A Rare Manifestation of Unknown Hyperparathyroidism as a Perforated Peptic Ulcer.

Hypercalcemia is a common electrolyte abnormality with different causes. Hypercalcemia is most often associated with malignancy and primary hyperparathyroidism and malignancy together account for most cases. Primary hyperparathyroidism manifests as hypercalcemia owing to the overproduction of parathyroid hormone. In most cases, primary hyperparathyroidism manifests due to a solitary parathyroid adenoma. Based on calcium levels, hypercalcemia can be classified as mild, moderate, and severe. Hypercalcemia typically presents with non-specific clinical features. Here, we present the case of a 38-year-old male patient who presented to the emergency department (ED) with acute abdominal pain and a tender abdomen with absent bowel sounds. He had chest radiography and blood tests initially. Chest radiography showed left-sided pneumoperitoneum, and the patient was suspected to have a perforated peptic ulcer due to hypercalcemia secondary to a parathyroid adenoma during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. The findings were confirmed by a computerized tomography scan of the abdomen, and the patient was treated with intravenous fluids for hypercalcemia and was managed conservatively for a sealed perforated peptic ulcer following discussion in the multi-disciplinary team meeting (MDT). The COVID-19 pandemic led to a long waiting list and delays in the timely management of patients requiring elective surgical intervention, such as parathyroidectomy. The patient made a complete recovery and had parathyroidectomy of the inferior right lobe two months later.

Mesenteric Ischemia: A Case of Extrapulmonary Presentation in COVID-19

Coronavirus 2019 (COVID-19) is a predominantly respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It creates a hypercoagulable milieu, manifesting at varied extrapulmonary sites as pulmonary embolism, deep venous thrombosis, stroke, myocardial infarction, and mesenteric ischemia. The pathophysiology behind this hypercoagulability is still not entirely understood, although a heightened systemic inflammatory response to the virus is deemed responsible. We herein report a case of a 36-year-old healthy male who presented with an acute abdomen and was found to have extensive mesenteric and portal venous thrombosis with bowel gangrene. The patient underwent emergency exploration with ileal resection and end-ileostomy. The hypercoagulability panel was negative, but a postoperative chest radiograph revealed suspicious ground-glass opacities. Given the ongoing global COVID-19 pandemic, we considered testing for SARSCoV-2. A positive test for SARS-CoV-2 led us to attribute the thrombotic event to COVID-19. With anticoagulation and supportive therapy, the patient went on to make a steady recovery. A non-specific clinical manifestation of COVID-19 necessitates considering mesenteric venous thrombosis as a differential diagnosis in patients with acute abdomen.Copyright © 2023 Author.

COVID-19 Infection and Acute Pancreas Transplant Graft Thrombosis.

The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented challenge for healthcare, and the world continues to struggle in recovering from its aftermath. COVID-19 has been clearly linked to hypercoagulable states and can lead to end-organ ischemia, morbidity, and mortality. Immunosuppressed solid organ transplant recipients represent a highly vulnerable population for the increased risk of complications and mortality. Early venous or arterial thrombosis with acute graft loss after whole pancreas transplantation is well-described, but late thrombosis is rare. We herein report a case of acute, late pancreas graft thrombosis at 13 years post pancreas-after-kidney (PAK) transplantation coinciding with an acute COVID-19 infection in a previously double-vaccinated recipient.

COVID-19 and pancreatitis: A review of the potential association

Originally thought to be a respiratory pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has been shown to cause a dizzying array of symptoms, including all major organ systems of the human body. As time elapsed, new strains of the virus have emerged, validating concerns about genetic mutation. No single treatment has proven beneficial in treating the consequences, and the world has been left at the mercy of this deadly pathogen. It has been proven that COVID-19 can cause strokes, myocardial infarcts, mesenteric infarcts, acute limb ischemia, and a wide array of other symptomatology. This review aimed to evaluate whether there exists an association between COVID-19 and pancreatitis. Forty publications (34 case reports and 4 case series) were included in the review. In total, 44 cases of acute pancreatitis (38 cases of acute edematous pancreatitis and 6 cases of necrotizing pancreatitis) in COVID-19 patients without any predisposing factors have been published since January 2020. Fortunately, only 4 (9.1%) of these patients were reported to have died. Although the exact mechanism by which COVID-19 causes pancreatitis is still unclear, studies so far have reported it as a multifactorial phenomenon. COVID-19 associated pancreatic injury is thought to involve direct cellular damage via local replication of SARS-CoV-2 within pancreatic cells, as they express angiotensin-converting enzyme 2 receptors even more strongly than lung cells. Our review concludes that acute pancreatitis should be kept in the differential list of all COVID-19 patients with gastrointestinal manifestations, especially in patients with acute abdomen.Copyright © 2023, Society of Gastrointestinal Intervention.

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

Patient with suspected severe acute respiratory syndrome coronavirus 2 infection with successful emergency surgery for ulcerative colitis-associated toxic megacolon.

BACKGROUND: In patients with acute severe ulcerative colitis with concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the treatment strategy should consider the presence of pneumonia, respiratory status, and the severity of the ulcerative colitis (UC). We report a case of a 59-year-old man with SARS-CoV-2 infection who was diagnosed with toxic megacolon caused by UC. CASE PRESENTATION: Preoperative computed tomography scanning of the chest showed ground-glass opacities. The patient was treated conservatively until the pneumonia improved, but developed bleeding and liver dysfunction associated with UC. As the patient's condition worsened, emergency surgery with subtotal colorectal resection, ileostomy, and rectal mucous fistula creation was performed while undertaking adequate infection control measures. Intraoperatively, contaminated ascites was observed, and the intestinal tract was markedly dilated and fragile. Nevertheless, the postoperative outcome was positive, with no pulmonary complications. The patient was discharged on postoperative day 77. CONCLUSIONS: The COVID-19 pandemic presented challenges in surgical scheduling. Patients with SARS-CoV-2 infection required close monitoring for postoperative pulmonary complications.

COVID-19 Associated Acute Pancreatitis: A Case Series from India.

INTRODUCTION: Initially, COVID-19 was typically concerned with respiratory symptoms and had a mild and asymptomatic to critical clinical course. Over time, many atypical presentations related to cardiac, hepatic, gastrointestinal, renal, musculoskeletal, and neurological features have been reported in COVID-19. CASE PRESENTATION: We present three confirmed cases of COVID-19 who developed acute pancreatitis without any other obvious discernible cause. One middle-aged patient of 48-years old male presented with severe abdominal pain with mild symptoms, COVID-19, later diagnosed as acute pancreatitis with a positive outcome. Another 40-year-old male, hospitalized due to moderate COVID-19, developed acute pancreatitis and managed successfully. The third patient of 58 years old with control diabetes and severe COVID-19 developed acute necrotizing pancreatitis. Unfortunately, he succumbed due to multiorgan failure while on the mechanical ventilator. CONCLUSION: Acute pancreatitis is uncommon in COVID-19. Although, it should be kept as a high index clinical suspicion if abdominal pain is reported. Early diagnosis and prompt management can significantly impact the patient's outcome.

Exclusion of Alternative Diagnoses in Children with Suspected Pimsts Referred to a Regional Critical Care Transport Service in the Uk: A Retrospective Audit

BACKGROUND AND AIM: Paediatric inflammatory multisystem syndrome temporally related with COVID-19 (PIMS-TS) has considerable overlap in presentation with Kawasaki disease, sepsis, toxic shock syndrome, and surgical abdominal pathology. National consensus guidelines were published in the United Kingdom in September 2020, detailing investigations that should be undertaken to exclude other diagnoses. This retrospective audit aimed to assess referrals to our regional critical care transport service to ascertain whether alternative diagnoses are being excluded in children with suspected PIMS-TS. METHOD(S): 66 referrals were made to the transport service from September 2020 to 2021 with a provisional diagnosis of COVID-19, PIMS-TS, atypical Kawasaki disease, acute abdomen or cardiac disease. Referral documentation was examined and excluded if PIMS-TS was not suspected, leaving a total of 41 referrals for audit. Documentation was examined for evidence of completion by the referring team of sepsis screen and abdominal imaging. RESULT(S): 24 (59%) patients had a sepsis screen already completed prior to referral. Of the remaining 17 referrals, 16 (94%) did not have a sepsis screen recommended by the transport service. 27 (66%) referrals had abdominal symptoms on referral. Of these, 9 (33%) had received abdominal imaging, 6 (22%) were recommended to receive imaging by the transport service, and 12 (44%) were not recommended to receive imaging. CONCLUSION(S): The majority of patients referred to the regional transport service had received a sepsis screen prior to referral. However the majority of patients with abdominal symptoms did not receive imaging. A referral proforma for suspected PIMS-TS patients has been developed to improve exclusion of alternative diagnoses.

Mesenteric Ischemia in Patients with Coronavirus 2019: A Scoping Review.

Background: Coronavirus 2019 (COVID-19) is a systemic disease associated with severe gastrointestinal complications including life-threatening mesenteric ischemia. We sought to review and summarize the currently available literature on the presentation, management, and outcomes of mesenteric ischemia in patients with COVID-19. Patients and Methods: The PubMed database was searched to identify studies published between January 2020 and January 2021 that reported one or more adult (≥18 years) patients with COVID-19 who developed mesenteric ischemia during hospitalization. The demographic characteristics, clinical and imaging findings, management, and outcomes of patients from each study were extracted and summarized. Results: A total of 35 articles reporting on 61 patients with COVID-19 with mesenteric ischemia met the eligibility and were included in our study. The mean age was 60 (±15.9) years, and 53% of patients were male. Imaging findings of these patients included mesenteric arterial or venous thromboembolism, followed by signs of mesenteric ischemia. Sixty-seven percent of patients were taken to the operating room for an exploratory laparotomy and bowel resection and 21% were managed conservatively. The terminal ileum was the most commonly involved area of necrosis (26%). The mortality rate of patients with COVID-19 with mesenteric ischemia was 33%, and the most common cause of death was multiorgan failure or refractory septic shock. Twenty-seven percent of patients managed operatively died during the post-operative period. Conclusions: Mesenteric ischemia in patients with COVID-19 is a devastating complication associated with a high rate of morbidity and mortality. Further efforts should focus on developing strategies for early recognition and management.

Functional Gastrointestinal Disorders as a Post-Covid Infection Sequel in Pediatric Patients in Mexico

INTRODUCTION: The rate of pediatric patients diagnosed with Sars Cov 2 has increased since the early stages of the pandemic. Gastrointestinal symptoms have been demonstrated to be relatively common in pediatric COVID-19 patients as well as severe complications like PIMS syndrome because of the expression of ACE II in different areas of the digestive tract which serves as a receptor for their entry and infection in the body. During the last months of the omicron variant wave, we observed some gastrointestinal conditions in pediatric patients days after the resolution of the Sars Cov 2 acute infection period, sparking our interest to execute further research and analysis. OBJECTIVE(S): Describe the presence of functional gastrointestinal disorders as a post-covid infection sequel METHODS: We performed a descriptive, cross-sectional, observational, retrospective study, were we recollected the clinical and epidemiological data from the medical records of pediatric patients with a history of Sars cov-2 infection confirmed with positive PCR or antigen (sars cov-2) tests at Hospital Angeles Lomas, Mexico City. We included children from 6 months up to 16 years of age, who presented functional gastrointestinal disorders at a minimum 15 days after the infection that fulfilled Rome IV criteria. We evaluated the frequency and proportion of the qualitative variables;we obtained the arithmetic mean and the standard deviation for the quantitative variables with normal distribution RESULTS: We included data from 30 patients with confirmed covid 19 diseases by positive pcr or antigen (sars cov-2) tests, with a mean age 5.327 +/- 3.8 years Min: 7 months Max: 16 years, with a female predominance of 56.7% vs 43% male patients. During the acute infection by covid, 20% presented respiratory symptoms, 13.3% gastrointestinal symptoms, 36.7% only fever, 3.3% dysgeusia and 26.7% were asymptomatic. Adequate nutritional status was detected in 93% of the patients. The mean days the patients presented manifestations was 32 +/- 14 days, at a minimum 15 days, with a maximum of 63 days, being the most frequent functional gastrointestinal disorders: abdominal pain 90%, bloating 76%, vomit and reflux 33%, diarrhea 30%, constipation 26.7%. There was no weight loss in the patients, the appropriate treatment was given for each case. There was no complication in 90% of the patients, 10% presented acute abdominal pain and were transferred to the emergency room, 1 patient was diagnosed with appendicitis and 2 patients with mesenteric lymphadenitis. CONCLUSION Special attention must be paid to toddler and preschooler patients with Sars Cov 2 infection, regardless of the clinical manifestation in acute infections, mild or asymptomatic, functional gastrointestinal disorders may occur in the first 2 months after a positive PCR test. The ileum and the colon are places in which there is a greater expression of the ACE II, so when the enterocytes are invaded by SARS CoV-2, they may produce alterations in absorption and other mechanisms that could be the cause of these consequences. It is of vital importance that all pediatricians are aware of the consequences of the disease to prevent misdiagnosis.

Post-COVID-19 superior mesenteric artery and jejunal branches thromboembolism.

The World Health Organization has declared the novel coronavirus disease 2019 (COVID-19) a global public health emergency. Despite the predominating respiratory symptoms occurring in COVID-19, thrombosis can occur in some patients, with morbidity and mortality increase due to the respiratory worsening. This article reports the case of a 62-year-old man with a flu-like illness that was diagnosed as COVID-19 by RT-PCR of SARS-CoV-2. After three weeks, he subsequently developed abdominal pain in addition to bloating, nausea, and vomiting. He underwent exploratory laparotomy after imaging tests suggested mesenteric ischemia. Intestinal ischemia was evident, due to the absence of flow in the superior mesenteric artery and jejunal branches. Embolectomy and enterectomy were performed and they resulted in a favorable outcome, with clinical improvement. This case adds data to the limited literature on extrapulmonary complications of COVID-19, notably those related to thromboembolic events.

La Organización Mundial de la Salud ha declarado la enfermedad del nuevo coronavirus 2019 (COVID-19) una emergencia de salud pública mundial. A pesar de los síntomas respiratorios predominantes en COVID-19, la trombosis puede ocurrir en algunos pacientes, con un aumento de la morbimortalidad debido al empeoramiento respiratorio. Presentamos el caso de un hombre de 62 años con enfermedad similar a la gripe que fue diagnosticada como COVID-19 por RT-PCR de SARS-CoV-2. Después de tres semanas, desarrolló dolor abdominal además de hinchazón, náuseas y vómitos. Fue sometido a laparotomía exploradora luego de que las pruebas de imagen sugirieran isquemia mesentérica. Se evidenció isquemia intestinal por ausencia de flujo en la arteria mesentérica superior y ramas yeyunales. Se realizó embolectomía y enterectomía con evolución favorable, con mejoría clínica. Este caso añade datos a la limitada literatura sobre las complicaciones extrapulmonares del COVID-19, en particular las relacionadas con eventos tromboembólicos.

The Benefits and Barriers of Using Point-of-Care Ultrasound in Primary Healthcare in the United States.

An effective healthcare system should embrace practices that enhance overall quality and productivity. Training primary care physicians in Point-of-Care Ultrasound (POCUS) has become part of the processes that improve the quality of patient care and serve to guide the diagnostic impression quickly and effectively. With the purpose of highlighting the applications and challenges of POCUS use in US primary health care, we conducted a narrative review based on PubMed-indexed and Cochrane Library English text publications searched in May-July 2022 using a combination of key terms including point of care ultrasound, primary care, and US healthcare. Many studies have shown that POCUS has a positive impact on fostering medical attention and reducing morbidity, mortality, and healthcare costs. Besides assisting in procedures, POCUS has a head-to-toe application in evaluating inflammatory and infectious conditions, acute abdomen, cardiopulmonary function, musculoskeletal and vascular pathologies. However, its uniform implementation is limited across the US healthcare system due to multitudes of barriers such as lack of training, resource scarcity, and low reimbursement. Training primary care physicians in general and emergency care providers, in particular, is key to scaleup POCUS use. Large size studies are paramount to further explore the effectiveness of POCUS and identify key challenges to its implementation.

Successful Treatment of Paraplegia Caused by Venous Hypertension Secondary to Extensive Iliocaval Deep Venous Thrombosis in the Absence of Phlegmasia Cerulea Dolens

Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]

Omental Infarction: Challenges in Managing Acute Abdomen During COVID-19 Pandemic

Acute abdomen is a common surgical emergency, yet is challenging especially during the COVID-19 pandemic. This article highlights the challenging management of acute abdomen and issues on preoperative nasopharyngeal swab testing, aerosol-generating procedures and non-operative management. A 36-year-old gentleman presented with acute right iliac fossa pain which was diagnosed as simple acute appendicitis and was managed non-operatively. He progressed well initially, but after 2 days, he developed localized abdominal guarding. The diagnosis was revised to perforated appendicitis and he was pushed to the operation theatre on the same day. Since the swab test was negative, we performed the surgery as a non-COVID-19 patient. To our surprise, the intraoperative finding was consistent with spontaneous omental infarction and mild appendicitis. Appendicectomy with omentectomy was done and the final diagnosis was consistent with acute omental infarction. Performing surgery on patients with active COVID-19 infection can lead to a high pulmonary complication and mortality rate. All cases require COVID-19 status as the screening prerequisites prior to admission and surgical intervention. Emergency cases such as acute abdomen warrant a surgical intervention regardless of COVID-19 status but with full personal protective equipment. Managing acute abdomen is challenging during the COVID-19 pandemic. The direction is towards non-operative management unless it is contraindicated. Omental infarction must be considered as one of the differential diagnoses for any patient with unexplained acute abdominal pain which warrants imaging assessment. (English) [ FROM AUTHOR] Akut karın yaygın bir cerrahi acildir, ancak özellikle COVID-19 pandemisi sırasında büyük zorluk oluşturmuştur. Bu makale, akut karının zorlu yönetimini ve ameliyat öncesi nazofaringeal sürüntü testi, aerosol oluşturan prosedürler ve ameliyatsız yönetim ile ilgili konuları vurgulamaktadır. Otuzaltı yaşında erkek akut sağ iliak fossa ağrısı ile başvurdu, basit akut apandisit tanısı aldı ve ameliyatsız tedavi edildi. Başlangıçta iyi ilerledi, ancak 2 gün sonra lokalize karın koruması geliştirdi. Tanısı perfore apandisit olarak revize edildi ve aynı gün ameliyathaneye sevk edildi. Swab testi negatif çıktığı için ameliyatı COVID-19 negatif hasta olarak gerçekleştirildi. Ílginç olarak;intraoperatif bulgu spontan omental enfarktüs ve hafif apandisit ile uyumluydu. Apendektomi ile omentektomi yapıldı ve kesin tanı akut omental enfarktüs ile uyumluydu. Aktif COVID-19 enfeksiyonu olan hastalarda ameliyat yapmak, yüksek pulmoner komplikasyon ve ölüm oranına neden olabilir. Tüm vakalar, kabul ve cerrahi müdahale öncesinde tarama önkoşulu olarak COVID-19 durumunu gerektirir. Akut karın gibi acil durumlar, COVID-19 durumundan bağımsız olarak ancak tam kişisel koruyucu ekipmanla cerrahi müdahale gerektirir. COVID-19 salgını sırasında akut karın yönetimi zordur. Genel eğilim, kontrendike olmadığı sürece ameliyatsız yönetime yöneliktir. Omentum enfarktüsü, açıklanamayan akut karın ağrısı olan ve görüntüleme değerlendirmesini garanti eden herhangi bir hasta için ayırıcı tanılardan biri olarak düşünülmelidir. (Turkish) [ FROM AUTHOR] Copyright of Gazi Medical Journal is the property of Gazi Medical Journal and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Ischemic Colitis in a Patient with Severe COVID-19 Pneumonia.

At the time of the current COVID-19 pandemic, on a daily basis, we encountered patients suffering from various manifestations of this infection. The most common are respiratory symptoms. Many of the patients require acute hospital care, and a smaller group of them are hospitalized in intensive care units. A subset of these critically ill patients demonstrates clinically remarkable hypercoagulability and thus a predisposition to venous and arterial thromboembolism, manifested by thrombotic events ranging from acute pulmonary embolism and splanchnic vascular ischemia to extremity ischemia. The article describes a case of a patient with COVID-19 pneumonia complicated by massive bleeding into the gastrointestinal tract due to ischemic enterocolitis in connection with COVID-19 infection.

MIS-CM imicking Acute Appendicitis

Introduction: Abdominal pain is one of the most common complaints seen in the pediatric acute care setting. SARS-CoV-2 disease in children includes a hyperinflammatory syndrome called Multisystem Inflammatory Syndrome in Children (MIS-C). Gastrointestinal symptoms are most common in pediatric acute SARS-CoV-2 infection as well as in MIS-C. Case Description: A 13- year-old female presented with diffuse lower abdominal pain for 3-days. Pain was 10/10 in intensity, worsened with movement, and had associated constipation, anorexia, nausea, and vomiting. Exam showed an ill-appearing female with labile vitals and generalized lower abdominal tenderness with good bowel sounds. Ultrasound suggested features of acute appendicitis but a follow-up CT did not visualize the appendix. She was admitted to the inpatient unit after routine screening revealed positive SARS-CoV-2 antibody but negative PCR. She received IV fluid bolus, narcotic analgesics, and ampicillin-sulbactam preoperatively. Within hours, she spiked high-grade fevers (101.4F), sustained hypotension, and tachycardia with concern for sepsis secondary to a possible ruptured appendix. She underwent emergency diagnostic laparoscopy which revealed bile-tinged fluid in the lower quadrant, a mildly inflamed appendicular tip without perforation, and thickened mesenteric nodes within the inflamed distal ileum. Intra-operatively, she had persistent hypotension requiring fluid boluses and vasopressors. Her admission labs revealed elevated inflammatory markers, deranged coagulation profile, and elevated cardiac enzymes. Her differential diagnosis was then revised to include MIS-C and severe sepsis. Antibiotic coverage was broadened to Vancomycin and Meropenem. An Echocardiogram showed mitral regurgitation with moderately to severely decreased right and left ventricular systolic dysfunction with an ejection fraction of 32.8% The patient was then transferred to the pediatric cardiac critical unit where she received treatment with IVIG, steroids, and anticoagulants. Her clinical status and lab studies improved with EF > 50%. She was discharged from the intensive care unit after 7 days and has had an uneventful follow-up. Discussion: Differential diagnosis for acute lower abdominal pain in an adolescent female is broad. Similar cases with predominant GI symptoms and later generalized multisystem involvement have been reported, however, most were managed conservatively. Two reports have been published on MIS-C presenting as acute appendicitis, but neither had significant cardiac involvement. Our patient's presentation can easily be confused with an acute surgical abdomen but the pathology report confirmed a congested appendix without any fecoliths supporting either inflammation or vasculitis as the cause for her presentation, which is in concordance with the hyperinflammatory state that has previously been described in patients presenting with a history of past SARS-CoV- 2 infections. Conclusion: MIS-C can mimic serious pediatric illnesses including sepsis, acute abdomen, and Kawasaki disease. Clinicians should have a low threshold for suspecting MIS-C, as prompt treatment can be lifesaving. Universal screening for COVID-19 infection with PCR and antibody tests can expedite the diagnostic evaluation of severely ill children. Showing reactive wall thickening of the cecum and small bowel loops (red arrow) and enlarged mesenteric lymph nodes (yellow arrow). The appendix could not be visualized here.

Lightning strikes thrice

Introduction: A case of multiple co-existing conditions during pregnancy in a previously fit and well individual. Case Report: A 24-year-old woman presented at 37 weeks during her second pregnancy with a five day history of vomiting and abdominal pain. She had no significant past medical history. Her oxygen saturations were low so she received treatment for aspiration pneumonia. Her initial COVID-19 antigen test was negative however subsequent PCR was positive. The cause of her acute abdomen was unclear, with the differentials being perforated duodenal ulcer, pancreatitis and appendicitis. With input from general surgery, obstetrics and anaesthesia a decision was made to proceed with a diagnostic laparotomy. Classical caesarean section was performed at the beginning of the procedure. A healthy baby was delivered and laparotomy revealed pancreatitis. Due to high intraoperative oxygen requirements, shewas kept intubated and transferred to intensive care post operatively. An echocardiogram revealed biventricular failure and she was commenced on treatment for peripartum cardiomyopathy. Overall, she remained intubated for nine days andwas discharged from hospital 16 days following her surgery. Followup echocardiogram four months after hospital discharge showed her left ventricular ejection fraction remained <35%. Discussion: COVID-19 is increasingly common these days so it is likely to co-exist with other conditions. The incidence of acute pancreatitis during pregnancy is approximately one in 3000 and the incidence of peripartum cardiomyopathy is also approximately one in 3000 in the western world [1,2]. This case serves as a reminder that multiple conditions may be present in one individual and highlights the importance of completing a full set of investigations. This patient had multiple reasons for respiratory failure, however, an echocardiogram was necessary to reveal peripartum cardiomyopathy. Her ejection fraction remains low which puts her at high risk of mortality for future pregnancies. However, this diagnosis has allowed her to receive the appropriate follow up and counselling.

UNUSUAL PRESENTATION OF RHABDOMYOLYSIS AFTER COVID-19 MODERNA VACCINATION

CASE: a 29-year-old male presented to the emergency room with diffuse abdominal pain associated with fever and loss of appetite. He received his Moderna COVID-19 booster Vaccine 24 hours before the onset of symptoms. Post-vaccine he had generalized muscle aches, fatigue, and subjective fevers. Examination revealed low grade fever, and diffuse abdominal tenderness. labs showed mild transaminitis (AST>ALT) and an acute kidney injury. His Urinalysis was positive for blood with no RBCs. An Abdominal U/S, CT abdomen and pelvis were unremarkable. A Creatinine Phosphokinase (CPK) was checked as the pattern of AST>ALT elevation, creatinine elevation, and evidence of myoglobinuria were consistent with rhabdomyolysis. CPK was 11,974 U/L. He received aggressive IV hydration, clinically symptoms resolved and CPK trended down before discharge. IMPACT/DISCUSSION: Rhabdomyolysis (RML) is a life threatening clinical syndrome resulting from muscle injury causing muscle breakdown and necrosis which releases intracellular components into the circulation. If missed, RML can lead to acute renal failure. Quite often RML can be caused by viral or bacterial infections. There is a known correlation of COVID-19 causing RML. Most recently there have been 3 published cases of COVID-19 vaccine causing RML. One of the cases resulted in Acute Renal Failure and eventual death of the patient. In our patient a diagnosis of RML was made based on acute abdominal pain that was musculoskeletal in origin, elevated CPK, acute kidney injury, and Transaminitis which is seen in severe RML. Other common causes such as trauma, immobilization, strenuous exercise,medication use, alcohol use, or drug use were ruled out. There was no clear infectious or inflammatory cause identified. His symptoms resolved with aggressive hydration and we had evidence of laboratory improvement of CPK, Creatinine and LFTs. Given that the patient was in good health and the timeline of his COVID-19 booster was followed by muscle aches, fever, abdominal pain combined with resolution of symptoms after treatment, a diagnosis of vaccine- related rhabdomyolysis was made. CONCLUSION: Given the importance of vaccination and the widespread efforts to fight the spread of COVID-19 we strongly encourage everyone to get vaccinated. But despite the high efficacy of the vaccine and its safety, side effects are possible. It is important for physicians to be aware of the potential development of vaccine-induced rhabdomyolysis. We encourage physicians to be attentive to patients' medical history, family history and medication list in an effort to screen for possible risk factors of developing rhabdomyolysis. Patients should be advised to stay hydrated, monitor for symptoms and signs such as muscle aches, weaknesss, and change in color of urine. Prompt identification of vaccine- induced rhabdomyolysis and treatment with aggressive fluid resuscitation can prevent serious complications such as acute renal failure.