We evaluated 40 patients with strangulated bowel obstructions who underwent surgery at our hospital between September 2000 and August 2005. Here, the patients' background characteristics, cause of strangulation, clinical symptoms, laboratory and imaging results, preoperative diagnosis, treatment and prognosis are discussed. The sex ratio was 1 : 1, the average age was 71.2 years, and 31 cases (77.5%) had past histories of abdominal surgery, mainly in the lower abdominal region. As for the causes of the constrictions, adhesions and funiculi accounted for half of the cases. We recognized 23 cases (57.5%) because of peritoneal irritation signs and 8 cases (20.0%) because of a state of shock ; both groups underwent emergency operations. Regarding imaging findings, abdominal computed tomography revealed ascites in 28 cases (77.8%) and limited bowel dilation in 25 cases (69.4%) the correct preoperative diagnosis rate was 85.0%. Bowel resections were performed in 29 cases (72.5%). Five patients (12.5%) died, three because of multiple organ failure and two because of respiratory insufficiency (i.e., pneumonia). Patients with a poor general condition or severe complications must be adequately cared for, although the diagnosis of this disease is comparatively easy.
Meckel diverticulum (MD) is the most common congenital anomaly of the small intestine. Its main importance lies in the possibility of complications, which can manifest as acute abdomen. In this study, we investigated the clinical findings of patients with MD complications. Thirty patients with MD complications (diverticulitis, 6 cases ; strangulated intestinal ileus, 4 cases ; perforation, 1 case ; ulcer of the ectopic gastric mucosa, 2 cases) underwent surgery at our hospital during the past 10 years (10 men and 3 women, aged 3 months to 64 years). About half of the MD complications occurred during childhood or early adolescence. The preoperative diagnosis of MD is difficult. A preoperative diagnosis of MD was made in only 1 of the 13 cases with complications. In this case (a 2-year-old boy who complained of melena), a correct diagnosis was made because of a small bowel enema. Overall, the chief complaints were right-side lower abdominal pain (46.2%), abdominal pain (15.4%), lower umbilical pain (7.7%), and so on. These symptoms continued for long periods (4 cases, more than 1 year ; 2 cases, more than 2 years ; 1 case, more than 3 years ; etc.). Eight diverticulectomies (wedge resections) and 5 partial resections of the ileum and MD were performed. The mean distance of the MD from the ileocecal junction was 70.0 cm (range, 30 to 150 cm). The size of the MD varied from 1 cm to 17 cm (mean, 4.9 cm). Ten cases (84.6%) were located on the antimesenteric border of the ileum and 2 (15.4%) were located on the lateral side of the ileum. Ectopic tissues were seen in 23.1% of the cases (3 cases : gastric mucosa, 2 cases and gastric mucosa with pancreatic tissue, 1 case). One case with a gastric ulcer (51-year-old man with a preoperative diagnosis of ileus) contained an adenocarcinoma. The resection of MD resulting in complications can be safely performed without postoperative complications.
Although there is increasing evidence suggesting that there are fundamental differences in the host responses between Gram-positive and Gram-negative organisms, the mechanisms underlying these disparate responses remain unclear. We compared the responses of murine bone marrow-derived dendritic cells (DC) to peptidoglycan (PGN) and lipopolysaccharide (LPS), components of Gram-positive and Gram-negative bacteria, respectively. Although PGN and LPS stimulated the DCs to an equal degree, with increased MHC Class II and CD86 expressions and decreased phagocytotic activity, we demonstrated considerable differences in the functional DC maturation status : PGN stimulated the DCs to produce higher amounts of TNFα and IL-10, and to show a higher migratory response to MIP-3β as compared to LPS. PGN-stimulated DCs induced naïve T cells to produce higher amounts of Thl cytokines as compared to LPS-stimulated DCs as judged by the mixed lymphocyte reaction. Thus, it is important to develop novel therapeutic strategies for sepsis based on the pathogen-dependent inflammatory responses.
Purpose : We studied the clinical characteristics of patients with ulcerative colitis (UC) and active bleeding who underwent appropriate emergent operations. Methods : Of the 103 patients with UC who underwent surgery in our department between 1998 and 2005, 9 (8.6%) received emergent operations because of bleeding. The clinical findings, including complications and operative procedures, were evaluated and compared. Results : The 9 patients who underwent emergent operations because of active bleeding consisted of 7 men and 2 women. The average age was 33.3 years (range, 21∼51 years). In all cases, the type of UC was total colitis. Emergent operations were performed after the sudden onset of bleeding. A total colectomy and ileostomy was performed in 2 cases, and ileal pouch anal anastomosis (IPAA) was performed in 7 cases. The previous procedure was performed prior to 1998, while the latter procedure was performed after 1998. IPAA enabled bleeding from the colon to be controlled, and the rate of anastomotic and postoperative complications was almost the same as that of the conventional procedure. Conclusions : IPAA is a useful procedure for controlling active bleeding in patients with UC.
The Delays in the establishment of a trauma system in Japan have recently attracted attention. Therefore, we evaluated in-hospital management strategies for moribund abdominal trauma with associated injury at a single trauma center. (Cases and Methods) We examined 20 abdominal trauma patients requiring an emergency laparotomy who had Abbreviated Injury Scale ; AIS extra-abdominal injuries ≥3. These cases were divided into two groups based on their outcome (survival or expired) and Probability of survival ; Ps value (≥0.5 or <0.5). (Results) Nine cases (56.3%) in the survival group (n=16) had Ps values less than 0.5, while 3 cases in the expired group (n=4) had Ps values less than 0.5. Nine cases (75.0%) in the Ps<0.5 group (n=12) required emergency room (ER) operations. The time intervals from the arrival at the hospital until blood transfusion were 31.8 minutes (group Ps <0.5) and 76.1 minutes (group Ps ≥ 0.5). Although the time interval from the arrival at the hospital until definitive surgery was the same between the survival group and the expired group, it was significantly shorter in the Ps <0.5 group, compared with the Ps ≥ 0.5 group. (Summary) The availability of urgent massive transfusion and an ER operation system is essential for the management of multiple trauma patients requiring a laparotomy.
Early diagnosis using computer tomography (CT) imaging is important for the accurate identification of acute abdominal diseases, and it could help in the early initiation of treatment. The latest development in MDCT (Multidetector-row CT) technology provides a rapidly acquired multiphase data set, and it is possible to examine an image from various angles through the use of computer-generated three-dimensional MDCT data. Crisp and clear images can be viewed using MDCT, not only of the site of interest, but also of the complete surrounding area. MDCT has the real potential to be a more powerful and user-friendly tool than angiography for the diagnosis of acute abdominal diseases, both of the bleeding and ischemic types.
Diagnosis based on portal hemodynamics is essential for the clinical treatment of esophago-gastric varices ; multidetector computed tomography (MDCT) is used at our institution for this purpose. Two analytic methods are used in conjunction with MDCT : volume rendering (VR) and partial MIP. At present, the partial MIP method is more useful than the VR method, as partial MIP images clearly show the feeding and collateral veins in minute detail. Improvements in the analyzing power of MDCT have permitted the visualization of feeding veins as well as faint images of collateral veins associated with the varices. These images can be seen with a high degree of probability on MDCT images obtained using endoscopic varicerography during injection sclerotherapy. Diagnosis of the portal hemodynamics using MDCT prior to clinical treatment is likely to be an effective clinical option. However, numerous images are needed for the diagnosis of portal hemodynamics using partial MIP, and a detailed map of the portal hemodynamics is required to understand this diagnosis. Our objective is to use VR to overcome these diagnostic problems, since the use of a single image, which can be constructed within minutes, should permit the portal hemodynamics to be visualized.
Although the early detection of pancreatic ischemia in patients with severe acute pancreatitis remains difficult, we successfully visualized ischaemic areas of the pancreas body using perfusion computed tomography (CT). Perfusion CT is widely used for the early detection of brain ischaemia but has not been previously used to evaluate pancreatic blood flow. In our study, perfusion CT was successfully used to detect early ischaemia with the potential to progress to pancreatic necrosis in patients with acute pancreatitis, possibly predicting the prognosis. Here, we report the utility of perfusion CT and describe the clinical importance of evaluating pancreatic blood flow during the early stage of pancreatitis.
A precise diagnosis and the optimum appropriate primary care decide the prognosis of the biliary emergency represented by acute cholangitis, cholecystitis, and obstructive jaundice. Direct biliary contrasting imaging, such as Percutaneous transheptatic cholangio drainage and endoscopic retrograde cholangio pancreatography, has been performed conventionally, but in recent years various devices such as Multidetector computed tomography, drip infunsion cholangiography-CT, and the fusion of direct biliary tract contrasting with contrast enhancement MDCT have been performed in the emergency clinical setting. We developed a new technique of MDCT-virtual cholangiography based on negative contrasting of carbon dioxide (CO2) injection from endoscopic naso-biliary drainage or PTCD. The biliary tract system was arrested as a transmission bile duct image through the negative contrasting effect of the CO2, and of blood vessels of a range of circumferences down to and including microvessels can be depicted faithfully at the same time by fusion with contrast enhanced MDCT angiography (the fusion CMCPA technique). It is a new diagnostic tool enabling on-site, quick, accurate and objective emergency evaluation of biliary tract stricture and confinement, the local existence and diagnosis of expansion and vascular invasion.
The AquariusNET® 3D PACS system not only facilitates dynamic 3D imaging of DICOM data and surgeon-mediated 3D image processing, but also allows interaction with software used by radiation room servers via a generic windows-based computer terminal. Utilization of the AquariusNET® 3D PACS system simplifies observation of 2D and 3D images obtained via techniques including MRCPA and MDCT, and also simplifies observation of dynamic images, thus making it useful for the diagnosis of diseases commonly encountered in abdominal emergency medicine, such as gallstones (acute cholecystitis) and acute appendicitis, as well as conditions difficult to diagnose, such as rupture of a splanchnic artery aneurysm, torsion of the greater omentum, and herniation through a defect of the broad ligament of the uterus. Advances in MRI and MDCT techniques will no doubt be matched by an increased necessity for the PACS system in the future.
A 64-raw multislice computed tomography (64-MSCT) machine, a new 1.5-T magnetic resonance imaging (MRI) machine, a flat-panel detector X ray, and a digital Xray TV were installed at the Ohtawara Red Cross Hospital in September 2005. Here, we explain the usefulness of “Traumatic Panscan” enabled by 64-MSCT and introduce the clinical experience and workflow of the new diagnostic imaging unit. In emergency situations, diagnostic imaging can be useful for triage, since its protocol remains the same for every situation.
The perforation of gastric cancer is rare and occurs in 1% to 3% of all cases of gastric cancer. Surgeons should consider the patient's general condition and the chance of a cure when selecting an operative method for the treatment of perforated gastric cancer. A 63-year-old man complained of continuous abdominal pain ; an endoscopic examination revealed advanced gastric cancer. After the examination, the patient complained of severe abdominal pain. An emergency laparotomy was performed under a diagnosis of diffuse peritonitis resulting from gastric cancer perforation. The intraoperative diagnosis was a perforated type 2 tumor with direct invasion to the gallbladder and the pancreas in addition to diffuse peritoneal metastasis. A transection of the stomach and a gastrojejunostomy were performed, and the patient recovered. We analyzed five patients with perforated gastric carcinoma who underwent surgery in our hospital between 2002 and 2006. The carcinoma was stage II in one case, stage III in two cases, and stage IV in one case, and the mean age was 70.6 years. Two patients underwent a total gastrectomy, and the other patients underwent a distal gastrectomy, a gastrojejunostomy, and an omental patch repair. We think that a gastrojejunostomy with a transection of the stomach is optimal for unresectable perforated gastric cancer.
A 77-year-old woman underwent a Gant-Miwa procedure at another hospital for the treatment of rectal prolapse. On the 21st postoperative day, she was introduced to our hospital because of massive melena. Multiple nodules in the sutured mucosa of her rectum were noted during a colonoscopy, but the origin of the bleeding could not be found. She was discharged after the melena stopped but was admitted again because of massive melena on the 59th postoperative day. Bleeding was observed near the surgical silk sutures in her rectum. We resected the sutures where possible. The patient was discharged, and the melena has not recurred. Attention should be paid to postoperative bleeding after Gant-Miwa procedures, even if several days have passed since the operation.
A 55-year-old woman with successive breast cancer recurrences underwent an emergent Hartman's operation for the treatment of pan-peritonitis arising from a large sigmoid colon perforation. Multiple large and amorphous ulcers were observed throughout the sigmoid colon, one of which was 5×2.5 cm in size. Microscopic findings showed nonspecific inflammation and ulcers without atypia, vascularitis or granulomas. A severe pain in her neck and shoulders had required treatment with morphine and diclofenac sodium suppository (25 mg, 3 to 4 times a day for 26 days). The latter agent was thought to be the cause of the ulcer perforation. She survived septic shock, DIC and breast cancer recurrences for five months without becoming bedridden.
A 73-year-old woman was admitted to our hospital because of gallstone-associated acute pancreatitis. The common bile duct stones were removed during an urgent endoscopic sphincterotomy. During the subsequent conservative therapy, repeated abdominal CT examinations showed progressive peri-and intra-pancreatic necrosis. A bacterial culture of a sample obtained using fine needle aspiration from the necrotic portion revealed the presence of Proteus mirabilis. Contrast medium injected through the needle flowed into the second portion of the duodenum. On the 29th day, we performed an open necrosectomy with continuous closed lavage of the retroperitoneum by placing multiple sump tubes in the pancreatic bed and around the duodenum. A transgastric intraduodenal sump tube was also placed for decompression. Eight weeks after the operation, the pancreatoduodenal fistula had closed ; all the drainage tubes were subsequently removed. The present case shows that even a giant pancreatoduodenal fistula caused by necrotizing pancreatitis can be closed using both intraduodenal decompression and peri-and intra-duodenal drainage and does not necessarily require a pancreatoduodenectomy.
A 75-year-old man was diagnosed with lung cancer (adeno, T2N1M0, stage III a) in November 2003, but he rejected chemotherapy and radiotherapy. He was admitted to our hospital because of a severe cough in April 2005. The following morning, he suddenly complained of a severe abdominal pain. An abdominal plain computed tomography (CT) examination showed free air in the abdominal cavity. He was diagnosed as having a gastrointestinal tract perforation and underwent an emergency operation. During the operation, yellowish ascites and a perforated jejunum were observed. Histological studies showed specimens of the small bowel lesion to be adenocarcinoma, similar to those of lung cancer. Although small bowel metastasis from lung cancer is rare, it should be considered when progressive abdominal symptoms are observed in patients with lung cancer.
A case of retroperitoneal abscess caused by duodenal penetration by an ingested fish bone is reported. This case is only the third to be reported in Japan. A 75-year-old woman was admitted to the hospital because of an upper abdominal pain. An abdominal CT scan revealed a small amount of free air at the back of the pancreas head. An esophagogastroduodenoscopy (EGD) revealed the penetration of the second portion of the duodenum by a fish bone, which was 32 mm in length. The fish bone was removed during the EGD. The administration of antibiotics for five days did not improve her symptoms, and the formation of an abscess at the back of the pancreas head was revealed. A laparotomy was subsequently performed. Only three cases, including the present case, of a retroperitoneal abscess caused by duodenal penetration by an ingested fish bone have been reported. These rare cases are reviewed.
An 80-year-old woman suffering from nausea and vomiting after meals consulted a nearby hospital. The abdominal X-ray film showed ileus and possibe diaphragmatic hernia. Therefore, she was referred to our department. The distended intestinal loops were palpable, however, no signs of peritoneal irritation were elicited. The chest and abdominal X-rays showed a loop of the colon in the mediastinum. Chest and abdominal CT revealed incarceration of a loop of transverse colon passing through the esophageal hiatus in the mediastinum. We performed emergency laparotomy, identified a strangulated transverse colon incarcerated in the mediastinum, and pulled it out into the peritoneal cavity. Because the colon had two constricted portions because of difficulty pas'during extncation, transverse colon resection and colostomy were performed. The stomach remained almost in its normal position. The hernia orifice was closed with a mesh and a Nissen fundoplication was performed. The postoperative course of the patient was uneventful. Although hiatal hernia with incarcerated transverse colon is very rare, it should be borne in mind as a probable diagnosis in eases of hiatal hernia with a large esophageal orifice.
We report a case of spontaneous rupture of the stomach in an adult. The patient was a 17-year-old male who presented with acute severe abdominal pain after several episodes of vomiting. Radiography and computed tomography of the abdomen showed intraabdominal free gas and massive ascites. We performed urgent surgery under the diagnosis of panperitonitis due to perforation of the upper gastrointestinal tract. Intraoperatively, a perforation measuring 5 cm in diameter was identified in the lesser curvature of the stomach. As the perforation wound appeared reasonably clean, primary closure of the perforation could be performed safely. While in many cases, spontaneous rupture of the stomach is preceded by gastric dilatation, finding was not observed in our case, it was not. Therefore, we concluded that the rupture had probably been caused by hiatal hernia and vomiting.
An 83-year-old woman was admitted to our hospital for the treatment of a colonic obstruction caused by stenosis developing at a site near a previous colostomy of the sigmoid colon. Two years earlier, she had undergone a resection of an anal tumor exhibiting the characteristics of extramammary Paget disease. Two months after the operation, she developed anal dysfunction as a complication of the previous surgery and had to undergo a sigmoid colon colostomy. A colonoscopy performed at the time of the most recent admission revealed the formation of a circumferential ulcer at a location 3 cm from the colostomy on the oral side. In spite of the insertion of a decompression tube through the colostomy site, a colonoscopy revealed little improvement in the stenosis. As a result, she underwent surgery again three weeks after admission. The stenotic lesion had twisted and had adhered to the omentum. The stenotic lesion was resected, and the colostomy was reconstructed on the descending colon. The stenosis was thought to have been caused by the abnormal fixation of the colon to the retroperitoneum, namely a kind of malrotation, that had caused a rotation of the splenic flexure of the colon.
Segmental arterial mediolysis (SAM) can cause abdominal apoplexy. We report the case of a 65-year-old man who presented with moderately acute abdominal pain. Abdominal and pelvic computed tomography examinations demonstrated intraperitoneal effusion and phlegmon-like hypertrophy of the mesentery. A diagnosis of intraperitoneal hemorrhage was made by exploratory puncture under ultrasound guidance. A visceral angiography revealed the irregular dilatation of the right colic artery, and a diagnosis of SAM was made based on this finding. While our case was cured with conservative treatment, surgical intervention should be initiated without delay because of the high mortality rate associated with intraperitoneal apoplexy. Because there was no intervention, this is the first reported case of the natural history of SAM leading to abdominal apoplexy.
A 76-year-old man visited a local doctor because of constipation and abdominal pain. He was admitted to our hospital under a diagnosis of acute appendicitis. He complained of a diffuse lower abdominal pain with developing pain and muscle guarding in the right lower abdominal area. He was diagnosed as having local peritonitis with wall thickening in the ileum and sigmoid colon, base on the results of a computed tomography examination. An emergency operation was performed on the same day. During the surgery, a perforation was observed at a mesenteric site of the ileum, about 6 cm on the oral side from the terminal ileum. An ileo-cecal resection was performed. Since a histopathological examination revealed only non specific inflammatory findings and no signs of Behcet's disease, he was diagnosed as having a solitary simple ulcer of the ileum. Simple ulcer of the small intestine is relatively rare. We report a case and review the literature.
A 78-year-old female visited the emergency clinic of our hospital due to persistent left lower abdominal pain and slight fever. Since abdominal CT revealed findings suggestive of inflammation extending from the sigmoid colon to the area around the superior portion of the rectum, the patient was admitted for observation. Colonoscopy after admission showed a sheet-like foreign body in the aforementioned area, and abdominal CT on the following day showed ascites and intraperitoneal free air around the siqmoid colon. Colonic peraoration due to the foreign body was suspected, and emergency operation was performed. There was much Eiterbelag and localized turbid ascites around the superior portion of the rectum. In addition, a small perforation with leakage of feces was observed in the right wall of the sigmoid colon. A Hartmann operation was performed. The resected specimen showed injury of the intestinal mucosa caused by the sharp angle of a press=through package (PTP) and ulcer formation. In recent years, reports of PTP ingestion have been increasing, but few cases of colon is perforation caused by it have been veported. Since patients are often unaware of having ingested a PTP and preoperative diagnosis is difficult, the possibility of PTP ingestion as a cause of perforation and peritonitis should be considered in the elderly.
Torsion of the gallbladder is a relatively rare cause of acute abdomen, and its preoperative diagnosis has been difficult. We report a case of torsion of the gallbladder that was preoperatively diagnosed using abdominal computed tomography CT. An 82-year-old women complained of a sudden pain in her right upper abdomen. A high-density lesion near the neck of the gallbladder was revealed using abdominal CT. During hospitalization, a high fever and peritoneal rigidity signs appeared. A subsequent abdominal CT examination showed swelling and wall-thickening throughout the gallbladder, which was displaced to the umbilical region. An emergent laparotomy revealed an extremely swollen gallbladder that had been twisted 360 degrees counterclockwise. After rotation to remove the torsion, the gallbladder was easily removed. These changes on abdominal CT findings are considered to be characteristic of gallbladder torsion and may be useful for diagnosing this disease.
A 70-year-old man was referred to our hospital complaining of abdominal pain after involvement in a traffic accident. A computed tomography (CT) examination revealed a contusion of the pancreatic head and ascitic fluid. An endoscopic retrograde pancreatography examination showed the leakage of contrast medium from the main pancreatic duct. During a laparotomy, the damage to the pancreatic head was observed to be so severe that the damaged main pancreatic duct in the pancreatic head could not be identified ; strict drainage from the pancreatic head region alone was performed. The patient was followed as an outpatient for 4 months, but the pancreatic fistula did not improve. We then performed a fistulojejunostomy the patient's postoperative course was uneventful. The present case shows that severe proximal pancreatic trauma with duct injury can be treated using drainage alone, followed by a two-staged fistulojejunostomy, if necessary.