Epiploic appendagitis: an underestimated self-limiting acute abdominal condition

OBJECTIVE: To describe the clinical findings in patients with epiploic appendagitis and to evaluate its natural course. DESIGN: Retrospective. METHOD: A review of the medical records was carried out for all patients who were diagnosed with epiploic appendagitis using ultrasonography and computed tomography (CT), during the period June 1988-October 2001, at the Haaglanden Medical Centre (Westeinde site), The Hague, the Netherlands. RESULTS: The study group consisted of 49 patients, 38 men and 11 women, with a median age of 41 years. The main symptom was focal abdominal pain, with a median diagnostic delay in the patients of 2 days, located in the left lower quadrant (n = 34), right lower quadrant (n = 8), right upper quadrant (n = 6) or left upper quadrant (n = 1) of the abdomen. No other complaints were present with the exception of nausea and vomiting in two patients. Leucocytosis was found in 21% of patients, the erythrocyte sedimentation rate was elevated in 26% of the patients, and signs of peritoneal irritation were found in 53% of the patients. Epiploic appendagitis was correctly included in the clinical differential diagnosis of 2 patients. All of the patients made a complete and uncomplicated recovery under conservative treatment; the majority were symptom-free within 9 days. CONCLUSION: Due to the increased use of diagnostic imaging in patients with acute abdominal symptoms, epiploic appendagitis is much more frequently diagnosed than before. Presenting symptoms of epiploic appendagitis are non-specific, leading to misdiagnosis in most cases. Epiploic appendagitis has a benign natural course and if patients are correctly diagnosed using ultrasonography and CT, unnecessary surgery and medical treatment may be avoided.     

A young woman with acute abdominal pain

A 21-year-old woman reported to the first aid with acute pain in the right lower abdomen since 5 days, diarrhoea and nausea. There was no fever or muscular guarding, and no signs of inflammation in the blood screening. An ultrasound and a CT-scan of the abdomen showed an ovoid, fatty mass compatible with an appendagitis epiploica. This self-limiting disease does not need treatment.     

延迟性脾破裂12例诊治分析

目的:探讨延迟性脾破裂的发病机制及诊治方法.方法:对 2000～ 2004年 5月收治的 12例延迟性脾破裂进行回顾 性分析.结果: 12例均有左侧胸、腹部外伤史,且伤后均有左上腹轻微胀痛或轻度压痛,入院时均有突然发生左上腹 剧痛. 8例(66.7%)伤后两次腹痛间有明显缓解期, 10例(83.3%)延迟性脾破裂发生于伤后 2周内, 4例于伤后腹 内压增加时突发左上腹剧痛;术中发现脾包膜下血肿破裂 7例(58.3%);行脾切除 10例(83.3%).脾部分切除及脾 修补各一例.全组无死亡.结论:延迟性脾破裂多发生于左侧胸、腹部外伤后 2周内,多伴有左上腹的胀痛和左上腹 的压痛,腹痛常有中间缓解期,腹压增加时可突发上腹部剧烈疼痛,它以脾包膜下血肿破裂最为多见,早期诊断困难, 诊断的关键是要有高度的警惕性.治疗以脾切除为主.     

Diffuse peritoneal chlamydial infection presenting as possible ovarian peritoneal carcinomatosis in an adolescent female

A 17-year-old girl presented with significant abdominal ascites associated with periumbilical pain. On examination, her abdomen was found to be soft and moderately distended with left lower quadrant tenderness. Abdominal computed tomographic scan demonstrated not only ascites but also diffuse peritoneal enhancement, a left-sided enhancing adnexal mass displacing the uterus to the right, as well as omental caking. Alpha fetoprotein level was normal, whereas carcinoembryonic antigen (3.4 ng/mL) and cancer antigen 125 (315 U/mL) were mildly elevated. Based on these findings, a presumptive diagnosis of peritoneal carcinomatosis of ovarian origin was made. However, intraoperative biopsy of the left adnexal mass showed only a lymphoplasmacytic infiltrate. Chlamydial polymerase chain reaction of an intraoperative cervical sample was positive, and the final diagnosis was complicated pelvic inflammatory disease. The patient responded well to a prolonged course of antibiotics.     

Stump appendicitis after previous appendicectomy

Two patients, a 25-year-old male and a 57-year-old female, were treated for stump appendicitis. Both patients had undergone appendicectomy 6 months previously and again presented with pain in the right lower abdominal region. On physical examination, the first patient had tenderness as well as rebound tenderness over the entire abdomen, indicative of a general peritonitis. The second patient had tenderness and rebound tenderness in the right iliac fossa alone. Both patients underwent a laparotomy. In the first patient a perforated appendiceal stump was found and removed. In the second patient an acutely inflamed appendiceal stump was found and removed. Appendicitis of a residual appendiceal stump following incomplete appendicectomy is a rare cause of abdominal pain. A lack of familiarity with this condition frequently causes a delay in diagnosis, which increases the chance of perforation and intra-abdominal sepsis. Therefore, all clinicians need to be aware of the possibility of stump appendicitis and to take appropriate measures to prevent serious complications should they suspect this.     

Painful rib syndrome: a cause of pain complaints that often goes unnoticed

Three patients, 2 women aged 30 and 64 respectively and one man aged 75, with upper abdominal pain (right in the youngest patient and left in the other 2 patients), experienced tenderness over the lowermost ribs, especially at the end of the lowest floating rib. The diagnosis 'painful rib syndrome' was established once other possible conditions had been excluded. Following an explanation of the condition and some advice about posture, the symptoms disappeared. Painful rib syndrome can be a cause of chronic debilitating pain located in the left or right upper quadrant of the abdomen. The pain is movement and posture dependent. The syndrome is often not recognised. No data on the prevalence are available.     

Deep venous thrombosis as a complication of congenital absence of vena cava inferior]

A 19-year-old man was admitted with fever, haematuria, general malaise, pain on the left side of the pelvis and a full feeling in the left lower abdominal quadrant of the abdomen. His history mentioned a varices operation. During admission he developed an acute abdomen and deep vein thrombosis in both legs. CT of the abdomen showed a pathologic mass and absence of the vena cava inferior. Laparotomy revealed extensive thrombosis in widened veins. Clinical improvement occurred following adequate thrombolysis. Congenital absence of the vena cava inferior results from aberrant development during organogenesis. Patients are typically asymptomatic, but may present with venous insufficiency at a young age and deep vein thrombosis. Absence of the vena cava inferior can be accompanied by other congenital abnormalities such as dextrocardia and congenital heart diseases. Diagnosis is made using CT or MRI. Treatment consists of lifelong anticoagulant therapy and, if necessary, surgery.     

Summary of the Dutch College of General Practitioners (NHG) practice guideline on 'Diverticulitis'

The NHG practice guideline on 'Diverticulitis' provides general practitioners with directions on the diagnosis and treatment of uncomplicated and complicated diverticulitis. Diverticulitis is primarily a clinical diagnosis which can be supported by assessment of CRP. Uncomplicated diverticulitis is strongly suspected if the patient reports the development of persistent sharp, stabbing pain in the lower left abdomen within a couple of days; if there is pressure or rebound tenderness only in the lower left abdomen; and if there are no alarm signals. Alarm signals of complicated diverticulitis are: guarded muscle response, signs of intestinal obstruction, locally palpable resistance, rectal loss of blood, hypotension, and high fever. The policy for uncomplicated diverticulitis is waiting without specific measures, provided that the general practitioner monitors the course actively. There is no indication for antibiotics in patients with uncomplicated diverticulitis. Patients with signs of complicated diverticulitis or with persisting symptoms should be referred.     

CT淋巴造影在下肢乳糜返流淋巴水肿的诊断探讨

目的 探讨下肢乳糜返流性淋巴水肿的MSCT的影像学表现。方法 回顾性分析经手术或临床证实的51例患者乳糜返流性下肢淋巴水肿的影像学资料。所有患者均接受直接淋巴管造影造影后行胸腹部CT扫描。分析病变累及的部位及病程，并进行统计学分析。结果 51例患者的MSCT均可见不同范围、不同脏器和组织的淋巴管异常，累及下肢、盆腔、腹腔、胸腔及心包等；按病情分型：轻型14例，中型22例，重型15例，不同病情分型的病程统计学差异具有显著性。结论 下肢乳糜返流淋巴水肿病为多部位、多系统表现, MSCT为诊断和鉴别诊断本病提供重要依据，病情与病程有较大关联。     

急性胰腺炎伴胃肠功能不全的临床探讨(附43例病例分析)

目的探讨急性胰腺炎病人胃肠功能不全的原因及发病机制.方法对43例急性胰腺炎病人的胃肠功能,从腹部体症的变化上判断胃肠功能受损的程度.结果轻型急性胰腺炎腹胀轻,腹部压痛及反跳痛局限,肠鸣音减弱;重型急性胰腺炎腹胀如鼓,全腹均有压痛及反跳痛,肠鸣音几乎消失.结论观察腹部体症可以作为急性胰腺炎判断病情轻重的一个指标和诊断急性胰腺炎的一个条件.     

Abdominal pain as a symptom of a late complication following endovascular treatment of an aneurysm of the abdominal aorta

A 72-year-old man presented with progressive pain in the left lower abdomen thought to be due to diverticulitis of the colon. Antimicrobial therapy had not reduced the symptoms. Four years before, during an endovascular procedure, the patient had been given a stent because of an abdominal aortic aneurysm (AAA). A CT scan showed a large retroperitoneal haematoma on the left side and an increased diameter of the AAA of 8.5 cm. X-rays showed a gap between the endovascular stent and the left iliac leg of the endoprosthesis. Due to the space between the two grafts, there was retroperitoneal leakage ofblood. In endovascular surgery this life-threatening situation is called a type III endoleak. The patient was operated immediately using the endovascular technique. Through the left femoral artery a new coated stent was positioned over the gap, which led to rapid recovery of the patient. Patients with abdominal pain and a history of a vascular endoprosthesis should be given a CT scan and plain radiography to exclude an endoleak.     

Pathologists' Pay Nears Radiologists'

A 37-year-old woman presented to the emergency department with severe right upper quadrant abdominal pain that had begun 12 hours earlier. The pain was persistent, non- radiating, and associated with nausea and anorexia. She had complained for the past six to 12 months of intermittent palpitation, gradually increasing fatigue and dyspnea on exertion, and intermittent abdominal fullness. She had no history of significant medical problems and took no medications.

The patient appeared anxious, with a blood pressure of 115/78 mm Hg. Pulse was 145 bpm and regular; respirations, 18 per min; temperature, 37°C; and oxygen saturation, 97% by pulse oximetry. Her breathing was labored, but without crackles on auscultation. No jugular venous distention or peripheral edema was noted. Cardiac examination showed only a rapid regular rhythm with normal heart sounds. The abdomen was soft, with diffuse tenderness, most marked in the right upper quadrant, but without rebound tenderness. A complete blood count was normal. The ECG is shown.     

Pancreas pseudocyst or metastasis?

The authors review a case of a 24-year-old male patient hospitalised for repeated acute abdominal symptoms. His medical history included no diseases worth of mentioning. By imaging techniques (abdominal US and CT scan) a cystic lesion, measuring 40 x 35 x 30 mm in diameter was found, and was diagnosed as pseudocyst in the region of the tail of the pancreas. Jejunal feeding was introduced. The lesion did not improve and the second CT scan suggested a suspicion of pancreatic cystadenoma. Three months after first presentation the surgical resection was performed. The tumour, however, was found independent of the pancreas (90 x 80 x 50 mm). Both histologically and immunohistochemically the lesion proved to be the metastasis of a germ cell (yolk-sac) tumour. Following the morphological diagnosis, detailed urological and medical check up was performed. A previously nonpalpable small tumour was found in the left testis which was radically resected. The testicular tumour measuring 9 x 9 x 5 mm in diameter was diagnosed as embryonal carcinoma. Later on the patient underwent chemotherapy. He has been undergoing close oncological followup. Clinically, he is disease free. Authors emphasize the importance of imaging techniques and fine needle aspiration cytology in the case of retroperitoneal masses in young males. The possibility of a metastasis, especially of germ cell origin, should be excluded (not only by physical examination, but by ultrasound of testis also) in case of retroperitoneal cystic tumours even with unusual morphology.     

A report of renal cell carcinoma in a horseshoe kidney

A case of renal cell carcinoma associated with horseshoe kidney is reported. The patient was a 67 years old man with the chief complaints of dull pain of right upper abdomen. Ultrasonography (US) revealed horseshoe kidney and abnormal mass sign at the right isthmus of the kidney. By the computed tomography (CT) and angiography, renal cell carcinoma associated with horseshoe kidney was diagnosed. Only 18 cases of this rare disease have been reported in Japan. The diagnostic procedures are discussed and the usefulness of selective arteriography of the isthmus is emphasized, as the presentation of vascular anatomy is of great value for diagnosis, surgical treatment and preoperative arterial embolization.     

拥有“飞行时间”技术的PET/CT性能分析

目的:研究并分析拥有飞行时间(TOF)技术的PET/CT相关性能。方法:参照美国国家电气制造协会(NEMA)NU2-2007标准和厂家测试手册,对PET/CT的能量与时间分辨率、空间分辨率、灵敏度、散射分数、计数特性和图像质量进行性能测试和分析,并对不同型号仪器的性能进行比较,初步探讨飞行时间(TOF)技术对设备性能的影响。结果:系统的能量分辨率和时间分辨率分别为11.59%和499.3ps;空间分辨率在1cm处为4.54mm(横向)和4.85mm(轴向),10cm处为5.13mm(横向径向)、5.55mm(横向切线)和5.76mm(轴向);中心和偏离中心10cm处的灵敏度分别为6.4和6.8(cps/kBq);散射分数为32%;等效噪声计数率(NECR)在14.03kBq/ml时达到峰值为97.6kcps;模体图像中可以清楚分辨直径为10mm的最小热球。结论:拥有飞行时间技术的PET/CT各项性能指标都很优越,尤其在于图像质量的提高,可以缩短采集时间和减少注射药物剂量。     

Douching, pelvic inflammatory disease, and incident gonococcal and chlamydial genital infection in a cohort of high-risk women

Douching has been linked to gonococcal or chlamydial cervicitis and pelvic inflammatory disease (PID) in retrospective studies. The authors conducted a 1999-2004 prospective observational study of 1,199 US women who were at high risk of acquiring chlamydia and were followed for up to 4 years. Cervical Neisseria gonorrhoeae and Chlamydia trachomatis were detected from vaginal swabs by nucleic acid amplification. PID was characterized by histologic endometritis or pelvic pain and tenderness plus one of the following: oral temperature >38.3 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital tract infection. Associations between douching and PID or gonococcal/chlamydial genital infections were assessed by proportional hazards models. The 4-year incidence rate of PID was 10.9% and of gonococcal and/or chlamydial cervicitis was 21.9%. After adjustment for confounding factors, douching two or more times per month at baseline was associated with neither PID (adjusted hazard ratio = 0.76, 95% confidence interval: 0.42, 1.38) nor gonococcal/chlamydial genital infection (adjusted hazard ratio = 1.16, 95% confidence interval: 0.76, 1.78). Frequency of douching immediately preceding PID or gonococcal/chlamydial genital infection was not different between women who developed versus did not develop outcomes. These data do not support an association between douching and development of PID or gonococcal/chlamydial genital infection among predominantly young, African-American women.     

Spontaneous splenic rupture in dengue fever with non-fatal outcome in an adult

A 26-year-old male presented with fever for five days and abdominal pain for 24 hours. System examination identified a soft abdomen with diffuse tenderness. CT-abdomen findings were consistent with splenic rupture with intra and peri-splenic hematoma. Laboratory investigations showed a platelet count of 40,000 per mm(3). In due course he developed hypotension and underwent splenectomy. Non-structural protein 1 (NS1) dengue antigen was positive in the admission sample and IgM dengue antibodies were detected in the follow-up sample. Histopathology of the spleen showed normal architecture with no evidence of hyperplasia, cellular infiltrates or haematological malignancy. Splenic rupture is a rare, but potentially fatal complication of dengue fever and severe dengue which should be suspected when a patient presents with abdominal pain and hypotension. Our case highlights the occurrence of splenic rupture in the viremic phase of dengue illness before the development of IgM antibodies.     

Amenorrhoea despite displaced levonorgestrel intra-uterine system

A 29-year-old woman presented to the gynecology outpatient clinic with abdominal discomfort following the insertion of a levonorgestrel intrauterine system (LNG-IUS). It was noted that although the patient remained amenorrheic since the insertion, there was a persistent left iliac fossa discomfort, which was constant in nature and not made worse by intercourse. On examination, there was a vague tenderness in the left iliac fossa, and a transvaginal ultrasound scan showed bright echoes outside the uterus suggestive of an extrauterine IUS. Thus, arrangements were made for an admission for hysteroscopy and laparoscopy, proceeding to laparotomy if required. Following the procedures, the patient reported disappearance of the discomfort, although the LNG-IUS had not yet been retrieved. X-ray revealed the device lying high in the abdomen and laparoscopy was conducted. The LNG-IUS itself was buried, but was easily retrieved with gentle counteraction on the omentum through a 5 mm laparoscopy portal. Overall, this case emphasizes the importance of an X-ray as well as an ultrasound investigation in such cases.     

A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease

Controversy surrounds the association between bacterial vaginosis (BV) and pelvic inflammatory disease (PID). Women (N = 1,140) were ascertained at five US centers, enrolled (1999-2001), and followed up for a median of 3 years. Serial vaginal swabs were obtained for Gram's stain and cultures. PID was defined as 1) histologic endometritis or 2) pelvic pain and tenderness plus oral temperature >38.8 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital infection. Exploratory factor analysis identified two discrete clusters of genital microorganisms. The first correlated with BV by Gram's stain and consisted of the absence of hydrogen peroxide-producing lactobacillus, Gardnerella vaginalis, Mycoplasma hominis, anaerobic gram-negative rods, and, to a lesser degree, Ureaplasma urealyticum. The second, unrelated to BV by Gram's stain, consisted of Enterococcus species and Escherichia coli. Being in the highest tertile in terms of growth of BV-associated microorganisms increased PID risk (adjusted rate ratio = 2.03, 95% confidence interval: 1.16, 3.53). Carriage of non-BV-associated microorganisms did not increase PID risk. Women with heavy growth of BV-associated microorganisms and a new sexual partner appeared to be at particularly high risk (adjusted rate ratio = 8.77, 95% confidence interval: 1.11, 69.2). When identified by microbial culture, a combination of BV-related microorganisms significantly elevated the risk of acquiring PID.     

Mesenteric hematoma; a pediatric case

A 3-Year-old girl was admitted to National Beppu Hospital due to abdominal mass. US examination revealed cystic mass with multiple scattered nonreverberatory echoes in right upper abdomen. CT examination revealed almost homogeneous mass (29-31 H.U.) with a few internal components (36-42 H.U.). US and CT were useful methods for diagnosis of mesenteric hematoma.