clinical and surgical findings and to explore factors and outcomes associated with appendiceal perforation in patients under 4 years of age with histologically confirmed acute appendicitis. Cross-sectional study of historical data is on patients with a pathologic diagnosis of appendicitis. Clinical, surgical, and pathological variables were described. The relationship between the presence of perforation and associated factors and outcomes was explored using odds ratios (OR) and 95% confidence intervals.ResultsSeventy-five patients were found between 2013 and 2019. Seventy-four cases presented with pain on palpation, 56 (75%) with signs of peritoneal irritation, and 70 (93%) with sepsis on admission to the emergency room. An ultrasound was done on 57 patients (76%), and only 26 (45%) were suggestive of appendicitis. Forty-one (55%) cases were operated on by open surgery and 34 (45%) by laparoscopy. In 61 (81%), they were perforated, and 48 (64%) presented peritonitis. Perforation was associated with increased hospital days (OR = 2.54 [1.60−4.03]), days of antibiotics (OR = 4.40 [2.09−9.25]), and admission to intensive care (OR = 9.65 [1.18−78.57]).ConclusionsAbdominal pain reported by parents, pain on abdominal palpation, and clinical criteria of sepsis on admission to the emergency room are common features. Acute appendicitis complicated by perforation leads to high morbidity due to longer antibiotic treatment, hospitalization days, admission to PICU, and postoperative ileus.

Point-of-Care Ultrasound in Diagnosing Emphysematous Pyelonephritis

A 57-year-old woman with no known systemic disease presented to the emergency department with abdominal pain and vomiting for 3 days. She was well-oriented, with a body temperature of 36.5°C, blood pressure of 133/80 mm Hg, and tachycardia of 118 beats/min. On abdominal palpation, she had tenderness, with no signs of peritoneal irritation. Right-sided costovertebral angle tenderness was elicited. Laboratory data revealed neutrophil-predominant leukocytosis (13,140/μL), thrombocytopenia (10,000/μL), and hyperglycemia (460 mg/dL), representing a new diagnosis of diabetes at the emergency department.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis. Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection. Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

Ectopic Schistosomiasis Presenting as Ruptured Appendicitis with Periappendiceal Abscess Formation: An Alternative Pathogenetic Perspective

Schistosomiasis is still a public health burden in the Philippines. Chronic infection with Schistosoma japonicum, the only species endemic in the Philippines, clinically manifests itself in a wide variety of pathologies usually correlated with the anatomical site of adult worm activity and deposition of eggs. One of the documented ectopic sites for Schistosoma ova is the appendix. A rare sequela of this is acute appendicitis and an even rarer consequence is progression to appendiceal rupture leading to acute peritonitis. We present a case of a 27-year-old Filipino residing in Davao City but born in Agusan Province who initially complained of right lower quadrant abdominal pain but presented at the emergency room with generalized abdominal tenderness with signs of peritoneal irritation. Exploratory laparotomy with an infraumbilical incision revealed ruptured appendicitis with periappendiceal abscess formation and appendectomy was subsequently done. Schistosoma infection of the appendix was subsequently established by histopathological analysis. Furthermore, features observed suggest an atypical pathogenetic process contrary to the putative pathogenesis of most cases of acute appendicitis.

Omental infarction, unusual cause of abdominal pain

Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain. An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours. Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

A CASE REPORT OF CHYLOUS ASCITES AND TRANSIENT MIDGUT VOLVULUS THROUGH PETERSENS DEFECT THREE YEARS POST ONE-ANASTOMOSIS GASTRIC BYPASS- MINIGASTRIC BYPASS

One-anastomosis gastric bypass- Minigastric bypass (OAGB-MGB) is an emerging bariatric surgery technique replacing the RYGP with reasonable short- and long-term side effects. Here we would like to present a late complication of OAGB-MGB associated with signs of peritoneal irritation and severe pain due to transient midgut volvulus associated with chylous ascites.. We observed peritoneal lymphatic collection in association with features suggestive for small bowel obstruction 3 years followingOAGB-MGB. So, we believe that such complication should be considered as a potential side effect during short and long term follow up after gastric bypass.A strong recommendation should be provided.