Traumatic Pancreatitis Research Articles

A case of staged treatment of acute traumatic pancreatitis and late complications in a patient with a thoracoabdominal injury

Acute traumatic pancreatitis is one of the etiological forms of acute pancreatitis, the main cause of the development of which is mechanical trauma to the pancreas. A clinical case of successful treatment of a patient with acute traumatic pancreatitis developed as a result of a shrapnel thoracoabdominal injury with pancreatic damage and its complications using a multidisciplinary approach is presented. The possibilities of implementing the tactics of “damage control” at all stages of medical care are demonstrated.

Still water run deep: Therapeutic TP effect of ucMSC-Ex via regulating mTOR to enhance autophagy.

Our previous study confirmed that umbilical cord mesenchymal stem cells-exosomes (ucMSC-Ex) inhibit apoptosis of pancreatic acinar cells to exert protective effects. However, the relationship between apoptosis and autophagy in traumatic pancreatitis (TP) has rarely been reported. We dissected the transcriptomics after pancreatic trauma and ucMSC-Ex therapy by high-throughput sequencing. Additionally, we used rapamycin and MHY1485 to regulate mTOR. HE, inflammatory factors and pancreatic enzymatic assays were used to comprehensively determine the local versus systemic injury level, fluorescence staining and electron microscopy were used to detect the effect of autophagy, and observe the expression levels of autophagy-related markers at the gene and protein levels. High-throughput sequencing identified that autophagy played a crucial role in the pathophysiological process of TP and ucMSC-Ex therapy. The results of electron microscopy, immunofluorescence staining, polymerase chain reaction and western blot suggested that therapeutic effect of ucMSC-Ex was mediated by activation of autophagy in pancreatic acinar cells through inhibition of mTOR. ucMSC-Ex can attenuate pancreas injury by inhibiting mTOR to regulate acinar cell autophagy after TP. Future studies will build on the comprehensive sequencing of RNA carried by ucMSC-Ex to predict and verify specific non-coding RNA.

Sertolioma en un perro senil criptorquídico con metástasis pulmonar: Reporte de caso

Sertolioma is a common testicular neoplasm in dogs, as are Leydig cell tumors and seminomas. Cryptorchidism is a highly relevant risk factor for the development of testicular neoplasms such as Sertoli cell tumors since, from a physiological point of view, the male gonads are at an unfavorable temperature for spermatogenesis and normal cell maintenance. The aim of this case report is to describe the clinical, diagnostic and therapeutic management of a canine with sertolioma secondary to cryptorchidism, aggravated by lung metastasis. The patient presented clinical signs of hyporexia, apathy, vomiting, abdominal distension and sudden darkening of the coat. The definitive diagnosis was established through histopathology after an orchiectomy and removal of the ectopic tumoral testicle. Fourteen days after surgery, the patient returned to the clinic with complaints of melena, vomiting, adipsia, hyporexia, apathy and abdominal pain. Based on the results of the ultrasound examination correlated with the clinical symptoms, it was concluded that the patient had developed traumatic pancreatitis secondary to intraoperative visceral manipulation. Due to the worsening of the condition, the patient died 15 days after the procedure. The case report was of great importance to the team, as understanding the disease in question and its consequences allows professionals to clarify to guardians the relevance of orchiectomies, especially in cryptorchid animals.

Paediatric pancreatic trauma in North Queensland: a 10-year retrospective review

PurposeTo establish the incidence of pancreatic trauma in North Queensland to the region’s only tertiary paediatric referral centre, and to determine the patient’s outcomes based on their management.MethodsA single centre, retrospective cohort study of patients < 18 years with pancreatic trauma from 2009 to 2020 was performed. There were no exclusion criteria.ResultsBetween 2009 and 2020 there were 145 intra-abdominal trauma cases, 37% from motor vehicle accidents (MVA), 18.6% motorbike or quadbike, and 12.4% bicycle or scooter accidents. There were 19 cases of pancreatic trauma (13%), all from blunt trauma and with associated injuries. There were 5 AAST grade I, 3 grade II, 3 grade III, 3 grade IV injuries, and 4 with traumatic pancreatitis. Twelve patients were managed conservatively, 2 were managed operatively for another reason, and 5 were managed operatively for the pancreatic injury. Only 1 patient with a high grade AAST injury was successfully managed non-operatively. Complications included pancreatic pseudocyst (n = 4/19; 3 post-op), pancreatitis (n = 2/19; 1 post op), and post-operative pancreatic fistula (POPF) (n = 1/19).ConclusionDue to North Queensland’s geography, diagnosis and management of traumatic pancreatic injury is often delayed. Pancreatic injuries requiring surgery are at high risk for complications, prolonged length of stay, and further interventions.

COMPARISON BETWEEN BISAP SCORE AND BALTHAZAR SCORE IN PROGNOSIS OF ACUTE SEVERE PANCREATITIS

Background Among the surgical causes of acute abdomen of non- traumatic origin pancreatitis is considered second most severe pain related problem preceded by abdominal colic. In view of this it was decided to carry out to study to compare the Balthazar scoring system with the BISAP scoring system so that this study could help in supplementing the existing data and compare the superiority of scoring system over other. The objective of the study was to compare the BISAP (Bedside index of severity in acute pancreatitis) and Balthazar scoring system in evaluating the prognosis in cases of acute severe pancreatitis. MethodsIt is a prospective study carried out between October 2018 to October 2020 documenting the events of 28 patients admitted with acute pancreatitis at a tertiary care centre. BISAP score and BALTHAZAR scores were calculated as per criteria highlighted in the literature. At the end of study period the scores were compared based on patient morbidity, mortality and treatment outcomes across various variables. Results There was a signicant association between BISAPScore and outcome with a p value 0.0211 at BISAP Score mortality was 14.3%. BISAP had a sensitivity of 92.00% and specicity of 50.00%. Balthazar at grade 4 had a sensitivity of 93.70% and specicity of 50.00%. A CTSI score of 7 had sensitivity of 95.65% and specicity of 50.00%. 82% of the subject were diagnosed as alcoholic pancreatitis and 17.9% had gall stone pancreatitis. Mortality rate in the present study was 3.57%. ConclusionWe conclude that both the BISAPand Balthazar score are good to assess the prognosis of patients. Both have an almost equal accuracy and specicity, but sensitivity of Balthazar 93.70% is better than BISAPof 92.00%.

Ulcerated, tender nodules of the lower extremities

Ulcerated, tender nodules of the lower extremities

Revisiting the Conundrum: A Case Report on Trauma Whipple's Pancreaticoduodenectomy

Despite its rarity, pancreatic trauma is a serious condition because of its retroperitoneal location, association with other organ injuries, and complex bilio-vascular anatomy. Even less common are isolated pancreatic injuries. In grade four injuries, there is a debate over resectional vs. non-resectional management and appropriate treatment is particularly difficult. Here we discuss a patient with grade four pancreatic injury with pancreatic ascites presenting four days after the incident and traumatic pancreatitis. She underwent pylorus-preserving pancreatoduodenectomy and recovered well with acceptable morbidity.

ISOLATED PANCREATIC INJURIES: A CASE SERIES

Context: Pancreatic injuries constitutes a set of rare abdominal solid organ injuries. Isolated pancreatic injuries are even more rare injuries and are often missed in initial clinical and radiological evaluation . such injuries present late and denitive guidelines to manage such injuries are lacking, considering rarity of such injuries. Unpredictable course involves traumatic pancreatitis, pancreatic necrosis, peripancreatic collections, infective complications and extra abdominal complication The aim of this study is to present clinical details and management outcomes of such casesAims: at our institute This study is a retrospective analytical study In this retrospective study medicalSettings and Design: Methods and Material: records of all the admissions were collected from trauma registry from may 2016 to april 2022 at Thanjavur medical college. All these records were screened for patients with isolated pancreatic injuries All continuous variables were analyzed with descriptive statisticsStatistical analysis used: and their mean, median, mode, range and frequencies were calculated. All categorical data are analyzed with frequencies. Comparison of data is done using: all nominal data is analyzed with parametric tests (Chi-square test, unpaired t test) and non-nominal data is analyzed with non- parametric tests (Fischer's exact test and Mann-whitney U test). In our study a total of 22 cases were included. Mean age being 33.91yearsResults: among which 81.8% were males. 72.7% of the patients suffered road trafc accidents. 77.3% of the patients had BMI less than 25. Main pancreatic duct (MPD) involvement was noticed in 22.7% patients. median levels of serum amylase levels were 390U/L. 22.7% patients underwent operative management were as rest were managed non-operatively. Two patients died due to severe pancreatitis. Isolated pancreatic injuries inConclusions: patients where surgery is otherwise not indicated due to other causes needs management tailored to the clinical needs of the patient. Diagnostic ambiguity is best resolved by combining computed tomography (CT) and Magnetic resonance cholangiopancreatography (MRCP). Patients with distal MPD injury are usually operated when presented early and pancreatic stenting is considered when proximal ductal injury is noticed. In selected cases conservative approach is not a contraindication, even in patients with MPD injury, considering high stula and peripancreatic collection rates in distal pancreatectomy.

Indications for the surgical management of pancreatic trauma: An update.

Pancreatic trauma is rare compared to other abdominal solid organ injuries, accounting for 0.2%-0.3% of all trauma patients. Moreover, this type of injury may frequently be overlooked or not readily appreciated on initial clinical examinations and investigations. The organ injury scale determines the severity of the trauma. Nonetheless, there are conflicting recommendations for the best strategy in severe cases. Overall, conservative management of induced severe traumatic pancreatitis is adequate. Modern imaging modalities such as ultrasound scanning and computed tomography scanning can detect injuries in fewer than 60% of patients. However, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) have diagnostic accuracies approaching 90%-100%. Thus, management options include ERCP and stent placement or distal pancreatectomy in cases of complete gland transection and wide drainage only for damage control surgery, which can prevent mortality but increases the risk of morbidity. In the majority of cases, surgical intervention is not required and should be reserved for only severe grade III to grade V injuries.

Human umbilical cord mesenchymal stem cells-derived exosomes for treating traumatic pancreatitis in rats

BackgroundThe therapeutic and protective effects of human umbilical cord mesenchymal stem cells-exosomes (hucMSC-Exs) on traumatic pancreatitis (TP) remain unknown. Here, we established a rat model of TP and evaluated and compared the therapeutic effects of hUC-MSCs and hucMSC-Exs.MethodsHucMSC-Exs were obtained by ultracentrifugation and identified using transmission electron microscopy and western blot analysis. TP rats were treated by tail vein injection of hUC-MSCs and hucMSC-Exs. Their homing in rats was observed by performing fluorescence microscopy. The degree of pancreatic tissue damage was assessed by HE staining, the expression levels of amylase, lipase, and inflammatory cytokines were detected by ELISA, apoptosis was detected by TUNEL assay, and the expression levels of various apoptosis-related proteins were detected by western-blot. The expression levels of apoptosis-related molecular markers were detected by RT-qPCR.ResultsThe colonization of exosomes was observed in pancreatic tissue. Compared to TP group, the histopathological score of pancreas was significantly decreased in the TP + hUC-MSCs group and TP + hucMSC-Exs group (P < 0.05). Compared to TP group, the activity of serum amylase and lipase was significantly decreased (P < 0.05). The expression levels of IL-6 and TNF-α were significantly decreased, while those of IL-10 and TGF-β were significantly increased (P < 0.05). The apoptosis index of the TP group was significantly increased (P < 0.05), whereas that of the TP + hUC-MSCs and TP + hucMSC-Exs groups was significantly decreased (P < 0.05). Compared to TP group, the expression levels of Bax, Bcl-2, and Caspase-3 were significantly decreased in the TP + hUC-MSCs group and TP + hucMSC-Exs group (P < 0.05).ConclusionHucMSC-Exs can colonize injured pancreatic tissue, inhibit the apoptosis of acinar cells, and control the systemic inflammatory response to facilitate the repair of pancreatic tissue.

Enhancing or inhibiting apoptosis? The effects of ucMSC-Ex in the treatment of different degrees of traumatic pancreatitis.

The animal models of traumatic pancreatitis (TP) were established to evaluate the specific mechanisms by which umbilical cord mesenchymal stem cell-derived exosomes (ucMSC-Ex) exert therapeutic effects. Sixty four rats were randomly divided into eight groups, including TP groups with three different degrees and relevant groups with ucMSC-Ex treated. The degrees of pancreatic tissue injury were evaluated by Histological Examination. Furthermore, enzyme-linked immunosorbent assay were applied to evaluate the activity of pancreatic enzymes and levels of inflammatory factors in serum. Finally, the apoptotic effects of each group were evaluated by TUNEL, western blot (WB), and real time fluorescence quantitative polymerase chain reaction (RT-qPCR). The pancreatic histopathological score and serum amylase and lipase levels gradually increased in various degrees of TP and the levels in the treatment group were all significantly decreased. The apoptosis index gradually increased in each TP group and significantly decreased in the treatment group in TUNEL results. WB and RT-qPCR showed the same trend, that bax and caspase-3 gradually increased and bcl-2 gradually decreased in TP groups. Compared with TP groups, the expression of bax and caspase-3 were lower while bcl-2 expression was higher in the treatment group. ucMSC-Ex suppressed the inflammatory response and inhibited pancreatic acinar cell apoptosis to promote repair of injured pancreatic tissue.

Gabexate Mesylate-Poloxamer 407 Conjugate Alleviates Sodium Taurocholate-Induced Severe Acute Pancreatitis in an Optimized Rat Model.

We have previously shown that gabexate mesylate-poloxamer 407 conjugate (GMTI) alleviates traumatic pancreatitis in rats. In this study, we evaluated the therapeutic effect of GMTI on sodium taurocholate-induced severe acute pancreatitis (SAP) in an optimized rat model. An SAP rat model was established via microinjection of 3.5% sodium taurocholate and retention in the bile duct for 1min. SAP rats were administered GMTI via tail vein injection (i.v.) or tail vein injection + intraperitoneal injection (i.v. + i.p.). All rats were sacrificed at 12h after treatment. Biochemical approach and enzyme-linked immunosorbent assay were performed to measure the serum levels of amylase (AMY), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6). Hematoxylin and eosin staining and TUNEL assay were conducted to examine histopathology and acinar cell apoptosis in the rat pancreas. SAP was successfully induced in all model rats, as evidenced by progressively aggravating SAP symptoms and signs, pancreatic histopathological abnormalities, as well as elevated serum levels of TNF-α, IL-6, and AMY. The mortality rates at 1h, 6h, and 12h were 0%, 0%, and 25%, respectively. GMTI therapy via i.v. or i.v. + i.p. significantly reduced pancreatic wet weights, ascites amounts, pathological scores, and circulating levels of TNF-α and IL-6 while promoting acinar cell apoptosis in SAP rats. GMTI therapy via i.v. + i.p. outperformed i.v. in improving pancreatic histology and reducing TNF-α and IL-6 serum levels in SAP rats. Our optimized SAP rat model is reliable and reproducible. GMTI therapy is a promising approach against SAP.

The Effects of Umbilical Cord Mesenchymal Stem Cells on Traumatic Pancreatitis in Rats.

This study explored the therapeutic and protective effects of umbilical cord mesenchymal stem cells (ucMSCs) on traumatic pancreatitis (TP) to provide a theoretical basis for TP treatment with MCSs by establishing a TP rat model. We used 60 healthy adult male Sprague Dawley (SD) rats to create four experimental groups: sham, ucMSC control, TP, and ucMSC treatment. We observed ucMSC homing in the rats by fluorescence microscopy and assessed the degree of pancreatic tissue injury by hematoxylin and eosin (HE) staining on days 1, 3, and 7 after transplantation. Furthermore, we used an in vivo imaging system to evaluate the localization of cell membrane-stained ucMSCs in rats with TP. Finally, we measured the serum levels of amylase, lipase, pro-and anti-inflammatory factors, and oxidative stress factors by enzyme-linked immunosorbent assay (ELISA). The pancreatic histopathological score and the serum amylase and lipase levels were lower in the ucMSC treatment group than in the TP group (P < 0.05). Interleukin (IL)-6, tumor necrosis factor-α (TNF-α), and oxidase malondialdehyde (MOD) levels were significantly higher in the ucMSC treatment group than in the TP group. However, IL-10, transforming growth factor-β, and superoxide dismutase (an antioxidant enzyme, SOD) levels were significantly higher in the ucMSC treatment group than in the TP group (P < 0.05). ucMSCs can migrate and implant in injured areas of the pancreas in rats. Furthermore, they participate in pancreatic tissue repair and regulate immunity by inhibiting the systemic inflammatory response and oxidative stress.

ЗАКРЫТАЯ ТРАВМА ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ, ЖЕЛЧНОГО ПУЗЫРЯ И ВНЕПЕЧЁНОЧНЫХ ЖЕЛЧНЫХ ПРОТОКОВ: ТАКТИКА, ОСНОВАННАЯ НА ПРИНЦИПАХ ДОКАЗАТЕЛЬНОЙ МЕДИЦИНЫ

Objective. Optimization of treatment and diagnostic tactics for blunt injury of the pancreas, gall bladder and extrahepatic bile ducts. Methods. This current review was undertaken by Russian and foreign literature (2015-2020 yrs) search according to the following themes: pancreatic injury, traumatic pancreatitis, gall bladder injury, extrahepatic bile ducts injury, damage control surgery tactics, blunt abdominal trauma, therapeutic and diagnostic algorithm, conservative (non-operative) management, with subsequent exception from the request of experimental studies and cases of open trauma in the Internation scientific datebase PubMed, Cochrane Library, Scopus, Embase, ScienceDirect, Google Scholar Search, eLibrary. Multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials were analyzed, indicating the levels of evidence and effectiveness of recommendations. An original algorithmfor thediagnosis and management is proposed, the concept of damage control is described, and indications for diagnostic methods, conservative treatment, and types of surgical, endovascular, and minimally invasive interventions are specified depending on the severity of organ injury according to the classification of the American Association of the Surgery of Trauma (AAST) (table). Results. The algorithmfor thediagnosis and management for combined blunt trauma of the pancreas, gallbladder, and extrahepatic bile ducts is standardized, and indications for minimally invasive and open interventions in this category of patients are clarified. Conclusion. Accurate knowledge of the algorithm for the diagnosis and management, indications for endovascular, minimally invasive techniques and open interventions, the choice of tactics based on the patient’s condition, the time of the injury, and possible complications can improve the results of treatment.

A tertiary care prospective of epidemiology and aetiopathogenesis of acute pancreatitis

Background: Acute pancreatitis is a potentially lethal condition resulting from an acute inflammatory process in the pancreas usually manifested by upper abdominal pain and raised concentration of pancreatic enzymes in blood, urine and peritoneal fluid. Aims and objectives were to study the epidemiology and aetiopathogenesis of acute pancreatitis in Jammu region of Northern India.Methods: This was a descriptive cross-sectional hospital based study, conducted in the postgraduate department of surgery, Government Medical College Jammu for a period of 3 years and included all admitted patients with diagnosis of acute pancreatitis. The main outcome variable was to find the various etiological factors associated with acute pancreatitis.Results: In our study acute pancreatitis was found to be more common in younger people. Most of the patients in the study population were below 40 years of age. Majority of the patients presented first time to the hospital with the chief complaints of pain upper abdomen. In this study, we found that the two principal causes of acute pancreatitis in our population were gall stones and alcoholism which contributed a total of about 68% cases followed by other causes such as hyperlipidemia, drug induced pancreatitis, worm induced acute pancreatitis, post-surgical pancreatitis, post traumatic pancreatitis, and hypercalcemia.Conclusions: Acute pancreatitis is a disease with high morbidity and mortality, and is quite common in Northern India. As such there is a need to make our population aware regarding the impact of alcoholism and bad dietary practices in causation of acute pancreatitis.

To study the clinical profile of patients with acute pancreatitis and to study it's aetiology. A hospital based cross sectional study

Aim: To study etiology and complications of acute pancreatitis, to assess the clinical profile of acute pancreatitis. Material and Methods: The study was a cross sectional study which was carried in the Department of General Surgery, Shri Shankaracharya Institute of Medical Sciences, Bhilai, Chhattisgarh, India for the period of 1 year. Total 100 patients who were diagnosed for acute pancreatitis were include in this study and data collection on admission included age, sex, address and clinical presentation with respect to pain vomiting, gallstones trauma and drugs was noted. Results: 56 men and 44 women were among the 100 patients. Patients aged 30-40 (42%) followed by 40-50 (33%). All patients (100%) had abdominal discomfort, 84 % had nausea/vomiting, 45% had fever, and 28% had jaundice. Acute pancreatitis is most often caused by biliary pancreatitis (46%) in patients. Alcoholism was the second reason (35%). Hyperlipidemia (4%) and traumatic pancreatitis (4%) were detected in 4 patients each. Idiopathic patients had no known aetiology (11%). Males had the greatest alcohol-induced pancreatitis, followed by biliary aetiology. Diabetes mellitus was found in 59% of the study population. Obesity was seen in 41%. Conclusion: Acute pancreatitis is one of the most common causes of increased morbidity and death in the general population. The clinical evaluation, in conjunction with laboratory indicators, was highly linked with death and morbidity.

Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomy

Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomy

Attention should be paid to the treatment of traumatic pancreatitis

Traumatic pancreatitis(TP) is an acute non-infectious inflammation secondary to pancreatic injury.TP can be masked by analgesia or other organ damage after pancreatic injury. So it is difficult to diagnosis in the early stage, easy to missed and misdiagnosis, subsequently prone to infection of pancreatic necrosis (IPN).At present, the treatment of TP is advocated as a step-by-step treatment strategy, which takes minimally invasive surgery as the guidance and takes into account of the principles of multiple injury treatment, inflammation control, infection and necrosis clearance, which runs through the two important links of pancreatic injury and IPN management.

CECT evaluation of rare and common complications of pancreatitis

AIM: To evaluate the role of CECT in diagnosis of common and rare complications of pancreatitis.Materials and Methods: Type of study: Retrospective study.Place of study: Dept. of Radio Diagnosis, KIMS, NARKETPALLY. Sample size: 129Duration of study: 1st October 2019-30th September 2020 (12 months).Inclusion criteria: Patients with clinical features and/or laboratory findings and/or ultrasonography findings of acute pancreatitis and chronic pancreatitis.Results: 129 subjects were included in the study, among which 88.3% were males. Most of them belonged to the 31-40years age group. On CECT, Acute peri-pancreatic fluid collection was seen in 43.4%, acute necrotic collection in 5.4%, Pseudocysts in 16.2% including rare locations like renal subcapsular, hepatic subcapsular, splenic subcapsular, perinephric and retrovesical sites and walled-off necrosis in 4.6%. Vascular complications were seen in 24.8%, among which, thrombosis was seen in 20%, pseudo-aneurysm in 0.7%, hemorrhage in 3.1% and collaterals in 10% of the cases. Pancreatico-pleural fistula was seen in 2.3%, Traumatic pancreatitis in 1.5%, groove pancreatitis in 0.7%, ascites in 72.8% and Pleural effusion was seen in 43.4% of the cases. Conclusion: Pancreatitis is associated with a wide variety of complications. Some complications of pancreatitis have atypical presentations. CECT plays an important role in diagnosing these complications, guiding management and reducing morbidity

Features of the development of traumatic pancreatitis with gunshot wounds to the abdomen

The features of the development of traumatic pancreatitis in gunshot wounds of the abdomen, which present difficulties in timely diagnosis, are considered, hypotheses are formulated for studying the problem. Two clinical cases of developing traumatic pancreatitis against the background of a gunshot wound to the abdomen with indirect damage to the pancreas are presented. Without taking into account the peculiarities of the formation of the wound canal relative to the organs of the abdomen, in conditions of limited diagnostic potential, there is a high probability of late diagnosis of traumatic pancreatitis, especially in indirect damage. Injuries to the organs of the upper half of the abdomen can be risk factors for indirect damage to the pancreas due to the effect of lateral impact energy and the formation of a temporary pulsating cavity. In general, the management of such wounded in a surgical hospital with limited diagnostic capabilities or with stage treatment in a local military conflict requires the surgeon to know the peculiarities of the course of traumatic pancreatitis, which make it possible to prevent the development of complications in a timely manner. The development of traumatic pancreatitis in penetrating gunshot wounds to the abdomen is not always a consequence of direct pancreatic injury. This circumstance must always be taken into account during a diagnostic laparotomy.