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This case report features the unusual presentation of a blind-ending ureteric duplication (BEUD) as acute abdomen. The partially obstructed BEUD had mimicked acute appendicitis, leading to previous errors in the diagnosis and management of the case. A high index of suspicion is necessary to diagnose such a rare congenital anomaly when it presents as acute abdomen.
The respiratory magnetometer method of Konno and Mead was used to measure separately the rib cage and the diaphragm-abdomen components of the total respiratory system compliance in 11 subjects with normal respiratory systems. Measurements made in the awake, relaxed state by the method of Heaf and Prime were compared with similar measurements made in the anesthetized, paralyzed state by the supersyringe method. The rib cage component was greater in the paralyzed than the relaxed state in 9 of 11 subjects, but the diaphragm-abdomen component was greater in the relaxed than the paralyzed state in 8 of 11 subjects. We believe that these differences can be explained by respiratory muscle activity in the presumed relaxed state. The fraction of the tidal volume attributable to rib cage displacement compared to abdominal displacement was greater during mechanical ventilation in the paralyzed state than during awake, spontaneous breathing. This can be explained by the different distribution of inflating forces produced by diaphragmatic contraction compared to positive airway and alveolar pressure, in particular by the very different patterns of diaphragmatic displacement in the 2 states.
The role of laparoscopy in the management of patients presenting to one surgical firm with an acute abdomen is discussed. Sixty-seven laparoscopies have been performed over an 18 month period and it has altered the diagnosis in 19.4% of cases and the management in 13.4% of cases. At laparoscopy the diagnosis of appendicitis was made in 37 patients (81% had attempted laparoscopic appendicectomies); pelvic inflammatory disease in 15 patients; torted fimbrial cyst in two patients; and free pus in the right lower peritoneum as a result of a perforated appendix was seen in two patients. Normal laparoscopy was performed in five patients and four patients who presented with a perforated duodenal ulcer had the diagnosis confirmed at laparoscopy, in three cases the perforation was oversewn laparoscopically. Two laparoscopies were performed on trauma patients; one stabbing and one blunt trauma to the right hypochondrium. It has been demonstrated that diagnostic laparoscopy is a useful adjunct to the general surgeon's armamentarium. It is suggested that the skill of laparoscopy is passed on to junior trainee surgeons who can use this technique to help attain a diagnosis in patients presenting with an acute abdomen.
The epidermis of the adult Drosophila abdomen is formed by a chain of anterior (A) and posterior (P) compartments, each segment comprising one A and one P compartment. In the accompanying paper (Struhl et al., 1997), we provide evidence that Hedgehog protein (Hh), being secreted from P compartment cells, organises the pattern and polarity of A compartment cells. Here we test whether Hh acts directly or by a signal relay mechanism. We use mutations in Protein Kinase A (PKA) or smoothened (smo) to activate or to block Hh signal transduction in clones of A compartment cells. For cell type, a scalar property, both manipulations cause strictly autonomous transformations: the cells affected are exactly those and only those that are mutant. Hence, we infer that Hh acts directly on A compartment cells to specify the various types of cuticular structures that they differentiate. By contrast, these same manipulations cause non-autonomous effects on cell polarity, a vectorial property. Consequently, we surmise that Hh influences cell polarity indirectly, possibly by inducing other signalling factors. Finally, we present evidence that Hh does not polarise abdominal cells by utilising either Decapentaplegic (Dpp) or Wingless (Wg), the two morphogens through which Hh acts during limb development. We conclude that, in the abdomen, cell type and cell polarity reflect distinct outputs of Hh signalling and propose that these outputs are controlled by separable gradient and signal relay mechanisms.
We describe a case of lead poisoning due to herbal remedies, presenting with an acute abdomen, raised porphyrins and increased liver enzyme activities. We suggest that lead poisoning should be considered in the differential diagnosis of the 'acute abdomen', and that the presence of liver dysfunction points to the possibility of Asian herbal remedies as the source of the lead poisoning.
A mechanical real-time ultrasonic scanner utilizing a rotating transducer head has been successfully applied clinically to visualize the heart and abdomen. The design features of this scanner are discussed. The small dimensions and the 90 degree field of view of the sealed oil-filled transducer head optimize visualization of the heart avoiding bone and lung. The single point of entry aspect of this scanner results in a good field of view from any point on the abdominal surface. For example, in upper abdominal studies the liver and kidney can be readily viewed. Rapid and thorough searching of the abdomen is easily carried out and good quality selected sections can be captured by optimizing frame rate and angle of view. In obstetrical applications the complete mature fetus can be visualized using the alternative large 180 degree field of view.
A recent gastric bypass can mask the symptoms of an acute abdomen. Physical examination is generally unreliable and subtle clinical symptoms or signs should alert clinicians to a significant postoperative problem. In morbidly obese patients, the presence of overt peritoneal findings is usually ominous, leading to sepsis, organ failure and death. We report a case of ruptured appendicitis following a laparoscopic Roux-en-Y gastric bypass. The patient developed tachycardia, fever, and leukocytosis in the absence of abdominal pain or positive upper GI contrast studies. Eventually, a CT scan revealed a large pelvic abscess and inflammation. A subsequent exploratory laparotomy confirmed a perforated appendicitis with pelvic peritonitis. Her recovery was rapid and uneventful. This case highlights the pitfalls in promptly diagnosing an unrelated acute surgical abdomen postoperatively in the morbidly obese patient. The need for extreme vigilance and a low threshold for aggressive intervention in the period after bariatric surgery is emphasized.
In 95 patients with acute abdominal pain seen in the emergency ward of a large urban teaching hospital, real-time sonography was performed in conjunction with a plain film of the abdomen in order to detect what, if any, added information was provided by the sonographic examination. In 20 patients (21%) the sonogram contributed important diagnostic information not provided by the plain film of the abdomen. Most of these patients had pathology referable to the biliary tract (14 of 20). In 28 patients (30%), the sonogram confirmed the diagnosis by abdominal film. In 39 (41%) the sonogram added no relevant information, and in three (3%) it was deleterious. In five (5%) the plain film provided more information than the sonogram.
Seven cases of increased echogenicity in the fetal abdomen detected on prenatal sonography were reviewed for findings and causes. In four cases, the findings corresponded to calcification secondary to meconium peritonitis, infection, or unknown cause. One infant with meconium ileus had inspissated but noncalcified meconium corresponding to the increased echoes. In two cases, follow-up prenatal sonography was normal, and the neonate was also normal. Eight cases from the literature with increased echogenicity in the fetal abdomen were also reviewed: Two cases were secondary to meconium ileus, and six were caused by meconium peritonitis. Increased abdominal echogenicity on prenatal sonography may result from various processes that may affect obstetric and neonatal management.
We describe five patients who presented with an acute abdomen in whom pneumoperitoneum was first detected by sonography. All five subsequently were proved to have a perforated viscus. In all cases, the pneumoperitoneum was seen as an echogenic line with a posterior ring-down or reverberation artifact between the anterior abdominal wall and the anterior surface of the liver. The finding was shown best in the right upper quadrant with the patient in the left lateral decubitus position. The echoes caused by the pneumoperitoneum overlapped the echoes of the lung during inspiration, but the echoes were separate during expiration. The probable cause of pneumoperitoneum was determined with sonography in four of the five patients: three had perforation of duodenal ulcer and one had perforation of gastric cancer. The fifth patient had a perforated ileum, which was not evident on the sonogram. Our experience with these patients suggests that the detection of pneumoperitoneum on sonography in patients with an acute abdomen is an important sign of a perforated viscus.
An acute abdomen is a clinical condition characterized by severe abdominal pain that develops suddenly over several hours or less [1]. Abdominal tenderness and rigidity, either generalized or localized, usually are severe and indicate an urgent need for prompt diagnosis and treatment. The underlying cause of acute abdomen varies, and some cases require immediate surgical treatment, whereas for others, surgery is unnecessary or contraindicated. This need for prompt diagnosis and treatment should not preclude an appropriate investigation to establish the precise diagnosis before undertaking surgery [1, 2].
OBJECTIVE: The purpose of this study was to describe the CT features of Castleman disease in the abdomen and pelvis. CONCLUSION: The most frequent appearance of abdominal or pelvic Castleman disease is of a single, well-defined enhancing mass. Smaller tumors (<5 cm) display homogeneous contrast enhancement; larger tumors (>5 cm) show heterogeneous enhancement and attenuation when correlated with central necrosis and degeneration. Calcification was seen in 31% of the cases. Castleman disease may be considered in the differential diagnosis of a discrete enhancing mass in the abdomen or pelvis.
OBJECTIVE: To correlate anatomic features of the abdomen of the ringed seal (Phoca hispida) identified in plastinated cross-sections with images obtained via computed tomography (CT) and thereby establish reference standards for normal abdominal organ size and position in this species. SAMPLE POPULATION: 2 adult male ringed seal cadavers. PROCEDURE: With the seal in sternal recumbency, CT images of the abdomen were acquired by use of a 4th-generation CT scanner. Image slice thickness was 1 cm, with no interslice gap. After imaging, the abdominal region was sectioned transversely into 4-cm slices, which were plastinated and photographed. Plastinated slices were matched to their corresponding CT images in preparation for anatomic descriptions. RESULTS: Relevant anatomic features were identified and labeled on both the plastinated tissue slice and corresponding CT image. Normal abdominal organ size and position were assessed, and topographic relationships among organs were ascertained. CONCLUSIONS AND CLINICAL RELEVANCE: The data obtained provide some reference standards for normal abdominal organ size and position in ringed seals. This information may aid researchers of future physiologic and clinical studies in this species.
PURPOSE: To evaluate the safety and diagnostic efficacy of two different doses of ferric ammonium citrate as a paramagnetic oral contrast agent for MR imaging of the upper abdomen. MATERIAL AND METHODS: Ninety-nine adult patients referred for MR imaging for a known or suspected upper abdominal pathology were included in this randomized multicenter double-blind clinical trial. Imaging was performed with spin-echo (T1- and T2-weighted) and gradient-echo (T1-weighted) techniques before and after administration of either 1200 mg or 2400 mg of ferric ammonium citrate dissolved in 600 ml of water. Safety analysis included monitoring of vital signs, assessment of adverse events, and laboratory testing. Efficacy with regard to organ distension, contrast distribution, bowel enhancement and delineation of adjacent structures was graded qualitatively. RESULTS: No serious adverse events were reported for either of the two concentrations. A total of 31 minor side effects were noted, of which significantly more occurred in the higher dose group (p<0.01). The diagnostic confidence in defining or excluding disease was graded as better after contrast administration for 48% of all images. Marked or moderate enhancement of the upper gastrointestinal tract was achieved at both doses in 69.5% of cases with no evident difference between the two doses. The higher dose tended to show better results in terms of the contrast assessment parameters. CONCLUSION: Ferric ammonium citrate is a safe and effective oral contrast agent for MR imaging of the upper abdomen at two different dose levels. The higher dose showed a tendency toward better imaging results while the lower dose caused significantly fewer side effects. Therefore the 1200 mg dose can be recommended in view of the risk-to-benefit ratio.
AIM: To evaluate the efficacy of a recently developed device that applies kneading-like motion on the abdomen in improving constipation in elderly long-term care patients. METHODS: Thirty constipated elderly patients were randomly selected from two nursing homes. They were instructed to use the device once daily for 20 min. Rate of bowel movements, volume and consistency of stool and the use of laxantia were all recorded during a 3-wk baseline period and for 12-wk treatment period. Colonic transit time (CTT) was measured in 13 patients by radiopaque markers during the baseline and at the end of treatment. RESULTS: Bowel movement rate (BM/week) increased from 1.4+/-0.4 BM/wk during baseline to 3.9+/-0.8 BM/wk during treatment (P<5.0x10(-7)). Stool amount that was "low" in 30 patients during baseline increased in 21 patients at the end of the study period (chi2 = 19.048-P = 1.3x10(-5)). Stool consistency, that was "hard" in 25 patients and "soft" in 5 patients during baseline, ameliorated in 23 patients at the end of the study (only 2 patients referred "hard" stool) (chi2 = 21.043-P = 4.0x10(-6)). The mean baseline CTT measured was 92.3+/-32.3 h at baseline and decreased to 49.4+/-31.3 h during the study period (P = 0.000208). No side effects were observed during the study period. CONCLUSION: External mechanical vibration of the abdomen reduced CTT and helped to relieve severe constipation in elderly constipated patients.
In this study, we explore the conditions for accurate localization of vibrotactile stimuli presented to the abdomen. Tactile orientation systems intended to provide mobility information for people who are blind depend on accurate identification of location of stimuli on the skin, as do systems designed to indicate target positions in space or the status of remotely operated devices to pilots or engineers. The spatial acuity of the skin has been examined for simple touch, but not for the types of vibrating signals used in such devices. The ability to localize vibratory stimuli was examined at sites around the abdomen and found to be a function of separation among loci and, most significantly, of place on the trunk. Neither the structures underlying the skin nor the types of tactor tested appeared to affect localization. Evidence was found for anatomically defined anchor points that provide localization referents that enhance performance even with wide target spacing.
A 76-year-old man presented to the emergency room with abdominal pain and fatigue. The patient had a history of gastrointestinal bleeding. An abdominal computed tomographic scan showed collections of free air in the abdomen with obstruction of the distal small intestine and multiple masses in the liver. Laparotomy revealed a widespread malignant neoplasm in the abdomen, with multiple tumor nodules in the ileal wall, mesentery, and liver. The ileal wall was perforated within the area of one of the tumors. Pathologic examination of the lesion showed a neoplasm composed of solid sheets of spindle and undifferentiated cells, forming interlacing delicate vascular channels with atypical endothelial cells. The tumor cells were positive for the endothelial marker CD31, whereas reactivity for a broad panel of epithelial and other endothelial markers was negative. This case demonstrates that although angiosarcomas of the gastrointestinal tract are rare, they should be considered in cases of intestinal perforation or severe bleeding, especially in the elderly. A broad panel of immunochemical markers might be necessary to establish the pathologic diagnosis.
The purpose of this study is to examine an antialiasing method in the breath-hold coronal imaging of the thorax or abdomen. This paper reports a new method of preventing the aliasing artifacts of arms using "Hertz II" as a electromagnetic-wave shield fabric (ESF),which is a very thin and flexible special synthetic fabric. In this study, the ESF method was compared with various conventional preventive measures. Temperature changed around the ESF was also measured by using a fiber optic temperature measurement system during the MR scanning procedure. In addition, the ESF method was tried to use for scanning with some volunteers and some patients in clinical examinations. The results of this study showed that the ESF method could efficiently prevent the aliasing of arms in the MR images. Furthermore, safety of the subjects was hardly affected by the ESF method during MR imaging. Therefore, we concluded that the ESF method was an effectual antialiasing method in the imaging of the thorax or abdomen by using the fast breath-hold scanning.