How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia.

OBJECTS: The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). METHOD: We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. RESULTS: The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). CONCLUSION: Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.

Development of refractory ascites during amiodarone therapy in a hemodialysis patient with nephrogenic and cardiogenic ascites.

In this report, the clinical characteristics of a 65-year-old female patient with tricuspid regurgitation, ischemic cardiomyopathy, congestive heart failure, and chronic renal failure were retrospectively evaluated. Laboratory studies revealed cardiogenic ascites coincided with nephrogenic ascites and subclinical amiodarone-induced hypothyroidism. The ascites of the patient was responsive to management of congestive heart failure and therapeutic paracentesis during the first episode, add-on therapy with intensified hemodialysis during the second episode, and add-on therapy with low-dose eltroxin during the third episode. When nephrogenic ascites and cardiogenic ascites of maintenance hemodialysis patients become refractory, hypothyroidism should be examined in these patients.

Diagnostic values of supine and erect abdominal radiographs for patients with acute abdomen: which is better for decision making?

BACKGROUND: Plain abdominal radiography including supine and erect abdominal radiographs (SAR and EAR) is a frequently used image modality for preliminary evaluation of acute abdomen. We aimed to explore which one of the SAR or EAR has a higher diagnostic value in overall diagnosis of acute abdomen, including their respective advantages over each other for the various underlying diseases. METHODS: We retrospectively analyzed the imaging findings of plain abdominal radiography of patients with acute abdomen who received abdominal computed tomography (CT) within 24 hours at the emergency department of a medical center in northern Taiwan between October 2019 and February 2020. Final diagnosis was made by CT reports and clinical data. The relevance between the imaging findings and clinical diagnosis in the groups of SAR and EAR were compared. RESULTS: A total of 1009 cases with acute abdomen were included, of which 341 (33.8%) underwent EAR and 668 (66.2%) underwent SAR. Among them, 820 cases had final diagnosis confirmed by CT and clinical data. In comparison of the diagnostic relevance of SAR and EAR, there were no significant difference in the overall acute abdomen, but EAR showed a better diagnostic relevance in cases with bowel obstruction than SAR did (100% vs 87.2%, p < 0.05). No statistical difference in other abdominal diseases. CONCLUSION: There is no significant difference between SAR and EAR in evaluation of overall acute abdomen. However, EARs has a diagnostic advantage over SAR for evaluation of suspected bowel obstruction.

Glomus tumor in the stomach.

Gastric glomus tumor is rare and most commonly described as a solitary, well-defined, submucosal lesion in the antrum with non-specific clinical manifestations. We report this case with representative image findings, correlate with clinical presentations and pathologic demonstrations that can help to early detect and distinguish it from other malignant tumors such as gastrointestinal stromal tumor.

Anticoagulant-induced intramural intestinal hemorrhage.

BACKGROUND: Long-term use of warfarin can provide benefits in the treatment of many diseases, but adverse bleeding events are unpreventable because of a narrow therapeutic range. OBJECTIVE: The aim of this retrospective chart review with data abstraction was to investigate the clinical presentations of intestinal intramural hemorrhage in emergency department (ED) patients. METHODS: We reviewed the cases of 17 patients with acute abdominal pain in our ED. Medical records including demographic data and results of abdominal computed tomography were retrospectively reviewed and analyzed. RESULTS: The mean ± SD age of the reviewed patients was 77.7 ± 8.5 years (range, 60-93 years). The mean ± SD duration from onset of symptoms to ED visit was 2.5 ± 1.3 days (range, 1-5 days). All patients had abdominal pain, and 64.7% had nausea/vomiting. A total of 64.7% of patients had peritoneal signs. The jejunum was most commonly involved (88.2% of all cases). The maximal mean ± SD wall thickening of the bowel was 14.1 ± 4.4 mm (range, 7.4-26.7 mm), and the estimated mean ± SD length was 35.6 ± 24.4 cm (range, 9-105 cm). The mean ± SD prothrombin time and activated partial thromboplastin time were prolonged to 86.5 ± 26.9 and 116.2 ± 43.1 seconds, respectively. All patients received medical treatment and survived. At the last follow-up (mean, 27.4 months), none of the patients had recurrence of intestinal intramural hemorrhage or intestinal obstruction. CONCLUSION: Prolonged prothrombin time and drug history can indicate the possibility of intramural intestinal hemorrhage, and abdominal computed tomography may help to exclude surgical diseases and prevent unnecessary surgery.

Can acute cholecystitis with gallbladder perforation be detected preoperatively by computed tomography in ED? Correlation with clinical data and computed tomography features.

PURPOSE: The purpose of this study is to determine which computed tomography (CT) findings and clinical data can help to diagnose gallbladder perforation in acute cholecystitis. MATERIALS AND METHODS: The medical records and CT findings of patients with surgically proven acute cholecystitis within the last recent 5 years were retrospectively reviewed and compared between 2 groups with and without gallbladder perforation. RESULTS: A total of 75 patients with acute cholecystitis were included in the study, and 16 patients were proven to have gallbladder perforation. Higher mortality rate was found in the perforation group (18.8% vs 1.7%; P = .029). Older age (>70 years; P = .004) and higher percentage of segmented neutrophil (>80%; P = .027) were significant clinical factors for predicting gallbladder perforation in acute cholecystitis. The significant CT signs related to gallbladder perforation included visualized gallbladder wall defect (P = .000), intramural gas (P = .043), intraluminal gas (P = .000), intraluminal membrane (P = .043), pericholecystic abscess or biloma formation (P = .009), intraperitoneal free air (P = .001), and presence of ascites in the absence of hypoalbuminemia or other intraabdominal malignancy (P = .017). In multivariate analysis, visualized gallbladder wall defect was the most significant predicting CT feature for diagnosing gallbladder perforation in acute cholecystitis. CONCLUSION: Elderly patients with higher segmented neutrophil and CT signs of gallbladder wall defect associated with acute cholecystitis may have high possibility of gallbladder rupture.

Reappraisal of radiographic signs of pneumoperitoneum at emergency department.

PURPOSE: This study aimed to evaluate the sensitivities of the reported free air signs on supine chest and abdominal radiographs of hollow organ perforation. We also verified the value of supine radiographic images as compared with erect chest and decubitus abdominal radiographs in detection of pneumoperitoneum. METHODS: Two hundred fifty cases with surgically proven hollow organ perforation were included. Five hundred twenty-seven radiographs were retrospectively reviewed on the picture archiving and communication system. Medical charts were reviewed for operative findings of upper gastrointestinal tract, small bowel, or colon perforations. The variable free air signs on both supine abdominal radiographs (KUB) and supine chest radiographs (CXR) were evaluated and determined by consensus without knowledge of initial radiographic reports or final diagnosis. Erect CXR and left decubitus abdominal radiographs were evaluated for subphrenic free air or air over nondependent part of the right abdomen. RESULT: Upper gastrointestinal tract perforation was proven in 91.2%; small bowel perforation, in 6.8%; and colon perforation, in 2.0%. The positive rate of free air was 80.4% on supine KUB, 78.7% on supine CXR, 85.1% on erect CXR, and 98.0% on left decubitus abdominal radiograph. Anterior superior oval sign was the most common radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air signs ranged from 0% to 30.4%. CONCLUSIONS: Most free air signs on supine radiographs are located over the right upper abdomen. Familiarity with free air signs on supine radiographs is very important to emergency physicians and radiologists for detection of hollow organ perforation.

D-dimer in patients with suspected acute mesenteric ischemia.

OBJECTIVES: The aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis. METHODS: A prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method. RESULTS: Acute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665). CONCLUSIONS: Detection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.

Turner syndrome phalangeal screening based on a two-stage linear regression concept.

BACKGROUND: Turner syndrome (TS) is a congenital chromosomal abnormality, resulting in short stature, short fourth metacarpal, and retarded skeletal maturation in children. The existing methods of diagnosis, which include carpal angle, metacarpal sign, and body mass index (BMI), cannot accurately diagnose TS. The authors propose a novel procedure for examining the hand skeleton to distinguish between normal individuals and patients with TS. METHODS: This investigation was divided into two parts. In the first part, existing methods (evaluation of the metacarpal sign, measurement of the carpal angle, and determination of BMI) were used. Examination in the second part was based on the two-stage screening method (TSSM). In the first stage in TSSM, the ratio of the lengths of the distal-middle phalanges of the fifth digit was determined in normal subjects with average range of satisfactory body height and TS patients. A suitable cut-off was found on linear regression and used to divide the plot into TS patients and normal subjects. In the second stage, the normal section was transferred to another group based on bone and chronological ages. A greater number of patients were diagnosed with TS using this method. Finally, four cut-off parameters were determined on linear regression analysis. Results with optimal sensitivity and specificity were automatically obtained. RESULTS: The combination of TSSM with optimal programming (sensitivity = 0.81 and specificity = 0.91) was satisfactory for diagnosing TS patients. CONCLUSION: TSSM can suitably evaluate growth of the hand skeleton to distinguish between normal individuals and patients with TS.

Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation.

Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p<0.001), a lower rate of ileum involvement (26.7% vs. 77.4%, p<0.001) and a higher rate of ascites (96.7% vs. 64.2%, p<0.001) compared with patients with AMI. Neither pneumatosis intestinalis (p<0.001) nor portomesenteric gas (p<0.01) were detected in SIIH patients but were observed in AMI patients. A receiver-operating characteristic (ROC) curve analysis showed that the optimal cut-off value for maximal intestinal wall thickening between groups was 10.4 mm and the area under the ROC curve between groups was 0.752 (p<0.0001). A multiple logistic regression analysis showed that the independent predictors of SIIH were non-involvement of the ileum (odds ratio, OR, 6.998; p=0.001), maximal intestinal wall thickening ≥10.4 mm (OR, 5.748; p=0.040) and ascites (OR, 13.348; p=0.023). The area under the ROC curve for the model was 0.854 (p<0.001). Conclusion The independent predictors of SIIH from AMI after abdominal CT in acute abdominal patients include non-involvement of the ileum, intestinal wall thickening ≥10.4 mm, and ascites.

Differentiating colonic diverticulitis from colon cancer: the value of computed tomography in the emergency setting.

BACKGROUND: The purpose of this study was to establish practical diagnostic criteria to differentiate colonic diverticulitis from colon cancer by computed tomography (CT) in the emergency department (ER). METHODS: Helical CT scans of 40 patients admitted to the ER with the clinical diagnosis of diverticulitis and 14 patients diagnosed with colon cancer were retrospectively reviewed. In total, 18 imaging parameters were analyzed and were compared between the 2 groups of patients. RESULTS: Thirteen parameters were found to be statistically significant for the diagnosis of colonic diverticulitis in excluding colon cancer: pericolic infiltration (p < 0.001); presence of lymph nodes (p < 0.001); inflamed diverticula (p = 0.001); non-inflamed diverticula (p = 0.001); degree of enhancement (p = 0.001); intestinal obstruction (p = 0.001); involved wall thickness (p = 0.005); lymph node size (p = 0.007); fascial thickening (p = 0.009); pattern of enhancement (p = 0.012); involved length (p = 0.014); free air (p = 0.035); and abscess formation (p = 0.042). Among these parameters, the most valuable imaging findings for diverticulitis were the presence of non-inflamed diverticulum, inflamed diverticulum, mild degree of enhancement, and small lymph node size. Three were found to have high specificity but low sensitivity: target enhancement pattern; abscess formation; and free air. When colonic obstruction is present, colon cancer is more likely than diverticulitis. CONCLUSION: Specific CT criteria help to differentiate colonic diverticulitis from colon cancer. CT scan with intravenous contrast administration would be the best noninvasive imaging modality in the ER for the accurate diagnosis and appropriate management of such disease.

Diagnosis of appendicitis with left lower quadrant pain.

Abdominal pain is one of the most common chief complaints of patients presenting to the emergency department and, among the diagnoses of abdominal pain, appendicitis is the most common surgical disorder. Traditionally, the diagnosis of appendicitis is based on well-established clinical criteria combined with physician experience. However, appendicitis presenting with rare and misleading left lower quadrant (LLQ) pain may result in an initial false-negative diagnosis by the physician and even result in failure to order the subsidiary examination of computed tomography (CT) or ultrasound, so increasing the risk of perforation/abscess formation and prolonged hospital stay. In this report, we present 2 cases of atypical appendicitis with LLQ pain where the correct diagnosis was not initially considered. One patient had right-sided appendicitis; the inflamed appendix was 12 cm in length and projected into the LLQ. Local peritonitis developed during observation. With the aid of CT, the diagnosis was established in time. The other patient had left-sided appendicitis with situs inversus totalis. Adverse outcomes with appendiceal rupture and abscess formation occurred due to inadvertent physical examinations and inadequate observation. Early clinical suspicion and adequate observation are indicated in patients with uncertain clinical features. However, in patients with unresolved clinical symptoms and/or local peritonitis that develop during observation, imaging studies play a significant role in preoperative diagnosis and determination of proper treatment.

Internal hernia: computed tomography diagnosis and differentiation from adhesive small bowel obstruction.

BACKGROUND: The goals of this study were to evaluate the specific computed tomography (CT) features of internal hernia (IH), and to verify CT features useful for the differential diagnosis of IH from adhesive small bowel obstruction (ASBO), and for the early detection of intestinal strangulation. METHODS: CT findings for 28 patients with surgically proven IH were retrospectively reviewed and compared with those for 50 patients with surgically proven ASBO. RESULTS: CT features most suggestive of IH versus ASBO included the following: a cluster of small bowel segments (100% vs 4% of patients; p < 0.0001); crowding and convergence of mesenteric vessels (79% vs 4%; p < 0.0001); mesenteric vessel engorgement (79% vs 26%; p = 0.0002); and mass effect to the surrounding bowels (82% vs 44%; p = 0.002). In addition, intestinal strangulation, the most severe complication, occurred more in IH than ASBO (39% vs 10%; p = 0.002), whereas proximal small bowel dilation (46% vs 100%; p < 0.0001) and small-bowel feces sign (0% vs 26%; p = 0.0029) were less common in IH than ASBO. The CT features indicative of intestinal strangulation were localized mesenteric fluid (p < 0.0001), mesenteric infiltrates (p = 0.0005), bowel wall thickening (p = 0.003), intramural hemorrhage (p = 0.005), mesenteric vessel engorgement (p = 0.03), and abnormal bowel wall enhancement (p = 0.008); the first 4 of these features were noted more in patients with IH than ASBO. CONCLUSION: The most specific CT criteria for the diagnosis of IH, rather than ASBO, were engorged mesenteric vessels, mass effect to surrounding organs, and bowel wall thickening. When associated mesenteric infiltrates were found, intestinal strangulation was highly suspected.

Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department.

BACKGROUND: The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). METHODS: The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. RESULTS: Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01). CONCLUSION: A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.