The purpose of the present study was to retrospectively assess the usefulness of MDCT in the diagnosis and evaluation of the severity of acute appendicitis by comparing to the patients with suspected appendicitis who underwent SDCT before the introduction of MDCT. A total of 47 patients with suspected appendicitis who underwent CT were included in this study. Patients were divided into two groups, 24 patients who underwent SDCT (the SDCT group) and 23 patients who underwent MDCT (the MDCT group). CT findings such as swelling of the appendix of more than 6 mm, condition of enhanced appendix, hazy periappendiceal density, appendicolith and ascites and/or abscess were evaluated. The findings such as swelling of the appendix of more than 6 mm and the condition of an enhanced appendiceal wall, especially partial defects, were useful in the diagnosis of appendicitis with CT in both the MDCT and SDCT groups. The CT findings such as condition of an enhanced appendiceal wall, especially identification of the entire wall, and detection of ascites or abscess appeared to be superior in the MDCT group compared with the SDCT group. In addition, MDCT may improve the diagnosis and evaluation of the severity in patients with suspected appendicitis by superior evaluation of the condition of the enhanced appendiceal wall.

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Transepiploic hernia is rare, making it difficult to diagnose preoperatively. This disease often requires emergency surgery due to strangulation of the ileus. We experienced six surgical cases of transepiploic hernia, 4 males and 2 females, whose ages of patients ranged from 41 to 85 years. The patients’body mass index ranged from 18.8 to 27.6. Three cases were diagnosed preoperatively with abdominal CT, so emergency surgeries were carried out with laparoscopy. Five cases were type A and one case was type C0. In four cases, the incarcerated intestine had become necrotic and resection of the intestine became necessary. In the treatment of patients with an intestinal obstruction who have not previously undergone a laparotomy, internal hernias including the transepiploic hernia must be kept in mind. It is important for early diagnosis to confirm the anatomic relations of the organs. Additionally, the laparoscopic procedure appears to be a superior method for both diagnosis and treatment in those cases in which transepiploic hernia is suspected.

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Necrotizing fasciitis (NF) is a severe bacterial infectious disease associated with necrosis of the skin or subcutaneous tissue. The prognosis of this disease is poor because of the rapidly progressive necrosis of the tissues followed by sepsis or multiple organ failure. We aimed to elucidate the clinical features of postoperative NF. Of 7 patients with postoperative NF, 6 had undergone colorectal surgery and NF occurred within 7 days after the operation in most of the patients. Four patients were infected with gram-negative rod bacteria and three with MRSA. Most patients had necrosis or rubor of the skin and tenderness. CT findings demonstrated subcutaneous gas in most of them. All patients underwent debridement of the subcutaneous necrotic tissues. The overall mortality rate was 28.5%. Risk factors for mortality in patients with postoperative NF were skin necrosis and the interval between the onset of the disease and debridement. These results indicate that early diagnosis and debridement could improve the outcome of postoperative NF.

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Unexpected deaths occasionally happen in patients undergoing emergency abdominal medicine. In such cases, it is unclear whether practitioners are obliged to report such deaths to the police in reference to the practitioners' duty to notify instances of any ‘unusual death' to the police under Article 21 of the Medical Act. Disputes have continued among clinicians, researchers in forensic medicine and lawyers, especially about reporting of the death of patients occurring in relation to clinical practice. Medical societies, in conjunction with the Ministry of Health, Labour and Welfare, have performed a model project in order to establish a new system to cope with this problem. New legislation has been prepared taking the results of this model project into consideration. Under this legislation practitioners are obliged to give notification of any death of a patient which has incidentally occurred during the clinical course, following which special committees review the clinical courses and results of autopsies. The committees consist of medical professionals, lawyers and others who represent patients in general. Only in patients' deaths which the committee judge as due to grave mistakes would the police be notified, and the application of due criminal process would be considered.

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DNR should be appreciated from two aspects ; Death with dignity (DWD) and avoidance of medical futility. It is considered as the least interventional or the most natural way for DWD. There should not be any difference in the quality of medical treatment with or without the application of the DNR order until cardiac arrest actually takes place. However, if intensive treatment is carried out merely for prolongation of a patient's life, the aim of DNR would be defeated. Thus, when DNR is planned, it is advised that not only DNR itself, but also suspension or avoidance of each life-sustaining treatment be discussed.

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Although the living will in the end stage of life has become topical in recent years in Japan, the present condition of the term ‘do not attempt resuscitation’ (DNAR) is not sufficiently clear. In order to clarify the actual situation of DNAR, a survey was performed on subjects who died during the period from September 2004 to August 2005 in the Nagoya University Hospital. Deaths in the over 15 years old accounted for 404 cases, from which death caused by an abdominal disease was 181 cases in the general ward and 2 cases in the Emergency department. In these 181 cases, DNAR orders were given by a written document in one patient, orally in 8, family transferred from patients in 4, orally from the family in 114, and were unknown 2 cases. On the other hand, in 46 of 52 cases without the DNAR order it was believed that the judgment of DNAR was possible by the patients, and in 13 cases of those patients without any DNAR order, resuscitation was attempted at the time of cardiac arrest. This study shows that even in the terminal stage of chronic abdominal diseases, documentation of written DNAR orders was hardly seen. Even in the case of patients capable of judging for themselves, no DNAR order was suggested, and resuscitation was not performed even in these situations. The current state of the DNAR order of the end stage of life in Japan is also discussed using the results of the Ministry of Health, Labour and Welfare study group.

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It is thought that a physician concludes a social contract with the public in exchange for social status, a reward, and securing autonomy as a profession. On the other hand, We often encounter treatment refusals based on the specialty of the doctor on night duty, the number of the available bed and other emergency patients who are occupying emergency departments in emergency care hospitals. We may recommend consultation at another hospital to patients examined at the outpatient department of the hospital for follow-up. We analyzed the process of transfer and the reason why our center was selected out of many emergency care hospitals of 106 patients with hematemesis and hematochezia for 4 years who were treated at our center, a tertiary lifesaving institution which has not had an outpatient department. Sixty-nine percent of the patients were directly transferred to our center. Twenty-four percent of patients did not routinely go to a medical institute. Thirty-three percent of patients routinely went to a hospital. Twelve percent of patients routinely went to a clinic. After emergency care hospitals carry out their duties and functions in the community, we should clarify the role of the public in promoting efficient functioning of medical emergency care system. Academic medical societies should devise a general ethics plan taking our customs into consideration.

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Inappropriate medical care often increases the risk of patient, especially during the emergency treatment of serious acute abdominal diseases. Medical doctor and other staff should learn about the actual risks involved, as well as appropriate methods for reducing error during medical care. In this paper, the methods that can be used to measure and reduce/minimize the risk of medical error are discussed. The conclusions are as follows:The SHELL model seems to be useful as a basic concept. Several classifications of error from different viewpoints are presented, which are thought to be important for understanding/analyzing the mechanisms causing errors. Based on the above concepts, the response measnres should be considered for each phase;i.e.the preparedness phase, emergency phase, and recovery phase. Furthermore, the concept of the safety model applied in the industrial field, such as PDCA cycle, should be adopted and scientific evidence should be provided as well.

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A 17-year-old woman visited our department with the chief complaint of right lower abdominal pain. In the right lower abdomen, pressure pain and muscular defense were confirmed. Abdominal CT showed a 1 cm luminal structure and increased intensity in the surrounding fat tissue in the right lower abdomen, thus strongly suggesting acute appendicitis. However, a definitive diagnosis could not be made, and, after several diagnoses and treatments, laparoscopy-assisted surgery was performed. In the right lower abdomen, an approximately 2-cm hematoma-like mass arising in the greater omentum was seen, which had partially adhered to the abdominal wall. Laparoscopic partial resection, including the greater omentum, was performed. The patient's postoperative course was favorable, and she was discharged four days after surgery. The histopathological findings confirmed necrotic fat tissue and inflammation accompanied by fibrosis and hematoma, but no tumorous lesions could be identified. Because the patient had no past history of abdominal trauma, anticoagulation therapy or vascular disease, she was diagnosed as having idiopathic omental hematoma which is a relatively rare disease, and, to the best of our knowledge, there has only been a single report of omental hematoma being treated laparoscopically. We report herein on our patient, with a review of the relevant literature.

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An 80-year-old woman was admitted to our hospital because of constipation persisting for 10 days, accompanied by abdominal pain and vomiting. Her abdomen was extremely distended with tenderness. A CT scan demonstrated massive clay-like feces in the sigmoid colon and extreme distension of the proximal colon. A gastrographin enema showed obstruction of the sigmoid colon due to fecal impaction. Under a diagnosis of fecal ileus of the sigmoid colon, a sigmoid loopcolostomy was performed. Because of necrotizing mucosa in the stoma, a laparotomy was performed under a diagnosis of obstructive colitis with colonic necrosis. Mucosal necrosis was detected in the colon from the sigmoid to the hepatic flexure. An extensive left hemicolectomy was performed. For massive feces in the upper rectum, an ascending colostomy and a sigmoid colostomy were carried out. Although necrotizing obstructive colitis caused by fecal impaction is very rare, we should consider the possibility of bowel necrosis when encountering a patient with fecal ileus of the colon. Furthermore, it is very important to identify the necrotized area of the colon correctly and to establish a colostomy of the distal colon at surgery.

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Small bowel volvulus is a rare cause of acute abdomen in adults. We report a rare case of spontaneous resolution of a small bowel volvulus secondary to unstable fixation of the jejunum to the retroperitoneum. A 77-year-old female presented with severe right upper quadrant pain, nausea, and vomiting. Abdominal CT showed distention of the jejunum and the“whirl sign” (whirling appearance of both blood vessels and the bowel). A small bowel volvulus was diagnosed, and a long ileus tube was inserted. Although the symptoms were dramatically alleviated, the long tube did not migrate distally. Enterography showed inversion of the jejunum in the right upper quadrant, suggesting that the jejunum was not fixed to the retroperitoneum around the ligament of Treitz. Laparotomy was scheduled, but, on hospital days 30, enterography of the ileus tube showed the jejunum in the normal position. Although small bowel volvulus is a fatal condition and usually requires surgical treatment, clinicians should be aware that some cases of small bowel volvulus resolve spontaneously and respond to conservative treatment with a long ileus tube.

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We experienced two cases of intussusception where an ileus tube was thought to be the inducing factor. Case 1 was a 44 year-old male. The procedure was performed for volvulus of the small intestine and involved untwisting of the volvulus and partial removal of the ileum ; the ileus tube was guided to the ileum terminus, and fixed there for the purpose of stenting. On the eighth day after surgery, even with release of the ileus tube, vomiting began on the following day. A diagnosis via CT inspection was made of intussusception, and an emergency operation was performed. Case 2 was an 80 year-old male. The ileus tube was inserted, and although there was temporary improvement of his symptoms, abdominal pain reoccurred. A diagnosis was made via CT imaging of intussusception of the upper portion of the small intestine where the ileus tube had been inserted, and an emergency operation was performed. Although an ileus tube is used for the purposes of reducing intestinal tract pressure at the time of treatment of an ileus and for post-synechiotomy stenting, it is thought that its use requires great care, as there are cases where intussusception occurs where an ileus tube is the inducing factor. We learned that one must always take into consideration the occurrence of intussusception as a complication resulting from the use of an ileus tube.

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We report on a case of massive hemorrhage from the colon diverticulum treated with transcatheter arterial embolization followed by a right colectomy. A 56-year-old man was admitted to our department complaining of melena. Because of the shock due to massive melena, we performed an emergency colonoscopy that showed the presence of multiple diverticula at the cecum and the ascending colon, but the actual bleeding point was not evident. The patient recovered from a critical condition after blood transfusion but intermittent bleeding continued. Hemorrhagic scintigraphy suggested the bleeding from the ascending colon, angiography revealed extravasation from the peripheral branch of the ileocolic artery, and transcatheter arterial embolization was carried out. On the day following embolization, a right colectomy was performed because of the possible induced ischemic change. The resected specimen showed necrotic change in the ascending colon corresponding to the site of the transcatheter arterial embolization. The result suggests that surgical resection should be considered even after transcatheter arterial embolization has been successful.

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A 36-year-old woman with no previous surgery was admitted to our hospital with abdominal pain. We diagnosed a broad ligament hernia with computed tomography (CT), and performed an emergency operation on the same day. During surgery, a fissure in the right broad ligament of the uterus about 2cm in diameter was disclosed and a part of the distal ileum about 30cm long and located 60cm proximal to the ileocecal valve was incarcerated through this defect. The intestinal constriction was reduced and the defect of the broad ligament was sutured. The patient had an uneventful postoperative course and was discharged from our hospital on the 10th postoperative day. Internal hernia through a defect of the broad ligament of the uterus is very rare and presents difficulty in preoperative diagnosis. We report on our experience of a hernia through broad ligament defect that was diagnosed with CT and successfully treated, together with a review of the relevant literature.

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We report a case of non-occlusive mesenteric ischemia (NOMI) presenting with portal venous gas (PVG). The patient was a 67-year-old female, who presented to our emergency clinic with sudden abdominal pain. Although CT detected PVG, neither metabolic acidosis nor elevation of serum markers of necrosis, such as CK, was observed. Furthermore, the abdomen was relatively soft. Therefore, the patient was treated conservatively. However, she subsequently developed rebound tenderness and elevated CK levels, and we performed an urgent laparotomy. Intraoperative findings revealed disseminated necrosis in the ileum, and a partial small bowel resection was performed. In addition, because ulcerative changes were observed on the mucosa of the anal side intestine, an ileocecal resection was also performed. Despite the intestinal necrosis caused by NOMI and the presence of PVG, the immediate surgery successfully saved this patient. This case highlights the importance of accurate and prompt diagnosis of intestinal necrosis.

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We report on a case of adult intestinal obstruction due to volvulus of Meckel's diverticulum. A 23 year-old woman admitted was referred to the hospital because of acute lower abdominal pain. Enhanced computed tomography showed a significant dilated intestinal loop which was 7 cm in diameter. She was diagnosed as having significant ileal dilation caused by obstruction and strangulation of the intestine and underwent an emergency laparotomy. The laparotomy revealed a spindle-shaped dilated ileum, obstructed due to volvulus. She was underwent enterectomy of all of the dilated ileum. Histological examination showed gastric glands from the mucosa to the submucosa of the most dilated part of the resected ileum, so we diagnosed it as Meckel's diverticulum. Although Meckel's diverticula with torsion usually have a pedicle and a tall body, our case had a spindle-shaped dilated ileum with an acaulous diverticulum. This appeared as a rare mechanism of volvulus of Meckel's diverticulum, so it is necessary to consider the involvement of Meckel's diverticulum in young patients who have no history of any laparotomy.

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A 34-year-old pregnant woman in her 28th gestational week was admitted with right lower quadrant pain to the Department of Obstetrics and Gynecology at Yamaguchi University hospital with a suspected diagnosis of acute appendicitis. Ultrasonography and plain CT could not detect any inflammatory change in the appendix. But MR imaging could diagnose acute appendicitis for this patient to magnetic resonance imaging (MRI) on the other hand demonstrated an enlarged appendix with periappendiceal inflammation as a high intensity area on the T2-weighted and fat-suppressed images. We performed an appendectomy, the patient's postoperative recovery was uneventful, and she was discharged on the 13th postoperative day. MRI is an excellent modality for the diagnosis of acute appendicitis and may be a good alternative to CT in pregnant women for whom sonographic findings are nondiagnostic.

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We report on a patient who survived surgery for barium peritonitis caused by oral side perforation of cancer of the transverse colon following upper gastrointestinal radiography. A 64-year-old man was referred to a physician because of a sensation of abdominal fullness. Upper gastrointestinal radiography was performed, and on the following day the patient suddenly suffered abdominal pain. He was referred to another hospital and was diagnosed as having barium peritonitis by plain X-ray film and abdominal computed tomography. He was admitted to our hospital and underwent emergency surgery. On laparotomy panperitonitis was demonstrated due to massive feces and barium dissemination, and perforation of the oral side of the transverse colon due to a tumor. Resection of the affected lesion, creation of a transverse colostomy and mucous fistula, and intraperitoneal drainage were performed with intraperitoneal lavage using 30 L saline. He was discharged 33 days after surgery, although intensive care including direct hemoperfusion with polymixin-immunobilized fibers was required postoperatively. The tumor of the transverse colon was a moderately differentiated adenocarcinoma classified as stage IIIB according to the pTNM classification. The patient is currently well without evidence of recurrence 11 months after surgery.

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We report on 2 cases of incarcerated internal hernias. Case 1 : A 53-year-old man was referred to our hospital because conservative therapy for ileus had been unsuccessful. On day 7, surgery was performed. The small intestine was incarcerated by a 2 cm hiatus in the omental bursa. The hiatus was closed by direct suture. Case 2 : A 90-year-old man was referred to our hospital with a diagnosis of ileus. Because his abdominal pain was not severe, we started conservative therapy under the diagnosis of pericecal hernia. Four hours later, however, we performed a laparotomy because his abdominal pain was severe. The small intestine was incarcerated into the space made by adhesion between the greater omentum and the cecum. The adhesion was released. In the case of unidentified ileus, an internal hernia should be included in the differential diagnoses. In our opinion, management of internal hernias should consist of planned surgical treatment. We should carefully follow those cases in which a diagnosis of internal hernia can not be clearly made, and consider surgical treatment when the early signs of a strangulated ileus first appear.

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A 74-year-old female with severe obesity and uncontroled diabetes mellitus presented with right lower abdominal pain. Cecal diverticulitis was diagnosed with by abdominal computed tomography (CT) scan. We started conservative therapy with antibiotics, but 3 days later, the abdominal pain became worse. The CT scan showed thickening of the wall of the cecal and ascending colon. The necessity of an operation was considered, but severe complications were anticipated and a wide range of intestinal resection would probably have been required. Percutaneous drainage appeared to be possible if a pericecal abscess had occurred, because the pain was localized, so we continued with more conservative therapy. Three days later, a pericecal abscess was detected which was drained via a percutaneous puncture. The patient improved and was discharged from hospital after control of her diabetes mellitus.

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