Gastrointestinal Bezoars in Paediatrics: Case Series and Literature Review.

BACKGROUND: Bezoars are indigestible lumps which are usually found in stomach. Types of bezoar include phytobezoar, trichobezoar, lithobezoar, pharmacobezoar, plasticobezoar, lactobezoar and metal bezoar. Trichobezoars mostly affect females in 20s and 30s with a rarity in paediatrics. Unexplained complaints with a palpable mass are commonly found in these patients. Treatment involves retrieval of mass with searching for others. The purpose of this study was to present data and surgical management of cases with trichobezoars. MATERIALS AND METHODS: We documented a retrospective review of trichobezoars done in our hospital between 2016 and 2022. All demographic data collected included gender and age of cases, composition and extent of bezoar, clinical presentation, imaging modalities, endoscopic trial, surgical approach and outcome. RESULTS: Five cases of gastrointestinal tract (GIT) trichobezoars underwent surgery. All cases were females between (13 and 16 years). Trichobezoars were three gastric, one ileal and one of combined gastric and colonic. Complaints were abdominal pain, vomiting, weight loss and halitosis. Three cases had a palpable abdominal mass. Different radiological modalities were performed. Endoscopic retrieval was tried in one patient and the laparoscopic approach in another one, but the first route failed. Laparotomy followed by gastrotomy, enterotomy and colotomy was done without complications. CONCLUSIONS: Trichobezoars should be suspected in any child with unexplained abdominal complaints or with a palpable abdominal mass, especially in girls. Imaging can be done in different modalities for diagnosis. Endoscopic retrieval could be tried; however, its failure is common, necessitating laparotomy, which has an excellent outcome.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia.

INTRODUCTION: Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias. MATERIALS AND METHODS: Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound. RESULTS: We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05). CONCLUSION: Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: A case report and review of the literature.

INTRODUCTION: A complete disruption of main pancreatic duct (MPD) presents a significant challenge to the surgeon. Historically, the standard surgical approach for addressing a complete disruption of the MPD involved distal pancreatic resection and pancreaticojejunostomy Roux-en-Y anastomosis. Nevertheless, there have been no reported cases of hybrid surgery being employed for the complete disruption of the MPD. PATIENT CONCERNS: A 63-year-old male patient presented with blunt trauma in the upper abdomen and was transferred to our trauma center 10 hours after injury. Upon arrival at the emergency department, he was conscious, hemodynamically stable, and complained of upper abdominal pain and distention. Physical examination revealed right upper abdominal tenderness and slight abdominal tension. Abdominal contrast-enhanced CT scan revealed a complete transection of pancreatic parenchyma at the junction of the head and neck. DIAGNOSES: Complete transection of pancreatic parenchyma at the junction of the head and neck combined with complete disruption of the MPD, AIS grade IV. INTERVENTIONS: The hybrid surgery was initially utilized for complete MPD disruption, incorporating endoscope-assisted stent placement in the MPD along with primary repair of the pancreatic parenchyma and duct. OUTCOMES: The postoperative period went smoothly, and the patient recovered and was discharged 4 weeks after operation. The MPD stent was removed under endoscope 4 months after operation, and Endoscopic Retrograde Pancreatography examination showed that the MPD was patency and slight MPD stenosis without pancreatic leakage. At the most recent follow-up, the patient had returned to normal life and work without any pancreatic endocrine or exocrine dysfunction. LESSONS: The hybrid surgery, incorporating endoscope-assisted MPD stent placement and primary repair of the pancreatic parenchyma and duct, emerges as a promising alternative for complete MPD disruption in hemodynamically stable patients. The challenge in this hybrid surgery is the precise localization of the distal end of the MPD.

A Case of Left-Sided Acute Appendicitis in a 45-Year-Old Man with Situs Inversus Totalis Managed by Emergent Laparoscopic Appendectomy.

BACKGROUND Situs inversus totalis (SIT) is a rare congenital abnormality that includes mirror-image transposition of both the abdominal and the thoracic organs. It may remain undetected into adulthood until an acute medical emergency results in diagnostic imaging. This report presents a challenging case of left-sided acute appendicitis in a 45-year-old man with SIT. CASE REPORT A 45-year-old man with a medical history of gastroesophageal reflux disease, class 2 obesity, prediabetes, and elevated low-density lipoprotein cholesterol presented with severe acute abdominal pain localized in the left lower quadrant with localized tenderness, nausea, and 2 episodes of non-bloody and non-bilious emesis that started a day before the clinical encounter. Computed tomography of the abdomen and pelvis revealed previously undiagnosed congenital SIT. In addition, physical, laboratory, and radiological findings suggested early acute appendicitis with no evidence of complications. Hence, the patient was managed with an emergent laparoscopic appendectomy. Acute appendicitis was confirmed in the post-surgery histopathological examination. The post-surgery recovery was uneventful, and the patient was discharged home on the second postoperative day. CONCLUSIONS This report highlights that SIT may remain undiagnosed into adulthood and poses a challenge in the diagnosis of left-side appendicitis due to atypical symptom presentation, supporting the findings of previous case reports. Therefore, the inclusion of left-sided acute appendicitis in the differential diagnosis of abdominal pain in the left lower quadrant is warranted.

Visceral symptoms in patients with anterior cutaneous nerve entrapment syndrome (ACNES): expression of viscerosomatic reflexes?

PURPOSE: Anterior cutaneous nerve entrapment (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected individuals reporting nausea, bloating, or loss of appetite mimicking visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms. METHODS: This prospective observational study was conducted between July 2017 and December 2020 at SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain. RESULTS: Data from 100 selected patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1-8) and after of 1 (range 0-6) (p < 0.001). A low baseline VICAS was associated with successful treatment outcome (OR 0.738, 95% CI 0.546-0.999). CONCLUSION: Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients.

[Diagnosis and treatment of Dunbar syndrome]. / Diagnostik und Therapie des Dunbar-Syndroms.

The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.

The burden of abdominal pain after bariatric surgery in terms of diagnostic testing: the OPERATE study.

BACKGROUND: Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found. OBJECTIVES: To quantify type and number of diagnostic tests performed in patients with abdominal pain after BS and evaluate the burden and their yield in the diagnostic process. SETTING: A bariatric center in the Netherlands. METHODS: In this prospective study, we included patients who presented with abdominal pain after BS between December 1, 2020, and December 1, 2021. All diagnostic tests and reoperations performed during one episode of abdominal pain were scored using a standardized protocol. RESULTS: A total of 441 patients were included; 401 (90.9%) were female, median time after BS was 37.0 months (IQR, 11.0-66.0) and mean percentage total weight loss was 31.41 (SD, 10.53). In total, 715 diagnostic tests were performed, of which 355 were abdominal CT scans, 155 were ultrasounds, and 106 were gastroscopies. These tests yielded a possible explanation for the pain in 40.2% of CT scans, 45.3% of ultrasounds, and 34.7% of gastroscopies. The diagnoses of internal herniation, ileus, and nephrolithiasis generally required only 1 diagnostic test, whereas patients with anterior cutaneous nerve entrapment syndrome, irritable bowel syndrome, and constipation required several tests before diagnosis. Even after several negative tests, a diagnosis was still found in the subsequent test: 86.7% of patients with 5 or more tests had a definitive diagnoses. Reoperations were performed in 37.2% of patients. CONCLUSION: The diagnostic burden in patients with abdominal pain following BS is high. The most frequently performed diagnostic test is an abdominal CT scan, yielding the highest number of diagnoses in these patients.

Surgical treatment of nutcracker syndrome results in improved pain and quality of life.

BACKGROUND: Left renal vein (LRV) compression, or nutcracker phenomenon, describes the compression of the LRV, most commonly between the aorta and the superior mesenteric artery. The outflow obstruction that occurs from the compression causes venous hypertension leading to the development of pelvic collaterals, lumbar vein engorgement and gonadal vein reflux. The symptoms associated with LRV compression include abdominal pain, left flank pain, back pain, headache, pelvic pain/pressure, and hematuria. Symptomatic LRV compression can cause chronic pain and disability that impedes activities of daily living. Left renal auto transplantation (LR-AT) is one mode of treatment, leading to decreased pain with no significant vascular or urological complications. Herein we present a five patient case series with symptomatic LRV compression who underwent LR-AT with improved pain and quality of life after surgery. METHODS: Five patients underwent LR-AT between June 2020-December 2020 to resolve their symptomatic LRV compression. These patients were given three validated surveys pre- and post- intervention, then again at their three month follow up visit to assess their pain and health-related quality of life. RESULTS: The five patients were all female with the average age of 36.8 years old (36-41) and underwent LR-AT to treat their symptomatic LRV compression. The average Numeric Rating Scale (NRS) pain score pre intervention was 8.3 (range 6.7 to 10) which improved to pain rating 5.22 (range 2.7 to 6) post intervention, p-value = 0.013. The average pain NRS score at 3 month follow up was 3.86 (range 1.3-6), p-value = 0.006 when compared to pre-intervention pain scores. The average pain intensity pre intervention was 4.5 (4 to 5) and 2.7 (1 to 4.3) post intervention, p-value = 0.024. The average pain intensity score at 3 month follow up was 2.24 (range 1.3-3.3), p-value = 0.002 when compared to pre-intervention. The VascuQoL-6 survey score pre intervention averaged score of 9.6 (range 7-12) which improved to an average score of 20.6 (range 18-24), p-value = 0.001. The average VascuQoL score at 3 month follow up was 22.6 (range 22-24), p-value = < 0.001 when compared to pre intervention QoL scores all showing a statistically significant improvement of health-related quality of life. CONCLUSION: The diagnosis of LRV compression can be challenging due to the non-descript symptoms and overall lack of awareness. Understanding venous tributary pathways and drainage can help clarify why patients present with unusual symptoms. Surgical treatment of LRV compression through LR-AT can improve patients' pain and improve vascular quality of life.

Radiofrequency Ablation's Effectiveness for Treating Abdominal and Thoracic Chronic Pain Syndromes: A Systematic Review of the Current Literature.

BACKGROUND: Many patients suffer from abdominal and thoracic pain syndromes secondary to numerous underlying etiologies. Chronic abdominal and thoracic pain can be difficult to treat and often refractory to conservative management. In this systematic literature review, we evaluate the current literature to assess radiofrequency ablation's (RFA) efficacy for treating these debilitating chronic pain conditions in the thoracic and abdominal regions. OBJECTIVES: The objective of this study is to determine the pain relief efficacy of RFA on chronic thoracic and chronic abdominal disease states. STUDY DESIGN: This study is a systematic literature review that uses the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to gather academic literature articles through a methodical approach. The numbers obtained from each academic manuscript were then used to calculate the percent efficacy of radiofrequency ablation on thoracic and abdominal pain relief. METHODS: Articles from 1992 through 2022 were gathered using PRISMA guidelines. The search terms "Radiofrequency Ablation Thoracic Pain" and "Radiofrequency Ablation Abdominal Pain" were used to identify articles to include in our study. Our search yielded a total of 575 studies, 32 of which were included in our study. The articles were then categorized into pain causes. The efficacy of RFA for each qualitative study was then quantified. Risk of bias was also assessed for articles using the Cochran Risk of Bias tool, as well as a tool made by the National Institutes of Health. RESULTS: The PRISMA search yielded a total of 32 articles used for our study, including 16 observational studies, one cohort study, 6 case reports, 6 case series, and 3 clinical trials. Twenty-five articles were labeled good quality and one article was labeled fair quality according to the risk of bias assessment tools. The studies examined RFA efficacy on chronic abdominal and chronic pain syndromes such as spinal lesions, postsurgical thoracic pain, abdominal cancers, and pancreatitis. Among these etiologies, RFA demonstrated notable efficacy in alleviating pain among patients with spinal osteoid osteomas or osteoblastomas, lung cancer, and pancreatic cancer. The modes of RFA used varied among the studies; they included monopolar RFA, bipolar RFA, pulsed RFA, and RFA at different temperatures. The average efficacy rate was 84% ranging from 55.8% - 100%. A total of 329 males and 291 females were included with ages ranging 4 to 90 years old. LIMITATIONS: Limitations of this review include the RFA not being performed at the same nerve level to address the same pathology and the RFA not being performed for the same duration of time. Furthermore, the efficacy of RFA was evaluated via large case series and single cohort observational studies rather than control group observational studies and clinical trial studies. CONCLUSION: A systematic review of the literature supports RFA as a viable option for managing abdominal and thoracic pain. Future randomized controlled trials are needed to investigate the efficacy of the various RFA modalities to ensure RFA is the source of pain relief as a large body of the current literature focuses only on observational studies.

Laparoscopic treatment of colonic endometriosis causing periodic abdominal pain and hematochezia: A case report.

RATIONALE: Endometriosis, a benign disease, has a malignant biological behavior and is highly prone to recurrence. Although gastrointestinal involvement is the most common site for extra-genital endometriosis, deep infiltrative endometriosis, which affects the mucosal layer, is very rare. PATIENT CONCERNS: A 44-year-old woman with a 6-month history of recurring abdominal pain and Hematochezia. The patient visited several hospitals over the past six months and was suspected to have been diagnosed with a digestive disease, for which medication was ineffective, leading to a great deal of anxiety. DIAGNOSES: Colonic endometriosis. INTERVENTIONS: After a thorough imaging evaluation and preoperative discussion, laparoscopic colonic endometriosis resection under indocyanine green indication was performed by gynecologists and gastroenterologists. OUTCOMES: After laparoscopic treatment, the patient's symptoms improved significantly, with occasional pain felt and no blood in the stool. LESSONS: This case provides a rare example of sigmoid endometriosis causing periodic abdominal pain and Hematochezia. We report a clinical case to investigate the feasibility of an indocyanine green fluorescent contrast technique to guide the scope of surgery in laparoscopic deep infiltrative endometriosis surgery. In intestinal endometriosis surgery, indocyanine green fluoroscopy may indicate the lesion's precise localization.

Laparoscopic cholecystectomy for giant gallbladder: A case report.

RATIONALE: An overdistended gallbladder is usually observed in cases of distal bile obstruction due to malignancy. The gallbladder may also become enlarged and distended during cystic duct or gallbladder neck obstruction due to gallstones. However, a grossly distended gallbladder ( > 14 cm in length) without any pathology is rare. We present the case of a 46-year-old female patient who suffered from acute right lower quadrant pain for 4 days. Initially, a liver cyst and a choledochal cyst were diagnosed by the local hospital. Then, the diagnosis of giant gallbladder (measuring approximately 20.0 cm × 7.0 cm and containing more than 30 gallbladder stones) was made by magnetic resonance cholangiopancreatography at our hospital. Finally, we successfully performed a laparoscopic cholecystectomy and the patient had an uneventful recovery. PATIENT CONCERNS: A 46-year-old female patient presented with acute right lower quadrant pain lasting 4 days. At first, the abdominal pain was severe and paroxysmal, and then it subsided spontaneously. Computed tomography of the abdomen at another hospital revealed a hepatic cyst and a choledochal cyst. Come to our hospital for surgical treatment. DIAGNOSES: giant gallbladder with gallstones. INTERVENTIONS: Laparoscopic cholecystectomy was successfully performed in this patient after decompressing the gallbladder. OUTCOMES: On the third postoperative day, the patient recovered well, and the abdominal pain resolved following the operation. At the 3-year postoperative follow-up, the patient was symptom-free, with no obvious abnormalities seen in liver function and hepatobiliary color Doppler ultrasound. LESSONS: The patient was successfully treated using laparoscopic cholecystectomy. This rare case may contribute to the development of mechanisms for treating giant gallbladders.

Colonic medullary carcinoma: an exceedingly rare type of colorectal malignancy: a case report and review of the literature.

BACKGROUND: Medullary carcinoma of the colon is a rare subtype of colorectal cancer that has a unique, and sometimes varied, clinical and histologic profile. It usually presents in adult patients older than 50 years. Here, we report a unique case of young male patient who initially presented with abdominal pain followed by a large bowel obstruction. CASE PRESENTATION: A 40-year-old SriLankan male presented with right-sided abdominal pain and on examination, there was a palpable right iliac fossa mass. Colonoscopy and a computed tomography scan revealed cecal mass. Later, while waiting for elective resection, the patient developed symptoms and signs of a large bowel obstruction. He underwent a laparoscopic right hemicolectomy with an uneventful postoperative course. The histopathologic evaluation of the resected specimens showed invasive carcinoma with syncytial growth pattern, foci of lymphoid host response, and dirty necrosis, in keeping with a medullary carcinoma pT4a pN2b. Unlike most reported medullary carcinoma cases, this patient was young and caudal-related homeobox transcription factor 2 positive. CONCLUSION: We have reported another case of medullary carcinoma of the colon in a young patient with unique histologic characteristics. Reporting such cases helps in refine understanding of the histologic and genetic, as well as clinical, phenotypes of medullary carcinoma of the colon.

Robot-assisted Laparoscopic Excision of Abdominal Wall Endometrioma Utilizing Intraoperative Ultrasound and Transabdominal Needle Placement.

OBJECTIVE: In patients with endometriosis, extra pelvic endometriosis is estimated to have an incidence of 11% and a rare subset of extra pelvic lesions include abdominal wall endometriosis with an incidence of 0.03% to 3.5% [1,2]. Evaluation for and surgical management of abdominal wall endometriosis are an essential skill set for the advanced gynecologic surgeon. In this video, we demonstrate a surgical technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intraoperative ultrasound-guided needle placement. DESIGN: Description and demonstration of surgical technique. SETTING: A patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain; a tertiary care, academic center. INTERVENTIONS: Intraoperative ultrasound-guided needle placement to map location and boundaries of the lesion followed by minimally invasive resection of the lesion with the intermittent advancement and withdrawal of needles to confirm clear margins. CONCLUSION: Minimally invasive resection of abdominal wall endometriosis using intraoperative ultrasound-guided needle placement is an effective technique to guide surgical dissection and allow for clear surgical margins and successful treatment of this rare condition.

A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review.

BACKGROUND: Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial. CASE PRESENTATION: A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy. CONCLUSIONS: This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

Intussusception revealing right colonic adenocarcinoma in a 61-year-old woman: a case report.

INTRODUCTION: Adult Intussusception is an uncommon diagnosis, with one to three cases occurring in a population of 1,000,000 per year, primarily due to underlying pathological lead points, of which 70% are malignant. Lipoma is the most common benign tumour, and primary adenocarcinoma is the most common malignant one. Early diagnosis and treatment are essential to reducing poor outcomes, including ischemia, perforation, and sepsis. Computed tomography imaging is a modality of choice for diagnosis. With a diagnostic accuracy of up to 100% and a specificity of up to 71%. Surgical intervention is the definitive treatment, and the decision is taken according to the situation. CASE PRESENTATION: A 61-year-old Black African female presented to our surgical casualty with intermittent colicky abdominal pain for 1 month. After that, she started to experience abdominal swelling in the right iliac fossa. A CT scan confirmed the presence of colo-colic Intussusception, cecum-ascending-transverse colon. Laparotomy was scheduled, and a right hemicolectomy was done accordingly. Diagnosis of adenocarcinoma (Dukes stage B2) was made histologically. CONCLUSION: Intussusception in adults is a challenging diagnosis requiring high clinical suspicion and has a high incidence of fatal complications. Colonic cancer can be worsening by any infection and chronic medical problem. CT imaging is the lifesaving modality of choice for diagnosis. Good patient outcomes depend on timely diagnosis and recruitment of a multi-disciplinary team.

Primary sclerosing encapsulating peritonitis: a case report.

BACKGROUND: Sclerosing encapsulating peritonitis is a rare condition with a typical macroscopic appearance, with fibrocollagenous membrane enclosing loops of the small intestine, causing intestinal obstruction. Unexplained recurrent abdominal pain, obstruction, and a large array of other possible clinical signs and symptoms make sclerosing encapsulating peritonitis a diagnostic challenge. CASE PRESENTATION: A 48-year-old man of Persian ethnicity was admitted multiple times to the emergency surgery department due to recurrent sudden abdominal pain and chronic obstruction without significant findings in medical history or clinical evaluation. Computed tomography was positive for proximal jejunal dilatation and duodenojejunal flexure stenosis due to internal mesenteric hernia. Exploratory laparoscopy, followed by laparotomy, confirmed thick membrane-like fibrous tissue with complete small intestinal loop envelopment. Extensive membrane excision and adhesiolysis was performed, but no mesenteric herniation was found. Early postoperative paralytic ileus with introduction of low-dose steroid therapy, based on histopathological and immunological results, confirming type III sclerosing encapsulating peritonitis, was completely resolved. CONCLUSION: Sclerosing encapsulating peritonitis is a rare and difficult-to-diagnose condition, further divided into primary and secondary sclerosing encapsulating peritonitis, on the basis of underlying etiology, dictating treatment modality and prognosis. Intraoperative diagnosis and surgical treatment are mandatory, besides a wide variety of abdominal computed tomography scans, inconclusive results, and clinical presentations. There are so far no known specific markers for the diagnosis of sclerosing encapsulating peritonitis.

[A pregnant patient with acute abdominal pain]. / Een zwangere met acute buikpijn.

A 33-year-old 20 weeks pregnant woman with severe abdominal pain in the past 1,5 hour visits the emergency department. MRI suggested an appendicitis. Laparoscopy showed an adnexal torsion. The right ovary was twisted back, and a good revascularization was observed shortly after. Patient was discharged one day post-surgery and had an uneventful pregnancy.