Chronic hematuria and abdominal pain

An 18-year-old Asian woman with a history of substance abuse presented to the Emergency Department with right-sided abdominal pain and hematuria of several months duration. Physical examination revealed right upper quadrant and suprapubic tenderness. Liver function tests were normal. Urinalysis showed: large blood, 30–50 red blood cells/high-powered field, and no bacteria. She underwent a CT of the abdomen and pelvis following oral and intravenous contrast.     

Splenic infarct presenting as acute abdominal pain in an older patient

A 67-year-old female presented to the Emergency Department with a several hour history of severe pain in the left upper quadrant, A computed tomographic study (CT scan) of the abdomen demonstrated a splenic infarct. The patient was subsequently found to have a patent foramen ovale, with a small right-to-left shunt. This patient's splenic infarct is considered to be embolie in etiology, either from the patent foramen ovale or severe atherosclerotic disease. Patients with left upper quadrant pain who do not have the etiology differentiated by initial testing should be considered to have the potential for splenic infarction. This case illustrates the uncommon occurrence of splenic infarction, presenting as left upper quadrant pain.     

Ultrasonographic measurement of aortic diameter by emergency physicians approximates results obtained by computed tomography

To assess agreement between emergency physicians' measurements of abdominal aortic diameter using ultrasound in the Emergency Department (ED) and measurements obtained by computed tomography (CT), a double-blinded, prospective study was conducted. The study enrolled a convenience sample of patients over 50 years of age presenting to the ED and scheduled to undergo CT scan of the abdomen and pelvis. Before CT scan, each patient received an ultrasound from a resident or attending emergency physician measuring anterior-posterior aortic diameter transversely at the approximate level of the superior mesenteric artery (SMA), longitudinally midway between the SMA and the iliac bifurcation, and transversely approximately 1 cm above the iliac bifurcation. Two radiologists blinded to the ultrasound measurements then independently measured aortic diameters at the corresponding anatomical points as imaged by CT. The ultrasonographic measurements were then compared with an average of the two CT measurements. Forty physicians enrolled a total of 104 patients into the study. Ultrasonographic measurements of aortic diameter were slightly smaller than those obtained by CT scan, with a difference of means of -0.39 cm (95% CI -0.25 to -0.53) at the level of the SMA, -0.26 cm (95% CI -0.17 to -0.36) on longitudinal view, and -0.11 cm (95 % CI -0.01 to 0.22) at the bifurcation. At the level of the SMA, the difference in measurements by ultrasound and CT would be expected to be less than 1.41 cm, 95% of the time. At the bifurcation, we expect 95% of the differences to be less than 1.05 cm. Agreement was closest on longitudinal view, with 95% of the differences expected to be less than 0.94 cm. Participating physicians estimated the time required to complete their ultrasound studies to be less than 5 min in a majority of cases. In conclusion, ultrasonographic measurement of aortic diameter by emergency physicians rapidly and effectively approximates measurements obtained by CT scan.     

A preschool-age child with first-time seizure and ataxia

We present a case of a 4-year-old previously healthy child who had a possible first-time seizure at home, and upon a second Emergency Department evaluation was found to have gross cerebellar ataxia suggestive of acute stroke. Initial computed tomography scan and metabolic work-up were unrevealing. Subsequent neuroimaging demonstrated stroke in the left medulla and cerebellum secondary to left vertebral artery dissection. Cervical artery dissection may cause up to 20% of strokes in childhood and adolescence. Unlike typical adult presentations, antecedent or concurrent head and neck pain occurs less often in pediatric dissections. Symptoms of posterior circulation ischemia resulting from vertebral artery dissection may include vertigo, vomiting, ataxia, dysarthria, and seizure. Willingness to utilize newer, non-invasive imaging modalities may lead to earlier recognition of cervical artery dissection when patients have prodromal symptoms or episodes of transient ischemia. Vertebral artery dissection should be included in the differential diagnosis when evaluating children with first time seizure, headache, or neck pain.     

Spontaneous celiac artery dissection

BackgroundSpontaneous celiac artery dissection is a rare visceral artery dissection that typically presents with acute abdominal or flank pain.Case reportWe describe a case of a 54-year old previously healthy male who presented to the Emergency Department with subacute back pain and was found to have a spontaneous celiac artery dissection.Why should an emergency physician be aware of this?Emergency medicine physicians frequently consider acute aortic dissection in patients presenting to the Emergency Department with acute chest, back, and/or upper abdominal pain. Less commonly thought of are variations of arterial dissection, including those involving the celiac artery. Given readily available diagnostic imaging modalities and therapeutic interventions, it remains important to consider visceral arterial dissection, and to recognize the varied clinical manifestations of this rare clinical entity.     

Appendicitis masquerading as tumor: a case of two diagnoses

Acute appendicitis remains one of the most difficult diagnoses to make in the Emergency Department. We present a puzzling and unusual case. A 47-year-old man had several hours of acute abdominal pain in the right upper quadrant, point tenderness in the right midquadrant on examination, and normal chemistries. Early appendicitis was suspected and a computed tomography (CT) scan of the abdomen was obtained. Appendicitis was not seen. What was evident was a retroperitoneal lipoma estimated to weigh 10 pounds. The general surgeon was consulted who believed that operation was necessary in light of the patient’s continuing abdominal pain and the presence of the mass. Masses this large could cause pain from local compression of structures, or ischemia of the mass from outgrowing its blood supply. In surgery, a lipoma was observed that filled most of the retroperitoneum and displaced all the contents of the abdomen, including the cecum and its appendix. Also present was an acute appendicitis. On retrospective analysis of the CT scan, the appendicitis was evident but atypically located in the epigastrium. This case illustrates once again that the CT scan is a useful diagnostic adjunct for the diagnosis of new onset abdominal pain and specifically for appendicitis.     

Spontaneous isolated inferior mesenteric artery dissection

This report presents a case of a spontaneous isolated inferior mesenteric artery (IMA) dissection. To the best of our knowledge, it is the first report in the literature. A fifty-eight-year-old female who suffered from acute left lower abdominal pain was admitted. CT scan and digital subtraction angiography indicated dilation in the proximal part of the IMA and occlusion in its distal part. Signs of peri-artery exudation also seen in the CT scan. Laparotomy confirmed the diagnosis of IMA dissection and secondary thrombosis in its branches. After thrombectomy and intimal flap resection, the artery was successfully reconstructed with an autogenous vein patch. Isolated IMA dissection should be considered as one of the differentiation for patients with acute abdomen. Dilation, occlusion of the artery, and signs of peri-artery edema were important clues to suspect the IMA dissection. High resolution spiral CT, which may sometimes reveal the signs such as double lumen and intimal flap, helped to establish the diagnosis of such lesion.     

Blunt carotid artery injury

Blunt carotid artery injury is an uncommon injury with a potentially devastating outcome. Although treatment is often unhelpful for an established neurologic deficit, there is frequently a delay between the episode of trauma and the onset of neurology. This delay provides a window of opportunity where early detection and intervention may significantly improve outcome and prevent lifelong morbidity in a generally young trauma patient population. This paper will review the literature regarding incidence, outcome, treatment options and optimal methods of diagnosis for this lesion. The following synopsis of a case seen at Royal Perth Hospital Emergency Department illustrates several of the classical features of blunt carotid injury, including delayed presentation and pattern of associated injuries. The patient, a 19‐year‐old female, presented following a single vehicle motor crash. On arrival she had a Glasgow Coma Scale (GCS) of 14 with no focal neurologic deficit. Multiple injuries were identified, including a large scalp laceration, a compound fracture of the mandible, pneumothorax, sternal fracture, subcapsular haematoma of the liver, and a knee laceration. Initial computed tomography (CT) scan of the head was normal. Twenty hours after the motor vehicle accident the patient's conscious state deteriorated to GCS 9. Repeat CT head demonstrated changes consistent with a left middle cerebral artery infarct. Cerebral angiography revealed traumatic dissection of the left internal carotid artery with complete occlusion of the lumen just distal to its origin. After 13 days in the intensive care unit and 2.5 months in the rehabilitation unit, she was discharged with a persistent severe receptive and expressive aphasia, as well as a dense right hemiparesis. She is now living at home with community supports.     

Perforated Meckel diverticulum

Perforation of a Meckel diverticulum (MD) is a rare complication that can often mimic appendicitis. This case report identifies a child who presented to our Emergency Department (ED) with right lower quadrant abdominal pain, free fluid and air in the abdomen and pelvis, and inflammatory changes visualized on Ultrasonography (US) and computer tomography (CT) scan. In our patient, ruptured appendicitis was suspected, and the diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis, particularly in the pediatric population.     

Mesenteric ischemia and protein S deficiency: a rare case report

We present an unusual case of a 31-year-old nulliparous woman who was in her normal state of health until 3 weeks before her Emergency Department visit, when she began to have generalized abdominal pain that got acutely worse over a few days. She had a soft abdomen, but complained of excruciating pain. Her computed tomography (CT) scan revealed thrombosis in the superior mesenteric, splenic, and portal veins. Her hematological work-up detected a protein S deficiency, which is associated with recurrent venous thrombosis. The finding of mesenteric venous thrombosis associated with protein S deficiency is rare. The most important factor in survival is early diagnosis and prompt treatment with anticoagulants. Properly treated, patients with mesenteric venous thrombosis should have a good long-term prognosis. Past medical or family history of thrombosis in combination with abdominal symptoms should increase the suspicion for the disease.     

Cumulative CT exposures in emergency department patients evaluated for suspected renal colic

Computed tomography (CT) is the diagnostic standard in Emergency Department evaluation of suspected renal colic but delivers substantial radiation. We determined the frequency of CT scan in suspected renal colic, diagnosis and outcome, and cumulative CT scans per patient. A retrospective chart review with waiver of informed consent was conducted. A total of 356 patient encounters were reviewed from January to October 2003. Mean age was 39 years. Seventy-four percent included a CT scan, with 38% normal, 58% showing urolithiasis, and 1% showing emergent etiologies. Six percent of patients undergoing CT were admitted for urolithiasis, and 6% had a urologic procedure within 7 days. Sixteen percent of patients did not have a CT scan, and 79% underwent two or more CT scans. Emergency Department patients presenting with symptoms suggesting renal colic are likely to undergo CT on multiple occasions. Radiation exposures from repeated CT scans are substantial, and a clinical decision rule for this scenario is needed.     

假囊肿型胎粪性腹膜炎的产前MRI和产后CT影像表现

目的 探讨假囊肿型胎粪性腹膜炎(MPC)胎儿期MRI和婴儿期CT的影像学特点。方法 回顾性分析10例经产后病理证实的MPC胎儿期及婴儿期影像资料,4例产前行胎儿MR平扫,4例出生后行腹部CT平扫及双期增强扫描,2例序贯行胎儿MR和产后腹部CT检查。观察其CT及MRI表现,并与病理结果对照。结果 3例病灶位于中上腹,右上腹肝下缘4例,右中下腹1例,左腹2例。MR检查的6胎中病灶T2WI均呈稍高/高信号,T1WI呈高信号1胎,低信号3胎,等/稍低信号2胎。CT检查的6例中5例壁囊薄,1例囊壁较厚;6例病灶囊壁均呈轻-中度强化;5例CT示病灶与邻近肠管关系密切、分界不清;4例囊壁及内部见多发钙化。具有产前及产后影像资料的2例中1例胎儿期腹腔积液于产后消失;2例产后CT检查囊壁及囊内出现多发钙化。结论 MPC的产前MRI及产后CT表现均具有一定特征性;认识MPC的病理生理过程和影像特征,有助于准确诊断胎儿或婴儿MPC。     

Traumatic, pericardio-diaphragmatic rupture: an extremely rare cause of pericarditis

A 54-year-old man with a recent history of blunt abdominal trauma presented to the Emergency Department with severe pain in the chest and abdomen. He was tachycardic, tacypneic, and hypoxic. An electrocardiogram (EKG) at that time showed ST elevation and PR depression consistent with acute pericarditis, and a computed tomography (CT) scan subsequently showed herniation of abdominal contents into the pericardium and left hemithorax. After surgical repair of the diaphragmatic defect and intrapericardial hernia, the EKG findings resolved. He recovered over the course of several weeks and was subsequently discharged home.     

Emergency department time for evaluation of patients discharged with a diagnosis of renal colic: unenhanced helical computed tomography versus intravenous urography

The objective of this study was to determine whether patients discharged from the Emergency Department (ED) with a proven diagnosis of renal colic require less total evaluation and treatment time if unenhanced helical computed tomography (CT) rather than intravenous urography (IVU) was the diagnostic imaging study used. A retrospective review was undertaken of the medical records of 98 consecutive patients with a final diagnosis of urolithiasis or renal colic evaluated with an unenhanced helical CT scan or an IVU between January 1, 1999, and December 31, 1999. All patients were managed by Emergency Physicians and discharged from the ED. The time the patient was brought to the treatment area, the time the imaging study was ordered, and the time the patient was discharged were recorded. There were 75 patients evaluated with CT scan and 23 patients with an IVU. Patients who underwent unenhanced helical CT scan were in the ED for a mean time of 291 min [95% confidence interval (CI) 266–316] and those who had an IVU were in the ED for an average of 410 min (95% CI 340–481). Use of unenhanced helical CT scan was associated with less total time in the ED compared to IVU for patients with renal colic by a significant mean of 119 min. It is concluded that ED evaluation and treatment time of patients ultimately discharged with a proven diagnosis of renal colic is significantly less when evaluated with unenhanced helical CT scan compared to IVU.     

Epiploic appendagitis: the emergency department presentation.

We performed a structured retrospective chart review to describe clinical characteristics of Emergency Department (ED) patients diagnosed by history, physical examination, and abdominal computed tomography (CT) scan with epiploic appendagitis (EA). EA is a disease caused by inflammation of the appendix epiploica, subserosal adipose tissue along the colon. It may mimic surgical causes of acute abdominal pain, but is treated conservatively with pain management. There were 19 patients diagnosed with EA, with follow-up performed on 85%. All had focal, nonmigratory symptoms. Common findings included left lower quadrant pain and guarding, and a normal temperature and white cell count. No patient required operation. This preliminary work characterizes some common clinical features of ED patients diagnosed with EA. As use of emergency CT scan for abdominal pain increases, clinicians will encounter this more often. These features should also prompt the clinician to consider CT scan in patients with similar signs and symptoms. Accurate diagnosis may avoid unnecessary surgery.     

Use of spiral computed tomography contrast angiography and ultrasonography to exclude the diagnosis of pulmonary embolism in the emergency department

Spiral computed tomography (CT) contrast angiography is a promising imaging modality for the diagnosis of pulmonary embolism but the negative predictive value of this test remains controversial. We performed a multi-center prospective cohort study to determine the safety of relying on a negative spiral CT contrast angiography scan to exclude pulmonary embolism. Patients presenting to the Emergency Departments of three tertiary care institutions with clinically suspected pulmonary embolism were potentially eligible for the study. Patients underwent a clinical evaluation to categorize pretest probability into low, moderate, and high categories, and had D-dimer testing performed. Patients at low pretest probability with normal D-dimer were considered to have pulmonary embolism excluded. The remaining patients underwent spiral CT contrast angiography scan of the pulmonary arterial circulation and bilateral venous ultrasound of the proximal leg veins. Patients who were confirmed to have pulmonary embolism or deep vein thrombosis were treated with anticoagulant therapy. Patients in whom the diagnosis of pulmonary embolism was excluded did not receive anticoagulant therapy and were followed for a 3-month period for the development of venous thromboembolic complications. Eight hundred fifty-eight (858) patients were enrolled in this study. Three-hundred sixty-nine (369) patients had low pretest probability and negative D-dimer results and no further diagnostic tests were performed. None of these patients subsequently developed venous thromboembolic complications (0%, 95% confidence interval [CI] 0% to 1.0%). The remaining 489 were referred for spiral CT contrast angiography scan and ultrasound. Sixty-seven patients were confirmed to have pulmonary embolism and an additional 15 patients with negative CT scans had proximal deep vein thrombosis (DVT) on ultrasound for a total prevalence of venous thromboembolism of 82/489 (16.8%). Two of 409 patients who had pulmonary embolism excluded in the initial evaluation phase developed proximal venous thromboembolism (0.5%; 95% CI 0% to 1.8%) in the 3-month follow-up period. These findings suggest that the combination of a negative spiral CT contrast angiography scan and normal venous ultrasound imaging safely excludes the diagnosis of pulmonary embolism in the Emergency Department setting.     

腹膜假黏液瘤的CT及MRI表现

目的 分析腹膜假黏液瘤(PMP)的CT及MRI表现。方法 回顾性分析经病理证实的27例PMP, 均接受全腹部CT平扫,其中25例接受增强扫描;7例接受盆腔MR平扫,3例同时接受上腹部MR平扫;观察PMP胶冻样腹腔积液出现的位置及影像学特征。结果 27例均可见不同程度的腹腔积液。22例肝脾周围可见"扇贝样"压迹,23例网膜增厚、呈污垢样改变,15例小肠移位,5例钙化,16例可见纤维分隔。腹腔积液量较少时,右侧结肠旁沟积、膈下间隙及肝周积液量多于左侧结肠旁沟、左侧膈下间隙及脾周;腹腔积液量较多时,均可见"扇贝样"压迹,右、左膈下间隙积液量无明显差异。与CT相比,MRI能更好地显示腹腔内黏液团、纤维分隔及卵巢原发灶。结论 CT及MRI显示肝、脾边缘"扇贝样"压迹、网膜及肠系膜增厚、小肠移位、腹腔积液中见纤维分隔或包裹等征象对诊断PMP具有一定价值。     

Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation

BackgroundAcute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection.Case ReportA 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival.Why Should an Emergency Physician Be Aware of This?An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.     

Racial disparities in health care—emergency department management of minor head injury

Background/aim

International research has demonstrated disparities in the Emergency Department care of patients of certain racial or ethnic backgrounds. The management of minor head injuries requires a careful clinical assessment to determine the requirement of a CT scan of the head. The aim of this study was to determine if there was any disparity, based on race, in the management of minor head injury.

Methods

This was a retrospective, structured, medical record review of patients presenting to The Townsville Hospital Emergency Department, between September 2004 and April 2007, with minor head injury. The main outcome measure was whether or not patients received a CT head scan when clinically indicated. The Canadian CT Head Rule was considered the standard for clinical indication for a CT head scan. Secondary outcome measures included triage category, waiting time, level of care provider, disposition and serum ethanol.

Results

A total of 270 patients (73 indigenous and 196 non-indigenous) were enrolled. There was no statistically significant difference in ordering CT head scans when clinically indicated between indigenous and non-indigenous patients. However, a trend indicating that indigenous patients were less likely to receive a CT head scan when clinically indicated (OR 0.35; 95% CI?=?0.07 to 1.77) was noted. Indigenous patients had a mean waiting time of 44.6 min (SD 49.6) compared to non-indigenous with 31.1 min (SD 36.4; p?=?0.02).

Conclusion

This study concluded that there was no statistically significant disparity based upon race in the management of minor head injuries with regard to decision to perform a CT head scan. There is some evidence that indigenous patients waited longer to be seen. A multi-centre prospective study is necessary to confirm these findings.     

Subcapsular Liver Hematoma after Colonoscopy Diagnosed by Emergency Department Bedside Ultrasonography

Background

Hepatic subcapsular hematoma is an uncommon cause of right upper quadrant pain in the Emergency Department. It must be recognized early, as large volumes of acute blood loss and rupture into the peritoneum carry significant morbidity and mortality. In the absence of gallbladder disease, the differential diagnosis should include liver pathology. Bedside ultrasonography can be used to identify such lesions.

Objectives

To discuss the presentation, evaluation, and management options of hepatic subcapsular hematoma.

Case Report

We report a case of a 30-year-old woman who presented with the chief complaint of right upper quadrant pain radiating to the right scapula 6 h after a screening colonoscopy for intestinal polyps. Emergency physician-performed bedside ultrasound revealed a large hyperechoic mass in the right lobe of the liver. Radiology-performed comprehensive ultrasound and subsequent computed tomography scan of her abdomen and pelvis revealed a subcapsular hematoma without intestinal perforation.

Conclusion

In a patient with undifferentiated right upper quadrant abdominal pain, bedside ultrasonography is a rapid and effective modality in the diagnosis of liver masses, including subcapsular hematoma.