[Purpose] We investigated the outcomes of 82 patients with perforating duodenal ulcers and developed criteria for selecting an appropriate treatment. [Methods] Conservative treatment (CTr) was used in patients that met the following conditions: age, 60 years or younger ; no risk; an interval of 6 hours or less between onset and treatment; no full stomach; 50mm or less of free gas or ascites retention visible on computed tomography (CT), images; and localized peritoneal irritative symptoms. Laparoscopic surgery (LC) was performed in patients treated within 24 hours of symptom onset and in whom conservative treatment was not indicated, excluding patients with severe or serious underlying diseases. A laparotomy (OC) was performed in patients with severe or serious underlying diseases, patients with a long interval between onset and treatment, and patients in whom the closure of the ulcer was difficult. [Results] CTr, LC, and OC were performed in 12, 65, and 5 patients, respectively. The duration of fasting, period during which analgesic agents were given, and the duration of admission were better shorter in the CTr and LC groups. [Conclusions] When treatment was selected based on the severity of the patient's condition, all treatments were safe and effective. In the future, however, the indications for conservative treatment and laparoscopic surgery should be clarified.

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Acute colorectal obstruction is a common complication of advanced colorectal carcinoma that necessi tates an emergency operation. However, because of colonic distension, fecal loading, and the poor general condition caused by colorectal obstructions, postoperative morbidity and mortality rates are high. Decompression using a transanal drainage tube is useful for avoiding an emergency operation or allowing a safe onestage operation to be performed. The use of a drainage tube is superior to that of an expandable metallic stent, from both a clinical and cost perspective, for preoperative therapy of acute colonic obstruc tion.

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We evaluated the effectiveness of interventional radiology (IVR) in combination with laparoscopic cholecystectomy (LC). Between November 1996 and September 2002, LC following percutaneous papillary balloon dilatation (PPBD) was performed in 43 patients for the treatment of cholecystocholedocholithiasis with cholangitis, and LC following percutaneous transhepatic gallbladder drainage (PTGBD) was performed in 36 patients for the treatment of acute cholecystitis. In 17 patients, PPBD following percutaneous transhepatic biliary drainage was performed 2 to 7 days prior to the LC, while in the remaining 26 patients, PPBD was performed simultaneously with the LC under a general anesthesia with the use of a muscle relaxant in one continuous session. The bile duct stones were successfully expelled into the duodenum in all the patients. The conversion to open surgery rate, the mean operative time for the LC and the average postoperative hospital stay were 0%, 73 minutes, and 11 days, respectively. PTGBD was performed 1 to 7 days prior to the LC. The success rate of the intraoperative cholangiography through the PTGBD tube, the conversion to open surgery rate, the mean operative time for the LC and the mean postoperative hospital stay were 97%, 3%, 82 minutes, and 10 days, respectively. We conclude that LC combined with IVR is an effective therapeutic option for cholecystocholedocholithiasis with cholangitis and acute cholecystitis.

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The characteristics of hemorrhagic findings on contrast-enhanced CT and angiography images were compared in patients with blunt liver and splenic trauma, and the efficacy of transcatheter arterial embolization (TAE) was clarified. Twenty cases of complex, severe liver trauma and nine cases of splenic trauma were analyzed. The frequency of extravasation findings tended to increase with the severity of the liver trauma; in cases with the same grade of injury, the presence of extravasation findings depended on the breadth of the damaged area. Infectious bile leakage, a postliver trauma complication, was seen in 6 cases after TAE, 4 of these 6 (67%) patients exhibited extravasation on CT and/or angiography images taken before the TAE. In contrast, the details of CT and angiography hemorrhagic findings were similar in cases of splenic trauma. In addition, the depiction of extravasation was more common in patients with severer diseases, as classified based on the CT findings. Some delayed hemorrhagic complications have been reported following TAE for liver and splenic trauma, but the incidence of these complications can be decreased by improving embolization techniques. We have performed TAE in segmental or subsegmental arteries in cases with liver or splenic trauma. Not only was a good hemostasis effect achieved, but rebleeding from the development of collateral arteries, was prevented and the undamaged regions of the liver or spleen were preserved.

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Interventional radiology (IVR) has become essential to the field of emergency medicine. This paper addresses the use of IVR in cases with blunt abdominal trauma, particularly in regard to the recent focus on the indications and methods of transcatheter arterial embolization (TAE). TAE should be adopted as a first line of treatment in cases with isolated abdominal parenchymal organ injuries and hemodynamic stability. TAE, originating from an expanded concept of “damage control”, is commonly used in conjunction with surgical interventions. However, concerns have been raised that delays in the selection of appropriate surgical interventions because of prolorged attempts to perform TAE may result in an escalation of mortality and morbidity rates. Thus, the general condition of a patient, in addition to local physical findings and the findings of imaging studies, must be taken into consideration when selecting appropriate therapeutic options.

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Abdominal visceral aneurysms and psuedoaneurysms are potentially life threatening. Recently, anincreasing number of patients have been treated using transcatheter arterial embolization (TAE). We reported the detailed presentation of 8 cases treated at our hospital and review the diagnosis and treatment of ruptured abdominal visceral aneurysms. Emergency angiography is essential for the diagnosis of a ruptured aneurysm. In our series, three of the aneurysms occurred in the hepatic artery, 3 in the splenic artery, and 2 in the superior mesenteric artery (SMA) region. TAE was performed in 7 cases, and one case, in which the aneurysm occurred in the SMA region, was treated by open laparotomy. TAE was successful in all 7 cases, and 6 out of 7 cases (86%) were rescued. The single fatality occurred in a patient with Ehlers Danlos syndrome, which is a serious disease with a poor prognosis. No complications of TAE were seen in any of the patients. Our results and several other case reports suggest that TAE is useful for primary hemostasis and can improve the mortality rate of patients with ruptured aneurysms. TAE should be used as the treatment of first choice in cases with ruptured abdominal visceral aneurysms.

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This review focuses on the technical aspects of IVR (Interventional Radiology) for the treatment of severe pelvic fractures. The important role of hemostatic transcatheter arterial embolization for the treatment of massive retroperitoneal hemorrhage associated with severe pelvic fracture and its timing are emphasized. The contribution of recent advances in angiographic catheters, embolic materials, and medical imaging equipment to this technique are stressed, and the limitations of this procedure are also discussed.

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Spigelian hernia is a rare hernia of the abdominal wall. We report a case of Spigelian hernia and an incarcerated small bowel. An 85-year-old man with no previous history of abdominal operation was referred to our hospital because of a pain in his left lower abdominal quadrant. A physical examination revealed a 4.5×4cm mass with tenderness in the left lower quadrant along the lateral border of the rectus abdominis muscle. Abdominal three-dimensional computed tomography (3D-CT) showed a defect of about 2.0cm aponeurosis at the lateral border of the rectus abdominis muscle and the prolapse of the small intestine through the internal and external oblique muscle under the aponeurosis of the external oblique muscle. Under a diagnosis of Spigelian hernia with incarceration of the small bowel that could not be reduced manually, we performed an emergency operation. Since ischemic changes in the herniated small bowel were slight, we performed a reduction of the small bowel and closed the hernia opening. The patient quickly recovered and was discharged from the hospital on the 10th postoperative day.

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A rare case of bladder diverticulitis with symptoms of peritonitis is reported. The patient was an 84-year old man who began to exhibit a fever around December 10, 2001, the patient received treatment for an urinary tract infection at a local hospital. He began to experience abdominal pain on December 13 and was referred to our hospital. A physical examination performed at the time of admission identified muscular defense and the Blumberg sign in the lower central abdomen. A contrast-enhanced CT scan of the abdomen showed a well-defined ventriculus extending from the bladder, leading to a diagnosis of peritonitis resulting from a bladder puncture; emergency surgery was performed on the same day. A diagnosis of bladder diverticulitis was made during the surgery, and a resection of the vesical diverticulum and a partial resection of the bladder were performed. The postoperative course was uneventful, and the patient was discharged on Day 28. Although bladder diverticulitis is a common condition, bladder diverticulitis combined with symptoms of peritonitis is rare and worth reporting.

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Duplication cysts of the alimentary tract are rare congenital malformations. Duplications usually present in infancy or chilhood, and presentation in adults is rare. A 35-year-old female was admitted to hospital because of the sudden onset of massive GI tract bleeding and abdominal pain. She had experienced several episodes of severe melena from the time of her infancy. Under a tentative diagnosis of a duplication of the small intestine, suggested by a closer examination, an emergency laparotomy was performed. During the laparotomy, a 30-cm long duplication cyst was found firmly attached to the ileum. A histological examination revealed that the ileal duplication contained gastric-pyloric glands and exhibited signs of ulceration. Careful angiograpies may be of great importance in the management of patients with massive hemorrhages of the gastrointestinal tract.

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We experienced a case of mesenteric abscess caused by an ingested fish bone that appeared to havepenetrated the third portion of the duodenum. A 48-year-old male with a 4-month history of repeatedabdominal pains visited our clinic because of increasing pain and a fever. The patient's body temperaturewas 39.5°C. On physical examination, a tender and firm mass was palpable around the umbilicus.Ultrasonography and computed tomography (CT) showed a cystic lesion containing a bone-like linearshadow contiguous with the third portion of the duodenum. When the patient's history was taken, hementioned that he had eaten sea bream. Therefere, a penetration of the duodenum caused by the fish boneand the formation of an abcess in the mesentery was suspected. Since the administration of antibiotics forone week did not improve his symptoms, surgery was performed. Intraoperatively, a hen's egg-sized masswas found in the proximal mesentery, with its superior margin contiguous with the third portion of theduodenum. To avoid injury of the superior mesenteric artery and vein, the abscess was opened and a fishbone, 2cm in length, was removed from the cavity under ultrasonographic guidance. The abscess cavity wasrinsed with saline, and a drainage tube was inserted. Postoperatively, the patient's general conditionpromptly improved, and he was discharged from hospital on the 12th postoperative day. Only ten cases, including the present case, of duodenal penetration by a fish bone have been reported in Japanese medicalliterature. These rare cases are reviewed.

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We report a case in which laparoscopic surgery was performed to remove an acupuncture needle lodgedin the abdominal cavity. The patient was a 71-year-old woman with a lodged acupuncture needle that hadbroken during treatment and had been left untreated. She visited our hospital about one month later becauseof an abdominal pain. An abdominal X ray revealed the broken needle, 50 mm in length, in the left abdomen.An abdominal CT showed the needle in the left retroperitoneal cavity and a thickened parietal peritoneumin the surrounding area. Haparoscopic surgery was performed to remove the needle. Unlike the preoperativediagnosis, the needle was found to have migrated to the greater omentum, accompanied by amesenteric hematoma and a small amount of bloody ascites. Although a fluoroscopy was used to find theneedle intraoperatively, the removal of the needle was not difficult. The postoperative course was uneventful, and the patient was discharged on the 5th postoperative day. To remove lodged needles in theabdominal cavity, laparoscopic surgery should be considered as the treatment of first choice since it has anumber of advantages compared to conventional surgery. The procedure is easy to perform and should beundertaken as early as possible, since a lodged needle could impair organs during its migration or the needleitself could erode.

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A 22-year old woman suffering from gunshot injuries was taken to our hospital. Her vital signs werestable, and two gunshot wounds, one on the right groin and one on the left buttock, were found. Macrohematuriaand vaginal hemorrhage were also present. A CT examination showed intraabdominal fluidcollection, so an emergent laparotomy was performed. On exploration, six perforations of the ileum werefound within an area of 20cm, located 50cm on the oral side of the ileum. The anterior wall of the uteruswas lacerated longitudinally, and the vagina was penetrated in the sagital direction. The posterior wall ofthe bladder was perforated at a position corresponding with the uterus laceration. The bullet appeared tohave entered from the right groin, penetrated the ileum three times, progressed between the uterus and thebladder, gone through the vagina, and exited from the left buttock. A 25-cm length of the ileum wasresected, and the uterus, bladder, and vagina were reconstructed. The postoperative course was uneventful, and the patient was discharged from hospital on the 21st postoperative day.

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A 53-year-old woman was admitted to our hospital because of bloody stools on June, 2001. Colonoscopicfindings led to a diagnosis of ulcerative colitis, and the patient was treated with mesalazine andpredonine. Her condition worsened, and leukocytopheresis therapy was started. In addition, predonine andulinastatin were injected via the superior and inferior mesenteric arteries. Despite these treatments, theclinical symptoms became aggravated, and colonoscopic findings indicated a worsening of the ulcerativecolitis. On August, 2001, the patient underwent an emergency operation because a toxic megacolon wasdetected by plain abdominal X-ray and severe peritoneal signs were recognized. Intraoperatively, the wallof the entire large intestine was found to be very thin, and the cecum was perforated. The large intestinewas resected, and an ileostomy was performed. Endotoxin adsorption therapy was performed twice becausethe patient showed signs of systemic inflammatory response syndrome (SIRS). The general condition of thepatient gradually improved, and the patient was discharged from hospital on November, 2001.

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The laparoscopic removal of a free intra-abdominal metallic foreign body, which had accidentally passedthrough the abdominal wall, was safely performed using an X-ray image scope. A 64-year-old man hadconsulted another doctor because of an abdominal pain that had occurred while he was operating a grinder.A metallic foreign body in his abdomen was suspected, based on the findings of a plain X-ray film, and hewas referred to our hospital. An abdominal CT scan revealed an intraabdominal metallic fragment ; noorgan injuries nor bleeding were visible. Preoperative examinations and preparations were performed withstrict observation of the patient's condition, and a laparoscopic operation was performed on the seventh dayafter the injury. Using an X-ray image scope, we found the metallic fragment completely hidden in thegreater omentum, the fragment was safely removed using laparoscopic forceps. The patient was dischargedfrom the hospital on the fourth day after the operation. Laparoscopic operations are minimally invasiveand can be safely performed using an X-ray image scope, which is a useful instrument for locating metallicforeign bodies.

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A case of allergic granulomatous angiitis (AGA) complicated by a gastric perforation is described. A 32-year-old woman who suffered from bronchial asthma was admitted to our hospital complaining of abdominalpain. Laboratory tests showed an increase in the WBC (29, 000/mm3) and eosinophil count (44.4%). Shewas tentatively diagnosed as having AGA, but gastric and colonic endoscopy examinations showed no signsof this condition. Six days later, the patient developed an acute abdominal pain and steroid-pulse therapywas started. In spite of the normalization of the WBC and eosinophil counts, a computed tomogramrevealed a small amount of free air in the ligamentum hepatoduodenale. A gastric perforation wasrecognized, and an emergency operation was performed. The histology of the resected stomach demonstratedvasculitis accompanied by granulomatus changes and eosinophil infiltration around the blood vessels. Onthe basis of the clinical and histologic features, she was dignosed as having AGA. She was effectivelytreated using 60mg of prednisolone daily.

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We report a case of Meckel's diverticulitis with abdominal wall abscess. A 76-year-old man was seen atthe hospital because of a right lower abdominal pain. A surgical scar was observed in the right lowerquadrant of the abdomen, and tenderness was noted at the same site. Meckel's diverticulitis was diagnosedbased on the findings of an abdominal CT scan and an oral small bowel fluoroscopy. His symptoms subsidedafter the administration of antibiotics, but stricture of the coronary artery and impaired cardiac functionwere noted during preoperative examinations. A percutaneous transluminal coronary angioplasty (PTCA) and the insertion of a stent were performed, followed by anticoagulation therapy for about one month.During this time, antibiotics therapy was conducted for a diverticulitis recurrence, but the treatment wasunsuccessful and an abdominal wall abscess gradually formed beneath the surgical scar. When a medianincision was made in the lower abdomen, the Meckel's diverticulum was found to have adhered to andpenetrated the abdominal wall right beneath the scar. After the adhesions were dissected, an ileocecalexcision was performed. The patient's postoperative course was uneventful.

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Atraumatic ruptures of the spleen are usually associated with hematologic and infectious diseases.Spontaneous splenic rupture without any underlying causative diseases is very rare. We report the case ofa spontaneous splenic rupture in a 13-year-old female admitted to hospital for a sudden abdominal pain.Abdominal computed tomography revealed multiple low-density areas in the spleen and intra-peritonealbloody ascites. Soon after a diagnosis of splenic rupture was made, a surgical operation was performed.Blood and clots totaling 700ml were aspirated from the peritoneal cavity, and a capsular tear in the lowerpole of the spleen was found; a splenectomy was therefore performed. The cut surface of the resectedspecimen revealed multiple hematomas of the spleen. On pathological examination, no findings of neoplasmwere found. The patient had no history of trauma, inflammation, hematologic abnormalities, vasculardisease, or any underlying causative diseases, such as neoplasm, so the case was diagnosed as a spontaneoussplenic rupture. The patient was discharged without complications on postoperative day 10. Spontaneoussplenic rupture should be considered in the differential diagnosis of acute abdominal pain in patients withno history of trauma or underlying causative diseases.

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We experienced a case with a localized abdominal abscess that was thought to be caused by an infectedurachal cyst; an emergency operation was performed because of localized peritonitis. A 38-year-oldfemale was admitted to hospital with severe abdominal pain and diarrhea. A mass was palpated in thecenter of her lower abdomen, and an abdominal computed tomography showed a cystic mass about 5cm indiameter lying beneath the peritoneum along the midline of the lower abdomen and in contact with thebladder. Coagulase-negative Staphylococcus (CNS) was detected in cultures of her watery stools. Inaddition, the patient had untreated diabetes mellitus. A laparotomy showed the formation of an abscess infront of the bladder and omentum penetration. The abscess cavity was surgically removed, and a drainagetube was inserted. CNS was detected in the abscess. The CT and operative findings suggested that theinfected urachal cyst had caused the abscess. A urachal cyst is a persistent structure of a fetus and isgenerally diagnosed by infection complications and the enlargement of the cyst. The formation of an intra-peritoneal abscess is rare. We suspect that the cause of the urachal cyst infection was a bacterialtranslocation from the intestine to the blood circulation because the patient was in an easily infectiouscondition as a result of her uncontrolled diabetes mellitus.

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A32-year-old man admitted for abdominal pain and vomitting was found on physical examination tohave a mass in the right lower abdomen. Abdominal US showed a mass surrounded by hyperechoic andhypoechoic layers. Abdominal CT showed a low-density tumor surrounded by concentric layers in theascending colon. A diagnosis of intestinal intussusception of the small intestine caused by lipoma made wasconfirmed upon lararotomy, i.e., ileum-colon antegrade intussusception, and an ileal tumor of 3.0×2.5cm.50cm from the Bauhin valve was found necessitating partial resection of the ileum. Resected materialshowed a 3.0×2.5cm polypoid tumor. Histopathologically, it revealed typical features compatible with thediagnosis of benign lipoma.

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A51-year-old woman reported discomfort in the right lower abdomen from around July 1999. Black feceswere seen from February 2000. A fist-sized tumor was felt at the right lower abdomen. Endoscopy of thelarge intestine showed blood accumulating in the ascending colon but no tumor. Suspected of hemorrhagein the small intestine, the patient was hospitalized. CT and MRI indicated a tumor in the pelvis. Surgeryshowed a tumor in the right pelvic cavity closely associated with the appendix, presenting infiltrativeadhesion with the uterus and the right ovary, and direct infiltration to the terminal end of the ileum. Basedon the diagnosis of appendix cancer, we excised an ileocecal segment, extracted the entire uterus andremoved bilateral adnexes. Histopathological examination showed cystadenocarcinoma in the mucosa ofthe appendix, the cause of melena probably resulted from the infiltration of appendix cancer into the ileum.

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