Obstructive icterus directly related to visceral artery aneurysm in a CAPD patient

Visceral artery aneurysms (VAA) are uncommon pathologies. We report a case of the first CAPD patient with obstructive jaundice directly related to VAA. A 25-year-old man with a four-year history of hemodialysis followed by two years of CAPD was admitted due to jaundice. He had two episodes of peritonitis. An abdominal ultrasonogram and a selective common hepatic arteriogram confirmed the presence of a 5 cm saccular aneurysm supplied from the gastroduodenal artery and a 4 cm fusiform aneurysm supplied from the proximal part of the common hepatic artery. The gastroduodenal artery was responsible for the impression of the common bile duct. In the operation, the gastroduodenal artery aneurysm was completely excised after its proximal and distal ends were ligated. The proximal and distal ends of the hepatic artery were also ligated. A prosthetic graft (PTFE), which extended from the splenic artery to the distal portion of the hepatic artery, was placed. In this way, the arterial blood flow of the liver was re-established. Patients with VAAs present with a constellation of symptoms including abdominal pain, jaundice and shock (due to rupture of aneurysm). Pancreatitis, and atherosclerosis have been reported to be the most common causes of VAAs. In conclusion, when CAPD patients present with jaundice or hemorrhagic shock with abdominal pain, VAA should be considered in differential diagnosis, especially if patients have a history of frequent pancreatitis episodes, and severe risk factors for atherosclerosis.     

A case of mycotic spermatic cord abscess in a continuous ambulatory peritoneal dialysis patient

A 66-year-old male patient has been on continuous ambulatory peritoneal dialysis (CAPD) since 1993, and was diagnosed with right hydrocele of the spermatic cord in 1998. He repeatedly developed CAPD-related bacterial peritonitis 3 times. In February 2001, hemodialysis was prescribed for treatment of mycotic peritonitis. A palpable mass was noted in the right inguinal region in October 2001 and a computed tomographic (CT) scan disclosed a 4 cm circular lesion with relatively low density and thick wall in the right inguinal region. Spermatic-orchiectomy was performed. Histological diagnosis was mycosis like Candida on the abscess wall. To our knowledge, this is the first case of spermatic cord abscess in a CAPD patient in the Japanese literature.     

Perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum in adulthood: report of a case

A 61-year-old man was referred to us for investigation of acute abdominal pain. Computed tomography showed a 5.9 × 5.3 × 5.0 cm lump of food residue in the jejunum, and a large amount of free air and ascites around the liver and right paracolic gutter. He underwent emergency laparotomy for suspected peritonitis from perforation by a foreign body in the small intestine. We identified purulent exudate in the abdominal cavity and perforation of a jejunal cystic mass, attached ~40 cm from Treitz’s ligament at the anti-mesenteric side of the jejunum. Based on a diagnosis of jejunal duplication with perforation, we resected that part of the small intestine and performed intra-abdominal drainage. Pathological findings confirmed the diagnosis of a perforated gastrointestinal stromal tumor (GIST) in a true jejunal diverticulum. Histopathological evidence suggests that intestinal pressure and/or hemorrhage can cause perforation in the background of a true jejunal diverticulum. To our knowledge, this is the first case report of a perforated GIST in a true jejunal diverticulum.     

Tamoxifen therapy in encapsulating sclerosing peritonitis in patients after kidney transplantation

Sclerosing encapsulating peritonitis (SEP) is a serious complication of long-term continuous ambulatory peritoneal dialysis (CAPD) associated with obstructive symptoms and sclerosis of the peritoneal membrane. We present two cases that were successfully treated with tamoxifen and corticosteroids. Case 1: A 40-year-old patient developed end-stage renal failure (ESRF) and was managed with CAPD. He was hospitalized with symptoms of small bowel obstruction. He underwent laparotomy confirming the diagnosis of SEP. The patient was given tamoxifen 20 mg twice a day. Case 2: A 55-year-old patient with ESRF secondary to membranous glomerulonephritis. After having a cadaveric renal transplant in 1978 that failed 20 years later, the patient returned to CAPD. Six years later he had an uneventful kidney transplant and the peritoneal dialysis catheter was removed. However, 8 months later he presented with symptoms of small bowel obstruction and gross blood stained ascites. He also underwent a laparotomy that confirmed the diagnosis of SEP after biopsy. The patient was started on 20 mg of tamoxifen twice a day. Both patients' symptoms were improved gradually with an increase of serum albumin and body weight. Tamoxifen may be useful in the treatment of patients diagnosed with SEP.     

Remnant of vitelline duct causing intestinal obstruction after commencement of CAPD

A 64-year old Japanese man began to experience intermittent epigastralgia, nausea, and vomiting just after commencing continuous ambulatory peritoneal dialysis (CAPD). Fourteen months after commencing CAPD, he had an intestinal obstruction. Because enhanced radiographs of the small intestine revealed that the occluded site was near the umbilicus, it was suggested that a remnant of the vitelline duct had adhered to and occluded the small intestine. Conservative treatment for the intestinal obstruction was not effective, and laparotomy was then performed. During the laparotomy, the first finding was a remnant of ligament-like vitelline duct connecting the protruding umbilicus and the small intestine. The second finding was that the small intestine was twisted around the remnant of the ligament-like vitelline duct at an angle of about 180° and completely occluded the intestine. Before the patient commenced CAPD, the remnant of the vitelline duct was asymptomatic, but it became symptomatic and finally caused intestinal obstruction after he commenced CAPD. This clinical course strongly suggested that the cue for the bowel obstruction caused by the remnant was the commencement of CAPD. This is the first report, to our knowledge, mentioning the relationship between CAPD and a remnant of the vitelline duct. Received: January 5, 2000 / Accepted: March 30, 2000     

Acute Emphysematous Cholecystitis Preceded by Symptoms of Ileus: Report of a Case

We herein describe a case of acute emphysematous cholecystitis in which the patient presented with symptoms of ileus. The patient was a 72-year-old man with no history of diabetes mellitus. He presented with epigastric pain, vomiting, and low-grade fever. Plain abdominal radiography showed some intestinal gas and niveau, and he was admitted to our hospital with a diagnosis of ileus. The next day, the abdominal pain increased and was accompanied by muscular defense. Plain radiography and computed tomography of the abdomen were carried out, and an emergency laparotomy was performed under a diagnosis of panperitonitis due to a perforation of the gallbladder caused by acute emphysematous cholecystitis. The patient made favorable progress after the operation and was discharged on postoperative day 14. Percutaneous transhepatic gallbladder drainage has been increasingly performed for the treatment of acute emphysematous cholecystitis, but when a perforation of the gallbladder is suspected, a laparotomy first should be considered. Received: March 23, 2001 / Accepted: September 11, 2001     

Surgical treatment of Meckel's diverticulum

The author analysed the results of operations on 19 patients with emergency diseases of the abdominal organs caused by pathological processes in Meckel's diverticulum. The inflammatory process in the diverticulum led to acute obstruction of the small intestine in 12, acute diverticulitis in 5, and peptic ulcer complicated by perforation of the intestinal wall in 2 patients. Two patients died in the postoperative period from progressing peritonitis. It was established that Meckel's diverticulum may occur in any area of the small intestine. Meckel's diverticulum detected during planned laparotomy must be resected.     

肝移植术后并发消化道穿孔六例报告

目的总结肝移植术后并发消化道穿孔的临床特点及诊疗体会。方法6例肝移植患者术后并发消化道穿孔,其中4例既往有腹部手术史。穿孔诊断时间在肝移植后7～12 d,确诊前2～4 d均有突发性腹部疼痛,但均能耐受,仅有1例腹痛较明显,上中腹压痛及反跳痛,其余5例腹肌不紧张,反跳痛不明显,6例均无明显的寒战及高热,5例的引流物细菌培养发现屎肠球菌感染,另1例未行引流物细菌培养。诊断明确后在全身麻醉下施行剖腹探查及穿孔修补术。结果3例(1例横结肠穿孔,1例胃壁、空肠穿孔,1例空肠憩室穿孔)穿孔直径较大,腹腔污染严重,手术过程中均出现感染性休克症状,分别于修补术后第2、9、33天死于多器官功能衰竭,另外3例(1例为回肠穿孔,1例为胃壁穿孔,1例为横结肠穿孔)的腹腔污染较轻,经穿孔修补术及营养支持治疗后痊愈。结论既往腹部手术史、医源性损伤及大剂量激素的应用,是导致肝移植后并发消化道穿孔的重要原因,而激素的应用使得患者的临床症状不明显,早期诊断、及时处理是治疗成功的关键。     

Massive ischemic intestinal necrosis at the onset of diabetes mellitus with ketoacidosis in a three-year-old girl

A previously healthy 3-year-old girl had severe diabetic ketoacidosis complicated by hypovolemic shock. When her abdominal pain and acidosis failed to improve despite vigorous fluid resuscitation and insulin therapy, further investigation found an intestinal perforation. At laparotomy, gangrenous bowel was found, requiring an extensive enterectomy from the distal jejunum to the transverse colon; less than 90 cm of viable small intestine remained. The child survived a complicated postoperative course and currently is thriving on a normal diet.     

Sclerosing peritonitis with gross peritoneal calcification: a case report.

We report the case of a patient on dialysis for 13 years, including continuous ambulatory peritoneal dialysis (CAPD) for 11 years, who developed sclerosing peritonitis with gross peritoneal calcification. The patient first presented with abdominal pain in January 1990, when peritoneal calcification was detected for the first time. Her symptoms settled spontaneously and 1 year later she presented with acute peritonitis and adynamic ileus. The peritonitis settled with antibiotics and Tenchkoff catheter removal, but the ileus persisted. She was commenced on long-term parenteral nutrition, but never recovered useful bowel function. After 8 weeks of hemodialysis and total parenteral nutrition, a further laparotomy for an acute abdomen showed what appeared to be extensive bowel infarction and peritoneal calcification. She died several days later. Of significance, peritoneal calcification was first noted on x-ray and computed tomography (CT) scan while the patient was still largely asymptomatic and before peritoneal ultrafiltration capacity was significantly impaired. Unlike other reported cases of calcifying peritonitis, sclerosing peritonitis was present and calcification was far more extensive. It was not associated with factors such as frequent infective peritonitis or acetate dialysate. Calciphylaxis was not present nor was there any abnormality of calcium-phosphate metabolism. The outcome of this case suggests that patients with recurrent or persistent bowel symptoms on long-term CAPD should have early abdominal x-ray or CT scanning to exclude sclerosing peritonitis or bowel calcification. If present, consideration should be given to transferring the patient to another therapeutic dialysis modality if possible.     

Lupus peritonitis mimicking acute surgical abdomen in a patient with systemic lupus erythematosus: Report of a case

A 25-year-old Japanese woman who had been suffering from systemic lupus erythematosus (SLE) for 12 years was admitted to our hospital with a suspected diagnosis of peritonitis after suddenly developing severe abdominal pain and distention which could not be relieved by treatment with anodyne. Noninvasive examinations did not provide enough evidence to rule out acute appendicitis, bowel performation, or ischemia due to vasculitis. Therefore, in consideration of the severity of her uncontrollable abdominal pain, an exploratory laparotomy was performed. The operative findings revealed nonbacterial peritonitis with a large amount of ascites and an edematous small bowel. No perforation of the intestine was found. On post-operative day (POD) 3, the severe abdominal pain redeveloped, but responded well to steroid pulse therapy. Based on the operative findings and her clinical course, the most likely diagnosis was thought to be acute lupus peritonitis. It is often difficult to ascertain whether abdominal pain in an SLE patient is due to lupus peritonitis or to an underlying cause requiring surgery. Thus, it is essential that continuous and careful assessment of the surgical abdomen is performed when a patient with SLE develops acute abdominal pain, and if a surgical condition cannot be ruled out, a laparotomy should be performed without delay.     

Peritonitis secondary to spontaneous perforation of a primary gastrointestinal stromal tumour of the small intestine: A case report and a literature review

IntroductionA few cases of acute abdomen caused by perforation of small-intestinal gastrointestinal stromal tumours (GISTs) have been reported in the literature.Presentation of caseTogether with a review of the published cases, here we report a case of an elderly patient with peritonitis due to spontaneous perforation of a GIST of the jejunum. An 82-year-old man was admitted to the emergency unit of our hospital with fever and severe abdominal pain. An abdominal enhanced computed tomography scan detected a 6 cm solid mass in the left upper quadrant adherent to a jejunal loop and surrounded by free fluid and free air. Due to the radiological features of the mass, the diagnosis of a perforation of a GIST arising from the jejunum wall was suspected. The patient underwent emergency laparotomy. Intraoperative findings confirmed diffuse peritonitis secondary to jejunal tumour perforation. A segmental resection of the jejunum containing the mass was performed followed by a mechanical end-to-side anastomosis. The histopathologic examination of the mass confirmed the diagnosis of a perforated GIST of the small intestine (high-risk category). The post-operative course was uneventful and the patient was treated with adjuvant imatinib therapy.DiscussionTwenty-one other cases of spontaneous perforation of small intestine GISTs are reported in the literature and are summarized in the present review.ConclusionThe described case is the tip of the iceberg and spontaneous rupture or perforation of GISTs are a far more frequent first presentation of this rare tumour.     

Laparoscopic resection of perforated Meckel's diverticulum in a patient with clinical symptoms of acute appendicitis

We report the laparoscopic resection of a perforated Meckel's diverticulum (MD) found in a 14-year-old boy who presented with abdominal pain and nausea. There was rebound tenderness in the right lower quadrant of the abdomen, which appeared suspicious for acute appendicitis. The patient was referred to the operating room, and laparoscopic appendectomy was performed. With the appendix showing no macroscopic signs of inflammation, laparoscopy was continued and a perforated MD was identified 50 cm proximal to the ileocecal valve. The findings included pus and localized peritonitis between the ileal loops adjacent to the perforation site. The diverticulum was longitudinally resected with an Endo-Gia stapler. The histopathologic workup confirmed the diagnosis of a perforated MD. The patient completely recovered and was discharged 8 days after the procedures. At this writing, he is completely asymptomatic 6 months later. We conclude from our observation that laparoscopic resection of a perforated MD can be performed safely even when localized peritonitis is present. Inspection of the small intestine should be performed to exclude a symptomatic or perforated MD when the appendix does not show any signs of acute appendicitis.     

Rupture of ovarian cyst: massive hemoperitoneum in continuous ambulatory peritoneal dialysis patients: diagnosis and treatment

Two women on continuous ambulatory peritoneal dialysis (CAPD) developed recurrent episodes of hemoperitoneum while in the reproductive age group. Initially, both were thought to have mechanical problems with the peritoneal catheter system. A laparotomy was performed in the first patient, and a bleeding ovarian cyst was identified. The second patient had ovarian cysts documented by ultrasound. Thus, abdominal pain and bloody dialysate should not just be ascribed to catheter-related problems. The second patient's midcycle bleeding was suppressed with birth control pills.     

Postoperative pancreatitis after total hip replacement under general anesthesia

A 61 year old male patient developed postoperative pancreatitis after total hip replacement under general anesthesia with sevoflurane. The patient had chronic renal failure and was receiving hemodialysis. The estimated intraoperative blood loss was 1500 ml, and 1200 ml of blood was administered. The intraoperative mean blood pressure was 60 to 70 mmHg and the central venous pressure at the end of anesthesia was 0 mmHg. Postoperatively he complained of severe upper abdominal pain. On the 1st postoperative day serum amylase level increased to fifteen times of the normal level. He complained again of severe abdominal pain on hemodialysis. From these episodes, we estimate that the circulatory disturbance of pancreas is the cause of this postoperative pancreatitis.     

Complicated small bowel diverticulosis--a case report and literature review

We report herein the case of a small bowel diverticulum perforation which has caused peritonitis and consequently has led to operation. The patient, a 79-year old woman, was hospitalized due to etiological clarifying and specifying of a newly diagnosed diffuse liver pathology. During the hospital stay, she has received severe abdominal pain with features of peritonitis. Suspecting perforated appendicitis she has undergone an operation. The explorative laparotomy has identified a purulent exudation in the abdominal cavity, resulting from a perforated inflammatory jejunal diverticulum and multiple middle-size diverticula all along the small bowel and the colon. The reported case as well as the review of the literature have shown that various and sometimes potentially fatal complications could occur even for such a relatively banal insignificant entity as is diverticular disease in elderly patients.     

Surgical management of Meckel's diverticulum in adults--retrospective analyses of 62 cases

Meckel's diverticulum (MD) is the most common congenital anomaly of the small intestine. We searched and analyzed the records of 62 cases with MD admitted in University Emergency Hospital Bucharest between 2001-2009. Sex ratio was M:F 3:1, with 74% male and 26% female. 51.6% (n = 32) of this where symptomatic and 48.4% (n = 30) asymptomatic, discovered during laparotomy for other reasons. The analysis highlights an increased frequency of symptomatic diverticulum at early ages, with a medium age of about 39.2 years comparing to asymptomatic group with a medium age of about 54.2 years. The diverticulum complication generated: occlusion--43.7% (n = 15), inflammation--37.5% (n = 12), bleeding, two cases of diverticulum tumor, an intussusception case and a perforation case with unknown object. 25% of the diverticulectomies were followed by postsurgery complications, the parietal suppuration being the most frequent (50%). Three patients died independent of the diverticulum or its resection, all three having an asymptomatic diverticulum. The difficult diagnosis and the seriousness of diverticulum complications force us to take into consideration DM in all cases of severe or chronic abdominal pain. The diverticulum has to be surgically removed to all patients under 50 years, especially men.     

Perforation of Meckel's Diverticulum Manifesting as Aseptic Peritonitis in a Neonate: Report of a Case

We report a case of perforated Meckel's diverticulum with aseptic peritonitis in a 17-day-old neonate. The baby had been brought to the hospital with fever and abdominal distention. Abdominal computed tomography showed a 5-cm abscess in the lower abdomen, and emergency laparotomy was performed for suspected perforated appendicitis. However, we found a perforated Meckel's diverticulum. No bacteria were detected in the purulent ascites from the peritoneal cavity. We speculate that the narrow lumen between the small intestine and the diverticulum, accompanied by poor self-emptying had caused acute inflammation resulting in perforation of Meckel's diverticulum. The anatomic limitations in “walling off” the perforated Meckel's diverticulum by the surrounding loops of small intestine prevented the bowel contents from spreading within the peritoneal cavity.     

Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: Difficulty in diagnosis

Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. He had been receiving nocturnal intermittent PD for 2 years and had ischemic heart disease and cirrhosis of the liver. Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The “board-like abdomen” sign was not noted. Air inflation and contrast radiography indicated a perforation in the upper gastrointestinal tract, and laparotomy disclosed a perforation in the prepyloric great curvature. Unfortunately, the patient died during surgery. This case illustrates that the “board-like abdomen” sign may be absent in PD patients with PPU because of dilution of gastric acid by the dialysate. Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.     

Meckel’s diverticulum perforation: Report of a case and review of the literature

Meckel’s diverticulum is the most common congenital anomaly of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications can occur, including diverticulitis, haemorrhage, obstruction, intussusception, and perforation. A 39-year-old man was admitted to the emergency department after complaining of abdominal pain for the past few days. Upon worsening of his clinical status and after completing the diagnostic workup, he was taken to the operating theatre where he was found to have faecal peritonitis due to perforated Meckel’s diverticulum. Although it might be difficult to diagnose Meckel’s diverticulum pathology preoperatively, it should always be sought and identified during a laparotomy for acute abdomen in order to exclude the increased morbidities resulting from its complications.