An Unexpected Case of Perforated Acalculous Cholecystitis Caused by a Fish Bone.

Gallbladder inflammation is most often determined by the presence of gallstones. Acalculous cholecystitis usually occurs in patients with multiple comorbidities or with an immunosuppressed status, and therefore its evolution is faster and more severe compared to acute calculous cholecystitis. The presence of a fish bone into the peritoneal cavity, through a gastrointestinal fistula is not very rare, but acute cholecystitis caused by a fish bone is unexpected. Here, we present the case of a 75-year old woman who had eaten fish two months before and presented at the Emergency Room with perforated acalculous cholecystitis and a right subphrenic abscess. The laparoscopic approach permitted the evacuation of the subphrenic abscess, bipolar cholecystectomy and removal of a fish bone from nearby the cystic duct. Postoperative evolution was uneventful, with hospital discharge after five days. The patient was in good clinical condition at two months follow-up.

Resolución de colección biliar gigante por fistulización espontánea al colon / Resolution of giant biliary collection by spontaneous colon fistulization

El tratamiento de las colecciones biliares puede consistir en actitud expectante con vigilancia radiológica del tamaño y las características de la colección, drenaje percutáneo guiado por pruebas de imagen (eco/TC), drenaje endoscópico dependiendo de la localización y la accesibilidad de la colección, o tratamiento quirúrgico. Se comenta el caso clínico de un hombre intervenido de forma programada realizándose una hepatectomía derecha, que presentó una colección adyacente al lecho quirúrgico, asintomática, sugestiva de bilioma, con aumento progresivo de tamaño, presentando de forma espontánea disminución hasta su resolución por fistulización al ángulo hepático del colon, confirmado por pruebas radiológicas. La formación de fístulas biliares al colon de manera espontánea se debe a la presión extrínseca de la colección sobre la pared intestinal con necrosis de la zona de contacto, siendo su presentación y documentación radiológica excepcionales

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional

Endoscopic ultrasound-guided transmural drainage for subphrenic abscess: report of two cases and a literature review.

BACKGROUND: An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route. CASE PRESENTATION: We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible. CONCLUSIONS: Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

A case of left subphrenic abscess caused by gastric ulcer penetration that was successfully treated with endoscopic transgastric drainage.

A 65-year-old male visited our hospital because of fever and difficulty in walking. He was suffering from left-sided hypochondrial pain for a month. Laboratory tests performed on admission revealed a white blood cell count of 1700/µl and C-reactive protein level of 9.51mg/dl, which were suggestive of severe inflammation. Contrast-enhanced computed tomography revealed a subphrenic abscess around the spleen, which we considered to be caused by gastric penetration into the gastrosplenic ligament. Upper esophagogastroduodenoscopy revealed a gastric ulcer together with a fistula that connected to the left subphrenic abscess. We thus performed endoscopic transgastric drainage through the fistula. Antibiotics and a proton pump inhibitor were administered, and drainage was continued. The patient's clinical and inflammatory symptoms subsequently improved. We thus consider that endoscopic transgastric drainage is an appropriate treatment option for subphrenic abscesses.

[Perforation of the right ventricle of the heart as a complication of CT guided percutaneous drainage of a subphrenic abscess - a case report]. / Perforace pravé srdecní komory jako komplikace CT navigované perkutánní drenáze subfrenického abscesu kazuistika.

INTRODUCTION: CT guided percutaneous drainage is currently the gold standard in the treatment of abdominal fluid collections, having substituted open surgical drainage in many cases. It burdens the patient less than surgical drainage. Its efficiency is comparable to standard surgical drainage when properly indicated. It is readily available even in smaller hospitals. However, this method can also have many complications, which originate most often from an improperly targeted drainage catheter. CASE REPORT: The authors describe a case report of a 55 years old man with a right-sided subphrenic abscess. The right ventricle of the heart was perforated during a CT guided percutaneous drainage. The bleeding was minimal, but the patient suffered a profound septic shock as a result of massive bacteremia during direct communication of the contents of the abscess cavity with blood circulation. He was operated immediately. The right ventricle was sutured, and the subphrenic abscess was drained. There were no complications after the operation, and the patient was discharged on day 17 after the surgery. CONCLUSION: The CT guided drainage of an abdominal abscess or a fluid collection in a risk area should be preferably done in hospitals whose therapeutic portfolio also includes the handling of serious complications. KEY WORDS: heart injury drainage.

Retroperitoneal abscess with retained gall-stones as a late complication of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the golden standard, considering treatment of cholelithiasis. During the laparoscopic procedure one may often observe damage to the gall-bladder wall, as well as presence of gall-stones in the peritoneal cavity, as compared to classical surgery. These gall-stones may be associated with the occurrence of various complications following surgery. The study presented a rare case of a retroperitoneal abscess, as a consequence of retained gall-stones, in a female patient who was subject to laparoscopic cholecystectomy two years earlier.

Laparoscopic sleeve gastrectomy: imaging of normal anatomic features and postoperative gastrointestinal complications.

Morbid obesity is a public health problem in the United States and Europe and its prevalence is on the increase. Despite certain progress the efficacy of medical treatment remains limited. Bariatric surgery has consequently become an effective alternative for patients with morbid obesity. The bariatric operations most frequently performed are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (LGB), but laparoscopic sleeve gastrectomy (LSG) is increasingly popular with both bariatric surgeons and patients due to its simplicity, rapidity and decreased morbidity. The purpose of this pictorial essay is to familiarize radiologists with the normal postoperative anatomic features and the imaging findings of postoperative gastrointestinal complications of laparoscopic sleeve gastrectomy because little literature exists on this subject.

[Endoscopic closure of a chronic colonic fistula using the over-the-scope clip (OTSC)]. / Endoskopischer Verschluss einer chronischen Fistel des Kolons unter Anwendung des "Over-the-scope"- Clips (OTSC).

HISTORY AND ADMISSION FINDINGS: A 64 year old male patient suffered from recurrent subphrenic abscesses following a complicated postoperative course after sigmoidectomy for chronic recurrent diverticulitis. Two previous attempts of abscess treatment by transcutaneous drainage had failed. Radiographic studies eventually showed a fistula of the descending colon leading to the abscess formation, which could be identified and confirmed endoscopically by installation of dye. TREATMENT AND COURSE: Endoscopic application of an "over-the-scope clip" (OTSC) onto the anchor-retracted enteric fistula orifice led to complete closure of the fistula within four days as demonstrated by radiographic studies and repeat dye installation. Subsequently the transcutaneous drainage could be gradually retracted and eventually successfully removed within 14 days of OTSC application without recurrence of abscess formation. CONCLUSION: The OTSC is a recently developed endoscopic tool, allowing the application of a large claw-like clip for endoscopic closure of full thickness enteric wall defects and cessation of large vessel bleeding within the gastrointestinal tract. It is a novel tool which can be safely and successfully employed to endoscopically close a fistula of the lower intestinal tract. Future controlled multicenter-studies should address the usefulness of OTSC in the conservative-endoscopic management of intestinal fistulizing disease.

[Aberrant gallstones--extraordinary complications of laparoscopic cholecystectomy]. / Gallensteine auf Abwegen - Ungewöhnliche Komplikationen der laparoskopischen Cholezystektomie.

About 0.2 % of patients undergoing laparoscopic cholecystetomy will suffer from complications caused by lost gallstones. Diagnostic and therapeutic measures are correlated to the symptoms. At different locations, abscesses can arise, which can be treated by direct access through the -abdominal wall, laparotomy or laparoscopy. Two cases are presented with the especially grave sequels of subphrenic abscess, infiltration of the thoracic wall, and pleural empyema, which -respectively needed several successive operations -after ten years. In laparoscopic cholecystectomy, all detected stones should be removed. In the case of a failure, conversion to laparotomy is not essential. The loss of stones has to be formally -documented, the patient and family doctor are to be informed.

Subphrenic abscess after cesarean section in term pregnancy complicated by chorioamnionitis.

BACKGROUND: Subphrenic abscess is rare after cesarean section. METHODS: Case report and review of the pertinent world literature CASE REPORT: A 22 year-old primigravida underwent a lower-segment cesarean section in the setting of chorioamnionitis, and had a good postoperative recovery initially. Eleven days after surgery, dyspnea and fever prompted a computed tomography scan, which revealed a large subphrenic abscess. The abscess resolved with percutaneous drainage and intravenous antibiotics. A placental swab, baby's skin swab, and abscess aspirate all grew group B Streptococcus. CONCLUSION: Although subphrenic abscess is rare in obstetric practice, it should be suspected in patients who remain unwell after chorioamnionitis.

A case of successful ablation of a gastrophrenic fistula with n-Butyl-2-Cyanocrylate.

A 79-year-old woman with a fistula between a subphrenic abscess and the fundus of the stomach was successfully treated with n-Butyl-2-Cyanoacrylate. Conservative management had failed. Clinical presentation, treatment progress and imaging findings by computed tomography scan, ultrasound, gastroscopy and fluoroscopy are presented, along with a brief review of the relevant literature.

Subphrenic abscess through esophageal leakage after laparoscopic initiated nissen fundoplication--case presentation.

A 56-year-old man with a large paraesophageal hiatus hernia, treated in a tforeign clinic with a Nissen fimdoplication (when a lesion of the gastric fornix during laparoscopic dissection has determined conversion to open technique) is admitted 3 weeks after surgery, being diagnosed with an esophageal leekage witch maintains a large subphrenic abscess with sepsis. The patient was cured by draining the leakage, excluding the esophagus by an "à minima" alimentary jejunostomy, under broad spectrum antibiotherapy.