Spontaneous Uterine Perforation Due to Pyometra Presenting as Acute Abdomen

Spontaneous perforation of uterus is rare, its incidence being about 0.01%-0.5%. We report a rare case of diffuse peritonitis and pneumoperitoneum caused by spontaneously perforated pyometra. A 50-year postmenopausal lady with abdominal pain was admitted to our hospital. Laparotomy was performed because of the suspicion of gastrointestinal perforation with generalized peritonitis. At laparotomy about 1,500 ml of pus present in peritoneal cavity and whole of alimentary tract and gallbladder were normal.A total abdominal hysterectomy with bilateral salpingooopherectomy was performed. Histopathological study revealed chronic suppurative endometritis with myometritis of the uterus with no evidence of malignancy. Although spontaneously perforated pyometra is rare, a perforated pyometra should therefore be considered when elderly female presents with acute abdomen.     

Mild Acute Biliary Pancreatitis vs Cholelithiasis: Are There Differences in the Rate of Choledocholithiasis?

The rate of choledocholithiasis at the time of elective surgery after mild acute biliary pancreatitis is still unclear because it decreases rapidly after the onset. The aims of this study are as follows: (1) To investigate whether the incidence of choledocholithiasis in mild biliary pancreatitis is higher than in patients with symptomatic cholelithiasis. (2) To evaluate the usefulness of intraoperative cholangiography in the diagnosis of unsuspected choledocholithiasis in mild pancreatitis. Prospective study including 130 patients undergoing laparoscopic surgery and classified into two groups: mild biliary pancreatitis (n = 44) and symptomatic cholelithiasis (n = 86). Choledocholithiasis was evaluated by endoscopic cholangiopancreatography, magnetic resonance, and intraoperative cholangiography. Preoperatively, choledocholithiasis was identified in five patients with symptomatic cholelithiasis and two with biliary pancreatitis (5.81 vs 4.54%; p = 0.472). In 117 cases (90%), intraoperative cholangiography was successfully performed, identifying unsuspected choledocholithiasis in five patients of the colelithiasis group and in three in the group of pancreatitis (5.81 vs 6.81%; p = 0.492). The total number of patients with choledocholithiasis in the whole series was 15 (11.5%); 11.6% in colelithiasis group vs 11.4% in biliary pancreatitis group; p = 0.605. The rate of choledocholithiasis was not significantly different between the groups of patients with mild acute biliary pancreatitis and symptomatic cholelithiasis. Intraoperative cholangiography identified unsuspected choledocholithiasis in 6.81% of patients with mild acute biliary pancreatitis.     

A Rare Complication after Thyroidectomy: Perforation of the Oesophagus: a Case Report

Perforation of the cervical oesophagus after thyroidectomy is an exceptionally rare complication. Total thyroidectomies, particularly for recurrent cases might possess an increased risk. Although rare, it has high mortality and morbidity. A patient that developed oesophagus perforation after a total thyroidectomy in a peripheral hospital for recurrent nodular goitre was treated and followed-up in our clinic. This well-documented case is discussed in conjunction with the information presented in the literature.     

Spontaneous Esophageal Perforation Related to a Duodenal Ulcer with Pyloric Stenosis: Report of a Case

This report describes a case of spontaneous esophageal perforation that was considered to be etiologically related to a duodenal ulcer with pyloric stenosis. The patient was a 54-year-old Japanese man who presented following the sudden onset of severe abdominal pain and dyspnea after an episode of vomiting. He had a history of duodenal ulcer. Computed tomography revealed an extremely dilated stomach containing abundant food residue, intraabdominal effusion, bilateral pleural effusion, and mediastinal emphysema, findings that strongly suggested esophageal perforation. Esophagoscopy confirmed perforation of the lower esophagus. Laparotomy revealed marked contamination, including food residue in the abdominal cavity, and a severely dilated stomach attributed to pyloric stenosis caused by a duodenal ulcer. A 2-cm longitudinal perforation was found on the right side of the lower esophagus. Because the patient's general condition was too poor to tolerate a one-stage operation (primary closure of the perforation, gastrectomy, and reconstruction), we initially performed decompression gastrostomy and control of the esophageal leakage with T-tube placement. Following the T-tube was removed 1 month later, distal gastrectomy and reconstruction of the gastrojejunostomy (Billroth II method) could be safely performed. Received: February 19, 2001 / Accepted: July 17, 2001     

Biliary hyperkinesia,a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report

IntroductionBiliary colic, characterized by intermittent right upper quadrant abdominal pain is a common complaint in the United States population. Patients whose pain is undiagnosed by ultrasound generally undergo hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (HIDA-CCK) to assess function of the gallbladder and biliary tree. Traditionally, two outcomes are possible based on a measured ejection fraction of the gallbladder: either dyskinesia or normal function is diagnosed. Biliary dyskinesia, or hypokinesia of the gallbladder, is accepted as an ejection fraction less than 35%, while an accepted normal functioning gallbladder ejection fraction is greater than 35%.CaseWe report a case of a fifteen-year-old female who had functional gallbladder disease per Rome IV criteria due to intermittent biliary colic, with exception to the ejection fraction measurement which was elevated at 96.5%. She underwent laparoscopic cholecystectomy with complete symptom resolution.DiscussionAs demonstrated in the literature reviewed here, these subsets of patients, who present with normal to high ejection fractions, have undergone laparoscopic cholecystectomy with resolution of pain in several case studies.ConclusionMany unknown variables still exist due to lack of prospective studies, most notably the pathophysiology and definitive indications for surgical treatment. As such, we propose that surgical options should not be limited to those who display the traditional findings of biliary dyskinesia, but also patients who demonstrate typical symptoms with normal to elevated ejection fraction, following work up to rule out the extensive differential diagnoses for right upper quadrant abdominal pain.     

Case report of a spontaneous splenic rupture in a patient with chronic lymphocytic leukaemia treated by arterial splenic embolization

Introduction and importanceSpontaneous splenic rupture (SSR) is a rare phenomenon where the spleen ruptures without associated trauma. SSR can lead to an intra-abdominal haemorrhage and an acute abdomen that can be life threatening.Case presentationIn this article, we present the case of an 81-year-old woman with chronic lymphocytic leukaemia who presented to the emergency department with severe abdominal pain.Clinical discussionIn order to stabilize the patient, while awaiting elective surgery, we managed the rupture with splenic embolization and we reviewed the literature related to the treatments of SSR especially, by arterial splenic embolization.ConclusionSplenic embolization is a safe treatment option, that allows a rapid stabilization and has the advantage of both, splenectomy and conservative treatment.     

Spontaneous gall bladder perforation: a rare condition in the differential diagnosis of acute abdomen in children

Gallbladder perforation is very rare in children and almost exclusively is a complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Here we present 4 cases of spontaneous gall bladder perforation, which should be kept in mind as a condition for inclusion in the differential diagnosis of an acute abdomen in children.     

Neuroendocrine Carcinoma of the Extrahepatic Biliary Tract with Positive Immunostaining for Gastrin-Releasing Peptide: Report of a Case

(Received for publication on July 2, 1997; accepted on Jan. 6, 1998)     

Acute abdomen in a patient with paraesophageal hernia,resulting in acute compromised respiratory function: A case report

IntroductionWe present a case of acute abdomen, causing increased intra-abdominal pressure, leading to further herniation of an existing paraesophageal hernia, and consequently acute compromised respiratory function. This acute respiratory complication to a paraesophageal hernia has not previously been reported.Presentation of caseWe present a case of a 75-year-old female who was acutely admitted with stridor. The patient was known to have a paraesophageal hernia monitored using watchful waiting, and dyspnoea. The patient's condition deteriorated, leading to intubation. Diagnostic imaging revealed a paraesophageal hernia pressing onto the trachea as well as appendicitis and ileus. Surgery confirmed perforated appendicitis, peritonitis, and ileus causing high intra-abdominal pressure, resulting in further herniation of the paraesophageal hernia as a cause for acute compromised respiratory function. Appendectomy and gastropexy were performed. The patient was later discharged to rehabilitation.DiscussionPatients with pulmonary symptoms caused by a paraesophageal hernia, especially patients with sizeable hernias, could potentially be in greater risk of severe airway affection if complicated by acute abdomen. These patients could benefit from elective hernia repair, rather than watchful waiting, as it would eliminate pulmonary symptoms and prevent similar cases. Patients monitored using watchful waiting should be informed that acute abdomen could cause acute compromised respiratory function.ConclusionAny case of acute abdomen causing high intra-abdominal pressure could potentially cause further herniation of an existing paraesophageal hernia, resulting in acute compromised respiratory function. In patients known to have a paraesophageal hernia, similar cases should be suspected if the patient presents with acute breathing difficulties.     

Perforation of the cecum resulting from a closed-loop obstruction in a patient with an adenocarcinoma of the sigmoid colon: a case report

IntroductionBowel obstruction is one of the principal non-traumatic causes of general surgery emergencies, both in Brazil and worldwide. This condition can be classified according to the degree (complete or incomplete), clinical course (acute or chronic) or nature (mechanical, vascular or functional) of the obstruction.Case reportESS, a 62-year old Brazilian woman from Rio de Janeiro, was admitted to the emergency department complaining of constipation of two weeks' duration. She also reported fever and fecal vomiting in the preceding two days.A syndromic diagnosis of bowel obstruction was made, and the patient was referred for CT. The sigmoid colon, descending colon, transverse colon, ascending colon, the cecum and the terminal ileum were resected.DiscussionColorectal cancer is one of the most common forms of cancer in the elderly, perforation of the cecum occurs in only around 3–8% of cases. 15 This can be explained by the fact that patients with colorectal cancer present with wasting syndrome before the bowel lumen becomes completely obstructed. In a literature review conducted for this study, only one publication was found in which rupture of the cecum was associated with colorectal cancer.ConclusionAlthough rupture of the cecum associated with colorectal cancer is a rare pathology, it constitutes a surgical emergency; therefore, all surgeons should be aware of the possibility.     

Perforation of the Stomach Due to Chest Tube Complication in a Patient with Iatrogenic Diaphragmatic Rupture

Diagnosis of diaphragmatic injury is difficult. A case of iatrogenic diaphragmatic rupture is reported in which perforation of a herniated stomach occurred following left lobectomy and partial resection of the diaphragm for lung cancer. On the second postoperative day, bile-stained fluid coming out from the chest tube revealed gastrointestinal leakage. This rare complication of chest tube insertion, early diagnosis and treatment are emphasized.     

Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency

IntroductionLaparoscopic adjustable gastric banding is one of the most frequently done procedures for morbid obesity. In most reported cases, the band itself is the cause of complications. There are only a few reports of morbidities caused by the connecting tube. This presentation describes a case of acute abdomen due to small bowel herniation between the connecting tube and the abdominal wall. This case report aims to remind clinicians of possible complications caused by the connecting tube of a gastric band.Case presentationWe report about a 24-year-old male patient, who presented with acute abdomen. He had undergone gastric banding three years ago. According to his clinical presentation, the patient was diagnosed as having acute appendicitis.Abdominal exploration revealed, total small bowel herniation between the connecting tube and the abdominal wall.DiscussionAlthough a simple procedure, laparoscopic gastric banding could have serious complications. Some of these complications could present years after the application of the gastric band. There are a few reports about complications caused by the connecting tube of the gastric band.ConclusionComplications caused by connecting tube should always be in mind, when assessing acute abdomen in patients with laparoscopic gastric band.     

Severe Proctitis,Perforation, and Fatal Rectal Bleeding Secondary to Cytomegalovirus in an Immunocompetent Patient: Report of a Case

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor–Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.     

Acute acalculous cholecystitis caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer: A case report

Introduction and importanceAcute acalculous cholecystitis (AAC) is associated with a high mortality rate. AAC caused by metastasis to the gallbladder is rare. We report a case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer.Case presentationAn 84-year-old male visited our hospital because of epigastric pain. Ultrasonography and computed tomography revealed swelling and thickening of the gallbladder wall, but stones were not observed in the gallbladder. We performed emergency surgery with a diagnosis of acute cholecystitis. Laparoscopy revealed the presence of many nodules around the abdominal cavity including the hepatoduodenal ligament. Inflammation of Calot’s triangle was severe, so we performed subtotal cholecystectomy. We also resected one of the peritoneal nodules. Macroscopically, there were no stones in the gallbladder and histopathological examination revealed acute cholecystitis and existence of adenocarcinoma involving the subserosa of the gallbladder wall and the resected peritoneal nodule. After surgery, esophagogastroduodenoscopy revealed Borrmann type II lesions at the antrum and gastric biopsy showed adenocarcinoma. He was diagnosed with advanced gastric cancer with peritoneal dissemination. His postoperative course was good.Clinical discussionThe cases of AAC caused by gallbladder metastasis have been little reported in the literature. This case is advanced gastric cancer with peritoneal dissemination and AAC was thought to be caused by peritoneal dissemination from operative and histopathological findings. We successfully treated this rare case of AAC with laparoscopic surgery.ConclusionAlthough metastasis to the gallbladder is rare, it is necessary to be aware of this possibility when treating AAC.     

Early-onset complete spontaneous migration of contraceptive intrauterine device to the bladder in a post C-section patient: A case report

Introduction and importanceSpontaneous migration of a contraceptive intrauterine device (IUD) to the bladder is very rare. It usually takes years for the IUD to migrate completely from the uterine cavity to the bladder. We report a case of early-onset complete spontaneous migration of contraceptive IUD to the bladder in a post C-section patient.Case presentationA 30-year-old woman presented with suprapubic pain and dysuria three weeks prior to hospitalization. She had C-section three months prior and underwent copper IUD insertion two months after the surgery. One week after IUD insertion, radiography showed that the IUD remained in the uterus, but the patient felt suprapubic pain and dysuria. Computed tomography (CT) three weeks after IUD insertions showed IUD migration to the bladder with its tips embedded in the uterine wall. Cystoscopy was performed one week later and the IUD was completely inside the bladder. By then, the IUD was removed completely via forceps with no complication.Clinical discussionThe exact pathophysiology of spontaneous IUD migration is unknown, but migration always starts with uterine perforation. In our case, uterine perforation was probably caused by immediate traumatic perforation. CT is the preferred radiological examination. IUD removal was performed one month after IUD insertion showing complete migration of the IUD, though CT one week prior suggested that the tips of the IUD remained embedded.ConclusionIn cases of early-onset complete spontaneous migration of contraceptive IUD to the bladder, CT is the preferred radiological examination, and delaying removal procedure may be beneficial.     

Papillotubular carcinoma with an invasive micropapillary carcinoma component of the breast,characterized by a rapid increase in size due to intra-tumoral hemorrhage: A case report

IntroductionRapidly enlarging mammary tumors, including invasive breast tumors, are clinically rare. Invasive micropapillary carcinoma (IMPC) of the breast is known to have aggressive behavior and poor clinical course compared to invasive ductal carcinoma.Case presentationAn 87-year-old woman presented with a rapidly enlarging tumor of the right breast over the course of 3 weeks. Ultrasonography and computed tomography of the chest revealed a giant tumor located on the right chest wall, with heterogeneous parenchymal components and several cystic lesions. Emergency mastectomy was performed because of rapid tumor enlargement complicated by hemorrhage. Histopathological diagnosis confirmed a papillotubular invasive ductal carcinoma with an IMPC component. Tumor cells were negative for estrogen and progesterone receptors, and the human epidermal growth factor receptor 2 score was 2+.DiscussionThere has been only one report of breast carcinoma with rapid enlargement caused by spontaneous intratumoral hemorrhage to date. IMPC is associated with a high incidence of axillary lymph node metastases, frequent local recurrence, and a poor clinical outcome. In the present case, the specific breast cancer type can be considered as potential factors responsible for hemorrhage induction within the tumor that further enhanced rapid tumor growth.ConclusionIMPC is a rare, clinically aggressive variant of invasive ductal carcinoma. Owing to its aggressive clinical behaviors, surgeons should readily recognize the morphology of IMPC.