Pseudo-submucosal tumor in the colon: seeing is believing

A 65-year-old woman was admitted to our hospital with complaints of lower abdominal pain. Her physical examination was unremarkable. The results of routine laboratory testing were within the normal limits. In addition, abdominal CT was normal. Colonoscopy showed a cecum submucosal tumor with a pale yellow surface. Endoscopic ultrasound revealed homogeneous hypoechoic lesions originated from submucosal layer. ESD was subsequently performed to remove the submucosal lesion. During the ESD procedure, fecal outflowed from appendix opening . Yellow fecal-like material was visible after submucosal incision. The trap electrocut surface uplift showed more fecal attachment on the lamina propria surface, and myolayer integrity after clean the fecal (Fig1c), The final pathology of the surface bulge suggested hyperplasia (Fig1d). Patients were discharged with relieved lower abdominal pain. The final diagnosis was submucosal fecalith mimicking a submucosal tumor, eventually leads to chronic appendicitis. Common causes of cecal submucosal tumor include neuroendocrine tumors, lipomas, etc. There was few report about fecalith mimicking a submucosal tumor. ERTA is currently an effective endoscopic method for treating appendicitis combined with fecalith blockage. To our knowledge, this is the first report on a case of cecum submucosal fecalith mimicking a submucosal tumor and was successfully removed using endoscopy. (AU)

Chronic constipation that resulted in fecal impaction and colon perforation: A case report.

RATIONALE: Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ. PATIENT CONCERNS: A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids. DIAGNOSIS: An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying. INTERVENTIONS: Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed. OUTCOMES: The patient had an uneventful postoperative course and was discharged in good condition. LESSONS: Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

Modern Management of the Appendix: So Many Options.

Nonoperative management (NOM) of acute appendicitis is becoming more popular, especially in resource-strapped locations, to minimize hospital system costs. In uncomplicated cases of appendicitis, NOM can effectively treat the patient. It does carry a 39.1% risk of recurrence in 5 years, and operative management (OM) does not increase morbidity or risk of complication, so the authors recommend laparoscopic OM for uncomplicated appendicitis. For complicated cases of appendicitis, the authors recommend initial NOM with interval appendectomy in all patients. All appendicitis patients should undergo surveillance endoscopy if older than 40 years to rule out a contributing neoplasm.

Hepatic abscess: An uncommon complication after laparoscopic appendectomy.

AIM: Laparoscopic appendectomy is currently the treatment of choice for acute appendicitis in emergency setting. When appendicitis is clinically suspected, an appendicolith can be found in 30% of the patients. Retained or dropped appendicoliths are an uncommon complication that may occur as a consequence of stone expulsion from the appendix, before or during laparoscopic appendectomies. This is very rare with only 30 reported cases of intra-abdominal abscess secondary to an appendicolith in the literature over the past 40 years. The objective of this case report is to illustrate an intrahepatic localization of a dropped appendicolith causing liver abscess. CASE PRESENTATION: A 23-year-old female was admitted to the emergency department of our hospital for an acute appendicitis with coprolite obstructing the lumen and periappendicular effusion. Laparoscopic appendectomy was performed. Persistent liver abscess due to appendicolith was a rare complication treated by percutaneous drainage. The appendicolith was successfully removed from the liver parenchyma by Dormia basket recovery system. DISCUSSION: Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. CONCLUSION: Only a handful of cases of hepatic abscess formation as a result of dropped appendicoliths have been reported in literature. Our proposal of treatment was the percutaneous approach. There was no need for a surgical procedure to remove the intrahepatic appendicolith. KEY WORDS: Dormia basket, Intrahepatic abscess, Laparoscopic appendectomy, Percutaneous drainage.

Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor.

BACKGROUND: Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. METHODS: Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). RESULTS: Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. CONCLUSIONS: Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.