A Rare Case of Extended Retroperitoneal Biloma Due to Spontaneous Perforation of Common Bile Duct, Mimicking a Strangulated Right Inguinal Hernia: A Case Report and Literature Review.

BACKGROUND Biloma is the collection of bile outside the biliary tree as a result of visceral perforation. The most common site of disruption is the gallbladder, whereas common bile duct lesions usually occur following medical procedures or trauma. Spontaneous perforation of the common bile duct has been previously reported in the literature. Retroperitoneal biloma secondary to spontaneous perforation of the common bile duct is an extremely rare pathological entity. The purpose of this report is to inform clinical doctors of this rare entity, which can have fatal consequences for the patient. CASE REPORT We present the case of an 89-year-old man who was hospitalized with symptoms of vomiting, nausea, fatigue, and diffuse abdominal pain. The clinical examination and blood tests revealed peritonitis, a finding which was confirmed by the computed tomography of the abdomen as a retroperitoneal fluid collection, extending from the region posterior to the duodenum and head of the pancreas to the right inguinal fossa. As the patient's clinical status deteriorated, an urgent laparotomy was performed, revealing the presence of retroperitoneal biloma secondary to spontaneous perforation of the common bile duct. The operation was never completed as the patient died during the operation. CONCLUSIONS The diagnosis of this entity is difficult and is made during surgery. A large spectrum of treatment approaches has been used, but, regardless of the method, the goal is to halt the spreading abdominal contamination with bile and to treat the associated biliary pathology.

Spontaneous common bile duct perforation in full term pregnancy: a rare case report and review of literature.

BACKGROUND: Spontaneous biliary system perforation is a rare presentation in clinical practice especially in adults. It is rarely suspected and diagnosed preoperatively due to small number of cases, vague sign and symptoms, and ambiguous presentation. CASE PRESENTATION: We describe an interesting case of spontaneous perforation of the common bile duct in a 16 year-old female who presented a week after her first birth to the emergency department with complaints of diffuse abdominal pain, abdominal distention, fever, vomiting, and constipation. She was having generalized peritonitis but the etiology was unclear despite a thorough workup. She underwent exploratory laparotomy, and a perforation in the supra duodenal region of the common bile duct was found intraoperatively. The common bile duct was repaired over T-tube, and cholecystectomy was performed; the patient was recovered uneventfully. CONCLUSION: Spontaneous biliary perforation is a rare cause of acute abdomen in adults and extremely rare in pregnancy. Its delayed diagnoses and management can lead to a high morbidity and mortality. All physicians, especially surgeons, should be aware of this possibility and consider it a cause of peritonitis on differential diagnosis particularly when there is no apparent etiology available for presentation.

Spontaneous Perforation Of Meckel's Diverticulum Presenting With Generalized Peritonitis.

Meckel's diverticulum is the most common congenital anomaly of the GIT with a low incidence of 2% and the complication rate is even lower with perforation being the rarest. We report an intriguing case of a 15-year-old male, who presented with one-week history of high-grade fever and diarrhoea followed by acute onset of abdominal pain in the periumbilical region which became generalized. On physical examination his abdomen was distended with guarding and rigidity. A provisional diagnosis of peritonitis secondary to enteric perforation was made and exploratory laparotomy was done which revealed a perforated Meckel's diverticulum and advanced peritonitis. A diverticulectomy with double barrel ileostomy were performed. No heterotopic tissue in the diverticulum was noted on histopathology, nor any other abnormal tissue identified. The patient made an uneventful recovery postoperatively and ileostomy reconstruction was done two months later. This case report is rare case of Meckel's diverticulum complications and highlights the importance of considering Meckel's diverticulum as a differential diagnosis in every patient presenting with acute abdomen, which can aid toward better management through laparoscopy.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis.

BACKGROUND: Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. CASE PRESENTATION: A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder. CONCLUSIONS: Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Prognostic nutritional index predicts mortality in infective endocarditis.

OBJECTIVE: The prognostic nutritional index (PNI), based on serum albumin and lymphocyte concentration, is an inflammation-based nutritional score that has been shown to be a prognostic determinant in several populations. The aim of this study was to investigate the impact of PNI on mortality in patients with infective endocarditis (IE). METHODS: A total of 131 patients with IE were enrolled in this retrospective study. The patients were divided into 2 groups based on in-hospital mortality. The PNI value of the patients was evaluated, as well as baseline clinical and demographical variables. RESULTS: Among the study group, 29 patients died in-hospital during the median follow-up of 37 days. The PNI was found to be lower in cases of mortality (35.90±6.96; 31.09±5.88; p=0.001). ROC curve analysis also demonstrated that the PNI had a good predictive value for in-hospital mortality with a cut-off value of 35.6 (Area under the curve: 0.691; 95% confidence interval [CI]: 0.589-0.794; p=0.002). In multivariate logistic regression analysis, advanced age (Odds ratio [OR]: 1.078; 95% CI: 1.017-1.143; p=0.012), PNI (OR: 0.911; 95% CI: 0.835-0.993; p=0.034), and leaflet perforation (OR: 5.557; 95% CI: 1.357-22.765; p=0.017) were found to be independent predictors of mortality. Kaplan-Meier survival analysis revealed that long-term survival was found to be significantly decreased in patients with a lower PNI (Log rank: p=0.008). CONCLUSION: The PNI result was associated with an increased in-hospital mortality rate in patients with IE. The PNI value, advanced age, and cardiac valve perforation as a complication of IE were found to be independent predictors of mortality.

Diaphragmatic Hernia Perforation Leading to Fecopneumothorax.

Hiatal hernia is a common diagnosis. Unless symptomatic, most hiatal hernias are not repaired; in rare cases, however, severe complications can develop during conservative treatment. Although fecopneumothorax occurrence has been described in trauma and related to colonic pathology, it has not been described as occurring from spontaneous strangulation of a hiatal hernia. Regardless of the etiology, prompt recognition of the rare occurrence of fecopneumothorax is imperative. This report describes the presentation, diagnosis, and treatment of a patient presenting with a type IV hiatal hernia that resulted in colonic ischemia, perforation, and fecopneumothorax.

Spontaneous acalculous gallbladder perforation post-cardiac transplantation.

Spontaneous acalculous gallbladder perforation is a rare radiological and clinical phenomenon with life-threatening consequences. In the setting of recent cardiac transplantation, the condition is increasingly uncommon and difficult to diagnose preoperatively. We describe a case of spontaneous acalculous gallbladder perforation in an intensive care unit (ICU) patient, most likely due to a combination of cardiac transplantation and immunosuppression. There are no such documented cases in the literature with an established preoperative diagnosis, to the best of our knowledge. Abdominal CT and targeted ultrasound proved complimentary in establishing the diagnosis, facilitating successful and timely treatment with urgent cholecystectomy.

ReShape Intragastric Balloon Complicated by Gastric Perforation and Peritonitis.

BACKGROUND: Obesity is a growing global epidemic with tremendous financial burden and health care costs worldwide. Restrictive surgery has emerged as the definitive treatment option to combat morbid obesity and its associated comorbidities. The advent of endoscopy has new grounds in obesity with the introduction of inflatable balloon placed in the stomach that decreases satiety by volume restriction. MATERIALS AND METHODS: We report a first case of gastric perforation with peritonitis after ReShape intragastric balloon placement that needed emergent surgical intervention. Decision was made to proceed with exploratory laparotomy, device deflation, and removal with subsequent gastric defect repair. RESULTS: Postoperative period was uneventful, drain was removed on postoperative day 2, and patient tolerated diet and was discharged home subsequently. Biopsy of the perforation site demonstrated mild non-specific chronic gastritis. CONCLUSION: In the modern era of minimal invasiveness, any new approach would roar popularity among patients and hence is of utmost importance for clinicians to be constantly educated on scientific research and innovations in their field.

LAPAROSCOPIC APPENDECTOMY DOES NOT INCREASE THE RATE OF NEGATIVE APPENDECTOMY along with a lower rate of perforated appendicitis - RESULTS IN 1899 PATIENTS at Zagreb UHC.

- Laparoscopic appendectomy is the method of choice of many professional societies owing to its many advantages. The question arises whether surgeons urge more easily to laparoscopic exploration due to its less invasiveness, faster recovery and adequate exploration of the entire abdominal cavity than to observation in unequivocal cases. This retrospective analysis (2009-2016) included 1899 patients undergoing laparoscopic (lap) or gridiron intra-abdominal approach treated at Zagreb University Hospital Centre. The analysis included total negative appendectomy, negative-negative appendectomy (normal appendix and no other pathology found), and negative-positive appendectomy (normal appendix but another pathology found) in children (≤16 years) and adults. There was no statistically significant difference in the rates of negative appendectomy (children) - lap vs. open (p=0.24); negative appendectomy (adults) - lap vs. open (p=0.15); negative-negative appendectomy (children) - lap vs. open (p=0.36); negative-negative appendectomy (adults) - lap vs. open (p=0.21); negative-positive appendectomy (children) - lap vs. open (p=0.53); negative-positive appendectomy (adults) - lap vs. open (p=0.56); and laparoscopy group negative appendectomy in children vs. adults (p=0.56). There was a statistically significantly higher perforation rate with the open approach in total (p<0.0001), in children (p<0.0001) and in adults (p=0.02). There was no statistically significant difference between adults and children in the perforation rate with laparoscopic approach (p=0.24) and perforation rate with open approach (p=0.29). Results confirmed that there was no statistically significant difference in the rate of negative appendectomy in all subgroups. It is concluded that laparoscopic appendectomy should be offered as the method of choice in any patient population with suspicion of acute appendicitis.

Perforated neuroenteric cyst masquerading as congenital pulmonary airway malformation.

A 3-month-old child was presented with haemoptysis with respiratory distress. Imaging was suggestive of a cavitary lesion in the lung with surrounding consolidation. Diagnosis of a primary lung pathology like congenital pulmonary airway malformation was considered. Based on clinical suspicion and prior experience, a Tc-99m pertechnetate radionuclide study was performed, which clinched the diagnosis of foregut duplication cyst. Intraoperative findings confirmed the presence of a neuroenteric cyst. The child remains asymptomatic on follow-up awaiting neurosurgical intervention for the intraspinal component of the cyst.

[Perforated gastric non-Hodgkin lymphoma]. / Linfoma gástrico no Hodgkin perforado.

Lymphomas are solid tumors of the lymphatic system and these are divided into Hodgkin's and non-Hodgkin lymphoma. Non-Hodgkin tumors may originate from non-nodal tissues such as the gastrointestinal tract and they are considered primary when extranodal involvement is equal to or greater than 75% according to the nodal involvement. Extranodal gastrointestinal lymphomas represent 1% to 4% of tumors of the digestive tract, and 10 to 15% of all non-Hodgkin lymphomas. The stomach is the most common extranodal lymphomas site. We present the clinical case of a sexagenarian male natural of Chiclayo who had an upper GI endoscopy for non-specific symptoms of dyspepsia that only reports gastritis and when admitted to our institution is diagnosed by endoscopy, biochemical markers and pathology as a perforated gastric non-Hodgkin lynphoma.

Gastric cancer with lesion extending to spleen and perforation into free peritoneum.

Perforated gastric carcinoma is a rare condition that is hard to diagnose preoperatively. It is associated with advanced cancer stages and has a high mortality, particularly in cases presenting preoperative shock. Few studies have investigated the presentation and adequate management of these carcinomas. In addition, there are no reports in the literature on perforations extending to the spleen, as described in this case, making the management of these lesions challenging. Our article reports a case of gastric tumor perforation extending to the spleen, which presented as a perforated acute abdomen. The patient was treated with total gastrectomy and D2 lymph node resection with splenectomy and progressed well with current survival of one year at disease stage IV.

Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis.

Cocaine abuse occasionally causes extensive destruction of the osteocartilaginous structures of the nose, sinuses and palate, which mimics the clinical picture of other diseases associated with necrotising midfacial lesions. The differentiation of cocaine-induced midline destructive lesions (CIMDL) and limited granulomatosis with polyangiitis (GPA) may be difficult, particularly if patients do not readily admit substance abuse. We studied 10 patients with CIMDL and palate perforation referred to our Unit between 2002 and 2015. All cases underwent nasal endoscopy, sinus CT or MRI and ANCA test. In 8 patients, a nasal biopsy was performed. The PubMed database was searched to review all cases of palate perforation described in patients affected by CIMDL or GPA. All 10 cases presented with septal perforation and inferior turbinate destruction. We found hard palate perforation in 7 patients, soft palate perforation in 2 patients, and perforation of both in one patient. ANCA testing was negative in 8 patients and positive in 2, with C-ANCA and P-ANCA specificity, respectively. A review of the English literature identified palate perforation in 5 patients with GPA and in 73 patients with CIMDL. The presence of palate perforation in patients with MDL may represent a clinical marker that strongly favors CIMDL over GPA.

Adaptive process triage system cannot identify patients with gastrointestinal perforation.

INTRODUCTION: Adaptive process triage (ADAPT) is a triage tool developed to assess the severity and address the priority of emergency patients. In 2009-2011, ADAPT was the most frequently used triage system in Denmark. Until now, no Danish triage system has been evaluated based on a selective group of patients in need of acute abdominal surgery. Gastrointestinal perforation (GIP) is acknowledged as one of the surgical conditions with the highest mortality rates. The aim of this study was to evaluate whether ADAPT can identify patients with GIP. METHODS: All abdominal emergency laparoscopies and laparotomies performed over a one-year period at Herlev Hospital, Denmark, were included. Patient data and triage levels were collected from medical records. We defined patients suspected of less severe surgical illness as green-yellow and patients suspected of severe/life-threatening illness as orange-red. RESULTS: A total of 803 patients with a known triage level were identified: 47% green, 38% yellow, 13% orange and 2% red. Of these patients, 136 were identified with a GIP. The negative predictive value was 83.2% (95% confidence interval: 80.1-85.7), meaning that one out of six abdominal surgery patients triaged as green or yellow had a GIP that was not identified by the triage system. CONCLUSION: ADAPT is incapable of identifying one of the most critically ill patient groups in need of emergency abdominal surgery. FUNDING: none. TRIAL REGISTRATION: HEH-2013-034 I-Suite: 02336.

Linfoma gástrico no Hodgkin perforado / Perforated gastric non-Hodgkin lymphoma

Los linfomas son tumores sólidos del sistema linfático y se subdividen en linfomas de Hodgkin y no-Hodgkin. Los tumores no Hodgkin pueden originarse en tejidos no ganglionares como el tubo digestivo y son considerados primarios cuando el compromiso extranodal es igual o superior al 75% con relación al compromiso nodal. Los linfomas extranodales gastrointestinales representan del 1% al 4% de los tumores del tracto digestivo y del 10 al 15% de todos los linfomas no Hodgkin. El estómago es el sitio extranodal más común de los linfomas. Presentamos el caso clínico de un paciente varón sexagenario natural de Chiclayo que se realiza una endoscopía particular por síntomas inespecíficos de dispepsia y sólo se informa gastritis eritematosa y al ser admitido en nuestra institución se le diagnostica por endoscopía, marcadores bioquímicos y anatomopatología como un linfoma gástrico no Hodgkin perforado

Lymphomas are solid tumors of the lymphatic system and these are divided into Hodgkin's and non-Hodgkin lymphoma. Non-Hodgkin tumors may originate from non-nodal tissues such as the gastrointestinal tract and they are considered primary when extranodal involvement is equal to or greater than 75% according to the nodal involvement. Extranodal gastrointestinal lymphomas represent 1% to 4% of tumors of the digestive tract, and 10 to 15% of all non-Hodgkin lymphomas. The stomach is the most common extranodal lymphomas site. We present the clinical case of a sexagenarian male natural of Chiclayo who had an upper GI endoscopy for non-specific symptoms of dyspepsia that only reports gastritis and when admitted to our institution is diagnosed by endoscopy, biochemical markers and pathology as a perforated gastric non-Hodgkin lynphoma

Gastric cancer with lesion extending to spleen and perforation into free peritoneum / Neoplasia gástrica perfurada com extensão da lesão para o baço

Summary Perforated gastric carcinoma is a rare condition that is hard to diagnose preoperatively. It is associated with advanced cancer stages and has a high mortality, particularly in cases presenting preoperative shock. Few studies have investigated the presentation and adequate management of these carcinomas. In addition, there are no reports in the literature on perforations extending to the spleen, as described in this case, making the management of these lesions challenging. Our article reports a case of gastric tumor perforation extending to the spleen, which presented as a perforated acute abdomen. The patient was treated with total gastrectomy and D2 lymph node resection with splenectomy and progressed well with current survival of one year at disease stage IV.

Resumo A neoplasia gástrica perfurada é uma condição incomum e de difícil diagnóstico pré-operatório, estando relacionada a estágios avançados e com alta mortalidade, principalmente na presença de choque pré-operatório. Poucos estudos foram feitos quanto a sua forma de apresentação e ao tratamento adequado. Além disso, não há nenhum relato em literatura quanto à extensão da perfuração para o baço, como é descrito neste caso, tornando mais difícil a conduta. Este artigo relata um caso de perfuração de neoplasia gástrica com extensão para o baço, que se apresentou como abdome agudo perfurativo. Submetido a gastrectomia total e ressecção linfonodal D2 com esplenectomia, apresentou boa evolução e sobrevida atual de 1 ano, em um estadiamento IV da doença.