Whether or not clinical treatment and research on emergent abdominal diseases should be based on “EBM” has not been widely discussed in Japan. Today, I will discuss my subjective strategy, especially with regard to EBM, for emergent diseases of the liver, biliary system, and pancreas. “Individuality” and “humanity” are essential to the practise of medicine, along with objective decision-making skills. Moreover, clinical guidelines for the treatment of various diseases should contribute to the well-being of patients. In this lecture, the clinical guidelines and an actual analysis of reports on fulminant hepatitis and biliary inflammatory diseases as well as the significance of minimal pancreatectomies for pancreatic trauma will be discussed. Moreover, recent limitations in emergent abdominal medicine, such as irreversible organ failures and uncontrollable infections, etc, will be described. Fundamental basic research towards the resolution of these pathophysiologies will also be introduced in particular, the importance of small hepatocytes in artificial bio-livers will be described.

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[Aim] To determine useful parameters for deciding when to withdraw acute apheresis therapy from patients with acute renal failure associated with abdominal disease, we evaluated the changes in parameters related to renal and non-renal functions in these patients. [Methods] Twenty patients with severe abdominal diseases who developed acute renal failure underwent acute apheresis therapy at our institution between 1994 and 2001. Seven of these patients were males and 13 were females, with a mean age of 76.7 years. Eleven parameters (leukocyte count, platelet count, base excess, blood urea nitrogen level, serum creatinine level, APACHE II score, septic severity score (SSS), serum bilirubin level, PaO₂, urine volume per hour, and mean blood pressure) were compared before induction and after the withdrawal of apheresis therapy. [Results] Continuous Hemodiafiltration (CHDF) and endotoxin adsorption (PMX) were applied in 17 cases. Among the parameters assessed, the platelet count, SSS, urine volume per hour, PaO₂, and mean blood pressure significantly improved with treatment (p<0.05). The platelet count, urine volume per hour, PaO₂, and mean blood pressure are related to the functions of four of the seven organs included in SSS evaluations. [Conclusion] These data indicate that SSS, a parameter of the severity of infectious disease, is a useful single factor for deciding when to terminate acute apheresis therapy.

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Informed consent (IC) consisting of informed disclosure, informed choice, and informed decision in acute abdomen is summarized as follows: (1) Acute abdomen is divided into 3 stages based on emergency. (2) Treatment without IC in acute abdomen is permitted. (3) Acute abdomen depends on individual diagnosis and treatment., (4) IC is a human right. (5) IC is based on the individual's permission. (6) Treatment without IC is exceptional in acute abdomen. (7) IC processes may be recorded after an emergency. (8) Medical records must be written reasonably. (9) IC after an emergency is important.

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Emergency abdominal surgery is sometimes done without confirmed diagnosis, so informed consent in emergency surgery of necessity differs from that for elective surgery. Particularly in intensive and critical care centers, the physical condition of patients is not always known, and in some cases, family members cannot be contacted preoperatively. In the physician-patient relationship, the discretionary power of physicians thus becomes much greater in such cases. To build favorable physician-patient relationships, informed consent must be viewed as an ongoing process and patient consent must be sought postoperatively.

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We have conducted 380 laparoscopic appendectomies since July 1991 involving injury to the bladder and bleeding of the omentum, but no wound infection, abdominal abscess, or ileus, which are common complications of open surgery. Since acute appendicitis is common, people tend to view its prognosis optimistically. In fact however, it is difficult to treat and to decide whether to operate. It also involves many postoperative complications. These facts must be explained to patients and their families to develop their awareness of what appendectomy actually involves.

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Abdominal emergency surgery has been done frequently to save lives, to impove general conditions and to removo discomforts. Informed consent forms are reqired to obtain from patients for anesthesia. Informed consent includes offering of informations by physicians and understandind, assenting selection and consenting by the patients. So, anesthsiologists have to inform the real risks of anesthesia. We analysed the mortality of patients with abdominal operation under anesthesia. The revealed was a high frequency of death as 3.8% within one month after anesthesia and operation. Theb reasons why the patients showed a high mortality were revealed as older age of patients, high rate of complications which are threatening lives of the patients. The informed consent should includs the informations on the higher mortality in abdominal emergency operations than elective ones.

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It is difficult to gain informed consent for patients with acute abdomen and abdominal trauma with hemorrhagic shock. We discuss issues involved in emergency blood transfusion. According to our medical manual, O+RBC is transfused first for patients unable to wait to complete blood typing. We conduct transfusion based on our direct examination and do not rely on examination at other hospitals or the Red Cross. We do not transfuse packed RBC brought to our hospital with a transfered patient. For patients who refuse blood transfusion, we do not conduct transfusion with an escape certificate if the patient is over 15 years old and alert or over 15 and unconscious but having a written statement of consent. We conduct transfusion if the patient is over 15 and unconscious and has a vague statement and if the family wants the transfusion.

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A 50-year-old woman was admitted to our hospital because of massive melena. She had experienced melena three times previously (one, five, and fifteen years earlier), CT and sonography examinations showed a tumor 5cm in diameter and located in her pelvis. During a laparotomy, the tumor was found in the jejunum, located 60cm from the Treitz ligament (toward the anus). The tumor was removed by intestinal resection. As the cells of the tumor were spindle-type and c-kit and CD 34 immunostaining procedures were positive, a gastrointestinal stromal tumor was diagnosed. In patients with massive melena, the possibility of a gastrointestinal stromal tumor in the small intestine should be considered.

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Two cases of chlamydia peritonitis presenting with an acute abdomen in teenaged women are reported. Case 1 was a 15-year-old woman with abdominal pain and nausea. Because the woman's abdominal paindid not improve after receiving an injection of antibiotics, she underwent a laproscopic-assisted operation. Case 2 was a 17-year-old woman with a right lower abdominal pain. She had been previously diagnosed as having chlamydia cervicitis and was taking clarithromycin at the time. She was suspected of having acute appendicitis and underwent a laparotomy. Yellowish-red ascities were found, but the appendix showed no evidence of inflammation. Swollen mesenteric lymph nodes were observed intra-operatively near the ileum in case 1. Both patients tested positive for chlamydia IgA and IgG antibodies in their sera a few days after their operations. Recently, the incidence of sexually transmitted diseases have been increasing in young women. Therefore, chlamydial peritonitis should be considered as a possible underlying disease, and confirmed by detecting serum chlamydial antibodies in young women presenting with lower abdominal pain.

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A 64-year-old female was referred to our hospital because of a left lower abdominal pain and melena. Upon admission, fever, abdominal pain in the left lower quadrant with defense musclare and rebound tenderness, leukocytosis, and an elevated CRP level were noted. Abdominal US and CT scans revealed a segmental wall thickening of the small intestine on the left side of the abdomen and ascites. Abdominal power-Doppler US and enhanced-CT scans revealed that blood flow was preserved on the mesenteric side of the small intestine. During surgery, a 90-cm-long jejunal segment was observed to be severely congested; this segment was located about 70cm distal from Treitz's ligament. The congestion was caused by strangulation from an adhesive band between the jejunum and sigmoid colon. The strangulation and intestinal ischemia were relieved after the resection of the adhesive band. The patient was discharged on the 23rd postoperative day.

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A 35-year-old man was admitted to our hospital after being involved in a traffic accident on November 19, 2000. A contrast-enhanced CT scan of his abdomen revealed a small amount of ascites. On the third post-admission day, his temperature rose to 39 degrees centigrade and his serum amylase level became elevated. We diagnosed the patient as having an intestinal perforation with general peritonitis and performed a laparotomy. Since the mesentery of the ileum was injured and the ileum was necrotic, a partial ileotomy and ileostomy were performed. On the 21st post-operative day, his temperature rose once again. CT and intravenous digital subtraction angiography examinations demonstrated a pseudoaneurysm in a branch of the superior mesenteric artery (SMA). Previous reports indicate that traumatic pseudoaneurysm of an SMA branch is relatively rare. To date, six cases have been reported. We decided not to treat the traumatic pseudoaneurysm of the ileal artery using transcatheter arterial embolization (TAE), Instead, we treated the patient surgically to prevent any injury to the pseudoaeurysm's wall, which had been weakened by the spread of inflammation and ileum necrosis. In retrospect, careful treatment of the injured mesentery to stop bleeding during the first operation could have prevented the formation of the pseudoaneurysm.

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Delayed stenosis of the small intestine after blunt abdominal trauma is rare. A 26-year-old male receiveda blunt force to his right elbow and abdomen during an accident. An emergency operation was perfomed at another hospital. However, his abdominal pain and diarrhea was aggravated when he ate, so he was admitted to our hospital. Although we attempted to treat him using conservative therapy for one month, his symptoms persisted. An exploratory laparotomy subsequently revealed stenosis and wall-thickening of the ileum in a section about 13cm long on the oral side, about 30cm distant from Bauhin's valve. A partial resection of the intestine was performed. The outcome of the surgical treatment in this case was good. Delayed stenosis of the small intestine should be considered when a patient complains of ileus symptoms after reuiving a blunt abdominal trauma.

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We treated a rare case of intestinal necrosis and intussusception caused by Meckel diverticulum. A 45-year-old man was admitted to hospital complaining of an upper abdominal pain. A fist-sized tumor was palpable, and computed tomography revealed intussusception of both the small and large intestines. During an emergency operation, the intussusception was observed to have been induced by an invaginated Meckel diverticulum. Since the ascending colon and terminal ileum were necrotic, a right hemicolectomy was conducted, involving a portion of the diverticulum. Histologically, the diverticulum exhibited ectopic pancreatic tissue. The patient's postoperative course was good, and he was discharged on the 14th postoperative day.

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Case 1 was a 64-year-old, unrestrained male driver who crashed into a street pole. He was transferred to our hospital and was in shock upon arrival. He underwent an operation for a liver injury (deep and complex), supermesenteric venous injuries, a mesenteric injury, and gastric rupture. During the operation, hypothermia, metabolic acidosis, and coagulopathy were observed to be progressing. We performed Damage Control Surgery (DCS), and a subsequent curative operation was performed fourteen hours later. The patient improved after receiving ARDS and DIC define. Case 2 was a 71-year-old, unrestrained male driver who crashed into a truck. He was in hypovolemic shock upon admission. A CT examination revealed mesenteric injuries. The patient underwent DCS, and a curative operation was performed seventeen hours after the initial operation. The complications in this case included heart failure and wound infection, but the patient eventually improved. We closed the abdomen using the “open method” to prevent Abdominal Compartment Syndrome. We believe that DCS should be a standard operation for patients with severe abdominal trauma and shock.

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We report a case of a bleeding Meckel diverticulum that was successfully diagnosed using intestinal barium studies and subsequently treated using laparoscopy-assisted surgery. A 17-year-old man was admitted to hospital because of melena. An upper and lower gastrointestinal endoscopy did not reveal anysite of bleeding. A selective angiography of the superior and inferior mesenteric artery did not demonstrate extravasation. Bleeding from a Meckel diverticulum was suspected and intestinal barium studies revealed an intrapelvic diverticulum with stalk. Laparoscopic surgery was performed, and a Meckel diverticulum was observed. The diverticulum was located 75cm from the ileocecal valve; a sleeve resection was performed. Ectopic gastric mucosa was observed in the resected specimen. Meckel diverticulum should be considered as a potential site of intestinal bleeding in youths; in such cases, minimally invasive surgery using a laparoscopy is useful.

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We report a gas-producing pyogenic abscess in the liver and review similar cases reported in Japanese medical literature. A 60-year-old male with a past history of diabetes mellitus was admitted to hospital complaining of a high fever and general malaise. He had undergone a pylorus-preserving pancreatoduodenectomy for the treatment of pancreatic head cancer. Ultrasonography and CT examinations showed a gas-producing pyogenic abscess in the right lobe of the liver. Percutaneous transhepatic drainage of the abscess was performed under ultrasonographic guidance. Klebsiella pneumoniae was detected in a culture of the abscess' contents. Both intrahepatic and subphrenic abscesses were successfuly drained, and the abscesses gradually decreased in size. Four weeks after drainage, the patient died from bleeding in the gastrointestinal tract, probably as a result of the local recurrence of pancreatic head cancer.

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Gallstone ileus is a relatively rare complication of cholelithiasis resulting from the passage of a gallstone into the bowel lumen. Cases involving impaction in the third portion of the duodenum are very rare. A 78-year-old woman was examined for ileus, and an endoscopic examination of the upper gastrointestinal tract revealed an obstruction caused by a gallstone. The gallstone was impacted in the third portion of the duodenum, resulting in a diagnosis of gallstone ileus. The patient underwent a one-stage enterolithotomy at the jejunum, cholecystectomy, and repair of the cholecyst-enteric fistula. Out of 111 cases of gallstone ileus reported in Japanese medical literature, impaction in the duodenum was described in only 13 cases. The present paper describes a case of gallstone ileus impaeted duodenum and reviews 13 similar cases.

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We report a case of a IIIb-type pancreas head injury diagnosed by bolus-injection, contrast-enhanced helical CT and treated using a distal pancreatogastrostomy. A 19-year-old woman, who had been involved in a traffic accident, in which she received a contusion in her upper abdomen, was referred to our department from a neighborhood hospital. Although a pancreas injury was diagnosed by a drip-infusion contrastenhanced CT examination, the degree of severity could not be assessed. Therefore, after an intra-tracheal intubation was performed, a bolus-injection, contrast-enhanced helical CT examination was performed; this examination revealed a complete transection of the pancreas on the right side of the superior mesentericvein and portal vein. She underwent an emergent laparotomy, and the same findings as those revealed by the CT scan were obtained. The proximal end of the main pancreatic duct was ligated, and the distal side of the duct was cannulated and anastomosed to the posterior wall of the stomach (distal pancreatogastrostomy). The postoperative course was uneventful; the patient's pancreatic function was well preserved, and she eventually returned to her routine work. In conclusion, bolus-injection, contrast-enhanced helical CT examinations are useful for assessing the degree of pancreatic injury. Moreover, a distal pancreatogastrostomy is a simple and safe procedure that enables pancreatic tissue function to be preserved in patients with III-type pancreatic injuries.

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Massive hemorrhage is a rare complication of Crohn disease. Although conservative treatment often produces favorable results, we report a case of Crohn disease with massive hemorrhage that was treated using emergency surgery. A 32-year-old man was diagnosed by a local medical doctor as having Crohn disease of the large intestine and was treated using an administration of mesalazine and an alimental diet. However, the patient was subsequently admitted to hospital because of severe abdominal pain. He was treated with intravenous hyperalimentation, but he subsequently developed melena. A colonoscopy showed an exposed vessel in a longitudinal ulcer within the sigmoid colon. The vessel was clipped and tattooed. On the following day, the melena recurred, and his blood pressure gradually decreased. Consequently, the patient underwent emergency surgery. Operative findings showed thickening and redness in the lower sigmoid colon. The sigmoid colon was partly cut to confirm the site of bleeding, and an expansive and exposed vessel was detected. We performed a wedge resection of the sigmoid colon and ligated the arterial branch that appeared to be a feeder from the serous membrane. The patient has not experienced any other bleeding for eleven months since the surgery.

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