Spontaneous Rectus Sheath Hematoma.

Rectus sheath hematoma (RSH) is one of the surgical emergencies that mimics peritonitis or other causes of acute abdominal pain. It is usually seen in old age, post-trauma, anticoagulation therapy pregnancy, chronic cough, and liver disease. Nevertheless, RSHs can be spontaneous without any underlying predisposing factors. Here, we present a 51-year-old female with sudden onset abdominal pain, abdominal distention, hypotension, and severe pallor. After initial resuscitation, the patient underwent radiological imaging. This suggested an RSH with active bleeding from the inferior epigastric artery or profunda femoris artery. The patient underwent digital subtraction angiography and angioembolization of the profunda femoris branch. After a few days, the patient continued deteriorating and succumbed to acute respiratory distress syndrome (ARDS).

Pancreatitis with infected pseudocyst presenting as a prevertebral abscess with spontaneous rupture into the oesophagus.

The development of a prevertebral abscess due to an infected pancreatic pseudocyst and its spontaneous rupture into the oesophagus is a rare complication. We report a man who presented with odynophagia, dyspnoea and abdominal pain. Contrast-enhanced CT showed evidence of pancreatitis and a prevertebral space abscess communicating with the pancreas through the oesophageal hiatus. The patient was diagnosed to have a prevertebral abscess with chronic pancreatitis. Surgical drainage was planned, but the patient died of spontaneous drainage of the prevertebral abscess into the oesophagus and aspiration of the collection into the lungs.

Effect of Trendelenburg's Operation With Subfascial Ligation of Perforators in Clinical Improvement and Quality of Life Among Patients With Varicose Veins.

Background Assessing patients' quality of life has received increasing attention, mainly because questions have been raised regarding the direct benefits of the treatment provided. Hence, clinical outcomes and quality of life must be measured after chronic venous disease treatment. The primary objective of the study was to assess the improvement in clinical outcome and improvement in quality of life using the revised venous clinical severity score and chronic venous insufficiency questionnaire-14, respectively, in patients with varicose veins undergoing Trendelenburg's surgery and subfascial ligation of perforators. The secondary objective was to identify the relationship between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. Method The present study is a single-center, prospective cohort study to assess the clinical improvement and quality of life in patients with varicose veins undergoing Trendelenburg surgery and subfascial ligation of perforators. All the study participants were evaluated preoperatively with the clinical, etiological, anatomical, and pathophysiological stage of the disease, revised venous clinical severity score for the clinical severity, and the chronic venous insufficiency questionnaire-14 questionnaire for the quality of life. The study participants were reviewed 90 days after surgery and reassessed for clinical severity and quality of life, both scores. Results Of the 87 screened varicose vein patients, 52 were included in the study. However, one patient was lost to follow-up. There were 38 (74.5%) males and 13 (25.5%) females. There was a significant difference in the preoperative and postoperative mean revised venous clinical severity score of the C3, C4, and C6 stages of the disease (p-value = <0.01). There was a significant difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score in C3, C4, and C6 (p-value = <0.01). There was a significant difference in the median preoperative and postoperative revised venous clinical severity score (p-value = <0.01). There was a considerable difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score (p-value = <0.01). The correlation coefficient between the preoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.26 (p-value = 0.58), and the correlation coefficient between the postoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.42 (p-value = <0.01).  Conclusion Patients undergoing Trendelenburg's surgery and subfascial ligation of perforators for varicose veins significantly improved the clinical severity and quality of life. There was significant improvement among the overall revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score after surgery among the different clinical classes. There was no preoperative correlation between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. However, there was a significant correlation between the postoperative revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score.

Aortoesophageal Fistula Occurring Due to Aortic Aneurysm.

Upper gastrointestinal bleeding is a rare presentation of the aortoesophageal fistula (AEF) and is usually caused by thoracic aortic aneurysms. We present the case of a 61-year-old male who presented with chest pain and hematemesis. A chest X-ray showed a widened mediastinum. The patient underwent computed tomography angiography (CTA), which showed the presence of a large aneurysm in the aorta, which caused compression of the trachea, esophagus, and left pulmonary artery. Additionally, there was evidence of an AEF. It was decided to perform an emergency surgical intervention on the patient. However, the patient had multiple episodes of hematemesis and expired.

A Rare Phenomenon of Stercoral Ileal Perforation in a Pregnant Woman.

Perforation peritonitis is one of the most common emergency presentations in Indian hospitals. Stercoral perforations are rare due to increased intraluminal pressure on the gut wall from impacted feces. This is associated with transmural necrosis. We present a 31-year-old pregnant woman who reported abdominal pain and vomiting at 34 weeks of gestation. The diagnosis was unclear from examination and imaging studies, and a provisional diagnosis of acute appendicitis was made. The patient underwent laparotomy and was found to have fecal contamination and multiple stercoral ileal perforations. The bowel segment was resected and exteriorized as a stoma.

Duodeno-duodenal intussusception presenting as upper gastrointestinal bleed.

Duodeno-duodenal intussusception (DDI) is the type of intestinal intussusception in which a segment of the duodenum invaginates into the next part of the duodenum. We present a case of a male patient in his 50s presenting with right upper abdominal pain with multiple episodes of vomiting and a history of melena for 1 month. Imaging studies showed the presence of DDI without apparent growth. The patient underwent upper gastrointestinal endoscopy, which showed a doubtful growth in the duodenum, and the biopsy, was suggestive of adenocarcinoma. The patient underwent Whipple's procedure, and postoperative histology was diagnostic of Brunner's gland adenoma. The patient improved well without any complications.

Incidental Meckel's Diverticulum in Umbilical Hernia.

The presence of a Meckel's diverticulum in the hernial sac is called a Littre's hernia. It is a rare complication of Meckel's diverticulum. We present a 56-year-old male patient who complained of swelling in the umbilical region. After the clinical examination and imaging studies, we diagnosed the patient with a partially reducible umbilical hernia. The patient underwent exploration and was found to have omentum, Meckel's diverticulum, and part of the ileum within the sac. The patient underwent segmental resection of the bowel, primary repair of the hernial defect, and onlay meshplasty. Postoperatively, the patient did not develop any complications.

Cardiac Arrest Due to Anaphylactic Shock Following Vecuronium Injection.

Anaphylaxis under anesthesia is a rare but potentially severe disease. Although anaphylaxis is rare, it can be lethal if not diagnosed and treated appropriately. We present the case of a 43-year-old male with no prior allergy history who experienced a severe anaphylactic reaction that resulted in cardiac arrest after the intravenous injection of vecuronium. His surgery was postponed, and the patient required intensive care with ventilator support and other supportive measures. Post-reaction dermal sensitivity tests revealed a clear allergic reaction to vecuronium which confirmed the diagnosis retrospectively. Eventually, the patient made a full recovery and was rescheduled for surgery at a later date.

Isolated pancreatic tuberculosis masquerading pancreatic malignancy.

Pancreatic tuberculosis is the rarest form of abdominal and extrapulmonary tuberculosis. We present a patient in his 40s who presented with pain abdomen and a fever. On examination, the patient had mild jaundice and right hypochondriac tenderness. Blood investigation was suggestive of obstructive jaundice. Imaging studies were representative of pancreatic head lesion, causing mild intrahepatic biliary radical dilatation. Endoscopic ultrasound-guided fine-needle aspiration done from the pancreatic head lesion was diagnostic of tuberculosis. The patient was started on antitubercular medications and responded well.

Small Cell Carcinoma of the Gallbladder.

Primary neuroendocrine carcinoma of the gallbladder (GB) is a rare, highly dismal lethal disease with a fatal prognosis. A 45-year-old female presented with right upper abdomen pain and multiple vomiting episodes. Imaging studies showed diffuse thickening of the wall of the GB with locoregional invasion into the nearby structures with extensive abdominal lymph node metastasis and arteriovenous encasements. Ultrasound-guided fine-needle aspiration was done, which was diagnostic of small cell carcinoma of the GB. The patient was planned for palliative chemotherapy. A small cell variant of neuroendocrine carcinoma of the GB is a rare entity with a moribund lethality associated with it. Patients are diagnosed in advanced stages with not many treatment modalities to offer. Usually, patients are treated with palliative chemotherapy.

Tension Pneumoperitoneum as a Result of Diastatic Perforation.

Tension pneumoperitoneum is a vapid presentation of pneumoperitoneum, which generally refers to free air in the abdomen and can mimic abdominal compartment syndrome. A diastatic perforation in the abdomen refers to a perforation of the cecum due to a distal obstruction in the colon, manifesting as a closed-loop syndrome. We present a 46-year-old male diagnosed with obstructed left inguinal hernia who underwent hernioplasty. Postoperatively, the patient had progressive abdominal distention and abdominal pain. An abdominal x-ray and computed tomography of the abdomen showed massive air in the abdomen. The patient was diagnosed to have tension pneumoperitoneum. Needle decompression of the abdomen was done, and the patient underwent an emergency laparotomy. Intraoperatively, we found a large cecal perforation and a large amount of pneumoperitoneum. The patient underwent limited resection and ileostomy and ascending mucus fistula. Postoperatively, the patient had an uneventful course and was discharged.

Volvulus of the Transverse Colon Herniated Through Drain Site.

Herniation of the transverse colon and volvulus of it occurring through the previous surgical drain site, presenting as intestinal obstruction, has never been reported. We present an 80-year-old female who complained of abdominal swelling for 10 years. She started developing pain abdomen for 10 days and obstipation for three days. Abdominal examination showed a tender mass in the right lumbar region, with all borders being distinct, and there was no cough impulse. There is a lower midline scar from the previous laparotomy and a small scar over the swelling (drain site). Imaging studies were diagnostic of large bowel obstruction due to the herniation and volvulus of the transverse colon through the previous surgical drain site. She underwent laparotomy, derotation of transverse colon with hernia reduction, and onlay meshplasty. She had an uneventful postoperative course and was discharged.

Paraneoplastic leukemoid syndrome in squamous cell carcinoma of the forearm.

The paraneoplastic leukemoid reaction is a rare haematological paraneoplastic syndrome, which is typically seen with solid tumours and squamous cell carcinomas. As an indication of bone marrow infiltration and malignancy involvement, it indicates a poor outcome and a grave prognosis. We report a woman in her 50s, who presented with an ulcer over the right forearm. Biopsy revealed squamous cell carcinoma. The patient underwent radiological investigations, which showed the presence of metastatic squamous cell carcinoma. Incidentally, the patient was found to have leucocytosis, which was attributed to a paraneoplastic leukemoid reaction, after ruling out all other causes of leukemoid reaction. Due to metastatic disease, the patient was planned for palliative radiotherapy and the best supportive care.

A Randomized Controlled Trial Comparing Ultrasonography-Guided Needle Aspiration and Surgical Drainage for the Management of Breast Abscess.

Background A breast abscess is a localized collection of inflammatory exudate in breast tissue. It is more common in lactating women. Treatment of the breast abscess is usually by incision and drainage, which is accompanied by extensive trauma, lengthy surgical incisions, psychological distress, surgical scar, and discomfort during dressing changes. Recent research has shown that ultrasonography-guided needle aspiration is an alternative to incision and drainage for breast abscess treatment, has superior cosmetic outcomes, and has fewer costs. However, there are no clear guidelines for the same. The primary objective of this study was to assess and contrast the outcomes and efficacy of two approaches in the treatment of breast abscesses: ultrasonography-guided needle aspiration and conventional incision and drainage. Methods This was a single-center, prospective, randomized, controlled, non-inferiority trial. Patients with breast abscesses were randomized either to receive needle aspiration or incision drainage. Patients with lactational breast abscesses were encouraged to breastfeed from either breast. The antibiotic was given for 10 days to all the patients. The study's main focus was on the primary outcome, which was the failure rate. Additionally, several secondary outcomes were examined, including postoperative pain, time required for healing, presence of residual abscess or recurrence, formation of fistulas, and the assessment of scar appearance. Results A total of 44 patients were randomized to 23 and 21 in each arm. There was no statistical difference in treatment failure (p-value=0.862), fistula formation (p-value=1.00), and recurrence (p-value=1.00). There was a significant statistical difference in healing period (p-value <0.001), scar formation (p-value <0.0001), continuation of breastfeeding (p-value=0.005), and clinical resolution (p-value=0.002). There was a significant reduction in post-intervention pain in the needle aspiration group than in the other group (p-value <0.001). Conclusion This study showed a significant difference in postoperative pain, healing time, the continuation of breastfeeding, and scar formation in the needle aspiration group, favouring minimally invasive treatment for breast abscess. However, due to the small sample size, we could not conclude that ultrasonography-guided needle aspiration of the breast abscess is non-inferior to the conventional incision and drainage.

Traumatic Diaphragmatic Rupture With Pericardial Tear and Transdiaphragmatic Herniation of the Stomach.

Traumatic diaphragmatic rupture is uncommon in blunt or penetrating abdominal trauma. Diaphragmatic injury associated with pericardial tear is even rarer. Here, we report a case of a 23-year-old female who presented with complaints of chest pain, abdomen pain, and breathlessness following blunt trauma abdomen. An imaging study showed the presence of transdiaphragmatic herniation of the stomach inside the thorax. Emergency exploratory laparotomy was done, and we found a large diaphragmatic defect with a pericardial tear with herniation of the stomach. Both diaphragmatic and pericardial tears were repaired primarily. Postoperatively, the patient improved well without any complications.