A 25-Year-Old Man with a History of Substance Abuse Presenting with Pneumomediastinum Due to Methamphetamine Vapor Inhalation.

BACKGROUND There has been an increase in the use of inhalation methods to abuse drugs, including freebasing crack cocaine (alkaloid) and inhaling methamphetamine vapor. This report is of a 25-year-old man with a history of substance abuse presenting with pneumomediastinum due to methamphetamine vapor inhalation. Acute pneumomediastinum is an extremely rare complication of methamphetamine use. CASE REPORT A 25-year-old man was treated for polysubstance abuse following 9 days of methamphetamine abuse. EKG did not show any ST &T change. D-dimer was normal, at 0.4 mg/L, so we did not do further work-up for pulmonary embolism. His chest pain worsened in the Emergency Department (ED), and a physical exam demonstrated crepitation of the posterior neck, trapezius, and right scapula. A portable chest X-ray revealed subcutaneous air over the right scapular region, in addition to pneumomediastinum. The urine drug screen test was positive for methamphetamine. A chest CT was ordered, which showed a moderate-volume pneumomediastinum with soft-tissue air tracking into the lower neck and along the right chest wall. The patient underwent an esophagogram, which showed no air leak, and Boerhaave's syndrome was ruled out. His symptoms improved and he did not require any surgical intervention. CONCLUSIONS Considering the higher rates of illicit substance use, especially methamphetamine, it is important to pay attention to the associated pathologies and to keep spontaneous pneumomediastinum on the list of differentials for patients using methamphetamine, particularly those who inhale it, which can cause pneumomediastinum, even without Boerhaave's syndrome.

Spontaneous splenic rupture and a congenital splenorenal anomalous shunt.

ABSTRACT: Atraumatic splenic rupture is rare and not often considered in the differential diagnosis for patients with abdominal pain. This article describes a patient with atraumatic splenic rupture complicated by a congenital splenorenal anomalous shunt. The congenital anomaly increases patient risk and the degree of surgical difficulty, even if it is identified preoperatively.

Idiopathic Spontaneous Rupture of a Subcostal Artery in a Patient Undergoing Hemodialysis: A Case Report.

The spontaneous rupture of a subcostal (12th intercostal) artery is exceptionally rare and could be fatal, requiring early diagnosis and treatment. Only one case of intercostal artery (ICA) bleeding in a patient undergoing hemodialysis (HD) has been reported. We additionally describe a 41-year-old man undergoing HD who presented with a spontaneous hemoperitoneum and shock resulting from a subcostal artery rupture. He initially complained of diffuse abdominal pain and dizziness at the emergency room. His abdomen was bloated, and there was tenderness in the right upper quadrant area. Enhanced computed tomography and arteriography revealed a rupture of the right subcostal artery. After the super-selection of the bleeding artery by a microcatheter, embolization was performed using a detachable coil and gelfoam. In a subsequent arteriogram, additional contrast leakage was no longer detected, and his blood pressure was restored to normal. The patient was discharged without any sequelae. He was followed up at our HD center without recurrence of ICA bleeding. To the best of our knowledge, this is the second case in the English literature documenting a spontaneous ICA rupture in a patient undergoing HD. This case indicates that injury to ICA should be suspected when patients undergoing HD complain of abdominal or chest pain and dizziness, although it is very rare.

Atraumatic splenic rupture.

Atraumatic splenic rupture (AMR) is a life-threatening condition with a wide range of aetiologies, and it may present with a vague symptomatology. Therefore, AMR can be diagnostically challenging. In this review, we wish to focus on the fact that guidelines only exist for traumatic splenic rupture although they may be applicable for AMR too. In addition, a stringent ABCDE approach for clinical examination may early and reliable diagnose the patients and guide further imaging examination and treatment.

Spontaneous rupture of bladder diverticulum with pseudo renal failure:A case report and literature review.

BACKGROUND: Spontaneous or non-traumatic bladder rupture is rare but can be life-threatening. Bladder rupture caused by a diverticulum is extremely rare, with only a few case reports in medical literature. CASE PRESENTATION: We report the case of a 32-year-old woman admitted to hospital complaints of abdominal pain, oliguria and ascites with no history of trauma. Laboratory tests revealed an elevated serum urea nitrogen(UN) level of 33.5 mmol/l and an elevated creatinine levels of 528 umol/l. X-ray cystography confirmed the rupture of a bladder diverticulum. Subsequent transurethral catheterization led to a prompt increase in urinary output, and serum creatinine level returned to 40 umol/l within 48 h. The patient was successfully treated with laparoscopic diverticulectomy. CONCLUSION: Clinicians should maintain a high level of suspicion for urinary bladder rupture in cases presenting with acute lower abdominal pain, urinary difficulties, and oliguria. When acute renal failure, complicated ascites, and an elevated peritoneal fluid creatinine or potassium level exceeding serum levels are observed, intraperitoneal urine leakage should be suspected without delay. This case emphasizes the importance of early diagnosis and intervention in managing this rare but serious condition.

Spontaneous uterine rupture with amniotic sac protrusion during the third trimester of a unicornuate uterus pregnancy: A rate case report.

RATIONALE: Uterine rupture is an obstetrical emergency associated with severe maternal and fetal mortality. It is rare in the unscarred uterus of a primipara. PATIENT CONCERNS: A 25-year-old woman in her 38th week of gestation presented with slight abdominal pain of sudden onset 10 hours before. An emergency cesarean section was done. After surgery, the patient and the infant survived. DIAGNOSES: With slight abdominal pain of clinical signs, ultrasound examination showed that the amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. INTERVENTIONS: Uterine repair and right salpingectomy. OUTCOMES: After surgery, the patient and the infant survived. The newborn weighed 2600 g and had an Apgar score of 10 points per minute. Forty-two days after delivery, the uterus recovered well. LESSONS: Spontaneous uterine rupture should be considered in patients even without acute pain, regardless of gestational age, and pregnancy with abdominal cystic mass should consider the possibility of uterine rupture.

[Spontaneous retroperitoneal hematoma]. / Spontaan retroperitoneaal hematoom.

Spontaneous retroperitoneal hematoma refers to bleeding of the retroperitoneal space without prior trauma or iatrogenic injury. Its diagnosis is often delayed due to a nonspecific clinical presentation. This case-series presents three patients with spontaneous retroperitoneal bleeding. Patient A presented with a spontaneous bleeding around the right iliopsoas muscle due to antiplatelet medication and was managed conservatively. Patient B had a spontaneous arterial bleeding near the right kidney, subsequently determined to be associated with a pheochromocytoma. Endovascular treatment successfully stopped the bleeding. The pheochromocytoma was resected during follow-up. Patient C had a spontaneous rupture of the left iliac vein with a concomitant deep vein thrombosis. She underwent emergent laparotomy, but unfortunately did not survive. This case-series emphasize the diverse presentation, varied causes, and different treatment strategies for spontaneous retroperitoneal hematoma. Timely diagnosis is hard, but crucial to enable an individualized treatment.

Multiple plaque ruptures healing assessed by serial optical coherence tomography.

A 30-year-old man with hypertension presented to the emergency department with a 30-minute episode of diaphoresis and chest pain, acute inferior myocardial infarction was diagnosed on electrocardiogram.

Boerhaave's Syndrome Presenting in the Setting of Third-Degree Heart Block.

Introduction: Boerhaave's syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave's syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave's syndrome and initiate treatment urgently. Case Description: This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery. Discussion: Complete heart block in the setting of Boerhaave's syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient's bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.

Spontaneous rupture of renal angiomyolipoma in pregnancy mimicking preterm labour.

Ruptured renal angiomyolipoma in pregnancy is uncommon. Pregnant women may present with nonspecific symptoms such as flank or abdominal pain, contraction pain and haematuria. A thorough assessment is needed to reach the correct diagnosis. Management varies between conservative measures, radiological intervention or surgery depending on the patient's haemodynamic status and foetal condition. We present a case of a woman in her 30s, gravida 5 para 3+1 at 28 weeks of gestation, who presented with pain. The pain worsened, and she went into hypovolaemic shock. An exploratory laparotomy and emergency caesarean section were done. Retroperitoneal haematoma was found intraoperatively, but the source of bleeding was difficult to determine. An abdominal CT angiogram subsequently revealed an ongoing bleeding from a ruptured angiomyolipoma. An emergency nephrectomy was performed, and the bleeding was secured.

Clonorchis sinensis on the prognosis of patients with spontaneous rupture of Hepatocellular Carcinoma: An inverse probability of treatment weighting analysis.

BACKGROUND: We examined the impact of the Clonorchis sinensis (C. sinensis) infection on the survival outcomes of spontaneous rupture Hepatocellular Carcinoma (srHCC) patients undergoing hepatectomy. METHODS: Between May 2013 and December 2021, 157 consecutive srHCC patients who underwent hepatectomy were divided into an no C. sinensis group (n = 126) and C. sinensis group (n = 31). To adjust for differences in preoperative characteristics an inverse probability of treatment weighting (IPTW) analysis was done, using propensity scores. Overall survival (OS) and recurrence-free survival (RFS) were compared before and after IPTW. Multivariate Cox regression analysis was performed to determine whether the C. sinensis infection was an independent prognostic factor after IPTW. RESULTS: In original cohort, the no C. sinensis group did not show a survival advantage over the C. sinensis group. After IPTW adjustment, the median OS for the C. sinensis group was 9 months, compared to 29 months for the no C. sinensis group. C. sinensis group have worse OS than no C. sinensis group (p = 0.024), while it did not differ in RFS(p = 0.065). The multivariate Cox regression analysis showed that C. sinensis infection and lower age were associated with worse OS. CONCLUSIONS: The C. sinensis infection has an adverse impact on os in srHCC patients who underwent hepatectomy.

Circadian characteristics of term and preterm labors.

The labor is a physiological event considered to have its own circadian (diurnal) rhythm, but some of the data remain conflicting, especially for preterm births. In this retrospective study, we analyzed the circadian trends of labor onset times in the Slovenian birth cohort from 1990 to 2018 with over 550,000 cases of singleton births. The number of term and preterm labor onsets was calculated for each hour in a day and circadian trends were evaluated for each of the study groups by modeling with a generalized Poisson distribution linked with the cosinor regression model using logarithmic link function. The induced labors were taken as the control group since the timing of labor depends mostly on the working schedule of personnel and not on the intrinsic rhythmic characteristics. For induced labors, the main peak in the number of labor cases was observed in the late morning hours (around 10 AM) for all gestational ages. The prominence of this peak becomes smaller in spontaneous premature labors with gradually disrupting rhythmicity in very preterm and extremely preterm cases. Labors starting with spontaneous contractions peak between 6 and 7 AM and lose the rhythmicity at 35 weeks of gestation while labors starting with a spontaneous rupture of membranes peak at 1 AM and lose the rhythmicity at 31 weeks of gestation, suggesting differences in underlying mechanisms. According to our knowledge, this is the first study that shows differences of circadian trends between different types of spontaneous labors, i.e., labors initiated with contraction and labors initiated with a spontaneous rupture of membranes. Moreover, the obtained results represent evidence of gradual disruption of rhythmicity from mild to extreme prematurity.

Alpha-fetoprotein-producing gastric cancer with ruptured liver metastasis mimicking hepatocellular carcinoma.

Alpha-fetoprotein (AFP)-producing gastric cancer is a rare subtype of gastric cancer known for its aggressive nature. We present an uncommon case of a 60s male with multiple liver tumors, initially suggested as hepatocellular carcinoma (HCC) by imaging. However, a subsequent gastric biopsy revealed a poorly differentiated adenocarcinoma with hepatoid features, and liver biopsy mirrored these findings. The disease progressed swiftly, with the patient representing owing to the spontaneous rupture of a metastatic liver tumor, an extremely rare occurrence, especially in metastatic liver cancers. Such ruptures in AFP-producing gastric cancer may be attributed to the tumor's rich blood flow. Distinctly differentiating this subtype from HCC is pivotal for apt management, as was evident in our case. The diagnosis was particularly challenging due to the similarities in imaging presentations between AFP-producing gastric cancer liver metastasis and HCC. This case underscores the need for vigilant diagnosis, emphasizing the importance of liver biopsy, especially in the absence of chronic liver disease. It also highlights the potential complications, like spontaneous rupture, associated with this rare form of gastric cancer.

Pyonephrosis complicated with spontaneous intraperitoneal rupture and diffuse peritonitis: Case report and literature review.

Pyonephrosis is a serious condition that can lead to kidney dysfunction, loss of the organ, and even fatal end due to its complications. The underlying etiologic factors include lithiasis, recurrent urinary infections, ureter stricture, ureteropelvic junction obstruction, malignancy, and retroperitoneal fibrosis. One of the rare possible complications of pyonephrosis is a retroperitoneal rupture with spontaneous communication to the abdomen causing secondary peritonitis. We present such a case which is the first video-documented report of the peritoneal rupture site within the abdominal cavity.

Transarterial embolization followed by staged hepatectomy versus emergency hepatectomy for ruptured HCC: a meta-analysis

Background To compare the efficacy and safety between emergency hepatectomy (EH) and emergency transarterial embolization (TAE) followed by staged hepatectomy (SH) in the treatment of spontaneous ruptured hepatocellular carcinoma (rHCC). Methods Databases (PubMed, EMBASE, Web of science, Cochrane Library, ClinicalTrial.gov, CNKI, Wanfang and VIP) were searched for all relevant comparative studies from January 2000 to October 2020. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were pooled for dichotomous and continuous variables, respectively. Subgroup analyses based on the kind of embolization were conducted. RevMan 5.3 software was adopted for meta-analysis. Results Eighteen studies with 871 patients were finally included in this meta-analysis, 448 in EH group and 423 in TAE + SH group. No significant difference was observed in successful hemostasis (P = 0.42), postoperative hospital stay (P = 0.12), complication rate (P = 0.08) between EH and TAE + SH group. However, TAE + SH group was associated with shorter operating time (P < 0.00001), fewer perioperative blood loss (P = 0.007), fewer blood transfusion (P = 0.003), lower in-hospital mortality (P < 0.00001) and higher 1-year survival as well as 3-year survival (P < 0.0001; P = 0.003) compared with EH group. Conclusion Compared with EH, TAE + SH could reduce perioperative operating time, blood loss, blood transfusion, mortality rate and increase the long-term survival rate of the rHCC patients, which may be a better treatment for resectable rHCC (AU)

Spontaneous splenic rupture in a neonate: a case report and literature review.

Splenic rupture in a neonate is a rare but potentially fatal condition that may trigger evaluation for child abuse. It is a diagnosis of exclusion that has been reported in the surgical literature but may be underrecognized by pediatric radiologists. We report a case of a newborn with an unremarkable prenatal, delivery, and nursery course who presented with anemia, abdominal distension, and lethargy. Abdominal ultrasound with Doppler and computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis without contrast showed findings of splenic rupture and anoxic brain injury. An extensive workup for traumatic, infectious, coagulopathic, and congenital etiologies was unrevealing, leading to a presumptive diagnosis of spontaneous splenic rupture in a neonate.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst.

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

Transarterial embolization followed by staged hepatectomy versus emergency hepatectomy for ruptured HCC: a meta-analysis.

BACKGROUND: To compare the efficacy and safety between emergency hepatectomy (EH) and emergency transarterial embolization (TAE) followed by staged hepatectomy (SH) in the treatment of spontaneous ruptured hepatocellular carcinoma (rHCC). METHODS: Databases (PubMed, EMBASE, Web of science, Cochrane Library, ClinicalTrial.gov, CNKI, Wanfang and VIP) were searched for all relevant comparative studies from January 2000 to October 2020. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were pooled for dichotomous and continuous variables, respectively. Subgroup analyses based on the kind of embolization were conducted. RevMan 5.3 software was adopted for meta-analysis. RESULTS: Eighteen studies with 871 patients were finally included in this meta-analysis, 448 in EH group and 423 in TAE + SH group. No significant difference was observed in successful hemostasis (P = 0.42), postoperative hospital stay (P = 0.12), complication rate (P = 0.08) between EH and TAE + SH group. However, TAE + SH group was associated with shorter operating time (P < 0.00001), fewer perioperative blood loss (P = 0.007), fewer blood transfusion (P = 0.003), lower in-hospital mortality (P < 0.00001) and higher 1-year survival as well as 3-year survival (P < 0.0001; P = 0.003) compared with EH group. CONCLUSION: Compared with EH, TAE + SH could reduce perioperative operating time, blood loss, blood transfusion, mortality rate and increase the long-term survival rate of the rHCC patients, which may be a better treatment for resectable rHCC.