Usefulness of Thin-Slice Contrast-Enhanced Computed Tomography in Detecting Perforation Site in Congenital Biliary Dilatation: A Case Report.

The site of perforation is difficult to identify preoperatively in many cases with spontaneous perforation of congenital biliary dilatation (CBD). We report a case of spontaneous perforation of CBD in which the perforation site was identified preoperatively using thin-slice contrast-enhanced computed tomography (CT). The patient was a girl aged 1 year and 4 months. She was admitted to our hospital because of vomiting and diarrhea that had continued for 3 days prior to admission. Abdominal contrast CT on admission showed dilated common bile duct, thickening of the gall bladder wall, and marked ascites. In addition, an area of low density with a diameter of 1 cm was detected near the neck of the gallbladder. We evaluated the area via thin-slice contrast-enhanced CT and detected a defect in the wall of the bile duct. Cholangiography revealed abnormal confluence of the pancreaticobiliary duct and a protein plug in the common duct. A diagnosis of CBD with perforation of the bile duct was made, and surgery was performed. The intraoperative findings matched that seen on the enhanced CT. There are some reports of pseudocysts and fluid retention around the perforation site; however, no reports are found in which the perforation site was confirmed by preoperative CT. If localized fluid retention is observed in cases with biliary perforation, confirmation with thin-slice contrast-enhanced CT might be useful for identifying the perforation site.

Should All Complicated Appendicitis Be Treated the Same? The Answer Is No.

Delayed presentation of acute appendicitis is associated with increased complications. We hypothesized that the outcomes of appendectomy in delayed presentations of acute appendicitis (>72 hours of pain) were dependent on radiologic findings rather than late presentation. We reviewed records from 2009 to 2015 and analyzed delayed presentations of acute appendicitis. We divided patients into three groups based on specific CT findings: uncomplicated appendicitis (UA), phlegmon or abscess (PA), and other perforated appendicitis (PERF, signs of perforation without abscess or phlegmon). One hundred thirty-eight patients were included in this study (58 in the UA, 67 in the PA, and 13 in the PERF groups). Overall, 78 (57%) patients underwent early appendectomy (EA) and 60 (43%) underwent initial conservative management. The incidence of adverse events was lower in EA than that in initial conservative management (17% vs 42%, P = 0.005). EA in the UA group was associated with shorter hospitalization (3.2 vs 5.6 days, P < 0.001) and less adverse events (6% vs 29%, P < 0.05). Severe adverse events (two colectomies and one fecal fistula) were observed in the PA group. In conclusion, in these late presentations of appendicitis, complicated appendicitis was common. EA was safe in selected patients, however, and associated with decreased adverse events.

Spontaneous perforation and intraabdominal abscess due to Meckel's diverticulum revealed on SPECT/CT with 99m-technetium pertechnetate: A case report.

RATIONALE: Meckel's diverticulum (MD) is common congenital abnormality of gastrointestinal tract, only about 6.4% of patients become symptomatic. A smaller minority develop potential fatal complications such as hemorrhage, perforation, abscess, and bowel obstruction. PATIENT CONCERNS: A 15-year-old boy with history of appendicitis was admitted due to worsening abdominal pain and nausea for 1 day. The physical examination showed the abdomen was soft, with the diffuse tenderness to palpation and voluntary guarding. DIAGNOSIS: Abdominal computed tomography showed a probable MD in the distal ileum. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging revealed the focal concentration at the right lower quadrant of abdomen region. INTERVENTION: After the initial management including antibiotic administration and intravenous fluid resuscitation, MD with perforation and localized suppurative peritonitis was confirmed in surgery. The patient underwent a diverticulectomy. Histological examination was confirmed as MD with focal heterotopic gastric tissue. OUTCOMES: After surgery, the patient had uneventful recovery during 3 months follow-up. LESSONS: Spontaneous perforation and intraabdominal abscess due to MD is very rare. Accurate diagnosis of MD remains challenging as clinical symptoms from these complications occur nonspecifically. SPECT/CT fusion imaging is critical for prompt recognition and accurate diagnosis in the successful management of this rarely life-threating complication.

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.

Perforation of a Peptic Ulcer in a Hiatal Hernia Into the Left Ventricle With Systemic Air and Food Embolism.

Perforation of a peptic ulcer into the ventricle is uncommon, and the definitive diagnosis is difficult in living patients. We herein report a case of perforation of a peptic ulcer in a hiatal hernia into the left ventricle with systemic air and food embolism. This is the first case report of the perforation diagnosed by computed tomography and confirmed by autopsy. Computed tomography was useful for the diagnosis of perforation into the ventricle.

Rare case of cystic artery pseudoaneurysm.

A patient with a cystic artery pseudoaneurysm (CAP) presented to the emergency department with upper abdominal and back pain. The patient also had clinical signs of sepsis. CT revealed gallstones with acute suppurative cholecystitis with a gallbladder perforation. In addition, a CAP was also suspected and subsequently diagnosed on CT angiography. The pseudoaneurysm was treated with embolisation and a cholecystostomy was performed for the gallbladder perforation. Following her acute admission, the patient underwent an elective cholecystectomy and made a good recovery post surgery.

A rare case of pharyngeal perforation and expectoration of an entire anterior cervical fixation construct.

Anterior cervical discectomy and fusion (ACDF) is a very common surgery performed globally. Although a few cases of expectorating screws or extrusion of screws into the gastrointestinal tract through esophageal perforations have previously been reported, there has not been a case reporting pharyngeal perforation and entire cervical construct extrusion in the literature to date. In this report the authors present the first case involving the extrusion of an entire cervical construct via a tear in the posterior pharyngeal wall. An 81-year-old woman presented to the emergency department (ED) with a complaint of significant cervical pain 5 days after a fall due to a syncopal event. Radiological findings showed severe anterior subluxation of C-2 on C-3 with no spinal cord signal change noted. She underwent ACDF at the C2-3 level utilizing a polyetheretherketone (PEEK) cage, allograft, autograft, and a nontranslational plate with a locking apparatus and expanding screws. The screw placement was satisfactory on postoperative radiography and the Grade II spondylolisthesis of C-2 on C-3 was reduced appropriately with the surgery. The postoperative radiographs obtained demonstrated good instrumentation placement. Three and a half years later the patient returned to the ED having expectorated the entire anterior cervical construct. A CT scan demonstrated the C-2 and C-3 vertebral bodies to be fused posteriorly with an anterior erosive defect within the vertebral bodies and the anterior fusion hardware at the C2-3 level no longer identified. The fiberoptic laryngoscopy demonstrated a 1 × 1 cm area over the importation of the hypopharynx, above the glotic area. The Gastrografin swallowing test ruled out any esophageal tear or fistula and confirmed the presence of a large ulcer on the posterior wall of the oropharynx. To the best of the authors' knowledge, this is the first ever reported case of a tear in the posterior pharyngeal wall along with extrusion of the entire cervical construct after ACDF. This case demonstrates a rare but potentially serious complication of ACDF. Based on the available literature, each case requires separate and distinct treatment from the others.

Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study.

Purpose To prospectively evaluate the diagnostic performance of ultrasonography (US) for differentiating perforated from nonperforated pediatric appendicitis and to investigate the association between specific US findings and perforation. Materials and Methods This HIPAA-compliant study had institutional review board approval, and the need for informed consent was waived. All abdominal US studies performed for suspected pediatric appendicitis at one institution from July 1, 2013, to July 9, 2014, were examined prospectively. US studies were reported by using a risk-stratified scoring system (where a score of 1 indicated a normal appendix; a score of 2, an incompletely visualized normal appendix; a score of 3, a nonvisualized appendix; a score of 4, equivocal; a score of 5a, nonperforated appendicitis; and a score of 5b, perforated appendicitis). The diagnostic performance of US studies designated 5a and 5b was calculated. The following US findings were correlated with perforation at multivariate analysis: maximum appendiceal diameter, wall thickness, loss of mural stratification, hyperemia, periappendiceal fat inflammation, periappendiceal fluid, lumen contents, and appendicolith presence. The number of symptomatic days prior to presentation was recorded. Surgical diagnosis and clinical follow-up served as reference standards. Results A total of 577 patients with a diagnosis of appendicitis at US met the study criteria (468 with a score of 5a; 109 with a score of 5b). Appendicitis was correctly identified in 573 (99.3%) of 577 patients. US performance in the detection of perforated appendicitis (5b) was as follows: a sensitivity of 44.0% (80 of 182), a specificity of 93.1% (364 of 391), a positive predictive value of 74.8% (80 of 107), and a negative predictive value of 78.1% (364 of 466). Statistically significant associations with perforated appendicitis were longer duration of symptoms (odds ratio [OR] = 1.46, P < .0001), increased maximum diameter (OR = 1.29, P < .0001), simple periappendiceal fluid (OR = 2.08, P = .002), complex periappendiceal fluid (OR = 18.5, P < .0001), fluid-filled lumen (OR = 0.34, P = .002), and appendicolith (OR = 1.67, P = .02). Conclusion US is highly specific but nonsensitive for perforated pediatric appendicitis. Several US findings are significantly associated with perforation, especially the presence of complex periappendiceal fluid. © RSNA, 2016.

An unusual diaphragmatic hernia with gastric perforation and sub-acute presentation.

Gastric perforation into the thoracic cavity through a diaphragmatic hernia is rare but, when it occurs, patients present in severe distress, with mortality approaching 50%. We present a unique case in which a fibrotic reaction between the stomach and the parietal pleura led to a subacute presentation upon perforation. The extra time that this afforded led to more effective multidisciplinary team management and ultimately an excellent outcome for the patient.