X-ray Abdomen Erect Research Articles

Clinical study of peptic ulcer perforation in eastern India: An tertiary institution-based study

Background: Every year peptic ulcer disease affects 4 million people around the world. Perforation is the second most common ulcer-related complication. Ulcer perforation was a lethal disease until surgical treatment was introduced. Objectives: This study was performed to assess the demographic distribution of peptic ulcer, to assess the clinical presentations of peptic ulcer perforation, to evaluate the site of perforation and effective method of treatment, and to study the complication of peptic ulcer perforation and its management. Material and Methods: This is a cross-sectional study, which was conducted from May 2013 until April 2016 at RIMS, Ranchi. A detailed history was taken and clinical examination of the patient was carried out at the time of admission. X-ray abdomen erect posture, leukocyte count, serum amylase were performed along with other investigations. After surgery, site of perforation type of surgery along with any complications and outcome of treatment were recorded. Patients were followed-up for 30 days. Results: A total of 91 patients were studied with men and women ratio of 3.55:1. Most common age group was the 4th decade with mean age being 36 years, while most common symptom was abdominal pain. X-ray abdomen erect showed gas under diaphragm in 75 (82.41%) patients and leukocytosis was present in 91.21% of cases. Duodenal perforations (n = 77, i.e., 84.62%) were more common than gastric perforations (n = 14, i.e., 15.38%). Simple closure with omental patch (n = 74, i.e., 81.32%) was the most common surgical method employed. Wound sepsis (n = 45, 49.4%) was the most common complication. Conclusion: Perforation of peptic ulcer is one of the most common causes which require emergency laparotomy. Duodenum and pylorus are commonly involved and simple closure with omental patch was effective. Early operation is the key to successful treatment and minimizes mortality.

Clinical study of perforative peritonitis and the role of mannheim peritonitis index in predicting its mortality

Background: A scoring system which can compare patient populations and severity of illness, objectively predict mortality, morbidity and can help to evaluate the treatment strategy is the dire need for evaluative research of intensive care. Methods: The study is done after obtaining a detailed history, complete general physical examination and systemic examination. The patients are subjected to relevant investigations like X-ray erect abdomen, CXR, USG and routine investigations like Hb, TC, urea, creatinine, serum electrolytes. Results: The study was conducted in a population of 50 patients who had been diagnosed as having peritonitis secondary to hollow viscous perforation. It was observed that perforated appendix was most common cause of peritonitis in our study accounting for 26 percent of the cases. Conclusions: Despite advancements in the realm of medical science, the management of patients with peritonitis continues to be demanding. In our study it was found that appendicular perforation was the most common cause followed by gastro duodenal perforation.

Prognostic factors in perforative peritonitis: an observational study

Background: Perforative peritonitis is the most common surgical emergency in India that requires prompt and optimum surgical attention. Despite advances in surgical techniques, antimicrobial therapy and intensive care support, management of peritonitis continues to be highly demanding, difficult and complex. This study was aimed to identify factors in patients with peritonitis which have a significant bearing on morbidity and mortality. Methods: The study was a single center, prospective observational study conducted in Lokmanya Tilak Municipal Hospital, Sion, Mumbai. 50 patients with perforative peritonitis presented to the emergency were included in our study. Detailed history & clinical examination performed, routine blood investigation were done followed by the use of appropriate diagnostic procedures such as X-ray erect abdomen, with additional help of abdominal ultrasound and abdominal CT scan. Different parameters were studied and analyzed. Results: 50 patients studied with age range 18-60 years with mean age of presentation 36.80 years and mortality rate was 16%. Majority of cases were male 88%. Tuberculosis was the most common co-morbidity (16%), most common site of perforation was gastroduodenal perforation (61%) [duodenum (48.9%) gastric (12.8%)] with peptic ulcer as the most common histopathology. We found most of the patients having no growth in peritoneal contamination followed by E. coli (34%) highly sensitive to amikacin. Most common complication was wound infection. We found delayed presentation >24 hrs, blood pressure /=24/min, number of perforation, size of perforation >/=1 cm, site of perforation, amount of contamination >1000 ml and Mannheim’s peritonitis index were the prognostic factors associated with morbidity. We could not find association between older age, sex, creatinine and hemoglobin but they were associated morbidity. Conclusions: The late admission to the hospital a very important cause of adverse outcome, leads to deterioration of patients. Tachycardia, tachypnea, hypotension, anemia, renal failure and septicemia, amount of contamination, size and number of perforations are the factors significantly predicting death (each significant at 5%). Thus, if patients having above mentioned symptoms could be detected early and prompt treatment could be provided accordingly; mortality can be reduced.

Angiosarcoma of small intestine presenting with intestinal obstruction

Angiosarcomas are rare high-grade vascular tumors that mostly have poor prognosis. The pathogenesis of an intestinal Angiosarcoma is not clear and many etiologic factors have been suggested. In this report, we reviewed the English-written literature about primary intestinal Angiosarcomas and analyzed a case of 50-year-old male patient with intestinal Angiosarcoma presenting with intestinal obstruction and acute abdominal pain and absolute constipation. We report a unique case of Angiosarcoma of small intestine presented with intestinal obstruction. A 50-year-old male patient came with complaint of pain, vomiting, abdominal distension and absolute constipation. Investigations suggested he was anemic. X-ray abdomen erect suggested multiple air fluid level. USG revealed intestinal obstruction. Emergency Exploratory Laparotomy was performed; there was Intra-abdominal tumor present over the serosal surface of ileum with torsion causing Volvulus of small bowel leading to obstruction. Histopathology and Immunohistochemistry confirmed the tumor to be Angiosarcoma arising from small intestine. Literature review has suggested exploratory laparotomy is the definitive diagnosis. Prognosis tends to be favorable after resection.

Acute Intestinal Obstruction in Children: Experience in a Tertiary Care Hospital

Acute Intestinal Obstruction is one of the commonest surgical emergencies in children. These cases are invariably operated upon by general surgeons as pediatric surgeons are very few in Nepal. Outcome to a great extent depends on prompt clinical diagnosis and treatment. This is prospective study of 51 cases of intestinal obstruction admitted, operated and treated at Manipal Teaching Hospital, a tertiary care hospital in the Western Region of Nepal from January 2011 to September 2015. Aim of the study was to observe the pattern of intestinal obstruction in children and the treatment outcome in the hands of general surgeons. Number of cases in the cohort was 51. Out of that 50 cases were operated upon and 1 case was managed conservatively. Age of the patients’ ranged from 1 day to15 years (median age 9 months); There were 33 males and 18 females with a ratio of 1.8:1. Causes of intestinal obstruction were Intussusceptions (33), Meckel’s diverticulum (6), obstructed /strangulated hernia(4), imperforate anus(2), Hirschprung’s disease(2), Meconium ileus (1), Ladd’s band with malrotation of mid gut (1),annular pancreas(1) and Adhesions (1) Base line investigations of CBC, BT, CT, PT and serum electrolytes were done in all the cases. Plain x-ray abdomen erect and supine, ultrasonography (USG) and computed tomography (CT) scan were done in most of the cases and. Contrast study using Diatrizoate Meglumine (Gastrografin) was done wherever necessary. There were 3 mortalities and 2 cases had postoperative complications. Average post operative Hospital stay was 6 days. Early diagnosis and surgical intervention gives favorable outcome, delay increases morbidity and mortality. All these cases were taken up by general surgeons and the results were encouraging and good.

English

INTRODUCTION: The kidney is the most commonly injured genitourinary organ in 1- 5% of all trauma patients. Blunt trauma is the most common mechanism of injury although penetrating injuries are becoming more common due to increasing violence. The management of patients with blunt abdominal injury has evolved greatly over the last few decades. Although renal trauma can be life threatening, most injures can be managed conservatively. AIMS AND OBJECTIVES: To evaluate the efficacy, safety and outcome of the conservative management of renal trauma and to study the role of surgical management of renal trauma in the present era. MATERIALS AND METHODS: From January 2012 to December 2013 42 patients admitted to our department with renal trauma were analyzed. All the patients were initially managed by resuscitation. The diagnosis was made by physical examination, clinical findings supported by plain X-ray abdomen erect posture, ultrasound Abdomen, CECT Abdomen. Associated organ system injuries were addressed accordingly. Stabilized patients (grade I-III) were kept on conservative management. Some grade IV and all grade V cases were taken up for surgery. RESULTS: Highest incidence of renal trauma was observed in 2nd and 3rd decade of life. Youngest being 6 years old and eldest was 55 years old. 35 males and 7 females. Blunt injury in 38 cases, stab in 2, fall on to a rod - 1, gunshot-1. Majority presented with hematuria and flank pain. 27 presented with minor injuries requiring conservative management. 15 presented with grade V injuries. Out of which 3 responded to conservative management 12 required surgery. CONCLUSION: in patients with AAST Grade I, II, III conservative management proven to have good success rate and high renal salvage. In AAST -Grade IV with other abdominal injuries renal

Cecal volvulus-a diagnostic challenge.

A 12-year-old male child with mental retardation and cerebral palsy since birth on treatment was admitted with pain and distension of abdomen since three days and vomiting since two days. He was not passing stools and flatus since three days. On examination, abdomen was distended and tense. There was tenderness on palpation and tympanic note all over abdomen on percussion. On per rectal examination, rectum was empty and no flatus was observed on passing the flatus tube. Initial X-ray abdomen in erect position showed dilated bowel loops filling the upper abdomen occupying both the hypochondria [Table/Fig-1a]. We managed conservatively by doing continuous nasogastric aspiration and passing flatus tube for 24 h. X-ray abdomen was repeated after 24 h which showed no much difference compared to the previous film [Table/Fig-1b]. Abdominal ultrasonography showed gaseous distended bowel loops without any free fluid in abdomen. Routine laboratory investigations including serum electrolytes were within normal limits. [Table/Fig-1a]: X-Ray abdomen erect on admission [Table/Fig-1b]: X-Ray abdomen erect after 24 h Based on the above findings, we suspected intestinal obstruction as the primary cause and planned for exploratory laparotomy. On exploration, it was found that, there was a gross dilatation of cecum, ascending colon and hepatic flexure and twisted around the mesocolon by two turns clock wise as the cecum and ascending colon was not fixed [Table/Fig-2a]. There was congestion of bowel which improved on oxygenation [Table/Fig-2b]. Hence, cecostomy was done after decompressing the colon by passing flatus tube per anus. Post operatively, patient improved and passed stools freely on third post operative day. Cecostomy drain was removed on ninth post operative day and he got discharged on 10th day. On follow up, he was doing well after three months. [Table/Fig-2a]: Showing dilated cecum, ascending colon, and transverse colon [Table/Fig-2b]: Showing congested bowel viable after detorsion of volvulus We would like to give attention to this uncommon cause of intestinal obstruction, which might be overlooked during the first hours after its onset and lead to serious sequelae, including cecal necrosis. Preoperative diagnosis of cecal volvulus is rarely achieved in most cases because of its rarity and non specific presentation [1]. Plain X-ray abdomen is the initial diagnostic test of choice in case of obstruction due to cecal volvulus [2]. It shows coffee bean sign where an axial view of dilated cecum with air and fluid pointing to left upper quadrant. Radiographs, however, will clearly diagnose the condition in less than 20% of the cases [3]. As in our case, we made an early diagnosis of cecal volvulus by serial radiological findings and clinical monitoring. Thus on exploration, detorsion made cecum viable and cecopexy with tube was performed. Prompt recognition and urgent treatment may avoid gangrenous changes of the bowel, which is believed to be an important cause of high morbidity and mortality.

Gangrenous Sigmoid Volvulus – A Case Report with review of literature

Sigmoid volvulus is a life threatening surgical emergency which demands early surgical intervention. The condition is prevalent all over the world. Both sexes can be involved but more common in males. Mostly it is a disease of elderly males but can occur in neonates to young individuals. The condition presents in two distinct form gangrenous and non gangrenous sigmoid volvulus. Gangrenous volvulus is associated with high morbidity. Volvulus patient presents with pain, distension of abdomen and absolute constipation. Plain X-ray erect abdomen will give us definite diagnosis. In doubtful cases double contrast barium enema will clinch the diagnosis. In non gangrenous sigmoid volvulus sigmoidopexy either by endoscopic or open surgery is the procedure of choice. Otherwise sigmoid resection with end to end anastomosis is a definite treatment of choice. In gangrenous sigmoid volvulus, Hartmann procedure with end colostomy is the safe and life saving procedure. We had a case of gangrenous sigmoid volvulus presented with pain, distension and absolute constipation with toxic symptoms. After taking X-ray erect abdomen the case was diagnosed as volvulus sigmoid. Hartmann's procedure was done after patient was resuscitated. Patient recovered well and discharged with a plan to close the colostomy after two months. We wish to present this case because it is a life threatening condition, death is certain if not treated early. We reviewed the literature regarding type of treatment since every surgeon is having his own line of approach to the problem.

English

• Introduction: peptic ulcer perforation in children is a rare entity. Very few cases have been reported. A case of peptic ulcer perforation in a 2-year-old child treated successfully is being reported. • Case Presentation : A 2-year old, Indian Hindu male child presented with pain abdomen, vomiting and absolute constipation. There was no past history suggestive of peptic ulcer disease in the patient or the family. Child was irritable & dehydrated with clinical features of peritonitis. X-ray abdomen erect posture showed bilateral gas under diaphragm. He underwent exploratory laparotomy; a perforation found in the first part of duodenum and was repaired with live omental patch. The post-operative period was uneventful. • Conclusion: The case presented, highlights an uncommon entity that is often not thought of. High level of suspicion will lead to early diagnosis & surgical intervention which will in turn reduce mortality.

English

Abdominal cocoon syndrome is characterized by encapsulation of the small bowel by a fibrous peritoneal sac. We describe the case of a middle aged male patient who presented with sub acute intestinal obstruction. Treatment involves exploratory laparotomy, excision of the sac and adhesiolysis. Early post operative small bowel obstruction is a rare entity in this disease and can be managed conservatively. It is important to have a high degree of suspicion as Abdominal cocoon syndrome has variable clinical presentation and non specific imaging findings. INTRODUCTION: Sclerosing peritoneal encapsulation is a rare developmental malformation characterized by the encasement of all or part of the small bowel by a thick, accessory peritoneal sheath [1]. It was first described by Owtschinnikow in 1907 as “peritonitis chronica fibrosa incapsulata” [2] and termed “abdominal cocoon” by Foo in 1978 [2,3] .It is characterized by a complete or partial encasement of the small bowel by a thick and fibrotic membrane (cocoons) The loops within the cocoon are normal and adherent to each other. Abdominal cocoon generally presents as recurrent acute or sub acute intestinal obstruction with or without a mass [4]. The ideal treatment is operative, with dissection of the membrane from the intestine and separation of adherent loops of the small bowel until they are laid free and return to their normal configuration. [5] CASE REPORT: A 35-year-old male presented with complains of multiple episodes of vomiting, constipation, and abdominal discomfort since twenty days. He suffered similar complaints about a month previously for which he underwent a diagnostic laparoscopy at a small nursing home, which revealed cocooning of small bowel loops. Patient was investigated for Tuberculosis of the abdomen; however ascitic fluid ADA levels and ESR were not suggestive of Tuberculosis. Physical examination revealed a mildly tender lump in the Left hypochondrium with minimal abdominal distension. There was no hyperperistalsis on auscultation of the abdomen. Patient was otherwise vitally stable and systemic examination was normal. Blood parameters were all within normal limits. X-ray erect abdomen revealed 4-5 air fluid levels; USG abdomen showed clumping of small bowel loops in the Left hypochondrium with distal small intestine free. A provisional diagnosis of sub acute intestinal obstruction was made and patient was kept nil per oral, nasogastric decompression and IV hydration was administered. CECT abdomen was done which revealed clumping of jejunal and ileal loops

Clinical Analysis, Management and Outcome of Intussusception in Children

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and management is essential to reduce morbidity and mortality. The objective was to To review the diagnostic criteria of intussusception in infants and children to increase awareness of attending personnel for effective management decrease the rate of operative treatment and complications. Materials and Methods: The data collected of all 38 patients admitted in Kanti Childrens Hospital between 2008 September to 2009 September were studied prospectively. Each patient was evaluated in regard to age at presentation, sex, signs and symptoms, diagnostic method, treatment (operative, non-operative). Results: During study period of one year there were a total of 20 (52%) males and 18 (48%) females of age 3 months to 6 years. Pain abdomen was seen in 25(66%), vomiting 16(42%), diarrhea 15(40%), blood mixed with stool 10(26%). These symptoms were seen in different combination. X-ray erect abdomen was done in 15 and ultrasound in all 38 cases. Ten out of 15 (66.6%) patients with early presentation and diagnosis had successful barium enema reduction.10 (66.6%) had successful reduction and admitted to our hospital. 28(74%) patients were undergone laparatomy. Among 28 (74%) patents that had lapartotomy, manual reduction was successful in 18 and 10 required bowel resection and anastomosis. Conclusion: The awareness of early features of intussusception is important for early referral to tertiary centers for successful non-operative barium reduction and reduce the need of laparotomies in children. Key words: Barium enema reduction; Children; Intussusception; Laparatomy DOI: http://dx.doi.org/10.3126/jnps.v32i1.5347 J. Nepal Paediatr. Soc. Vol.32(1) 2012 9-13

AN EXPERIENCE OF SIGMOID COLON VOLVULUS AT EMMERGENCY WARD LRH

BACKGROUND: Sigmoid volvulus is a serious condition due to rotation of sigmoid colon. Volvulusoften presents with abdominal colic and distention. It can be managed conservatively by colonoscopicdecompression, followed by optimization of patient and finally surgical procedure. The present studywas based on the comparison of resection of sigmoid colon and double barrel colostomy or resection andprimary anastomosisOBJECTIVE: Objective of the study was to compare the results of primary anastomosis and colostomyin patients presenting with sigmoid volvulus.METHODOLOGY: In this study a total of 48 patients with sigmoid volvulus coming to Accident &Emergency Department were included. All the patients were examined and investigated. After diagnosisbased on x-ray erect abdomen all the patients were admitted in Accident and Emergency ward. Afteradmission Full Blood count, urea, sugar, S. Electrolysis and ECG were also performed. Patients werecatheterized and a nasogastric tube passed for gastric decompression. All the patients were givenintravenous fluids antibiotics and prepared for surgery as facilities for colonoscopic sigmoidscopicdecompression were not available and decompressions by rectal tube was unsuccessfulRESULTS: Among the cases with sigmoid volvulus there were 36 males and 12 were females. Majority28 cases were in age range of 61-70 years. Eight patients had gangrene of sigmoid colon, 23 patients hadresection and colostomy while 20 had resection and primary anastomosis. Among the postoperativecomplications, 05 patients had wound infection and 01 wound dehiscence. Two patients died because ofsepsis and cardiopulmonary complications.CONCLUSION: Patients presenting as acute abdomen should have urgent laparotomy as soon aspossible. Decompression by colonoscope is the gold standard procedure for stable patients with sigmoidvolvulus. Sigmoidectomy and primary anastomosis is the procedure of choice as it not only avoidssecond admission and operation, but it also avoids the side effects and care of stoma, which is majorcause of morbidity and mortality.

Early management of mesenteric cyst prevents catastrophes: A single centre analysis of 17 cases

Mesenteric cysts are rare intra-abdominal masses in the paediatric age group with varied presentation, ranging from an asymptomatic mass to acute abdomen. This study reviews our experience in the diagnosis and treatment of 17 mesenteric cysts in our centre, with especial reference to acute abdominal symptoms. Seventeen patients (age less than 10 years) with mesenteric cysts were managed in our hospital. The age ranged from 15 days to 10 years. Patients were admitted with acute or chronic symptoms. They were evaluated with complete history, clinical examination, blood investigations and radiological investigations (x-ray abdomen erect, ultrasound abdomen (USG) and computed tomography (CT) scan in selected cases) to reach a provisional diagnosis. The diagnosis was proven on laparotomy and histologically confirmed. The main presenting symptoms were abdominal pain or lump. The most common mode of presentation was acute small intestinal obstruction. USG was not conclusive in all. Abdominal CT scan with intravenous contrast was diagnostic in nine patients. Five patients had volvulus on exploration. Cysts were located in small intestinal mesentery in 14 cases and three were in the sigmoid mesentery. Seven patients had complete excision, intestinal resection was required in four and marsupialisation with cauterisation of margins was done in six patients. Histologically, all were lymphangiomatous mesenteric cysts. The diagnosis of mesenteric cysts should be kept in mind in any patient presenting with acute abdominal symptoms. Small bowel volvulus with mesenteric cyst constituted a significant number in children with acute abdominal symptoms. Early diagnosis and treatment yields excellent outcome.

Massive air shadow in the abdomen

A two-month-old male infant presented in surgical emergency of our institution, with complaints of excessive crying, epigastric swelling and non bilious vomiting of one day. There was no history of such events before. On clinical examination, the infant was febrile with a temperature of 100°F, a pulse of 110/min, respiratory rate 30/min and BP within normal range. The epigastrium revealed fullness and tenderness on palpation. Bowel sounds were audible. X-ray abdomen erect was performed with AP and lateral views [Figures ​[Figures11 and ​and22]. Figure 1 Anteroposterior view Figure 2 Lateral view