A woman in her 90s visited another hospital with a history of abdominal pain and vomiting. Abdominal computed tomography (CT) showed ascites, which was subsequently diagnosed as bloody. She was brought to our hospital because of suspected bowel necrosis. Abdominal CT at our hospital revealed ileus, and we suspected the presence of non-occlusive Mesenteric ischemia (NOMI). Therefore, immediate surgery was performed after intra-arterial injection of papaverine hydrochloride. Intraoperatively, skip small intestinal necroses were observed extensively. We resected two segments of the intestine, but did not perform anastomoses as a damage control strategy. The patient was brought back to the intensive care unit with an open abdomen and was administered a continuous intra-arterial infusion of papaverine hydrochloride. The second-look surgery was performed about 40 hours later to confirm absence of progression of the intestinal necrosis before performing intestinal anastomoses. The postoperative course of the patient was good. Delayed diagnosis of NOMI may be fatal；however, no definite diagnostic criteria for NOMI have been established yet. Therefore, a strong index of suspicion for NOMI should be entertained at the first medical examination. Quick diagnosis and treatment are indispensable life-saving measures.
We report herein a case of small bowel perforation caused by a Press-Through Package (PTP) in a nonagenarian, which were able to diagnose preoperatively and successfully treat by laparoscopic surgery. A 92-year-old woman was admitted to the hospital with a history of abdominal pain. Abdominal CT at admission revealed a foreign body, seen as a circular high-density area surrounded by a low-density area, in the ileum, associated with ascites and air in the mesentery. We made the diagnosis of small bowel perforation caused by a PTP, and performed emergent laparoscopy. We found the perforation at a site 20 cm proximal to the terminal end of the ileum, and performed partial resection. The resected specimen confirmed that the perforation was indeed caused by a PTP. Although the number of reports of ingestion of PTPs is increasing, small bowel perforation caused by a PTP remains difficult to diagnose prior to surgery. It is important to improve the design and material quality of PTPs to avoid accidental swallowing and gastrointestinal injury.
A-68-year-old man was transported to our hospital by ambulance with a history of acute abdominal pain and vomiting. Abdominal CT revealed small intestinal obstruction and high-density materials on the oral side of the obstruction. Furthermore, the patient gave a history of eating 4 rice cakes the previous day. We made the diagnosis of small intestinal obstruction caused by the rice cakes, and the patient was observed under fasting and intravenous fluid administration. His symptoms improved within a few hours and he was discharged from the hospital on the third day after admission. While intestinal obstruction caused by specific foods is rare, rice cake ingestion is a well-known cause. Rice cakes consist of starch without amylose and do easily disintegrate；furthermore, swelling and bonding occur readily. Therefore, it is thought that ileus can easily occur with insufficient chewing. Detection of high-density materials on CT is a characteristic finding of rice cake ileus. Thus, a careful meal history and CT are useful for making the diagnosis.
An 81-year-old woman with a history of recurrent vomiting after meals was referred to our hospital for endoscopic evaluation to detect possible gastric stenosis. Abdominal computed tomography and an upper gastrointestinal series showed a calcified gastric tumor prolapsing into the duodenal bulb, causing the ball-valve syndrome. Emergency operation was performed. The gastroduodenal intussusception identified laparoscopically was reduced by Hutchinson’s maneuver through an extended incision. Intraoperative endoscopy revealed the diagnosis of gastric cancer in the middle-third of the gastric corpus, and open gastrectomy with systematic lymph node dissection was performed. Macroscopically, the resected specimen showed an elevated tumor measuring 4.5cm in diameter. Microscopically, the gastric tumor was identified as a mucinous carcinoma, classified as pT1b, pN0, M0, fStage IA according to the UICC classification. Herein, we have reported a rare case of calcified gastric cancer presenting with the ball-valve syndrome.
Objective: We describe a rare case of strangulated internal hernia occurring through the slit between the right iliac vein and ureter after laparoscopic radical hysterectomy. Case and Methods: A 43-year-old woman who had undergone laparoscopic radical hysterectomy and pelvic lymphadenectomy was admitted to our hospital complaining of upper abdominal pain. Abdominal contrast-enhanced computed tomography showed evidence of strangulated intestinal herniation. Emergency surgery was performed, which revealed a strangulated small bowel loop through the slit between the right iliac vein and the ureter. While we could not directly visualize the strangulated hernia, we could palpate a band corresponding to the strangulated bowel loop and released the strangulated small bowel by hand manipulation. A slit between the right iliac vein and ureter was found as the orifice for the internal herniation, which was closed it by simple suture to prevent recurrence. Results： There were no postoperative complications, and the patient was discharged on postoperative day 9. Conclusions：We considered that the slit through which the herniation occurred was an iatrogenic slit caused during pelvic lymphadenectomy, which has rarely been reported before. In cases of strangulated intestinal obstruction in the postoperative pelvic cavity, bands should be incised with care to ensure safety, because they might be closely related to blood vessels and/or the ureter.
A 68-year-old man was transferred by air ambulance to our hospital after sustaining injury in a traffic accident He had a past medical history of recurrence after surgery for distal bile duct carcinoma, diabetes, hypertension and benign prostatic hyperplasia. An emergency laparotomy was performed, because abdominal CT showed free air in the right abdominal wall and abdominal cavity. We found ascending colonic injury at the site of the peritoneal metastasis, and right hemi-colectomy with abdominal wall resection and ileostomy were performed. After the surgery, the patient developed deep surgical site infection (DSSI), and eventually died of cancer three months after the operation. Although colonic injury by blunt trauma is rare, the peritoneal recurrence infiltrating into the colon was thought to be a cause of the colonic injury in this case. Furthermore, the chemotherapy received before the injury and diabetes increased the susceptibility of the patient to DSSI caused by fungi and MRSA.
The patient was a 46-year-old man with a history of diabetes mellitus and three episodes of colonic diverticular bleeding. He had never been abroad, and there was no history of homosexuality. He visited our hospital with a history of fever and abdominal pain. Abdominal enhanced CT revealed multiple diverticula and extravasation in the ascending colon. Because the CT showed a dilated and thickened wall of the appendix, we diagnosed acute appendicitis resulting from appendiceal cancer, and performed an emergency right hemicolectomy. The removed colon showed multiple diverticula and the appendix wall was thickened. On day 7 after the operation, evidence of an inflammatory reaction remained. On day 8, a histopathological diagnosis of colitis caused by amoebiasis was obtained and the patient was treated with metronidazole. We report a rare case of amoebic colitis diagnosed by pathological examination after the operation.
While complications of cardiopulmonary resuscitation (CPR) have occasionally been described, there have been no reports yet of diaphragmatic injury occurring during CPR. Herein, we report a case of out-of-hospital cardiac arrest who was brought to the hospital with diaphragmatic injury, presumably caused by the chest compressions during CPR. An ambulance call was received for the patient, an 80-year-old man, after he collapsed at a cheap rooming house. When the emergency crew reached the patient, pulseless electrical activity (PEA) was recorded and CPR was started. Return of spontaneous circulation (ROSC) was initially achieved in the ambulance, but upon arrival at the hospital, only PEA could be recorded again. Therefore, the CPR was restarted, and ROSC was obtained. CT revealed multiple costochondral fractures on the right side, diaphragmatic injury, pneumothorax, and pneumoperitoneum. Despite thoracic drainage and intensive care management, the patient eventually died of cerebral edema. Chest compressions during CPR mainly cause injuries of the chest cage, particularly rib and sternal fractures. Our patient reported here also developed diaphragmatic injury, presumably caused by the costochondral fractures. We would like to emphasize here that a reduced incidence of the complications of CPR and consequently, an improved prognosis, can be obtained if CPR is administered in conformity with the Resuscitation Guidelines 2015.
A 28-year-old man was referred to our hospital with trauma sustained in a traffic accident. Physical examination revealed decreased breath sounds over the right chest regions. Contrast-enhanced multidetector-row CT (MDCT) with multiplanar image reconstruction (MPR) showed a focal constriction and a linear area of hypoattenuation in the herniated liver. No improvement of the breath sounds was noted even after placement of an intercostal drain. Surgery was performed under the diagnosis of right traumatic diaphragmatic hernia, which revealed herniation of the liver into the thoracic cavity. It was possible to restore the liver to its position with the addition of a thoracotomy in the seventh intercostal space. The right diaphragm showed a 15-cm long tear in the muscle extending from the dome to the ventral side. The diaphragmatic tear was sutured and the surgery was completed. The patient was transferred for rehabilitation after pelvic fracture on postoperative day 23, with no serious complications.
A 47-year-old man presented to the emergency department of our hospital, with a few days' history of right lower quadrant abdominal pain associated with nausea, chills and cold sweats. The pain was localized in the right lower quadrant, but there was no fever. Enhanced abdominal computed tomography showed a high-density lesion of fat tissue adjacent to the ascending colon, and we made the diagnosis of primary epiploic appendagitis of the ascending colon. The inflammation improved with antibiotic treatment initiated at the outpatient clinic. Primary epiploic appendagitis is a self-limiting disease with a good prognosis. The differential diagnosis includes acute appendicitis, because of the similar clinical course, and diverticulitis, because of the similar abdominal findings. As imaging often reveals characteristic findings in cases of epiploic appendagitis, this condition must be included in the differential diagnosis of patients presenting with acute abdomen, so that unnecessary surgery can be avoided. We have reported a case of primary epiploic appendagitis that was successfully diagnosed by computed tomography, and treated conservatively with antibiotics.
Case 1: A 78-year-old man was diagnosed as having perforation of a duodenal ulcer and retroperitoneal abscess. Conservative treatment by percutaneous drainage failed to yield improvement of the fistula. Case 2: A 40-year-old woman was diagnosed as having traumatic duodenal perforation caused by a traffic accident. Simple duodenal simple closure and omental patch closure were performed, however, leakage from the closure site and peritoneal abscess formation were observed. Therefore, both patients were transferred to our hospital for further treatment. Both received conservative treatment; in addition to drainage of the abscess, enteral nutrition was provided via a feeding tube that was guided caudally beyond the site of perforation. As a result, the abscess cavities shrank and the fistulae gradually closed, with improvement of the nutritional condition, in both patients. It is possible to guide a feeding tube caudally beyond the fistula site even in patients with upper gastrointestinal fistulae. We consider that enteral nutrition is effective for patients with upper gastrointestinal fistulae in terms of improving the nutrition status and reducing the invasiveness of treatment, and may serve as a good therapeutic alternative for patients with a poor performance status.
We report a case of acute appendicitis associated with appendiceal endometriosis. A 48-year-old woman was admitted to our hospital with right lower abdominal pain. Although blood examination showed only slightly increased levels of the inflammatory reactants, abdominal computed tomography showed a markedly swollen appendix, with a small fluid collection around the swollen appendix. Under a suspected clinical diagnosis of acute appendicitis, we performed emergency laparoscopic surgery. Dark red tissue was found adhering to the tip of the acutely inflamed appendix, a finding that was highly suggestive of appendiceal endometriosis. Based on a diagnosis of acute appendicitis associated with appendiceal endometriosis, we performed laparoscopic appendectomy. Histological examination of the resected specimen showed endometrial gland proliferation in the appendiceal muscularis propria. Although intestinal endometriosis is not uncommon, endometrial involvement of the appendix is rather rare. In females, endometriosis of the appendix should be considered as a possible cause of acute appendicitis.
Intestinal obstruction caused by Meckel's diverticulum is rare, and is reported to account for 0.3 to 1.5％ of all cases of bowel obstruction. Herein, we report four patients with intestinal obstruction caused by Meckel's diverticulum encountered by us over the past 9 years. All patients were male, ranging in age from a few days old to 76 years. Three patients were suspected as having ileus involving Meckel's diverticulum based on the findings of abdominal enhanced computed tomography. All the patients were treated by surgery. The following causes of intestinal obstruction were diagnosed intraoperatively: internal hernia caused by Meckel's diverticulum (three patients) and adhesive intestinal obstruction caused by Meckel's diverticulitis (one patient). Surgical treatment involved partial resection of the small intestine (two patients), wedge resection (one patient), and simple excision of the diverticulum (one patient). Pathological examination revealed ectopic tissue in one patient. The postoperative course was good in all cases. Enhanced computed tomography is useful for investigation of unexplained intestinal obstruction, and Meckel's diverticulum should be considered as a possible cause.
A 65-year-old woman visited another hospital with a history of abdominal pain. As a plain abdominal X-ray showed free air in the abdomen and abdominal CT scan showed evidence of perforation and peritonitis, the patient was transferred to our hospital for emergency operation. Physical examination revealed tenderness in the left lower quadrant. Laboratory data were consistent with an inflammatory process；the white blood cell count was 4,700/μL and the serum C-reactive protein level was 37.21mg/dL. Abdominal CT showed perforation of the proximal jejunum, with free air and a fluid collection around the perforation. We performed emergency laparotomy for proximal jejunal perforation. Intraoperatively, the jejunal perforation was seen 10 cm distal to the ligament of Treitz. We performed jejunal resection with duodeno-jejunal anastomosis (side-to-side) for reconstruction. The histopathological diagnosis was perforation of a pseudo-diverticulum in the proximal jejunum. The patient's postoperative course was uneventful.
We report a rare case of internal herniation through a defect in the right broad ligament of the uterus. A 55-year-old woman with a history of vaginal deliveries, but no previous abdominal surgery, was admitted to our hospital with a history of lower abdominal pain. We made the diagnosis of intestinal ileus and inserted a long nasointestinal tube for fluid drainage. However, on day 6 after admission, abdominal computed tomography revealed strangulation of the small intestine in the right pelvic cavity. We found that the internal herniation had occurred through an abnormal defect of the broad ligament of the uterus. Emergency operation was carried out, and intra-operatively, we found a 15-cm long segment of the ileum herniated through an abnormal defect of the right broad ligament measuring 3cm in diameter. The blood flow to the strangulated loop of ileum was good, therefore, no resection of the bowel was performed. The defect of the broad ligament was closed by direct suture. We emphasize the importance of considering this disease in female patients presenting with agnogenic intestinal obstruction, so as to ensure early diagnosis and prompt treatment.
A 45-year-old woman was transferred to our hospital with upper abdominal pain and discomfort caused by intussusception. Abdominal computed tomography showed multiple concentric ring signs in the transverse colon induced by a cystic tumor. The intussusception was easily reduced twice by air injection of colonoscopy colonoscopic air injection. From the endoscopic view, the tumor had a submucosal tumorlike appearance Endoscopically, the tumor was visualized as a submucosal tumor in the cecum. At surgery, a cecum-colon type of intussusception was seen, which was treated successfully by laparoscopic reduction, revealing a mucocele of the appendix. Laparoscopy-assisted ileocecal resection was then performed. The pathological diagnosis of the resected specimen was low-grade appendiceal mucinous neoplasm. We report a rare case of intussusception caused by a low-grade appendiceal mucinous neoplasm, which could be effectively treated by preoperative colonoscopic reduction followed by laparoscopic reduction and surgery.
A 25-year-old male patient was referred to our hospital with a history of lower abdominal pain. He had been diagnosed as having the vascular type of Ehlers-Danlos syndrome. Physical examination revealed slight tenderness and muscle guarding in the left lower abdomen, however, blood examination revealed no evidence of an inflammatory process. We suspected gastrointestinal perforation, which is often encountered in patients of Ehlers-Danlos syndrome. Abdominal CT revealed free air and a fluid collection in the lower abdominal space. We diagnosed acute peritonitis caused by perforation of the intestine, and performed emergency surgery. A pinhole perforation was found in the sigmoid colon. As the surrounding intestinal wall and mesenterium of the colon looked healthy, we performed wedge resection and suture of the perforated sigmoid colon. The postoperative course was uneventful and the patient was discharged 13 days after the surgery. Ehlers-Danlos syndrome is a hereditary disease characterized by lax tissues. The vascular type is the most serious type of the disease, as it is known to be complicated by vascular rupture, dissociation, and gastrointestinal perforation even at a young age of the patients. We report a case of Ehlers-Danlos syndrome, vascular type, in which we performed wedge resection and suture of the perforated sigmoid colon and obtained a good outcome.
Gallbladder injury due to blunt abdominal trauma is rare, because of the anatomical protection afforded to the gallbladder. Our case reported herein was a 29-year-old man who had been admitted to another hospital with pelvic bone fracture sustained in a traffic accident. As he developed a fever five days after the accident and his abdominal pain worsened in severity, he was brought to our hospital. Abdominal ultrasonography and contrast-enhanced CT revealed swelling of the gallbladder, and double layering of the gallbladder wall. We had a diagnosis of traumatic gallbladder injury and performed emergency cholecystectomy. Gallbladder injury is a rare disease, but could be fatal. Careful monitoring and prompt surgical treatment are necessary for life-saving.
A 78-year-old woman who had been on maintenance hemodialysis for diabetic nephropathy since 2005 and had taken sodium polystyrene sulfonate （Kayexalate, SPS） to control her potassium levels presented to our hospital with a history of abdominal pain. Abdominal computed tomography revealed free air and feces outside the intestinal tract. We diagnosed perforation of the sigmoid with perforative peritonitis, and performed emergency Hartmann’s operation. A 2-cm perforation was detected in the sigmoid colon. On histopathological examination, the SPS was found adhering to the perforated site on the intestine. As perforation and ulceration of the intestine have been reported as side effects of SPS, we considered that the perforation of the sigmoid colon in the present case might have been caused by the SPS.
Gallbladder torsion is a surgical emergency, but a preoperative diagnosis is sometimes difficult. With improvements in the techniques of imaging, some typical findings have been reported. Herein, we report a case of gallbladder torsion. The patient was a 93-year-old female who was admitted to our hospital with a history of abdominal pain. Abdominal CT showed a distended floating gallbladder, poor enhancement of the gallbladder wall and a tapering interruption of the cystic duct. From these findings, we made the diagnosis of gallbladder torsion and performed laparoscopic cholecystectomy. The postoperative course was favorable. We wish to emphasize that it is important to have knowledge of the typical imaging findings of gallbladder torsion and to perform imaging for accurate diagnosis of this condition.
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