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The acute abdomen in childhood is in most cases caused by an acute appendicitis and rarely it is secondary to other diseases. It is for that reason, that we present two cases extremely rare of acute abdomen: the first one was an abdominal Actinomycosis secondary to acute appendicitis that looked like a tumor and the second that was an acute omentitis due to pinworms.
We report a case of renal adenocarcinoma that was diagnosed after an emergency nephrectomy procedure. The patient had presented with a typical acute abdomen. The diagnostic methods and treatment are briefly discussed. The uncommon form of presentation (renal adenocarcinoma coexisting with multiple renal abscesses presenting as acute abdomen) prompted us to report this case.
The fat-saturation (FAT-SAT) MR technique decreases the signal intensity of fat in tissues, though yielding the T1, T2 and proton-density (PD) information available on spin-echo (SE) sequences. To investigate the potentials of FAT-SAT sequences in MRI of the upper abdomen, the authors carried out a prospective study including 129 subjects, namely 12 normal volunteers and 117 patients with different abdominal conditions. The patients were submitted to T1-weighted SE sequences (TR 500-600 ms, TE 15 ms), T2W SE (TR 1600-1730 ms, TE 80 ms) and PD SE (TR 1600-1730 ms, TE 20 ms). The images obtained with and without fat suppression were compared both qualitatively and quantitatively, with a special emphasis on the normal anatomy of the upper abdomen: we investigated the efficacy of subcutaneous and retroperitoneal fat suppression (116/129 cases, 90%), the reduction in respiratory and chemical shift artifacts (112/129 cases, 87%) and the better visualization of parenchyma (119/129 cases, 93%) and of other abdominal structures. Concerning the quantitative study, we calculated the signal-to-noise ratio (S/N) for liver, spleen, pancreas, adrenal glands, renal cortex and medulla, the improvement of contrast in these organs after retroperitoneal fat suppression (conspicuity) and the increase in contrast between organs (dynamic range). The statistical analysis showed significant differences between the sequences with and those without fat suppression. Correlations were found between observers' and quantitative evaluations, suggesting that the better yield of FAT-SAT sequences is probably due to three factors: 1) retroperitoneal and subcutaneous fat suppression; 2) increase in S/N ratio for pancreas and renal cortex on T1W images; 3) reduction in the dynamic range of signal intensity, which increases contrast between pancreas, adrenal glands and renal cortex relative to adjacent structures, especially on T2W or PD sequences. The results of this study suggest that FAT-SAT sequences are useful because fat suppression increases contrast and improves image quality, reducing respiratory and chemical shift artifacts.
The diagnostic work up of an acute abdomen may be more difficult in pregnant than in non-pregnant women due to the normal anatomical and physiological changes that occur during pregnancy. Delayed diagnoses and treatment may have more serious consequences for pregnant women than for other patients. We report the cases of two pregnant women, one with a volvulus of the small intestine and the other with a perforated appendix. We discuss important aspects of the diagnostic work up for acute abdomen with surgical etiology in pregnant women. If a surgical etiology is suspected in a pregnant women with acute abdominal pain, the patient should be examined and followed closely both by a surgeon and a gynaecologist until a final diagnosis is reached.
Presentation of two clinical cases of spontaneous vesical rupture secondary to bacterial cystitis in elderly patients. One corresponds to an intraperitoneal perforation while the second case was extraperitoneal. The patients were, in both cases, diabetic women admitted in emergency due to acute abdomen. We considered that although vesical perforation secondary to bacterial cystitis is a very uncommon process, it should be taken into account in the differential diagnosis of acute abdomen in predisposed patients (diabetic elderly patients with pyuria). In such instances, a retrograde cystography would provide the diagnosis. Although extraperitoneal vesical perforations can be resolved with a vesical catheter or cystostomy, extravasation of the infected urine may result in a perivesical abscess and septic shock. Early surgical management should be considered in these cases.
The case of a female patient aged 34 suffering from abdominal actinomycosis is reported. She underwent emergency surgery for an abscess-forming tumour infiltrating the lateral abdominal wall and giving rise to the clinical picture of acute abdomen. The casuistry is complemented by two further case histories of actinomyces infections in patients with fistulas of the anal region and pilonidal sinus respectively. Abdominal actinomycosis presents itself as a rare chronic bacterial inflammation, usually located in the right lower abdomen, with local abscess or fistula formation as well as tumour-like infiltration of the surrounding tissues. Exceptionally, the diagnosis is ascertained prior to surgery. Postoperative antibiotic therapy with penicillin for several months ist essential.
Ruptured phaeochromocytoma may mimic other cause of acute abdomen and though it is rare, it must be remembered as a possible differential; clinical suspicion should be increased when there is lability in blood pressure. We report a patient whose presentation closely resembles that of a leaking aortic aneurysm. The ultrasound performed was non conclusive and was followed by a computerised axial tomography which showed a retroperitoneal mass. A laparotomy was performed and histology of the mass revealed a haemorrhagic phaeochromocytoma. A computerised axial tomography is a useful investigation to distinguish it from other causes of acute abdomen and in particular a leaking aortic aneurysm.
CT has become the primary imaging modality for the evaluation of the patient with clinical symptoms of an acute abdomen and a confusing clinical picture. Because these patients may have a range of various pathologies, CT has been used successfully to define the presence of disease and localize it to a specific organ or organ system. In this article, we review the various processes that resulted in acute abdomen focusing on the small bowel and colon. Specific entities discussed include appendicitis, diverticulitis, Crohn disease, and ulcerative colitis. Other less common processes, including pseudomembranous colitis, intussusception, and bowel ischemia are also discussed. The specific role of CT scanning and specific CT signs are discussed and addressed. The value of CT in relationship to other modalities and clinical evaluation is discussed and key statistics provided.
Correct decision, when managing the acute abdomen in children, are based on careful clinical assessment. An accurate history and a detailed examination will provide more information than a multitude of investigations. The chronological order to appearance and the progression of each individual symptom must be obtained. Consideration of these dynamic changes will often yield an accurate diagnosis. This article outlines a structured approach to history taking and details the common causes of acute abdomen in childhood.
The neurologically or immunologically impaired child suspected of having an acute abdomen presents a formidable challenge. However, a thorough understanding of the underlying pathophysiology of the disease on the normal host response to an intraabdominal disease permits early recognition and initiation of treatment. Classic findings of the acute abdomen are the exception rather than the rule. These children require constant vigilance and repeated examination. Radiographic studies should be used early and often. The advent of minimally invasive surgical techniques offers the opportunity to intervene early both diagnostically and therapeutically. Ultimately, however, the best outcomes will be achieved by those who employ sound surgical judgment and avoid unnecessary therapeutic delay owing to inexperience, inattention, or indecision.
In the last ten years we have seen two cases from which we can prove that the cause of the acute abdomen was an intraperitoneal urinary bladder perforation. One had previously undergone radiation treatment of the abdomen and the other had a total abdominal hysterectomy.
The authors compare the importance of modern imaging methods and simple X-rays of the abdomen for the accurate diagnosis of ileus conditions. They discuss the possibilities of different methods and emphasize the importance of series of simple X-rays of the abdomen in different positions. The objective of the recommended procedures is to examine as well as possible a group of patients with an obstruction in the small or large intestine, to localize the obstruction, assess its etiology and not merely state that on the simple X-ray the horizontal beam reveals levels.
Eleven cases of acute necrotic pancreatitis had been treated by "open abdomen" at the author's departments. Nine patients survived, but 2 patients had been lost in MOF. Indication, technics and complications are discussed. The author's opinion is, that--on the basis of a suitable indication--"open abdomen" is a good method in the treatment of the necrosis in acute pancreatitis.
Over a period of three years, 122 patients who presented with acute abdomen, and had normal abdominal x-rays on admission were examined with Ultrasonography (U/S) in order to evaluate the use of Abdominal Ultrasonography in patients with negative x-ray findings. Sonographic evaluation was undertaken with Siemen's equipment (Sonoline S1-2) with a 3.5 MHz sector transducer for the abdominal organs and 5 or 7.5 MHz sector transducer for the abdominal organs and 5 or 7.5 MHz linear array for the intestines and right iliac fossa. Analysis included features or organ inflammation, bowel wall changes, and motility and collections. Ultrasound guided aspiration and drainage were done when necessary. Surgical confirmation was obtained in 86 out of the 122 cases. The commonest finding were appendicitis, intestinal obstruction and gynaecological pathologies. Ultrasound correctly identified 76 out of the 86 positive cases (88%). The sensitivity, specificity, positive predictive valve and negative predictive valves were 88%, 78%, 96% and 83% respectively. There were seven (7) false negative findings, and three (3) false positive cases. Pancreatitis was the commonest cause of false negative findings. The study clearly shows that ultrasound imaging can identify the underlying pathology in 88% of patients with acute abdomen with negative, plain abdominal x-ray findings. Ultrasound guided interventional procedures can also be done without delay.
The experience of operative treatment in 14 cases of acute abdomen complicated by malignant hemopathy was reported. Primary diseases consisted of AL, NHL, MM, MH and MDS-RA, 13 cases of them were at progressing stage. The acute abdominal conditions included acute appendicitis, acute pancreatitis, acute cholecystitis, peritonitis secondary to intestinal perforation, intestinal obstruction, primary peritonitis and ileocecal syndrome. The type of acute abdomen was related with primary desease and chemotherapy. 8 cases were operated and 2 of them died of complications after operation. Biopsy of excised tissue showed tumor cells in 2 cases. The rate of correllation between preoper active and postoperative diagnosis was 62.5%. These findings suggest that malignant infiltration in the viscera, duration of abdominal pain before operation and the change of blood picture are the major factors for determining operative indication and the postoperative prognosis.
Proceeding from a comprehensive literature survey the urgency of acute abdomen conditions in elderly and senile patients is thoroughly discussed. Not infrequently, geriatric surgeons face serious difficulties of diagnostic and therapeutic character relating to the severity of clinical picture and elevated postoperative lethality, explaining in turn the great surge of interest in the problem. Recent achievements along this line, surgery in particular, provide for adequate conditions for performing early surgical interventions with reduced intraoperative risk in elderly and old age patients presenting acute abdomen.
Management of the open abdomen in the setting of massive visceral swelling or extensive intra-abdominal abscess may pose an extremely difficult surgical scenario. We herein describe the technique and results of dynamic-retention sutures used in 13 patients with abdominal catastrophes after trauma, vascular reconstruction, tumor extirpation, and intra-abdominal infection. Three of these patients died during their acute care hospitalization. The remaining 10 patients were discharged to home with no resultant fistulas and 1 recurrent hernia (10%). Dynamic-retention sutures provide a useful technique for the closure of the complex surgical abdomen. We observed a low complication rate. In properly selected patients, this technique avoids the use of mesh or additional surgical procedures such as skin grafting or plastic surgical reconstruction of the abdominal wall.
This prospective study includes 146 patients with gunshot wounds of the abdomen. One hundred and five patients (72 per cent) had an acute abdomen on admission and were operated on immediately. The remaining 41 patients (28 per cent) had minimal or equivocal abdominal signs and were observed with serial clinical examinations. Seven of the observed patients needed subsequent laparotomy, but there was no mortality or serious morbidity. Had a policy of mandatory exploration for abdominal gunshot wound been applied the incidence of unnecessary or negative laparotomies would have been 27 per cent. By using a policy of selective conservatism this figure was only 5 per cent. We suggest that abdominal gunshot wounds should be assessed and managed exactly like knife wounds. Physical examination is reliable in detecting significant intra-abdominal injuries. Many carefully selected patients with abdominal gunshot wounds can safely be managed non-operatively.