Although the frequency of surgical site infection (SSI) has decreased in elective digestive surgery, it remains high in stage 3 wounds such as those which occur in panperitonitis. We examined retrospectively whether subcutaneous drains helped prevent incisional SSI (I-SSI) associated with panperitonitis surgery for digestive duct perforation. We analyzed data on 97 patients who underwent surgery for small intestinal (18), colon (36), and appendix (43) perforations between April 2006 and December 2011. Forty received subcutaneous drainage and 57 did not. All drains used were the closed and self-sustaining suction types of size 10 Fr. I-SSI occurred in 4/31 (12.9%) in the drainage group and 25/66 (37.9%) in the non-drainage group (p=0.0097). In the 42 patients with colon perforation, I-SSI decreased from 54.5% to 7.1%, demonstrating the usefulness of subcutaneous drainage. There was no difference between drainage systems in the frequency of I-SSI. Subcutaneous drains can reduce the frequency of I-SSI caused by wound pollution from panperitonitis surgery, provided that drain removal time, prevention of obstruction, and effective tube placement are considered.

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Introduction: here are two objectives in the treatment of perforated gastric cancer：to try and improve the general status from acute abdomen and sepsis and to conduct treatment so as not to damage the curability of the cancer. However, we often have difficulty in deciding the best treatment strategy. Subjects：A total of 321 patients were hospitalized at our hospital for upper gastrointestinal perforation from August 2004 to July 2012；among them, 154 had perforation of the stomach. In 10 patients, the perforation was diagnosed to be caused by a gastric malignancy. Results：Two patients (20%) were treated primarily by conservative therapy, and for the remaining 8 patients, surgery was selected as the primary treatment. The prognosis was very poor：five patients (50%) died of cancer within 13 months, and 3 patients (30%) died during the course of hospitalization. Conclusion：Perforation due to gastric cancer was more frequent in elderly people, the cancer was often far advanced, and the prognosis was extremely poor. It would be important to decide the treatment strategy by assigning top priority to averting the risk to life.

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We retrospectively investigated 60 patients who were admitted to Showa University Hospital from November 2002 through September 2011 and performed continuous regional arterial infusion (CRAI) with protease inhibitor and antibiotics for severe acute pancreatitis (SAP) (median age, 53 years old; 47 male and 13 female patients). The median Japanese prognostic factor score was 4 points. 35 patients were Grade 2 and 25 were Grade 3 in enhanced CT Grading, and 86.7% had a pancreatic area that was not contrasted. We performed CRAI for SAP in 58 patients from the celiac artery and superior mesenteric artery, and in to 2 patients from the celiac artery. We started CRAI at the first hospital day, and performed it for 5 days (median). Abdominal pain disappeared at 5 hospital days (median), the late severe infectious complication rate was 16.1%, and the mortality rate was 8.3%. The severity of the pancreatitis and inflammation improved significantly following CRAI. A randomized controlled trial is necessary to prove the usefulness of CRAI for SAP.

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Objectives) The usefulness of early assessment within 48 hours after onset of acute pancreatitis (AP) with contrast-enhanced computed tomography (CECT) was investigated. Methods) Clinical data of 699 patients with AP, who were examined with CECT within 48 hours after onset, were obtained from a 2007 nationwide survey in Japan. Results) Low enhanced pancreatic parenchyma detected with CECT within 48 hours after onset of AP was associated with organ failure (OF), multiple OF, infectious complications as well as mortality (p<0.0001). Moreover, the extent of a low enhanced lesion in the pancreas was associated with OF, multiple OF and mortality (p=0.0038, 0.0024 and 0.0020, respectively). Conclusion) Low enhancement of pancreatic parenchyma could be detected with CECT examination performed within 48 hours after the onset of AP. These findings could predict a poor prognosis in patients with AP.

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In incarcerated hernia case, delay in the diagnosis and treatment decision sometimes leads to serious complications such as sepsis, peritonitis and intestinal ischemia. Therefore, an early diagnosis and treatment decision are important. We retrospectively analyzed the clinical characteristics of 35 patients with incarcerated hernia who required emergency or semi-emergency operations in our hospital from April 2008 to March 2011. They were divided into two groups: the bowel resection group (the A group: n=15) and the non-resection group (he B group: n=20). As for the time to diagnosis and blood tests, there were no significant differences between the two groups. Ileus findings based on CT scans were significantly higher in the A group. Furthermore, contrast enhanced CT scans showed high sensitivity in decreased enhancement of the intestinal wall. Contrast enhanced CT scans may be required for determining the therapeutic strategy in cases of incarcerated hernia.

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A 68-year-old woman who was admitted for epigastralgia was diagnosed as having gastric cancer. On the second day of the hospitalization, she suddenly developed massive hematemesis and hemorrhagic shock. We treated her with fluid resuscitation and blood transfusion, but her condition did not improve. Therefore, we decided to perform an emergency operation. The laparotomy findings showed that the tumor had invaded the pancreas and the gastroduodenal artery. A pancreaticoduodenectomy was performed because of uncontrolled bleeding from the invaded pancreas and the invaded gastroduodenal artery. The pathological examination revealed gastric malignant lymphoma (diffuse large B cell type), and the clinical stage was II 1E (pancreas). After her condition improved, she received chemotherapy in the hematological department.

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Pancreatic metastases are very rare. We experienced a case of pancreatic metastases from a papillary thyroid carcinoma diagnosed after hemorrhagic shock originating from a retroperitoneal hematoma. A 39-year-old man was transferred to our hospital because of shock. His previous medical history included subtotal thyroidectomy for papillary carcinoma of the thyroid 10 years previously. CT scan findings suggested a retroperitoneal hematoma. Emergency angiography was performed which revealed bleeding from the splenic artery. The bleeding was temporarily stopped with transarterial embolization (TAE). However hemorrhagic shock occurred again. Emergency laparotomy, distal pancreatectomy and splenectomy were performed. Rebleeding appeared from the tumor. The pancreatic tumor was histopathologically diagnosed as pancreatic metastases from the papillary thyroid carcinoma. Pancreatic metastasis from papillary thyroid carcinomas could occur in the long term even in case where the primary lesion has been resected. Pancreatic metastasis should be diagnosed and treated taking into account the features of the original tumor.

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An 85-year-old woman visited our hospital with lower abdominal pain. An abdominal computed tomography scan revealed intraperitoneal free air. An emergency operation was performed under the diagnosis of colorectal perforation and septic shock, and the patient underwent direct closure of the perforated colon, sigmoid colostomy, and drainage. During the operation, various vasopressors (dopamine, noradrenaline, and ephedrine,) were administered for severe hypotension. After the operation, we started mechanical ventilation and blood purification (PMX-DHP+CHDF), and in consequence the blood pressure increased. On the second day after surgery, acute lung injury with bilateral diffuse infiltrates of the lungs and severe anasarca appeared. Furosemide and mannitol were started, but they were not effective to improve these conditions. We started Goreisan a traditional Oriental medicine in addition to these drugs on the third day after surgery via a nasogastric tube. After administration of Goreisan, the acute lung injury with bilateral diffuse infiltrates of the lungs and anasarca improved rapidly, and the patient was weaned from ventilator support on the fourth day. These findings suggest that Goreisan is a candidate drug for additional treatment for refractory acute lung injury and/or severe anasarca associated with sepsis following peritonitis.

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We report herein on the case of a 25-year-old man who sustained a high pressure air blow gun injury via the transanal route, while another man was cleaning industrial parts with an air blow gun. When the patient came to the hospital, he complained of abdominal fullness and pain. There was guarding at the whole abdomen, and the CT findings showed free air around the rectum, thickening of the sigmoid colon wall, and whole colonic distension. In addition sigmoid colon fiberoscopy revealed a longitudinal ulcer in the sigmoid colon. We diagnosed colon perforation and diffuse peritonitis and thus an emergency operation was performed. The findings were multiple serosal damage and especially necrosis of the membrane in the sigmoid colon. We performed a left hemicolectomy with a diverting ileostomy. The patient was discharged 39 days after the operation. We present this rare case of multiple colon injury caused by an air blow gun.

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The incarcerated obturator hernia is comparatively rare and an emergency operation is performed frequently. Recently, some papers have presented cases of incarcerated obturator hernia treatment with non-operative reduction. We report herein on three cases of incarcerated obturator hernia reduced by the manual femoral pressure method. This paper describes the indication and method of the non-operative reduction with some literature reviews. The three patients comprised two 98-year-old women and one 84-year-old woman. All patients were diagnosed beyond 48 hours after the onset and had small bowel obstruction. On CT imaging, a low density spherical tumor was seen between the right external obturator muscle and the right pectineal muscle. We concluded that reduction was an indication for cases within 3 days after the onset and where bowel necrosis was not suspected. In cases to be reduced with the pressure method, it is important for patient to be placed in the outward rotation position with abduction and flexion of the hip joint. Due to this posture, we were able to apply pressure to the tumor directly and the incarcerated intestine was reduced easily.

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A 62-year-old disabled male with cerebral palsy, developed paralytic ileus, and was treated with the insertion of a long intestinal tube. His abdominal distension decreased, and four days later, we performed the long intestinal tube imaging. The small intestine gas disappeared, and the tip of the long intestinal tube was advancing to the ascending colon. Five days later, the discharge from the long intestinal tube changed became bloody, and the patient was complicated with disseminated intravascular coagulation (DIC). Contrast-enhanced abdominal CT showed abnormal hypertrophy and a gas in the small intestine wall. We diagnosed intussusception due to the long intestinal tube with small intestine necrosis, and emergency surgery was performed. Intussusception in the jejunum was resolved by manual reduction, and 140 cm of necrotic jejunum from Treitz’s ligament was resected. We experienced a rare case of intussusception as a complication of placement of a long intestinal tube.

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We report herein on a case of small bowel perforation caused by T cell lymphoma in a patient on blood maintenance dialysis. A 74-year-old man was admitted as an emergency for sudden fever and right lower abdominal pain. Blood maintenance dialysis was being carried out for chronic renal failure. Because abdominal CT showed remarkable free air and ascites, an emergency operation was performed. The patient was diagnosed as having a gastrointestinal perforation and so a partial resection of the jejunum was done. He died after the operation on the 93rd postoperative day. A partial jejunectomy specimen showed CD3-positive T cell lymphoma cells infiltrating the intestinal wall. T cell malignant lymphomas are is very rare, and have a poor prognosis because of the high perforation rate. Furthermore, chemotherapy is not effective and accumulation of cases with this disease is needed to elicit the ideal therapeutic strategy.

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A 45-year-old man was admitted to our hospital with high fever and abdominal pain of 5 days' duration. There was a wide distribution of lower abdominal tenderness, but no peritoneal signs were observed. The right inguinal region had a chicken egg-sized mass, and repositioning was impossible. Laboratory testing revealed an elevated white blood cell count of 12,800/μL and a C-reactive protein of 36.31mg/dL. On abdominal CT scan, the greater omentum showed a layered structure consisting of a high density area, that was continuous with the right inguinal canal. Based on a diagnosis of omental torsion caused by a right inguinal hernia, the patient underwent surgery on the day after admission. The operation was performed through a lower abdominal midline incision. A part of the greater omentum had twisted and entered into the right inguinal hernia sac. Resection of the necrotic omentum and contract sewing of the internal inguinal ring were performed. In addition, the mesh plug method was performed on the inguinal hernia on day 19 after surgery. Omental torsion should be considered in patients with an inguinal hernia and abdominal pain, and a CT examination can facilitate the diagnosis.

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A 77-year-old man complained of sudden right upper quadrant pain one month after distal gastrectomy with D2 lymphadenectomy. We diagnosed acute cholecystitis and performed cholecystectomy. Inflammation and necrosis was observed in the gallbladder wall. Acute acalculous cholecystitis is a high risk group of gallbladder perforation and gallbladder necrosis. Perforation and necrosis are associated with a high incidence of peritonitis. Although various causes of the acalculous cholecystitis have been reported, surgery is one of the possible etiologies. It is rare for acalculous cholecystitis to develop in the early postoperative period after distal gastrectomy. We performed cholecystomucoclasis (subtotal cholecystectomy and cauterization of the residual gallbladder mucosa), because of severe inflammation of Calot's triangle. The postoperative course was uneventful. In this case, cholecystomucoclasis was a safe and valid surgical procedure.

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An 89-year-old woman was admitted to our hospital for calculus cholecystitis. She showed improvement after conservative treatment. However, she presented with sudden episodes of vomiting with loss of appetite. Abdominal computed tomography revealed a gallstone that was 40 mm in diameter；the calculus had been displaced from the gallbladder to the duodenal bulb through a fistula. An upper gastrointestinal series revealed a cholecystoduodenal fistula. Bouveret’s syndrome was diagnosed. We attempted to crush the gallstone endoscopically, but the attempt was unsuccessful. Therefore, an operation was performed. We extracted the gallstone from the stomach, and performed a palliative gastrojejunostomy because of duodenal stenosis and cholangitis.

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A 66-year-old woman who had experienced left thigh pain and numbness since 2008 was diagnosed as having sciatica at an orthopedic clinic and took painkillers. In October 2011, she presented at another hospital with epigastric pain and distention. As computed tomography showed an incarcerated bowel in the region between the pectineus and obturator muscles, a left obturator hernia and ileus were diagnosed. She was referred to our hospital for treatment. We performed an emergency laparotomy and found that a portion of the intestine about 50 cm oral from the ileocecal region was incarcerated into the left obturator foramen. Because it was Richter's hernia, ileal resection was not needed and it was repaired with polypropylene mesh. After the operation, the left thigh pain and numbness disappeared. The Howship-Romberg sign is a well-known indicator of obturator hernia；however, in our case, the patient’s thigh pain was lateral and dorsal, both of which were unusual. Physicians should consider obturator hernia among the differential diagnoses when elderly patients being treated for orthopedic illnesses complain of thigh pain.

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A 39-year-old male construction worker had undergone distal gastrectomy for a gastroduodenal ulcer at the age of twenty. He suffered a fall at a construction site and a reinforcing bar got stuck in his abdomen, so he was then transported to our hospital by ambulance. He was conscious, but could not lay on his back and had to remain in a sitting position because of severe abdominal pain. Abdominal X-ray films confirmed that the rebar was embedded in his abdominal cavity, but no further examinations such an abdominal CT could be conducted and an emergency operation was performed. The rebar had passed through the abdominal wall, the transverse mesocolon, the omental bursa and the posterior wall of the remnant stomach. Because of presence of the severe adhesions in the peritoneal cavity, it was difficult to repair the remnant stomach, and we only performed peritoneal drainage. On the first postoperative day, left hemopneumothorax was detected and thoracentesis was performed. An upper GI series revealed that the injury to the remnant stomach had healed in a week. He was discharged on the 20th postoperative day with a good postoperative course. We herein report on a case of abdominal impalement, in which appropriate assessment and prompt treatment were needed during the perioperative period.

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A 77-year-old male (Case 1) visited our hospital with retching and an unpleasant sensation in his abdomen, Based on the abdominal CT findings, portal venous gas (PVG) was diagnosed, and hospitalization was recommended. Due to the mild subjective and abdominal symptoms, the patient refused hospitalization and he was followed up as an outpatient. After arriving home, the abdominal unpleasant sensation disappeared following a bowel movement, and an abdominal CT scan 2 weeks thereafter showed disappearance of PVG. An 89-year-old male (Case 2) visited our Emergency Unit because of abdominal pain and poor appetite. Close examinations revealed PVG due to constipation, and he was treated as an inpatient. The abdominal pain was relieved after bowel movements and his appetite recovered. Abdominal CT findings 4 days after admission (Day 4) showed disappearance of the gas patterns. He was discharged on Day 6. A 91-year-old female (Case 3) was taken to our Emergency Unit by ambulance due to vomiting, melena and consciousness disturbance. Abdominal CT showed gas patterns in the small-intestinal wall and PVG. However, since the abdominal findings were mild and the arterial blood gas measurement did not show acidosis, intestinal necrosis was ruled out in the diagnosis. She was treated as an inpatient. Abdominal CT findings at Day 3 showed disappearance of the gas patterns in the small-intestinal wall and portal vein. She became able to take food orally, oral ingestion, and was discharged 17 days after admission. In this study, we presented 3 cases of PVG in which conventional treatments could be applied, and discussed them with reference to previous reports.

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Identification of vascular injuries is difficult due to mesenteric hematoma in emergency surgery for traumatic mesenteric injuries. We report herein on our experience of a case in which confirmation of the site of injury was obtained by arterial injection of dye during surgery. The patient was a 32-year-old man who was transported to our center because he had been injured having fallen from height. An abdominal CT revealed aneurysms in the mesentery and vascular occlusion of the iliac artery. Accordingly transcatheter embolization was performed for the aneurysms, followed by an emergency laparotomy. The range of mesenteric injury was confirmed easily by being stained blue-green in the area of the small intestine and mesentery by arterial injection of dye via a microcatheter that was placed in the central part of the site of the vascular injury. In emergency surgery for mesenteric injury, arterial infusion of dye using a microcatheter was considered useful for the confirmation of the extent of mesenteric injury and the reduction of the intestinal resection.

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A 79-year-old woman was urgently admitted to our hospital with complaints of frequent nausea and vomiting. Based on the computer tomography findings, she was diagnosed as having a giant esophageal hiatal hernia showing an upside down stomach. Gastrofiberscopy revealed grade D gastro-esophageal reflux disease (GERD). She underwent a surgical procedure composed of a hiatal hernia repair and Nissen fundoplication after conservative treatment. The esophageal hiatus was wide measuring 4 by 3 cm and it was repaired using a mesh. Moreover, the gastric fundus was sutured with the diaphragm to fix the stomach. The postoperative course was favorable, and the patient was discharged on post-operative day 15. She remains in good condition without recurrence 6 months after surgery. Although an esophageal hiatal hernia showing an upside down stomach is rare, early diagnosis and accurate surgery with a lower recurrence rate is required because a severe condition might occur in acute cases.

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A 74-year-old male presented with right lower abdominal pain. A physical examination revealed symptoms of peritonitis in the right lower abdomen. Abdominal CT showed a high density line in the ileum, accompanied by local peritonitis. Based on these findings we made the diagnosis of local peritonitis due to intestinal penetration caused by an ingested fish bone. Conservative therapy with antibiotics was employed and the patient's abdominal pain was relieved with lessening of the abdominal tenderness. On the 5th hospital day, CT showed that the fish bone had moved into the ascending colon and we allowed oral intake. On the 11th hospital day, CT showed the disappearance of the fish bone from the abdomen, indicating that the fish bone had been excreted from the intestinal tract. There have been few cases treated with conservative therapy for penetration of the small intestine caused by an ingested fish bone. In the present case, CT was useful for the diagnosis and the follow-up.

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A 72-year-old male was referred to our hospital from another institution due to abdominal distention. Physical examination revealed severe fullness and tenderness of the lower abdomen. Abdominal X-ray and computed tomography demonstrated massive free air in the peritoneal cavity and pneumatosis intestinalis in the intestinal wall. Pneumatosis cystoides intestinalis (PCI) was judged to be the most probable diagnosis, and laparoscopic exploration was performed to rule out perforated peritonitis. The laparoscopy demonstrated extensive pneumatosis around the small intestine, but there were no findings of intestinal perforation or necrosis. Therefore, the diagnosis of PCI was established, and the patient was followed conservatively. His clinical course was uneventful and he was discharged from the hospital on the 12th hospital day. Laparoscopic exploration in the current case was effective for making a diagnosis of PCI.

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A 77-year-old woman visited our hospital due to acute and severe abdominal pain. Abdominal computed tomography showed intestinal ileus with ascites and intramural air. We considered it was a strangulated ileus. We performed laparotomy after laparoscopy. The ileum was strangulated due to knot formation in the cecal intestine. We undid the knot and resected the ileum, which was necrotic. We reconstructed the ileum with end to end anastomosis at 10cm from the ileum end. The resected ileum measured 75cm. There was cecal ileum at the opposite site of the mesenterium and 45cm distal from the distal end that measured 12cm and had an ampulla at its distal end. We diagnosed strangulation of the ileum due to knot formation in Meckel's diverticulum. Management of an incidentally detected Meckel’s diverticulum remains controversial. We considered we should resect this Meckel's diverticulum, however, that was unusually long and possessed an ampulla at its distal end.

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None-occlusive mesenteric ischemia is a rare disease that is characterized with a bad prognosis. We report herein on a case of NOMI that required two operations for rescue. A 68-year-old man was admitted to our hospital with sudden abdominal pain. Abdominal CT examination revealed portal venous gas. Based on the finding of acute abdomen, we performed an exploratory laparotomy, the findings of which showed discontinuous intestinal necrosis from the terminal ileum to the ascending colon. Therefore we diagnosed NOMI. Although the patient's postoperative course was favorable, 19 days later we had to perform a second laparotomy due to a second bout of acute abdomen. The intraoperative findings showed bloody ascites and extensive discontinuous intestinal necrosis, so we performed extensive small intestinal resection and an ileostomy. After the second operation, we prescribed an anticoagulant. Therefore, the patient suffered from a short bowel syndrome, however, he remains alive without recurrence 5 years after the surgery.

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Cases of obstructive colorectal cancer often require immediate colon decompression techniques before radical surgery for cancer. In our hospital, two cases of obstructive colon cancer were treated with laparoscopic surgery after decompression with an emergency colostomy. In these two cases, selection for the stoma site of the colostomy was very important when performing the subsequent radical surgery using laparoscopy. To date, such case reports have been very rare in the literature, therefore, a detailed analysis with many cases is required to find the efficacy of laparoscopic surgery after decompression with a colostomy for obstructive colon cancer.

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An 83-year-old female who underwent transabdominal pre peritoneal repair (TAPP) for a left femoral hernia in July 2011 was admitted due to left inguinal pain in March 2012. An abdominal computed tomography (CT) scan showed a herniated intestine filled with intestinal gas; a recurrent left incarcerated femoral hernia was diagnosed. We performed emergency surgery using a femoral approach with laparoscopy. Laparoscopy showed the incarcerated tissue and the small intestine was released from the left femoral canal. The color of the strangulated portion of the intestine recovered following laparoscopy, and the hernia space was repaired using a piece of Mesh plug^® via the femoral approach. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. A femoral approach with laparoscopy is good option for a recurrent incarcerated hernia without ischemia of the intestine.

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A 58-year-old woman, with a medical history of gastric cancer and post-operative bowel obstruction, was admitted to another hospital under the diagnosis of bowel obstruction. She was treated with bowel decompression via a nasogastric tube, however, 3 days later, septic shock occurred, and she was transferred to our hospital. On arrival, her BP was 75/49mmHg, and laboratory data showed disseminated intravascular coagulation (DIC). Treatment for DIC was started immediately. By the following day, her BP had failed to respond to pressors, and the DIC did not respond to the initial treatment. A probing laparotomy was performed, because bowel strangulation might exist with diagnostic difficulty. Intraoperatively, no particular problem was seen other than some adhesion which might have caused bowel obstruction. Klebsiella oxytoca, a gut flora, was detected in the blood culture taken on the day of admission, and no other source of the infection was revealed. Therefore bacterial translocation was highly suspected as the cause of sepsis. The post-operative course was uneventful, and the patient was discharged on the 17th POD. As shown here, bacterial translocation could occur in mild bowel obstruction or in the early phase of treatment for bowel obstruction, and requires special attention.

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A 44-years-old woman, who underwent the surgery for scoliosis, was admitted to our hospital with a sudden onset of dyspnea and fever. After inserting a thoracic drainage tube under the diagnosis of a left pyothorax, a brownish fluid was discharged. The patient was treated with drainage and antibiotics, and food residuum was contained in the fluid. Contrast radiography demonstrated leakage of soluble contrast medium into the left pleural space, and endoscopic examination showed a peptic ulcer on the gastric fundus. Therefore, we diagnosed a gastropleural fistula due to a perforated gastric ulcer. We inserted a drainage tube into the stomach through the fistula and pleural space, and performed chest drainage. In addition, nutritional management was performed through a transgastrostomic jejunum tube. As a result, the inflammation was improved, and the pyothorax cavity was reduced. Finally, the drainage tube in the stomach was removed, and the fistula was closed. A gastropleural fistula due to gastric ulcer perforation is rare, and there are few reports. We report herein on one case of gastropleural fistula.

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A 20-year-old female was hit in the abdomen with a soccer ball and had a checkup immediately in a nearby medical clinic because of epigastralgia and nausea. As computed tomography (CT) of the abdomen showed a hepatic tumor of 7 cm in diameter and hemorrhagic ascites, she was referred to our hospital. Our enhanced CT findings revealed that one part of the tumor capsule was disrupted and was suspected as the hemorrhage site caused by rupture of the tumor. The interior of the tumor showed low density and was enhanced at the early phase of the CT scan with contrast media. We performed an angiography, which showed no further bleeding. The patient underwent surgery four weeks after the injury. The extrahepatic pedunculated tumor was found to be connected to the liver (segment 4) only by the blood vessels. The pathological diagnosis was hepatic angiomyolipoma.

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A 56-year-old man complaining of right lower abdominal pain with muscular defense presented to our hospital's emergency outpatient department. The lower right abdomen was tender, and there was muscular defense. Multidetector-row computed tomography (MDCT) showed a blind-ending intestine-like structure from the small intestine, increased density of the surrounding fat tissue, and ascites. The patient was diagnosed as having diffuse peritonitis due to a perforated Meckel's diverticulum and underwent emergency surgery. Cloudy ascites had accumulated intraperitoneally, and Meckel's diverticulum, which was enlarged and erythematous, was observed 80 cm proximal to the terminal ileum. A diverticulectomy was performed. The postoperative course was uneventful and the patient was discharged seven days after surgery. Histopathological examination showed a Meckel's diverticulum with ectopic gastric mucosa which had developed an ulcer and perforation at the border with the small intestinal mucosa. In the past, special imaging examinations, such as small-bowel series and technetium scintigraphy, were thought to be necessary for the diagnosis of Meckel’s diverticulum. Since 2007, there have been reports on the diagnosis of Meckel's diverticulum based on MDCT findings of a blind-ending pouch. MDCT is useful in the diagnosis of morphologic abnormalities of the digestive tract, including Meckel's diverticulum.

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