Intraperitoneal focal fat infarction: the great mimicker in the acute setting.

The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However, although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention. We review cases with IFFI in order to identify specific involvement patterns. Cases of epiploic appendages reported to an acute, subacute, and more chronic phase in order to present the self-limiting nature of this entity and the resultant absorption. We also present cases with falciform ligament infarction, as well as primary ("whirl sign" on CT due to greater omentum torsion) and secondary omental infarctions. The aim of this pictorial review is not only to extensively explore the imaging findings of IFFI but to also describe the clinical presentation and pathophysiology of the prementioned conditions.

Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy.

PURPOSE: To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. METHODS: A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. RESULTS: Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO2/FiO2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. CONCLUSIONS: This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.

Pathophysiological Mechanism of Extravasation via Umbilical Venous Catheters.

A rare complication of umbilical venous catheter (UVC) insertion is the extravasation of the infusate into the peritoneal cavity. We report 3 cases of abdominal extravasation of parenteral nutrition (PN) fluid via UVCs. Two of these cases presented as "acute abdomen" which were assumed to be necrotizing enterocolitis clinically; however, during postmortem, PN ascites and liver necrosis were found. A further case is described in an infant with congenital diaphragmatic hernia. While we were unable to ascertain direct vessel perforation by the catheter in any of these cases, based on pathological and histological examination, the proposed mechanism of PN fluid extravasation is leakage through microinjuries of liver vessel walls and necrotic parenchyma. PN extravasation should be considered as a differential diagnosis of acute abdomen when PN is infused via an UVC presumably as PN may have a direct irritant effect on the peritoneum.

[WAYS OF THE SURGICAL MISTAKES OVERCOME IN THE PAIN ABDOMINAL AND THORACIC SYNDROMS].

Experience of differential diagnosis of pleural diseases, accompanied by pleuroabdominal pain syndrome, simulating «an acute abdomen¼, was summarized. In a pleural exudate syndrome such a course was noted in 17 (3%) patients, of them 7 (1.23%) were operated on; and in a syndrome of spontaneous pneumothorax ­ in 3 (1.7%), 1 (0.4%) was operated. Diagnostic algorithm was proposed.

MODERN VIEWS ON THE MECHANISMS OF FORMATION AND PROSPECTS OF THERAPY OF THE PAIN ABDOMINAL SYNDROME IN PATIENTS WITH CHRONIC PANCREATITIS.

Pain in chronic pancreatitis is one of the most mysterious and complex problems of modern gastroenterology. In a review article presents current information about intrapancreatic and central mechanisms of formation of pain in patients with chronic pancreatitis. Based on the pathogenetic mechanisms outlined prospects for the treatment of patients with chronic pancreatitis with pain syndrome.

History-taking and the Usefulness Index in the diagnosis of functional dyspepsia.

BACKGROUND: The primary diagnosis of functional dyspepsia (FD) is made on the basis of typical symptoms and by excluding organic gastrointestinal diseases that cause dyspeptic symptoms. However, there is difficulty reaching a diagnosisin FD. OBJECTIVES: To assess the efficiency of the Usefulness Index (UI) test and history-taking in diagnosing FD. METHODS: A study on acute abdominal pain conducted by the World Organization of Gastroenterology Research Committee (OMGE) included 1333 patients presenting with acute abdominal pain. The clinical history-taking variables (n = 23) for each patient were recorded in detail using a preedefined structured data collection sheet, and the collected data were compared with the final diagnoses. RESULTS: The most significant clinical history-taking variables of FD in univariate analysis were risk ratio (RR): location of pain at diagnosis (RR = 5.7), location of initial pain (RR = 6.5), previous similar pain (RR = 4.0), duration of pain (RR = 2.9), previous abdominal surgery (RR = 4.1), previous abdominal diseases (RR = 4.0), and previous indigestion (RR = 3.1). The sensitivity of the physicians' initial decision in detecting FD was 0.44, specificity 0.99 and efficiency 0.98; UI was 0.19 and RR 195.3. In the stepwise multivariate logistic regression analysis, the independent predictors of FD were the physicians' initial decision (RR = 266.4), location of initial pain (RR = 3.4),duration of pain (RR = 3.1), previous abdominal surgery (RR = 3.7), previous indigestion (RR = 2.2) and vomiting (RR = 2.0). CONCLUSIONS: The patients with upper abdominal paininitially and a previous history of abdominal surgery and indigestion tended to be at risk for FD. In these patients the UI test could help the clinician differentiate FD from other diagnoses of acute abdominal pain.

[The particularities of acute surgical diseases treatment of abdominal cavity organs in patients with haemophilia].

The experience of treatment of 366 patients with haemophilia who were urgently hospitalized in hеmatological Scientific Center over the last 10 years is presented in the article. There were 114 (31.1%) patients with acute diseases of abdominal cavity organs, 150 (41%) patients with bleeding from upper gastrointestinal tract, 102 (27.9%) patients with acute hematomas of retroperitoneal space. Urgent operations were performed in 48 (22.2%) patients who were hospitalized with clinical symptoms of acute abdomen syndrome. It was developed the criteria of diagnosis and choice of treatment tactic on the basis of the received results. Application of presented algorithms led to improve the quality of urgent surgical care to patients with haemophilia.

[Role of heat flow generated by an abdominal cavity in monitoring of acute surgical pathology of abdominal organs].

Despite of significant development of modern surgery results of treatment of acute diffused peritonitis and acute intestinal obstruction are still unsatisfactory. Successful treatment of these conditions depends considerably on timely and adequate diagnosing as it gives a choice of optimal treatment tactics. Measuring of a human body heat flow in areas of organs affected by pathology in cases of acute diffused peritonitis and acute intestinal obstruction provides a possibility to improve the principles of early differential diagnosing, to form new approaches to treatment tactics and monitoring of general health status of a patient during early postoperative treatment. 47 patient suffering from acute diffused peritonitis and 42 patients suffering from acute intestinal obstruction have been examined; the patients were divided into groups based on abdominal cavity exudates character, intestinal obstruction type and intra-abdominal hypertension grade. Measurement of abdominal cavity heat flow was performed by a contact method with use of thermoelectric medical thermometer. Intra-abdominal hypertension was measured by generally used transvesical method. It has been established that abdominal cavity heat flow correlates with character of abdominal cavity exudates; this is also confirmed by reliable difference between serous peritonitis and fibrinopurulent peritonitis indices. Indices in case of acute intestinal obstruction are lower than ones in case of acute diffused peritonitis as there are no inflammatory changes of peritoneum. Development of intra-abdominal hypertension of grades 3-4 directly influences the heat flow extent; this is explained by accelerated and aggravated pathological changes of inner organs cased by the main disease. Thus, abdominal cavity heat flow fully reflects degree of purulent and inflammatory processes of abdominal cavity organs and can be used for additional diagnosing and clinical course monitoring.

The bases of the inflammatory acute abdomen.

Vermiform appendix is an anatomical structure, which due to its topographical relations usually causes many complications, especially in inflammation such as appendicitis. One of the manifestations of the inflammatory processes is pain, which may have different location. It could be probably a result of the neuron stimulation. The nerve formation and distribution of the vermiform appendix is still unknown in fine details and is a subject of further studies (Fig. 8, Ref.12).

[Extraperitoneal ligation herniorraphy by the acute infectious diseases of the abdominal cavity in children].

Surgery on the reason of the "acute abdomen" in children often reveals the persisting vaginal peritoneal defects, which further lead to hernia formation. 23 children (aged 4-15 years) were operated on the acute uncomplicated appendicitis (n=10), acute mesadenitis (n=3), appendicular local and pelvioperitonitis (n=9) and ovary apoplexia (n=1). Inguinal hernia was revealed in all patients during laparoscopy. After videoendoscopic sanation of the abdomen and appendectomy (if it was necessary) the extraperitoneal ligation herniorraphy in author's modification was performed. The were no cases of abdominal complications as well as hernia recurrence among the treated patients.

Outcomes prediction score for acute abdomen: a proposal. / Proposta de escore preditor de desfechos para abdome agudo.

OBJECTIVE: to establish a correlation between objective data collected at the initial evaluation and the outcomes in cases of acute abdominal pain. METHODS: we conducted a retrospective, case-control study in which we reviewed medical records of patients treated at an emergency room in 2016, diagnosed with abdominal and pelvic pain. RESULTS: of the 2,352 medical records evaluated, we considered 330 valid for the study. Of these patients, 235 (71.2%) were discharged and the remaining 95 (28.8%) were hospitalized, submitted to surgery, or died. The statistical analysis demonstrated that male gender, age ≥50, axillary temperature >37.3ºC, anemia, leukocytosis >10,000/mm3, neutrophil count above 7,700/mm3, lymphocyte count less than 2,000/mm3 and hyperamylasemia were variables in independently associated with worse outcome. CONCLUSION: the presence of three or more of the evaluated variables greatly increases the chances of a patient suffering the outcomes of surgery or death, the chance of death being greater the greater the number of variables present.

OBJETIVO: estabelecer a correlação entre dados objetivos coletados na avaliação inicial e os desfechos nos casos de dor abdominal aguda. MÉTODOS: estudo retrospectivo, de caso controle, em que foram revisados prontuários de pacientes atendidos em um serviço de urgência e emergência no ano de 2016, diagnosticados com dor abdominal e pélvica. RESULTADOS: de 2.352 prontuários avaliados, 330 foram considerados válidos para o estudo. Destes pacientes, 235 (71,2%) receberam alta e os 95 (28,8%) restantes foram internados, submetidos à cirurgia ou morreram. A análise estatística demonstrou que sexo masculino, idade ≥50 anos, temperatura axilar >37,3ºC, anemia, leucocitose >10.000/mm3, neutrocitose acima de 7.700/mm3, linfopenia <2.000/mm3 e hiperamilasemia são variáveis isoladamente associadas a pior desfecho. CONCLUSÃO: a presença de três ou mais das variáveis avaliadas aumenta fortemente a chance de um paciente sofrer os desfechos de cirurgia ou morte, sendo a chance de óbito tanto maior quanto maior o número de variáveis presentes.

Severe SARS-CoV-2 Infection in Children With Suspected Acute Abdomen: A Case Series From a Tertiary Hospital in Spain.

We describe 5 children with severe SARS-CoV-2 infection, hemodynamic instability and suspected acute abdomen. This form of the disease has not been previously documented. Four of the cases were confirmed SARS-CoV-2 infection and 1 probable. All of them were previously healthy and needed a pediatric critical care unit admission. The respiratory symptoms were not dominant or were absent. Also, fever was observed. Laboratory testing revealed lymphopenia and high levels of C-reactive protein and procalcitonin with D-dimer, ferritin and interleukin-6 usually elevated. Respiratory support and inotropic support were almost always necessary. In all of them, deterioration occurred on the day of admission.

The value of intra-abdominal pressure measurement in patients with acute abdomen.

AIM: To find out the potential benefit of bladder pressure (BP) measurement as a diagnostic tool for acute abdomen. BACKGROUND: Acute abdomen is one of the most important clinical entities among general surgical clinics. The diagnosis can be achieved by considering the patient's history, physical examination, laboratory analysis or by different imaging modalities. Abdominal compartment syndrome (ACS) occurs due to elevated intra-abdominal pressure (IAP), and can be diagnosed by measurement of BP. We observed in our clinical routine elevated IAP levels in patients with acute abdomen. METHODS: Two groups were established: one containing 65 consecutive patients diagnosed as having acute abdomen in the emergency room, and the control group of 10 consecutive patients with no acute abdominal complaints elected for laparoscopic operation. IAP measurements were performed before the operations. BP was measured in the supine position with 50 mL of sterile saline instilled into the bladder after the bladder had been emptied. The catheter was connected to a water manometer with the reference point being the symphisis pubis. BP levels greater than 7 cmH2O were accepted as abnormal and interpreted as a diagnostic criteria for acute abdomen. RESULTS: Sensitivity, specificity, positive predictive value, negative predictive value and the accuracy are calculated 95.4%, 80%, 96.9%, 72.7%, 93.3%, respectively. CONCLUSION: We found elevated IAP may support the physicians diagnosis of acute abdomen with approximately 27.3% false negative rate.

Radiologic assessment of gastric emptying of water-soluble contrast media: New data security from a longitudinal study. / Evaluación radiológica del vaciamiento gástrico de medio de contraste hidrosoluble: nuevos datos de seguridad de un estudio longitudinal.

BACKGROUND AND OBJECTIVES: Practice guidelines for preoperative fasting have not clearly established the fasting time needed after oral administration of water-soluble contrast media. The aim of this study was to determine the time required for the gastric emptying during the water-soluble contrast media in patients with acute abdominal pain. METHODS: This prospective longitudinal study included sixty-eight patients older than 18 years of age with acute abdominal pain, who required a water-soluble contrast media enhanced abdominal computed tomography study. Plain radiographs were obtained hourly until complete the gastric emptying. Patients with probable bowel obstruction were not included in the study. RESULTS: A total of 31 (45,6%), 54 (79,4%), and 64 (94,1%) patients achieved a complete gastric clearance of barium in 1, 2 and 3 hours, respectively. All patients achieved complete emptying of water-soluble contrast media within 6 hours. Gastric emptying time was not associated with gender (P=0,44), body mass index (P=.35), fasting time prior to water-soluble contrast media intake (P=0,12), administration of opioids in the emergency room (P=0,7), and the presence of comorbidities (P=0,36). CONCLUSION: Ninety-four percent of the patients with acute abdominal pain achieved complete gastric emptying within 3hours after the administration of water-soluble contrast media. All of them achieved complete gastric emptying within 6hours. The results suggested 6hours after oral intake of the contrast media is enough to complete transit of water-soluble contrast media through the stomach and avoid unnecessary risks.

[Anesthesiological management of patients with an acute abdomen]. / Anästhesie berim akuten Abdomen--Aspekte des perioperativen Managements.

Patients with an acute abdomen present with marked deterioration in physiological and pathophysiological conditions, which make general anesthesia to a challenging but also potentially dangerous procedure. A broad and fundamental knowledge of the pathophysiologically involved mechanisms of cardiovascular functions during anesthesia and appropriate anesthesiological approach are crucial for a successful peri-operative management. The anesthesiologist's goal is to perform adequate anesthesia while maintaining cardiovascular stability. Monitoring and management of acid-base-status as well as cardiovascular functions are required to maintain sufficient tissue oxygenation during anesthesia. The postoperative anesthesiological management may also crucially influence the further course and therefore should be considered in the anesthesiological planning. Finally, adequate pain management in all these patients is an important and not to underestimate part in the treatment. This article gives an overview on the major aspects in the different fields in the anesthesiological management of patients with an acute abdomen.

Intestinal nonrotation and left-sided perforated appendicitis.

Acute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Approximately one third of cases have pain unexcepted location due to its various anatomical location. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, a few congenital anomalies should be considered such as Situs Inversus totalis and Midgut Malrotation (MM). MM is a rare congenital anomaly; it occurs due to error in process of rotation or fixation of intestines around the superior mesenteric vessels and it refers to nonrotation or incomplete rotation of intestines. Here we report a case who presented with left lower abdominal pain and was diagnosed with acute perforated appendicitis with intestinal nonrotation. Clinicians should be aware that intestinal nonrotation may be presented with left lower quadrant pain and complicated by acute appendicitis.

An Unusual Case of Acute Abdomen: Ovarian Vein Thrombosis.

Ovarian vein thrombosis is one of the rare causes for acute abdomen. Occult presentation of this disease may lead to diagnostic dilemma. A sixteen years female who was operated as a case of ectopic pregnancy was finally diagnosed as having ovarian vein thrombosis. She was successfully treated with anticoagulant.

Nonmalignant gastric causes of acute abdominal pain on MDCT: a pictorial review.

Acute abdominal pain is a common indication for imaging. The stomach may be poorly assessed or overlooked on multidetector computed tomography (MDCT), despite the high prevalence of gastric pathology as the source of abdominal pain. We review the pathophysiology, imaging features, and clinical management of common and uncommon nonmalignant gastric conditions on MDCT. As the stomach is often difficult to assess on MDCT, and pathology overlooked, corresponding increased awareness of gastric causes of pain is critical for radiologists to accurately interpret imaging in the setting of acute abdominal pain.

What to Expect When They are Expecting: Magnetic Resonance Imaging of the Acute Abdomen and Pelvis in Pregnancy.

In this article, we discuss the challenges in the diagnosis of acute abdominopelvic pain in pregnant patients, role of imaging, and advantages of MRI over other modalities. Methods consist of pictorial review. We review the differential diagnoses and illustrate the MRI findings in pregnant patients with acute abdominopelvic pain, including gastrointestinal, gynecologic, urologic, and vascular etiologies.