We collected data from 39,712 patients with acute pancreatitis, investigating the association between length of stay (LOS) or medical costs and severity of acute pancreatitis based on the Diagnosis Procedure Combination (DPC) database. LOS and medical costs became significantly higher according to the severity of acute pancreatitis (p<0.001). A multivariate regress regression analysis revealed that the prognosis factor and CT grade were significantly associated with higher LOS and medical costs during hospitalization. Unstandardized coefficients of the prognosis factor were 2.49 days (95% confidence interval: 2.30-5.49; p<0.001) and JPY ¥149,611.2 (95% CI 139,055.0-160,167.4; p<0.001) while those of the CT grade were 4.55 days (95% CI: 4.15-4.96; p<0.001) and JPY ¥225,884.6 (95% CI 203,924.9-247,844.4; p<0.001). This study suggests the importance of revision of DPC reimbursement systems according to the assessment in detail of the severity of acute pancreatitis.

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We evaluated the utility of the severity assessment criteria of the new JPN Guidelines (JPN13). We retrospectively studied 183 acute cholangitis (AC) cases with CBD stones that had been diagnosed as being of severe or moderate grade on the conventional JPN Guidelines (JPN05). Eleven severe cases [JPN05] were reorganized into 8 severe and 3 moderate cases of AC [JPN13]. 172 moderate cases [JPN05] were reorganized into 19 severe, 58 moderate and 95 mild cases [JPN13]. Ninety-five point eight percent of mild cases [JPN13] were moderate grade having one criterial factor in JPN05. On the other hand, 86.4% of severe cases [JPN13] were moderate grade having several criterial factors in JPN05. Between the moderate and mild group [JPN13] that had been reorganized from the moderate group [JPN05], a significant difference existed in the bilirubin level and positive rate of purulent bile. The wide range of the moderate group associated with overdiagnosis in JPN05 has been improved, it was considered useful to apply the severity assessment criteria in JPN13 for selecting the true adaptation cases for early drainage.

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Currently, a single-incision laparoscopic appendectomy is generally performed in many institutions with the pneumoperitoneum method. An expensive and specific multi-channel port and disposable roticulating instruments are required. We have performed gas-less single incision (umbilical region: 2-2.5cm) laparoscopic appendectomies with abdominal wall lift using a muscle hook and retractor for open surgery. This method does not need trocars, and is performed via 30°en block laparoscopy (diameter 5mm) and laparoscopic forceps (2～4). The surgical instruments usually employed for a laparoscopy are used, and those associated with open surgery (suction apparatus, syringes, gauze and so on) can also be used. Forty-five patients underwent single-incision laparoscopic appendectomy with abdominal wall lifting using a muscle hook from April, 2010 to May, 2012 at our institute. The number of pneumoabdominal approaches with 3 ports enforced in the same period was 72. Comparing these two methods, there was no difference in the amount of bleeding, operation time, and the postoperative number of days in the hospital. In neither method was any intraoperative problem seen, nor was postoperative infection a concern, Our results strongly suggest that there was no real difference between the pneumoabdominal method, and our single-incision laparoscopic appendectomy with abdominal wall lift using a muscle hook, whereas we believe that the latter is a surgical procedure offering many advantages, including its low cost.

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Children are at an increased risk of button battery ingestion because of the increased prevalence of button batteries in toys, games and so on, especially the higher voltage large (20mm) lithium batteries. We examined the treatment outcomes and problems of the patients suffering from button battery ingestion in our hospital. Between January 1988 and October 2014, 124 patients largely composed of infants under 3 years of age were admitted to our hospital. The sites of the batteries at diagnosis were the esophagus in 8%, the stomach in 65%, and the intestine in 27%. Symptoms of battery impaction in the esophagus were vomiting, anorexia, or fever. If the batteries remained over 2 hours in the esophagus, endoscopic removal of batteries was needed under general anesthesia and there were 6 patients with ulcer formation. Batteries in the stomach were removed with a magnet tube if possible. If not, small batteries in the stomach were excreted spontaneously and large batteries in the stomach were removed with endoscopy. Laparotomic removal of a small battery was needed in a baby because of pyloric injury. In conclusion, button batteries in the esophagus should be removed as an emergency procedure to prevent ulcer formation. Emergency removal of batteries in the stomach is recommended in the cases of infants, or large batteries.

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Background：In recent years, conservative treatment has been administered to generally stable patients with perforation of the upper gastrointestinal tract. However, some cases require additional treatment. There are few reports of investigations to identify predictors of the need for such additional treatment at the commencement of conservative treatment. Subjects and Methods：We retrospectively analyzed 64 consecutive patients who were diagnosed as having perforation of the upper gastrointestinal tract and treated conservatively. We used CT to calculate the amount of ascites on the liver surface；in addition, a three-dimensional image analysis software was used to calculate the amount of ascites in the pouch of Douglas. We determined the cutoff values for ascites, which can be useful for evaluating the risk for additional treatment. Results：A total of 21 patients required additional intervention, including surgery. The probability of requiring additional intervention was 6% (2/33) in patients who met the following criteria: liver surface ascites ≤5mm and pouch of Douglas ascites ≤60mL; on the other hand, the probability increased to 85% (11/13) in patients who did not satisfy either of these criteria. Conclusion: Our results indicate that the need for additional treatment can be predicted through the quantification of ascites using CT.

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We evaluated the usefulness of contrast-enhanced US (CEUS) for the diagnosis of strangulated ileus. The data of 21 patients (adhesive ileus: 8/22; femoral hernia, 4/22; inguinal hernia, 3/22; ventral hernia, 3/22；obturator hernia, 2/22: mechanical ileus without ischemia, 2/22) were reviewed. CEUS was performed with perfluoro-butane gas. We undertook laparotomy and enterectomy for 11 cases in which bowel wall enhancement was absent, and all of the 11 patients showed bowel necrosis at laparotomy. US plus contrast study with perfluoro-butane gas might be potentially useful to elucidate the hemodynamics of a strangulated ileus.

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The aim of this study was to clarify the usefulness of reconstructed images made from arterial phase images in contrast computed tomography (CT) scans of strangulation ileus in order to make an early diagnosis of bowel ischemia. We have previously reported on the utility of the arterial phase of CT for detecting intestinal ischemia associated with strangulation ileus. Based on the results of that previous study, we made a reconstructed image (ileus mode) that emphasized the ischemic part of the bowel in patients with strangulation ileus. From the results of the interpretation of the ileus mode by three trained surgeons, the diagnostic performance was thus analyzed. The accuracy was 88%, and the sensitivity and negative predictive value were 100% for two of the three surgeons. These findings suggest that reconstructed images from the arterial phase of multi-detector row CT scans demonstrated excellent visibility of the ischemic site in strangulation ileus patients, and they may therefore be useful for making an accurate diagnosis of intestinal ischemia.

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Background: Since the pathogenesis of bowel strangulation is bowel ischemia, contrast enhanced CT (CECT) is important for the diagnosis. However, it is unclear which findings of CECT are useful for the diagnosis. Method: Study patients include 15 patients with necrotic bowel strangulation and 25 patients with non-necrotic bowel strangulation. Results: We found mesenteric vascular dilatation, intestinal wall thickness, and the mesenteric edema sign in over 70% of the patients with bowel strangulation. Ascites, lack of contrast enhancement of the intestinal wall, indistinct valves of Kerckring, and the dirty mesenteric fat sign emerged at a higher rate in the patients with necrotic bowel strangulation than in the patients with non-necrotic bowel strangulation. Discussion: To diagnose bowel strangulation with CECT, we should pay attention not so much to the ascites and lack of contrast enhancement of the intestinal wall but to mesenteric vascular dilatation, the intestinal wall thickness, and the mesenteric edema sign.

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In the present study, we divided 103 patients diagnosed as having a strangulated small bowel obstruction at surgery into 2 groups according to the presence of intestinal necrosis. The clinical symptoms, blood test results, blood gas analysis results, and computed tomography (CT) images of the patients were examined and compared. A univariate analysis indicated significant differences in the presence of systemic inflammatory response syndrome before surgery, increased white blood cell count, arterial partial pressure of carbon dioxide （PaCO₂）, elevation of mesenteric attenuation, intestinal wall thickening and reduced enhancement of the intestinal wall. A multivariate analysis indicated the presence of significant differences in PaCO₂ and increased mesenteric density. A strangulated obstruction can progress to a serious condition. Thus, it is important to diagnose and treat intestinal necrosis in high-risk cases at an early stage. Moreover, it is essential to increase the accuracy of interpreting the symptoms and test results, as well as CT image evaluations, while carefully considering the items that were significantly different in our examination.

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Data of subjects who underwent surgery for small intestinal obstruction from 2000 to 2013 were analyzed. There were 152 cases of adhesional obstruction, and 71 cases of strangulated obstruction. Strangulated obstruction was classified as being in the 1st phase (venous strangulation phase), 2nd phase (arterial strangulation phase), or 3rd phase (intestinal necrosis phase). [Results]: The percentage of cases in each phase of strangulated obstruction was as follows；1st phase：7.0%, 2nd phase：47.9%, 3rd phase：45.1%. In 95.5% of cases, strangulated obstruction was diagnosed by computed tomography. The percentage of cases with ascites was 67.6% in patients with strangulated obstruction in the 2nd phase, and 75.0% in those with strangulated obstruction in the 3rd phase；48.8% of the patients of these cases? had only a small amount of fluid in the pelvis. Usefulness of blood testing for the diagnosis of strangulated obstruction was not demonstrated. The incidence of perioperative complications was about 60%. In regard to the complications, there were 2 cases of leakage, 4 cases of pneumonia, and 6 cases of death. For the diagnosis of strangulated obstruction caused by preoperative CT, the proper diagnosis rate should be placed high. If the CT and clinical findings do not match, it may be important to consider early diagnosis and treatment by laparoscopic examination or other methods.

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[Purpose] An important part of an examination for an intestinal obstruction is early confirmation of the presence of strangulation. However, no reliable method for that has been reported. For such cases, we generally perform minimally invasive laparoscopic surgery, as it is considered to be the most simple and reliable means available to directly observe the abdominal cavity. ［Subjects］ We investigated 27 patients who underwent laparoscopic surgery as a first choice procedure and received a definitive diagnosis of strangulating intestinal obstruction in the period from January 2009 to September 2013. The diagnostic rate, operative procedure, and peri-and postoperative courses were noted. [Results] Twenty-two of the patients received a definitive diagnosis from laparoscopic findings. For the operative procedure, 11 underwent total laparoscopic surgery and 16 had conversion from a laparoscopic technique to open surgery. Postoperative complications were observed in 3 patients, none of which was related to the laparoscopy procedure. Laparoscopic surgery was found to be less invasive than open surgery performed during the same period. [Conclusion] Laparoscopic surgery was shown to be minimally invasive, safe, and useful for diagnosis and treatment of strangulating intestinal obstructions.

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A 63-years-old man presented with pan-peritonitis during a course of chemotherapy for adenocarcinoma of the lung. An emergency operation was performed, which delineated a number of nodules in the peritoneum and gut wall. The diagnosis of metastatic lung cancer in the abdomen was made, and a perforation was found in one of these lesions. Although such perforations are rare, intestinal metastasis of lung cancer should always be taken into consideration during chemotherapy. The patient's post-operative hospital stay was prolonged for granulocytopenia due to cancer chemotherapy and the he was discharged at 38 POD without complications.

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An incarcerated obturator hernia is an uncommon and emergency disease, which is seen mostly in elderly, thin females, and the operative procedure for which has not yet been standardized. We report herein on a case of incarcerated obturator hernia repaired with the laparoscopic transabdominal approach. A 96-year-old woman, who had complained of abdominal distention, right lower abdominal pain, and vomiting for a week, was admitted to our hospital. She was diagnosed as having a right incarcerated obturator hernia with ileus by abdominal and pelvic CT scan and underwent an emergency operation. Laparoscopic observation revealed the right obturator hernia with incarcerated small bowel within the hernia sac. After the incarcerated small bowel was reduced, the hernia was repaired with a laparoscopic transabdominal preperitoneal approach using polypropylene mesh sheet. The postoperative course was uneventful.

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An 86-year-old man presented to a hospital with vomiting. An endoscopic examination showed type 3 gastric cancer with pylorus stenosis. Because peritoneal carcinomatosa was suspected from an abdominal CT scan, an endoscopy digestive tract stent placement was performed. Abdominal pain appeared 4 days after the stenting. An abdominal CT scan revealed a large amount of free air and ascites mainly in the upper abdominal cavity, so he was transferred to our hospital under the suspected diagnosis of upper gastrointestinal perforation. On the same day, an emergency operation was carried out. A large amount of purulent ascites, a huge tumor at the gastric antrum, peritoneal dissemination, and a perforation at the duodenal bulbus were confirmed. A diagnosis of iatrogenic duodenal perforation due to the physical contact of the distal end of the stent was made, so we removed the stent, sutured the perforated site, performed a gastro-jejunal bypass, washed and carried out drainage inside the abdominal cavity. Endoscopic stent placement is one of palliative treatments for unresectable malignant digestive stenosis. Although it is minimally invasive compared with a digestive bypass operation and is equal to the digestive bypass operation in terms of its effect of the improvement of the patient’s quality of life, we must be careful to avoid fatal complications including perforation and bleeding.

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A 76-year-old man was admitted to our hospital with left inguinal pain and swelling. Thirteen years previously, he had undergone left inguinal hernioplasty with a mesh plug at another hospital. Abdominal CT revealed abscess formation adjacent to the sigmoid colon, and the presence of a colocutaneous fistula. After a barium enema, he was diagnosed as having a colocutaneous fistula between the sigmoid colon and the left inguinal region due to penetrated diverticulitis. After conservative drainage therapy for regression of the inflammation, an operation was performed. The operative findings showed that the sigmoid colon had strongly adhered to the left lower abdominal wall and the mesh plug had penetrated into the sigmoid colon wall. The mesh plug was removed and a sigmoidectomy was carried out. The patient was discharged from the hospital on the 18^th day after the operation. Colocutaneous fistulas are a relatively rare complication in patients with inguinal hernioplasty with a mesh plug.

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We present herein on the case of an 80 year old woman who was transported to our institution by ambulance after being diagnosed as having strangulated right inguinal hernia, and who then underwent emergency surgery (laparoscopy-assisted hernioplasty). The hernia included the small intestine and greater omentum, which were subsequently partially resected under the suspicion of necrosis. Post-operative blood sampling revealed persistent inflammatory findings, and on CT performed on day 7 a Douglas' abscess was suspected, which was treated with continued administration of antibiotics. However on day 13 sudden abdominal pain appeared, which led to the diagnosis of panperitonitis and emergency surgery was performed. After the incision into the abdomen was made, contaminated ascites was observed. The examination of the pelvic cavity revealed pyometra perforation induced panperitonitis. The patient had worn a ring pessary for many years to treat a uterine prolapse, which is believed to have caused the pyometra. Peritoneal drainage and a simple hysterectomy were performed. In patients who wear a ring pessary for a long period of time as contraception or to prevent uterine prolapse, it is important to note that the ring may cause pyometra and pyometra perforation.

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An 82-year-old male visited our hospital with recurrent vomiting. This patient had type 2 diabetes and developed a slight fever of 37℃ and anorexia with the duration of a week. Abdominal CT revealed excessive accumulation of gas in the small intestine. He had increased plasma CPR levels and was hyperglycemic. Therefore, he was diagnosed as having an ileus and was hospitalized. The next day, the hypogastric pain increased and abdominal CT showed free gas in the pelvic cavity. Thus an exploratory laparotomy was performed with a preoperative diagnosis of gastrointestinal perforation. No gastrointestinal perforation was found during surgery, however, a snowball crepitation and edematous change were observed in the bladder wall. A cystoscope test showed submucosal accumulation of bubbles and he was diagnosed as having emphysematous cystitis. The treatment, which included urethral catheterization, antibiotics and insulin for glycemic control upon fasting, resolved the inflammation as well as the images of gas in the bladder wall. Additionally, we herein report on a case series of 6 cases of emphysematous cystitis seen over the course of a year.

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A 93-year-old woman suffered from choking during a meal. A bystander initiated cardiopulmonary resuscitation including mouth-to-mouth ventilation, and chest compression was performed for approximately 5 minutes. Spontaneous breathing was regained and the patient was transported to our hospital. An abdominal computed tomography scan revealed a large volume of free air in her abdominal cavity. We diagnosed her case as a gastrointestinal perforation following cardiopulmonary resuscitation and performed emergency surgery. A longitudinal laceration approximately 4 cm in length was found along the lesser curvature of the upper body of the stomach and was sutured. We also placed a gastrostomy tube for the purpose of the decompression in the stomach and postoperative feeding. Upper gastrointestinal endoscopy revealed some lacerations and ulcerations on her gastric mucosa in the same region as the surgical findings. She was discharged on the 42nd postoperative day. Since gastric rupture is a rare complication of cardiopulmonary resuscitation, we report herein on this case with a review of the literature.

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A 43-year-old woman who had given birth 2 months previously was admitted to our hospital with upper abdominal pain and vomiting. An abdominal CT scan showed dilation of the intestine with incarceration through the foramen of Winslow. Under the diagnosis of a Winslow foramen hernia, an emergency operation was performed. Operative findings showed that a loop of distal ileum about 90cm proximal from the terminal ileum had herniated through the foramen of Winslow into the omental bursa. Since the herniated ileum showed ischemic change, about 40cm of ischemic ileum was resected. Although it was unclear whether or not the Winslow foramen hernia had been caused by pregnancy and the subsequent birth, there have been several reports of strangulated obstruction in pregnant women without a history of abdominal surgery. In our case, it was presumed that the distal ileum was lifted by the enlarged uterus during pregnancy and herniated through the foramen of Winslow.

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A 69-year-old woman visited our hospital with persistent abdominal pain. Abdominal enhanced CT scans revealed dilation of the small intestine on the left side of the ligament of Treitz and behind the transverse colon. The patient was diagnosed as having strangulated ileus due to an internal hernia through the transverse mesocolon, and emergency laparoscopic surgery was performed. The jejunum was incarcerated into the hernia orifice of the transverse mesocolon, which was repositioned successfully with traction. The hernial orifice was sutured closed laparoscopically. The postoperative course was uneventful. An internal hernia through the transverse mesocolon is an uncommon cause of intestinal obstruction, and it is difficult to diagnose preoperatively. We report on this rare case of internal hernia through the transverse mesocolon that was diagnosed preoperatively and repaired laparoscopically, together with a discussion of the relevant literature.

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An 11-years-old boy fell while cycling and sustained an injury in the left upper quadrant where he was struck by the left edge of the handlebar. A feeling of nausea persisted followed by actual vomiting, so he consulted our institution. CT imaging revealed free gas in a small abdominal cavity, and laparoscopic surgery was performed. A perforation approximately 1.5 cm long was recognized in the jejunum approximately 30-40 cm from ligament of Treitz. Closure was achieved with the Albert-Lembert method.

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A 62-year-old woman was found to be hyperglycemic during a medical examination 3-4 years previously, but did not seek medical attention. She presented at our hospital with a 5-day history of epigastric pain, nausea, and loss of appetite. Laboratory tests showed severe inflammation and diabetic ketoacidosis. An abdominal CT revealed a small amount of intraperitoneal free gas under the liver, and a gas-containing low-density area between the pancreas and descending part of the duodenum. Although duodenal perforation was strongly suspected, upper gastrointestinal endoscopy showed no abnormal findings. In the absence of findings suggestive of acute pancreatitis, the patient was diagnosed as having a gas-forming idiopathic peripancreatic abscess associated with untreated diabetes, and administration of antibiotics and continuous injection of insulin were initiated. However, since the abdominal CT on the 4th day showed that the abscess around the pancreatic head had grown, and a new abscess had developed above the pancreatic head, emergency open abdominal drainage was performed. Her postoperative course was uneventful, and she was subsequently discharged from the hospital. A search of the literature revealed no reported cases of idiopathic peripancreatic abscess associated with diabetes.

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A 29-year-old man had sustained injuries in a traffic accident and was admitted as an emergency. Subcutaneous hemorrhage with a seat belt sign was found on his lower abdomen. A whole-body CT scan revealed multiple bone fractures and fluid collection in the peritoneal cavity. Pneumoperitoneum was not detected and diagnostic laparoscopy was performed. At laparoscopy, a small amount of unclotted blood was found with laceration of the sigmoid colon and mesenteric injuries. He underwent sigmoid colectomy. On 2 days after surgery, however, he had abdominal distention with nausea. A CT scan showed the laceration of the rectus abdominis muscle and herniation of the small intestine into the defect. He was diagnosed as having a traumatic abdominal wall hernia and underwent a reoperation. At laparotomy, disruption of the fascia and the peritoneum were found not at the port site but at the linea alba near the arcuate line. The patient underwent a partial resection of the small intestine and a direct suture of the rectus abdoministo repair the abdominal wall hernia. The number of diagnostic laparoscopies for patients with abdominal blunt trauma has been increasing. A traumatic abdominal hernia should be kept in mind as a probable differential diagnosis, since it is easily overlooked in laparoscopic surgery.

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A 53-year-old woman with a 3-year history of umbilical hernia was referred to the emergency department in our hospital due to severe swelling and pain in the umbilical region. Abdominal computed tomography (CT) revealed an incarcerated umbilical hernia. Swelling and pain improved completely with insertion of an indwelling urethral Foley catheter；therefore, abdominal computed tomography (CT) was re-performed, revealing an umbilical hernia including only a short length of the small intestine. A semi-emergency operation was performed under the suspicion that incarceration had recurred. Intraoperatively, the hernia ring was about 3.0 cm in size, and necrosis of the small intestine was not seen；therefore, enterectomy was not performed and primary suture repair was applied. The postoperative course was good and the patient was discharged on postoperative day 14. No postoperative recurrence has been encountered.

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We encountered 2 elderly patients aged over 90 years in whom we performed a two-stage procedure after initial decompression by cecostomy or colostomy under local anesthesia for obstructing carcinoma of the left half of the transverse colon. In the first, a 92-year-old woman, open cecostomy was performed because of unsuccessful placement of the transanal drainage tube. We performed a bypass procedure and closure of cecostomy at the second operation because of disseminated carcinoma. In the second case, a 94-year-old woman, endoscopic transanal decompression with a drainage tube was not performed in consideration of her age and general condition. Tube transversostomy was performed at the initial operation, followed by partial resection including the colostomy and anastomosis at the second. In both cases, colonic decompression was achieved by evacuation of the liquid contents by these procedures. Both patients could eat orally subsequently, and received home nursing care. In cases of unsuccessful transanal decompression who are high-risk cases for non-surgical decompression, the procedures under local anesthesia seem to be useful for successful decompression.

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We report four cases of perforation of the gastrointestinal tract caused by an ingested fishbone at our hospital over the last 10 years. In all four cases, the patients were men, ranging in age from 64 to 91 years. The affected sites included the ileum in three patients and the sigmoid colon in one patient; all the three patients showed acute inflammatory findings necessitating emergency surgical operation. Although the cause of peritonitis was not identifiable preoperatively, multi-slice CT revealed the high absorption-density image of the suspect fishbone in all three cases. Although the postoperative condition was relatively good in the two cases with ileal perforation, the third patient with sigmoid colon perforation died of endotoxic shock on the second postoperative day. Furthermore, one of the patients with ileal perforation also died of aspiration pneumonia three months after the operation. Our findings show that in cases with a linear high-density opacity seen on multi-slice CT, the possibility of perforation of the gastrointestinal tract by an ingested fishbone should be considered at the time of the surgical operation.

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We report our experience of three cases of foreign body perforation of the small intestine in which a laparoscopic approach was useful for diagnosis and treatment. Case 1：A 65-year-old woman. She presented with the chief complaint of right lower quadrant abdominal pain. Abdominal CT showed free air around the liver. Emergency surgery was performed by the laparoscopic approach. Meckel’s diverticulum was identified 40cm cephalad to the terminal ileum, We observed inflammatory changes in the surrounding omentum and penetration of the same site by a fish bone (about 3cm). Case 2: An 82-year-old man. He presented with the chief complaint of abdominal pain after eating fried shrimp. Abdominal CT revealed no free air, but escape of the intestinal tract outside of the tip and visualization of a high-density region led to the suspicion of perforation of the small intestine by a foreign body. Emergency surgery was performed by the laparoscopic approach. Edematous changes were seen in the surrounding small intestine and penetration of the mesentery in the upper abdomen. Case 3: A 93-year-old man. He presented with the chief complaint of stomach ache after ingestion of fried shrimp. Abdominal CT revealed no free air, but showed an increase in the fat content in the surrounding mesentery and a high-density region measuring about 3cm in the distal ileum. Emergency surgery was performed by the laparoscopic approach. Penetration by a fish bone, about 3cm, was observed 20cm cephalad to the terminal ileum. The laparoscopic approach allowed a definitive diagnosis and minimally invasive treatment in all three cases.

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An 83-year-old woman visited us with the chief complaint of malaise. She also had fever. Laboratory data showed high levels of the acute inflammatory markers. Ultrasonography (US) and computed tomography (CT) showed a hepatic abscess with a sharp linear density in the abscess extending from the stomach. On detailed questioning, she revealed that she had eaten boiled fish 9 days earlier. Percutaneous transhepatic drainage was performed, however, the inflammation persisted. We decided to perform laparotomy, which revealed a 4.5-cm-long fish bone in the left lateral segment of the liver extending into the omentum minor. The foreign body was removed, and the abscess was drained. The postoperative course was uneventful. We reviewed the literature for reports of hepatic abscess caused by a fish bone. In most reported cases, removal of the bone was achieved by open or laparoscopic surgery. Ingestion of a foreign body is easily forgotten. Both US and CT are helpful for diagnosis. Clinicians need to recognize that ingested foreign bodies can even cause a liver abscess.

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In recent years, serum procalcitonin has emerged as a promising biomarker for sepsis, with a high sensitivity and specificity. We report the usefulness of procalcitonin as a predictive marker of sepsis and disseminated intravascular coagulation (DIC) in patients with non-perforated acute appendicitis. A 72 year old man was referred to us because of abdominal pain and generalized fatigue. Blood analysis revealed slightly elevated inflammatory markers. CT revealed findings suggestive of a non-perforated appendicitis and emergency operation was performed. The serum PCT level was 53.4 ng/mL, and the patient developed septic shock and DIC after the operation. The postoperative course was uneventful and the patient was discharged on postoperative day 15. Early identification of severe sepsis is sometimes very difficult. Serum procalcitonin is a useful tool for the early diagnosis of sepsis and DIC, especially in patients with non-perforated acute appendicitis.

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We report the case of a 3-year-old girl with lymphangioma in the greater omentum. The child was brought with a history of fever and abdominal pain since the day before admission. Laboratory tests revealed elevated markers of inflammation. Contrast-enhanced computed tomography and ultrasonography revealed a huge cystic lesion in the left hypogastric region, however, the appendix could not be identified. As the patient presented with an acute abdomen, emergency surgery was performed. Laparotomy revealed a normal appendix, along with a cystic lesion twisted 720° at its root, which was resected. The patient was discharged on postoperative day 7. Histopathological examination revealed the diagnosis of lymphangioma. In a child with an intraperitoneal cystic lesion presenting with an acute abdomen, torsion of the cystic lesion should be suspected.

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A 53-year-old man was admitted to our hospital with tarry stools. Upper gastrointestinal endoscopy revealed an activity bleeding ulcer on the oral aspect of the papilla of Vater. Abdominal CT showed marked hypervascularity of the pancreas head, and early filling of the portal vein and superior mesenteric vein in the early phase. Based on the findings, a diagnosis of AVM in the pancreas head was made. An attempt at treatment of the lesion by TAE with n-butyl-2-cyanoacrylate proved successful, and the AVM regressed. The symptoms of the patient disappeared and no signs of recurrence have been seen for more than 3 years 4 months since the TAE　procedure. Although pancreatic AVM is a rare disease, it may cause acute pancreatitis and gastrointestinal bleeding. TAE for treatment of the lesion might allow pancreatectomy to be avoided. We report a case of pancreatic AVM with duodenal ulcer that was successfully treated by TAE with n-butyl-2-cyanoacrylate.

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