Traumatic Testicular Dislocation after Minor Trauma in a Pediatric Patient

Background

Traumatic dislocation of the testicle is a rare injury that may result from blunt abdominopelvic trauma. The majority of cases reportedly occur in young adults secondary to severe scrotal trauma during high-speed motorcycle crashes. Our review of the available English medical literature revealed only one pediatric case.

Objective

We present a case of pediatric testicular dislocation and torsion resulting from minor abdominopelvic trauma. The case report is followed by a brief review of the available literature.

Case Report

A 10-year-old boy presented to the Pediatric Emergency Department with abdominal pain. He had suffered a strike to the abdomen and groin during an attempt at flipping over a “monkey bar” at school. A tender mass was found in his right inguinal canal and the genital examination revealed an empty right hemiscrotum. Bedside ultrasonography was used to locate the testicle and it was noted by color-flow Doppler to lack demonstrable blood flow. The patient was taken emergently to the operating room, where he underwent orchiopexy and hernia repair after a viable testicle was found. He had a subsequently uneventful recovery.

Conclusion

Although rare, testicular dislocation may be a serious result of abdominopelvic trauma. Emergency providers who care for trauma patients must include this condition in their differential diagnosis; to do otherwise risks a delay in diagnosis that may affect testicular viability. In this case, testicular dislocation may have resulted from the combination of trauma and a previously undiagnosed indirect inguinal hernia.     

Right-sided Diverticulitis Mimics Appendicitis

Background

Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients.

Objectives

In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis’ diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery.

Case Report

A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days.

Conclusions

Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery.     

Is urinary 5-hydroxyindoleacetic acid helpful for early diagnosis of acute appendicitis?

Objective

Acute appendicitis is the most common abdominal emergency in children and young adults. There are a lot of serotonin-containing cells in the appendix, which release serotonin into the bloodstream in response to inflammation. Consequently, serotonin is converted to 5-hydroxyindoleacetic acid (5-HIAA) and secreted into the urine. On this basis, urinary 5-HIAA could be a marker for acute appendicitis. In this study, we investigated the value of 5-HIAA levels in spot urine in the diagnosis of acute appendicitis.

Methods

The urinary 5-HIAA was measured by an enzyme-linked immunosorbent assay in the spot urine of 70 patients who presented to the emergency department with a clinical picture of acute appendicitis. Urine concentration results were correlated to final histopathologic reports, and the diagnostic value of this factor was measured.

Results

Diagnosis of appendicitis was confirmed by histopathologic reports in 59 of 70 patients with presumptive diagnosis of appendicitis. Considering 5.25 mg/L as the cutoff point for urinary 5-HIAA, 28 patients had high urinary 5-HIAA levels, whereas 42 patients had values within reference range. The sensitivity and specificity of this test was 44% and 81%, respectively.

Conclusions

The measurement of urinary 5-HIAA levels is not an ideal diagnostic tool for ruling out or determination of acute appendicitis.     

Left-sided Acute Appendicitis: A Pitfall in the Emergency Department

Background

Acute appendicitis continues to be a condition at high risk for missed and delayed diagnosis. It characteristically presents with right lower quadrant pain after vague epigastric or periumbilical discomfort. Left-sided appendicitis is an atypical presentation and has been reported rarely. The majority of these cases have been described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix. We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon.

Objectives

To alert emergency physicians to an anatomical anomaly that could delay the diagnosis of appendicitis.

Case Report

A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant. Abdominal computed tomography scan revealed a redundant, floating, ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. Exploratory laparotomy was performed and perforated appendicitis with turbid ascites was found during the surgery. Appendectomy was performed and the patient recovered uneventfully.

Conclusion

This case is presented to increase awareness among emergency physicians of this anatomical variant and atypical presentation of appendicitis.     

A Rare but Distinctive Cause of Acute Abdomen: Appendiceal Diverticulitis

Background

Diverticulosis and diverticulitis of appendix vermiformis is a rare diagnosis. Clinical and laboratory examinations do not show a difference between a progressing diverticulitis and simplex appendicitis. But this entity has a higher mortality rate than common appendicitis.

Objective

This case is presented to illustrate the point that preoperative simple diagnosis of acute appendicitis according to the clinical signs and physical examination may not only be insufficient, but could be fatal in certain circumstances, like appendiceal diverticulitis, if surgical intervention is delayed.

Case Report

Here we present a female patient with a history of right lower abdominal pain and fever of 3 days duration. She was diagnosed with acute appendicitis according to the preoperative physical, laboratory, and imaging examinations. The appendiceal diverticulitis accompanying acute appendicitis was an intraoperative finding, which was proven by histopathologic examination.

Conclusion

It is not easy to document this entity preoperatively. When diagnosed either preoperatively by imaging studies or intraoperatively, the only choice is appendectomy to prevent its serious complications.     

Acute Appendicitis Presenting As Acute Gastritis in an Adult Patient with Undiagnosed Congenital Gut Malrotation: A Case Report

Background

We report a case of an atypical presentation of acute appendicitis in an adult due to an undiagnosed congenital gut malrotation.

Objective

The obvious benefit of observation with serial examinations followed by the use of computed tomography (CT) is discussed in aiding in the diagnosis for atypical presentations of appendicitis.

Case Report

A 45-year-old man who presented with epigastric pain and vomiting was diagnosed with acute left-sided appendicitis on CT scan. The patient’s appendix was located in the left lower quadrant of the abdomen due to undiagnosed congenital gut malrotation, thus resulting in an atypical presentation of a common illness.

Conclusion

Observation with serial examinations, followed by CT scanning if indicated, is an invaluable strategy to use in diagnosing atypical presentations of common pathology.     

A Rare Case of Appendicitis-Like Syndrome: Prompt Laparoscopic Diagnosis and Management

Background

Hyperpyrexia associated with right iliac fossa pain and tenderness in a young patient is a common finding in an Emergency Department, and is frequently caused by acute appendicitis or genitourinary affliction. Especially in the case of young males, it is debated whether the patient should undergo immediate surgery or be referred for imagery, and, when surgery is finally planned, whether an open incision of the iliac fossa or a laparoscopic approach is preferred.

Objective

We describe a case of a patient with a twisted, ischemic ileal hemangioma mimicking an acute appendicitis, which was diagnosed and managed laparoscopically.

Case Report

A 16-year-old boy was admitted to the Emergency Department with a 2-day history of hyperpyrexia, nausea, right iliac fossa pain, and tenderness. Perioperative computed tomography scan showed a 3-cm image that was interpreted as a periappendicular abscess. At laparoscopy, a twisted ischemic mass adherent to the surrounding ileum was located and removed. The patient’s outcome was uneventful. Pathology showed a benign hemangioma of the ileal mesentery. To our knowledge, this is the first case treated by laparoscopic resection.

Conclusions

Rare conditions, such as peduncolated tumors, can mimic common conditions like acute appencitis. Also, due to the aspecificity of symptoms and difficult interpretation of imagery, diagnosis can be difficult to achieve preoperatively and surgery can be challenging. Laparoscopy can allow a diagnosis to be made and the appropriate treatment to be performed without the need for laparotomy. Rare causes of appendicitis-like syndrome represent an argument in favor of a laparoscopic approach, even in the case of young male patients.     

Seat Belt Injury to the Inguinal Region Presenting with Hemorrhagic Shock

Background

Seat belts uncommonly result in various injuries to the abdominal area, such as mesenteric tears, bowel perforations, and abdominal aortic ruptures. We describe a case of a massive subcutaneous hematoma causing hemorrhagic shock from significant lacerations to the inguinal region, related to the use of a seat belt.

Objectives

To describe a seat belt injury to the inguinal region that presented with a massive subcutaneous hematoma, and to speculate about the mechanism that caused the injury.

Case Report

A 60-year-old woman, who was wearing a seat belt, was brought to our tertiary hospital Emergency Department after a head-on motor vehicle accident. The patient had vascular injury around the right inguinal region resulting in hemorrhagic shock. Transcatheter arterial embolization (TAE) was successfully performed to stop the bleeding.

Conclusion

Seat belts can cause serious injury to the inguinal region, mainly due to shearing forces. In addition to gauze packing, TAE was used effectively to control the hemorrhage in this patient.     

Myocardial Infarction in a Young Man Due to Coronary Artery Aneurysms after an Undiagnosed Kawasaki Disease

Background

Kawasaki disease usually affects infants and young children. It often goes unrecognized in adults due to varying symptoms and lack of definite diagnostic criteria.

Objectives

To describe the potential for acute myocardial infarction as a complication of antecedent Kawasaki Disease (KD).

Case Report

We describe a case of a 19-year-old man who presented to the Emergency Department (ED) with an acute myocardial infarction that was subsequently determined to be the result of previously untreated KD.

Conclusion

Kawasaki disease can cause coronary complications in a teenager. A high level of suspicion in the ED can help in proper management of these patients.     

Cryptorchidism as a potential source of misinterpretation in FDG-PET imaging in restaging lymphoma patients

Purpose

The estimated prevalence of cryptorchidism in young males is close to 2%. In oncological PET/CT studies, it might be difficult to recognize false-positive ¹⁸FDG uptake due to an ectopic testis.

Materials and methods

In this pilot study, we report on three patients with lymphoma referred for assessment of response to treatment and in whom cryptorchidism was not known at the time of ¹⁸FDG-PET/CT imaging.

Results

In each of these patients, moderate ¹⁸FDG uptake corresponding to an ovoid mass in the inguinal canal was (or could has been) misinterpreted as a lymphoma-involved inguinal lymph node. Clues to avoid misinterpretation are discussed.

Conclusion

Moderate ¹⁸FDG uptake in ectopic testes represents a potential source of false-positive at initial staging or evaluation of therapeutic response of lymphomas and other malignancies that needs to be recognized.     

Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?

Background

Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery.

Objective

The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era.

Methods

A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data.

Results

One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order.

Conclusion

Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis.     

Acute Appendicitis: Investigating an Optimal Outer Appendiceal Diameter Cut-Point in a Pediatric Population

Background

Acute appendicitis is the most common cause of abdominal pain in children requiring operative intervention. Among a number of sonographic criteria to aid in the diagnosis of appendicitis, an outer diameter >6 mm is the most objective and widely accepted. However, there is a lack of evidence-based standards governing this consensus.

Study Objectives

The aim of this study was to determine the outer appendiceal diameter that maximizes sensitivity and specificity in a pediatric population.

Methods

A retrospective review of all urgent diagnostic ultrasounds (US) was performed over 2 years in children aged <18 years. The diagnostic accuracy of various cut-points was assessed by calculating the sensitivity and specificity and plotting a receiver operating characteristic (ROC) curve.

Results

The study sample consisted of 398 patients in whom the appendix was visualized on US. The median outer appendiceal diameter was significantly higher in the surgical group compared to the nonsurgical group (9.4 mm; range = 8.1–12.0 vs. 5.5 mm; range = 4.4–6.5, p < 0.01). The optimal cut-point with the greatest area under the ROC curve was determined to be an outer appendiceal diameter of 7.0 mm.

Conclusions

In our patients, adopting a 7-mm rather than a 6-mm appendiceal diameter threshold would balance a greater number of missed cases of acute appendicitis for a reduction in the number of unnecessary surgeries.     

Functional Outcomes Associated With Adaptive Seating Interventions in Children and Youth With Wheeled Mobility Needs

Objective

To determine the parent-reported functional outcomes associated with adaptive seating devices for wheeled mobility devices used by young people aged 1 to 17 years.

Design

Longitudinal case series.

Setting

Homes of participating parents.

Participants

Parents (N=70, 63 mothers, 6 fathers, 1 grandmother) who had children with adaptive seating needs.

Intervention

Adaptive seating system for wheeled mobility devices.

Main Outcome Measure

Family Impact of Assistive Technology Scale for Adaptive Seating (FIATS-AS).

Results

All parents completed the FIATS-AS 4 times—2 times before and 2 times after their child received a new adaptive seating system. Mixed-design analysis of variance did not detect significant mean differences among the FIATS-AS scores measured at baseline and 2 and 8 months after receiving the seating system (F_2,134=.22, P=.81). However, the FIATS-AS detected a significant interaction between age cohort and interview time (F_4,134=4.5, P<.001, partial η²=.16). Post hoc testing confirmed that 8 months after receiving the seating system was associated with a large improvement in child and family functioning for children <4 years, maintenance of functioning for children between 4 and 12 years, and a moderate decline in functioning for youth between 13 and 17 years.

Conclusions

Adaptive seating interventions for wheeled mobility devices are associated with functional changes in the lives of children and their families that interact inversely with age. Future controlled longitudinal studies could provide further empirical evidence of functional changes in the lives of children and their families after the introduction and long-term use of specific adaptive seating interventions.     

A Case of Hickam's Dictum: Concurrent Appendicitis and Ectopic Pregnancy

Background

Both ectopic pregnancy and appendicitis are surgical emergencies that should be considered in female patients who present with right lower-quadrant pain. Deciding on the appropriate imaging modality in the pregnant patient can be difficult. The challenge of diagnosis is compounded when one considers that both pathologies may be present simultaneously.

Objectives

We present a case demonstrating co-occurrence of ectopic pregnancy and appendicitis and suggest an algorithm for evaluation and management of cases with this presentation.

Case Report

A 25-year-old woman presented to the Emergency Department complaining of 3 days of abdominal pain and a positive urine pregnancy test. After consultation with Obstetrics/Gynecology (OB/GYN) and General Surgery, a nondiagnostic pelvic ultrasound (US), and a magnetic resonance imaging (MRI) study consistent with appendiceal inflammation, the patient was taken to the operating room for a laparoscopic appendectomy. While removing the inflamed appendix, the general surgeon noted the right fallopian tube was enlarged, suggestive of an ectopic pregnancy. OB/GYN was consulted again intraoperatively and noted a right ectopic pregnancy. The surgical intervention was completed with a right salpingectomy.

Conclusion

In a pregnant patient with right lower-quadrant pain, the differential diagnosis includes ectopic pregnancy, acute appendicitis, or in rare cases, both.     

Hypertensive encephalopathy presenting as status epilepticus in a three year old

Background

Hypertensive encephalopathy is one of the few neurologic emergencies in which prompt diagnosis and treatment can prevent permanent neurological damage. This syndrome is rarely seen in children.

Objectives

To discuss the recognition of hypertensive encephalopathy as a cause of acute neurological changes in children.

Case Report

We present the case of a 3-year-old boy who presented to the Emergency Department with seizures due to hypertensive encephalopathy. A review of the literature on the subject follows the case report.

Conclusions

Hypertensive encephalopathy is a rare cause of acute neurological changes in children that can cause permanent damage if not recognized early. This case illustrates the importance of considering this syndrome as a potential cause of neurological symptoms, especially as neuroimaging can initially be misleading.     

Bilateral Spontaneous Dissecting Common Iliac Artery Aneurysms: A Rare Presentation

Background

Spontaneous iliac artery dissection is a rare clinical entity, reported previously in pregnant patients in association with collagen vascular disease, and in cases of high-energy trauma or intensive activity in athletes.

Objective

To alert clinicians to the incidence of spontaneous iliac artery dissection in the absence of any risk factors.

Case Report

We report a case of a 45-year-old man brought into the Emergency Department with severe lower abdominal pain. Computed tomography angiography revealed bilateral common iliac artery dissecting aneurysms with a dissection flap extending into the left internal iliac artery.

Conclusions

This case demonstrates that despite being a rare condition, in cases of acute lower abdominal, inguinal or lower back pain, even in the absence of risk factors and limb ischemia, emergency physicians should maintain a broad differential that includes intra-abdominal/pelvic vascular pathology such as iliac artery dissection.     

Is Pelvic Ultrasound Associated with an Increased Time to Appendectomy in Pediatric Appendicitis?

Background

Appendicitis is a common pediatric condition requiring urgent surgical intervention to prevent complications. Pelvic ultrasound (US) as a diagnostic aid has become increasingly common. Despite its advantages, evidence suggests US can lead to delayed definitive management.

Objective

The objective was to test the hypothesis that US is associated with an increased time to appendectomy in children with acute appendicitis.

Methods

A chart review was conducted of all children aged 0−17 years who presented to the pediatric emergency department (ED) with a discharge diagnosis of appendicitis. The primary outcome variable was the interval between initial evaluation to appendectomy between patients who received an US and those who did not.

Results

Of 662 cases included, 424 patients (64%) underwent a pelvic US and 238 patients underwent an appendectomy without US. Median time interval from initial evaluation in the ED by a physician to appendectomy among patients who received an US was 9.7 h (interquartile range [IQR]: 6.8−15.0 h) compared with 5.5 h (IQR: 3.8−8.6 h) among patients who did not receive an US (Mann-Whitney, p < 0.001). The increased time to appendectomy in patients who received an US was dependent on the patient being female and presenting to the ED after hours (univariate analysis of variance test for interaction, p < 0.05).

Conclusions

Female pediatric patients and those presenting after hours that undergo an US have a significantly increased time to appendectomy compared with those who do not undergo diagnostic imaging.     

A Case of Spontaneous Pneumomediastinum and Epidural Pneumatosis in a Young Woman in the Emergency Department

Background

Pneumomediastinum is a relatively rare, yet typically benign, clinical condition that usually presents in young men.

Objective

This report will describe a relatively rare event of pneumomediastinum with epidural extension in a young woman and will discuss the etiology, clinical manifestations, and treatment options for this condition.

Case Report

The patient presented to the Emergency Department (ED) with typical symptoms of shortness of breath and chest pain, but was found on computed tomography to have epidural pneumatosis. No precipitating event was found.

Conclusion

This case of spontaneous pneumomediastinum with associated epidural pneumatosis in a young woman presenting to the ED is a relatively benign condition that typically does not require any significant work-up or treatment.     

Utility of the Digital Rectal Examination in the Emergency Department: A Review

Background

The digital rectal examination (DRE) has been reflexively performed to evaluate common chief complaints in the Emergency Department without knowing its true utility in diagnosis.

Objective

Medical literature databases were searched for the most relevant articles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the correlation between DRE and anal manometry in determining anal tone.

Discussion

Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no additional diagnostic information and confounded the diagnosis in acute, undifferentiated abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and adults. No statistical differences in the number of colonic pathologies were found between stool collection methods in those with positive FOBT. The DRE correlation with anal manometry in determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, respectively.

Conclusion

We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in determining anal sphincter tone.     

Is early analgesia associated with delayed treatment of appendicitis?

Purpose

We sought to investigate the relationship between delay in treatment of appendicitis and early use of analgesia.

Basic Procedures

We designed a matched case-control study, with patients having delayed treatment of appendicitis as the cases and patients with no delay in treatment of appendicitis as controls matched for age, sex, Alvarado score, and date of diagnosis. Of 957 patients with appendicitis, there were 103 delayed cases. Matching patients were identified yielding 103 controls.

Main Findings

In comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), there was no association with delayed treatment (odds ratio, 1.11; P = .745; 95% confidence interval, 0.59-3.89). When comparing cases and controls for early NSAID use (29/103 cases, 17/103 controls), an association was found with delayed treatment (odds ratio, 1.98; P = .045; 95% confidence interval, 1.01-3.89).

Conclusion

For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia.