Giant peritoneal loose body and its protein composition: a case report.

Peritoneal loose body (PLB) is a kind of lesions located in the abdominal cavity or pelvic cavity, which is rare and difficult to diagnose. The diameter of PLB is mostly 0.5-2.5 cm. Most PLBS are asymptomatic. Here we reported a case of giant PLB in the pelvis and analyzed its structure and protein composition. Surgical exploration revealed a white oval mass (4.5*4*3 cm) in the pelvic cavity. After the mass was removed, the symptoms of hematuria disappeared and the patient was discharged on the second postoperative day. Histochemical staining showed that PLB was mainly composed of collagen and scattered calcification. The protein components of PLB were detected by proteome analysis, and a variety of proteins related to collagen deposition and calcification were identified in PLB.

Do women with suspected endometriosis benefit from pelvic examination to improve diagnostic and management strategy?

OBJECTIVE: To analyze the literature and expose best evidence available regarding the benefit of pelvic examination for women with suspected endometriosis METHODS: the AGREE II and GRADE systems for grading scientific evidence. RESULTS: Endometriosis is characterized by the heterogeneity in its clinical presentation with many different symptoms reported by patients. In the literature, questioning for each symptom has a high sensitivity, reaching 76-98 %, but lacks specificity (20 - 58 %). The symptom-based approach is limited by its low specificity, the absence of external validation for most of the models developed and the inability to characterize the extent of the disease, which could have major implications in the decision - making process. The latest systematic review and meta-analysis included a total of 30 studies with 4,565 participants, compared the diagnostic performance of several modalities for endometriosis. Physical examination had a pooled sensitivity of 71 % and a specificity of 69 %, with an average diagnostic accuracy of 0.76. Overall, the value of pelvic examination is conferred by its high positive likehood ratio and specificity. Besides its diagnostic value, pelvic examination improves patients' management by allowing the identification of a possible myofascial syndrome as a differential diagnosis. It also increases the quality of the preoperative workup and influences the quality of surgical excision and decreases the time to diagnosis. CONCLUSION: Despite the lack of studies in the primary care context, pelvic examination (vaginal speculum and digital vaginal examination) increases the diagnostic value for suspected endometriosis in association with questioning for symptoms.

Management of uroperitoneum through combination of conservative and surgical treatments in two colts.

Background: Ruptures of the urinary bladder and urachus are the most frequent cause of uroperitoneum in foals. Surgical correction is often the first treatment choice, however, nonsurgical methods, such as urine removal via urinary catheters and abdominal drains, have been successfully performed in foals. Case Description: Two foals were referred to the Equine Perinatology Unit for suspicion of uroperitoneum. The diagnosis was confirmed by hematobiochemical and ultrasound examinations, thus cystorrhaphy and cystoplasty were attempted. Surgeons found a lesion in the dorsocranial margin of the bladder (Case 1) and a tear in the pelvic urethra (Case 2); in the first case, the defect was routinely repaired, while the last lesion was impossible to repair due to its localization. A urinary catheter was left in place in both cases. Uroperitoneum recurred 72 hours after the surgery in both foals: a second surgical correction was not recommended due to the localization of the tears and conservative treatment, with the placement of a 32F chest tube in the most ventral part of the abdomen, was preferred. Abdominal drains were removed 5-7 days after surgery, while urinary catheters were left in place for up to 7-8 days. Colts' conditions improved during hospitalizations. Two months after bladder surgery, Case 1 was euthanized due to multiple adhesions between the small intestine and the abdominal wall. Case 2 was still alive one year postoperatively. Conclusion: Although it cannot be considered the first choice for the treatment of uroperitoneum in the foal, nonsurgical treatment was successful in both cases in the short-term follow-up. However, the prognosis should be cautious due to the risk of long-term complications. Conservative management may be used to manage bladder/urethral tears that cannot be solved by surgery.

Case Report: A Child With Omental Infarction.

BACKGROUND: Omental infarction (OI) is a rare cause of acute abdominal pain, which is benign and self-limited. It is diagnosed by imaging. The etiology of OI is either idiopathic or secondary and due to torsion, trauma, hypercoagulability, vasculitis, or pancreatitis. CASE REPORT: Here, we present a case of OI in a child with acute severe right upper quadrant pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Correct diagnosis of OI via imaging can prevent unnecessary surgery.

Rare causes of acute abdomen and review of literature: Primary/secondary omental torsion, isolated segmental omental necrosis, and epiploic appendagitis.

BACKGROUND: Primary/secondary omental torsion (POT/SOT), isolated segmental omental necrosis (ISON), and primary epiploic appendagitis (PEA) are rare causes of acute abdominal pain that often lead to misdiagnosis. Although the differential diagnosis may vary according to the localization and severity of the pain, and associated symptoms such as nausea-vomiting and fever, depending on the disease and site of involvement, the character of the pain is generally similar and in a continuous form. Depending on pain localization, it can mimic different clinical pictures such as acute appendicitis, acute diverticulitis, ovarian pathologies, urinary tract stones and acute cholecystitis, and patients are often diagnosed after surgical exploration. With the increased availability of computed tomography and awareness of these diseases, more patients can be diagnosed in the preoperative process and unnecessary operations can be avoided. In particular, PEA is a self-limiting local inflammatory disease and can often be managed conservatively. For all diagnoses, the surgical treatment option is local excision of the relevant epiploic appendix or omental segment, preferably laparoscopically. The most common surgical indication is diagnostic confusion and the second is persistent pain. METHODS: The data of patients followed up and treated for a diagnosis of POT, SOT, ISON or PEA between 2006 and 2021 were recorded in a specially prepared database. The demographic characteristics of the patients, and the data regarding the diagnosis and treatment process were evaluated retrospectively and discussed in the light of the relevant literature. RESULTS: The reason for hospitalization and treatment in 12 of the 42 patients included in the study was necrosis of a part of the omentum. Of these patients, 4 were followed up and treated with a diagnosis of POT, 3 with SOT, 5 with ISON and 30 with a diagnosis of PEA. Thirty-three of the patients were diagnosed preoperatively, and 9 intraoperatively, 22 patients were operated on, and 20 patients with PEA were treated conservatively. After surgical or medical treatment, all the patients were discharged without complications. In the comparisons between the patients, no significant difference was observed in terms of clinical and laboratory findings. CONCLUSION: POT, SOT, ISON and PEA should be considered in the differential diagnosis of patients with acute abdominal findings. In patients with PEA diagnosed in the preoperative period, a conservative approach should be considered first. In patients with a diagnosis of POT, SOT, and ISON, a surgical or conservative approach should be evaluated according to the patient's clinical condition.

Intra-Peritoneal Pseudocyst as a Rare Complication After Peritoneal Dialysis: The Use of a Staged Surgical Approach in Management.

Despite its numerous benefits, peritoneal dialysis (PD) can rarely result in dangerous and even life-threatening complications, including peritonitis, hernias, encapsulating peritoneal sclerosis (EPS), and rarely peritoneal pseudocysts. Herein, we present a rare case of a giant intra-peritoneal pseudocyst that presented four months following the discontinuation of a 5-year course of complicated PD. Despite the initially successful drainages, the patient's symptoms continued to recur, and the imaging findings were concerning for underlying neoplastic processes. As such, a staged surgical approach was performed, starting with a diagnostic laparoscopy and was subsequently followed with cyst excision and marsupialization to the peritoneal cavity. While previous reports of such rare pseudocyst have been documented in the literature as a complication of PD, to our knowledge, this is the second case of pseudocyst formation to occur months after the discontinuation of PD therapy. This case emphasizes the importance of close follow-up in PD patients and showcases how a staged surgical approach can be utilized to accurately diagnose and manage such complicated cases.

Can serum tumor necrosis factor-alpha predict peritoneal adhesions prior to secondary laparoscopic procedures?

AIM OF THE STUDY: This study aimed to investigate the incidence and degree of postoperative intra-abdominal adhesions(POAs) in secondary laparoscopic procedures and assess the power of the preoperative levels of tumor necrosis factor-alpha(TNF-α) and interleukin-1 beta(IL-1ß) and selected peripheral inflammatory biomarkers(PIBs) in the prediction of the development and extent of POA. PATIENTS AND METHODS: This prospective study enrolled 103 patients who had previously undergone at least one or more laparoscopic abdominal or gynecological operations. We examined TNF-α, IL-1ß, and PIBs, namely C-reactive protein, white blood cell count, neutrophil-to-lymphocyte ratio(NLR), platelet-to-lymphocyte ratio, and systemic immune-inflammation index(SII) according to the presence, location, and score of adhesions determined during secondary laparoscopic procedures. RESULTS: Only age, postoperative adhesion index(PAI) score, NLR, SII, TNF-α, and IL-1ß resulted in a significant difference in the existence of adhesion(P<0.05). The correlation analysis of TNF-α with variables showed that the PAI score and IL 1ß levels had a significantly positive correlation. CONCLUSION: The presence and extent of POA could be predicted by examining the preoperative TNF-α level in patients who had laparoscopic abdominal surgery previously. We could overcome adverse events during secondary laparoscopic procedures by assessing high-risk patients and integrating a personalized surgical approach to managing selected patients.

[Omental infarction, unusual cause of abdominal pain]. / Infarto omental, causa poco común de dolor adbominal.

INTRODUCTION: Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain. CLINICAL CASE: An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours. CONCLUSION: Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

Magnetic resonance imaging characteristics of polypoid endometriosis and review of the literature.

AIM: Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy. METHODS: MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature. RESULTS: All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies. CONCLUSIONS: Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature.

Acute abdomen caused by torsion of the omentum: A pediatric case report.

RATIONALE: Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations. PATIENT CONCERNS: A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis. DIAGNOSIS: The patient was diagnosed with omental torsion based on imaging and laparoscopy. INTERVENTIONS: Laparoscopic exploration was performed. OUTCOMES: The patient was discharged seven days after satisfactory postoperative recovery. LESSONS: Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis.

The new method to make diagnosis and identify the location of leakage of pleuroperitoneal communication in peritoneal dialysis patients.

Pleuroperitoneal communication is a severe complication in peritoneal dialysis, and about half of the patients forced to discontinue peritoneal dialysis. The method of coloring dialysis solution by indocyanine green or CT peritoneography have been reported to make diagnosis of pleuroperitoneal communication, however sensitivity of these tests is not a satisfactory level. By repairing the pleural hole with thoracoscopic surgery, it is possible to resume peritoneal dialysis. However, the recurrence rate is very high unless precisely detecting the location of the pleural hole during surgery. We report three cases of pleuroperitoneal communication in peritoneal dialysis patients, in which we found the combination of contrast-enhanced ultrasonography and the indocyanine green fluorescence system are reliable method to make diagnosis and identify the location of leakage of pleuroperitoneal communication. By making definite diagnosis and precisely identifying the localization, we were able to close diaphragm holes by video-assisted thoracoscopic surgery.

Omental torsion at the time of COVID-19 in Northern Italy: a case report of conservative management with a review of the pertinent literature.

BACKGROUND AND AIM: In middle-aged men, omental torsion (OT) can be a cause of acute abdomen.The right side of the omentum is longer, heavier and more mobile than the left one and, as a consequence, it can twist more easily on its vascular axis. Consequently, OT localization in the lower right quadrant is more frequent, and therefore it can mimic acute appendicitis clinical onset.In most cases, OT is defined as "primary" in the absence of any other underlying pathologies, or,  rarely, "secondary", when caused by other intra-abdominal diseases such as inguinal hernia, tumors, cysts or post-surgical scarring. To date, clinical diagnosis of OT still remains a challenging one in a preoperative setting and most cases are diagnosed intraoperatively. If diagnosis is correctly achieved preoperatively by adequate imaging examinations, most patients presenting with OT do not undergo surgery anymore. Such considerations gain importance at the time of COVID 19 pandemic, where a conservative management and an early discharge may be preferred owing to in-hospital morbidity after abdominal surgery whenever surgery may be avoided. METHODS AND RESULTS: We present a case of an OT successfully treated in a non-operative manner during COVID-19 outbreak in Norhern Italy and offer a review of the literature that supports such a clinical attitude.  Conclusions:  OT preoperative diagnosis is challenging and is usually achieved by abdominal CT-scan. The suggested OT initial management is conservative, leaving a surgical approach, preferably by laparoscopy, for the 15% of cases not improving with a non-surgical approach.

A new technique to detect communication sites for pleuroperitoneal communication.

Pleuroperitoneal communication is one of the complications for continuous ambulatory peritoneal dialysis. Communication sites, such as defects or bleb-like lesions, are found in the diaphragm, but it is sometimes difficult to detect these sites. We combined the infrared thoracoscopy and negative pressure technique to detect communication sites. We think our new technique will become an alternative option for difficult and complex cases.

Omental Fat Torsion: A Rare Mimicker of a Common Condition.

Acute abdomen is a common emergency condition affecting young adults, and the first consideration is usually aimed to rule out acute appendicitis in this age group. Omental fat torsion has emerged as one of the rare etiologies of acute abdomen in the younger population. It warrants serious consideration as it closely mimics acute appendicitis in its clinical presentation. Herein we report a case of omental fat torsion in a 22-year-old male patient who presented with an acute right-sided lower abdominal pain which was highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum with an infarcted omental segment on the right side of the greater omentum. A laparoscopic omentectomy and an appendectomy were performed with an uneventful postoperative recovery. The pathology report confirmed omental fat infarction and a normal appendix. This case highlights omental fat infarction as a rare etiology of acute abdomen in a young male patient.

Recent updates in diagnosis of abdominal tuberculosis with emphasis on nucleic acid amplification tests.

INTRODUCTION: Abdominal tuberculosis (TB) is a common epitome of extrapulmonary TB (EPTB), wherein peritoneal and intestinal TB are the most prevalent forms. Diagnosis of abdominal TB is a daunting challenge owing to variable anatomical locations, paucibacillary nature of specimens and atypical clinical presentations that mimic other abdominal diseases, such as Crohn's disease and malignancies. In this review, we made a comprehensive study on the diagnosis of abdominal TB. AREA COVERED: Various modalities employed for abdominal TB diagnosis include clinical features, imaging, bacteriological tests (smear/culture), histopathological/cytological observations, interferon-gamma release assays and nucleic acid amplification tests (NAATs). Among NAATs, loop-mediated isothermal amplification assay, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® MTB/RIF were discussed. Identification of circulating Mycobacterium tuberculosis cell-free DNA by real-time PCR within ascitic fluids is another useful approach. EXPERT OPINION: Several novel molecular/immunological methods, such as GeneXpert Ultra, aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR) and nanoparticle-based I-PCR have recently been developed for detecting pulmonary TB and several EPTB types, which may also be explored for abdominal TB diagnosis. Precise and prompt diagnosis of abdominal TB may initiate an early therapy so as to reduce the complications, i.e. abdominal pain, ascites, abdominal distension, intestinal obstruction/perforation, etc., and avoid surgical involvement.Plain Language SummaryAbdominal tuberculosis (TB) is a manifestation of extrapulmonary TB (EPTB), where peritoneal and intestinal TB are two major forms. Diagnosis of abdominal TB is difficult owing to low bacterial load present in clinical samples and non-specific clinical presentations as it mimics other diseases such as inflammatory bowel diseases, abdominal malignancies, etc. Bacteriological tests (smear/culture) almost fail owing to poor sensitivities and it is not always possible to get representative tissue samples for histopathological and cytological observations. In recent years, molecular tests i.e. nucleic acid amplification tests (NAATs), such as PCR/multiplex-PCR (M-PCR), nested PCR and GeneXpert are widely employed. Markedly, PCR/M-PCR and nested PCR exhibited reasonable good sensitivities/specificities, while GeneXpert revealed low sensitivity in most of the studies but high specificity, thus it could assist in differential diagnosis of intestinal TB and Crohn's disease. Further, novel molecular/immunological tests employed for pulmonary TB and other EPTB types were described and those tests can also be utilized to diagnose abdominal TB. Reliable and rapid diagnosis of abdominal TB would initiate an early start of anti-tubercular therapy and reduce the severe complications.

Keratin Granulomas in the Peritoneum on Frozen Section: A Case Report with Multiple Suspects and the Search for the Culprit.

Keratin granulomas in the peritoneum are a rare finding with multiple etiologies and can be especially challenging for both the pathologist and the surgeon when these lesions are grossly visible. We report a case of a unique frozen section diagnostic scenario of evaluation of keratin granulomas in the peritoneum of a 47-year-old woman in the setting of multiple potential culprits: endometrial endometrioid adenocarcinoma following fertility sparing treatment, and a concurrent dermoid cyst. We discuss the various etiologies of keratin granulomas in the peritoneum, mechanism of their formation, diagnostic significance, as well as implications of fertility sparing treatments. To the best of our knowledge, this is the only case of keratin granulomas in the peritoneum with multiple distinct potential pathologic culprits as well the only case following fertility sparing treatment.

Acute intraperitoneal rupture of hydatid cysts of the liver: Case series.

ABSTRACT: Hydatid cyst is a parasitic infection caused mainly by Echinococcus granulosus, which is generally considered benign. However, the hepatic hydatid cyst rupture in the abdominal cavity is a life-threatening incident that requires urgent and multidisciplinary management (emergency physicians, radiologists, anesthetists, and surgeons). This study describes clinical and paraclinical liver hydatid cyst rupture in the peritoneal cavity and details the appropriate treatment.A retrospective review of clinical records of patients hospitalized in Jendouba Hospital for liver hydatid cyst was performed over 8 years, from January 1, 2012 to December 31, 2019. Fifteen cases of liver hydatid cyst complicated with acute rupture into the abdominal cavity were collected out of 625 hydatid liver cysts. All patients underwent emergency laparotomy allowing conservative unroofing procedure associated with peritoneal lavage and external drainage combined with necessary intensive care measures. Clinical features, therapeutic procedures' details as well as postoperative outcomes are reported. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.There were 9 men and 6 women. Patients' age ranged from 14 to 59 years, with an average of 38 years. Two patients were admitted with abdominal trauma. Acute abdominal pain was the most common complaint. Only 1 patient had an anaphylactic shock. Abdominal ultrasonography and computed tomography scan showed discontinuous cyst wall associated to intraperitoneal fluid in all cases. Intraoperatively, the intraperitoneal effusion was clear in 13 cases and purulent in 2. All patients underwent unroofing procedures associated with intra-operative peritoneal lavage and external drainage. The mean hospital stay was 6.11 days, and the mean follow-up was 19 months. No case of recurrence was reported among the patients.In endemic areas, rupture of a hepatic hydatid cyst in the abdominal cavity should be considered in every case of acute abdominal pain, especially if associated with anaphylaxis signs. Early management starting in the emergency room is needed to ensure good outcome.

Pathogenesis Based Diagnosis and Treatment of Endometriosis.

Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.